A Reference Handbook OF THE MEDICAL SCIENCES EMBRACING THE ENTIRE RANGE OF SCIENTIFIC AND PRACTICAL MEDICINE . AND ALLIED SCIENCE VARIOUS WRITERS ILLUSTRATED BY CHROMOLITHOGRAPHS AND FINE WOOD ENGRAVINGS Edited by ALBERT H. BUCK, M.D. New York City VOLUME II NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Lafayette Place 1886 Copyright, 1886, By WILLIAM WOOD & COMPANY TROW'9 PRINTING AND BOOKBINDING COMPANY, NEW YORK. LIST OF CONTRIBUTORS TO VOLUME II. BENJAMIN VAUGHAN ABBOTT. New York, N. Y. Author of "Abbott's Law Dictionary," and Various Digests. SAMUEL W. ABBOTT, M.D Boston, Mass. Health Officer of the Massachusetts State Board of Health, Lunacy and Charity. ADOLF ALT, M.D St. Louis, Mo. W. C. AYRES, M.D New Orleans, La. Late Assistant Surgeon to the New York Ophthalmic and Aural Institute. GORHAM BACON, M.D New York, N. Y. Aural Surgeon, New York Eye and Ear Infirmary. JAMES B. BAIRD, M.D Atlanta, Ga. FRANK BAKER, M.D Washington, D. C. Professor of Anatomy, Medical Department of George- town University. ELIAS H. BARTLEY, M.D Brooklyn, N. Y. Lecturer on Chemistry, Long Island College Hospital; Chemist to the Board of Health of Brooklyn. HENRY W. BERG, M.D New York, N. Y. Assistant Surgeon, New York Orthopaedic Dispensary and Hospital. ALBERT N. BLODGETT, M.D Boston, Mass. Professor of Pathology and Therapeutics, Boston Den- tal College. W. P. BOLLES, M.D Boston, Mass. Professor of Materia Medica and Botany, Emeritus, at the Massachusetts College of Pharmacy ; Visiting Surgeon to the Boston City Hospital. NORMAN BRIDGE, M.D Chicago, III. Professor of Hygiene and Adjunct Professor of Princi- ples and Practice of Medicine, Rush Medical Col- lege. EDWARD B. BRONSON, M.D... .New York, N. Y. Professor of Dermatology, New York Polyclinic ; Der- matologist to the Northern Dispensary. W. K. BROOKS, Ph.D ..Baltimore, Md. Associate Professor of Morphology, Johns Hopkins University; Director of the Chesapeake Zoological Laboratory. PETER II. BRYCE, M.D Toronto, Canada. Professor of Chemistry, Ontario Agricultural College ; Secretary of the Provincial Board of Health. ALBERT H. BUCK, M.D New York, N. Y. Formerly Instructor in Otology in the College of Phy- sicians and Surgeons, New York, and one of the Aural Surgeons to the New York Eye and Ear In- firmary. LUCIUS D. BULKLEY, M.D New York, N. Y. Surgeon to the New York Hospital, Out-Patient De- partment, Section of Skin Diseases. WILLIAM N. BULLARD, M.D Boston, Mass. Physician to the Nervous Department, Boston Dispen- sary ; Physician to Out-Patients, Carney Hospital. FRANK BULLER, M.D Montreal, Canada. Professor of Ophthalmology and Otology, McGill Uni- versity. WILLIAM II. BYFORD, M.D Chicago, III. Professor of Gynaecology, Rush Medical College. WILLIAM S. CHEESMAN, Jr., M.D. .Auburn, N. Y. SAMUEL C. CHEW, M.D Baltimore, Md. Professor of Principles and Practice of Medicine in the University of Maryland, Baltimore. W. J. CONKLIN, M.D Dayton, 0. Professor of Diseases of Children, Starling Medical College. P. S. CONNER, M.D Cincinnati, O. Professor of Anatomy and Clinical Surgery in the Medical College of Ohio ; Professor of Surgery in the Dartmouth Medical College. WILLIAM T. COUNCILMAN, M.I)..Baltimore, Md. Associate Professor of Pathological Anatomy, Johns Hopkins University. EDWARD CURTIS, M.D New York, N. Y. Professor of Materia Medica and Therapeutics, College of Physicians and Surgeons, New York. LESTER CURTIS, M.D Chicago, III. Professor of Histology, Chicago Medical College ; Lec- turer on Diseases of the Throat and Chest, South Side Dispensary ; Visiting Physician to Mercy Hos- pital. CHARLES L. DANA, M.D New York, N. Y. Professor of Diseases of the Mind and Nervous System, and of Medical Electricity, New York Post-Graduate Medical School and Hospital ; Visiting Physician to Bellevue Hospital, and to the Northwestern Dis- pensary, Nervous Department. ISRAEL T. DANA, M.D Portland, Me. Professor of Pathology and Practice of Medicine, Medical School of Maine; Attending Physician, Maine General Hospital, Portland. ROBERT II. M. DAWBARN, M.D..New York, N. Y. Instructor in Obstetrics and Diseases of Women and Children, College of Physicians and Surgeons ; Visit- ing Surgeon to the Northwestern Dispensary, De- partment of Diseases of Children. D. BRYSON DELAVAN, M.D... .New York, N. Y. Surgeon to Department of the Throat, Demilt Dispen- sary. WILLIAM S. DENNETT, M.D... .New York, N. Y. Assistant Surgeon, Ophthalmic Department, New York Eye and Ear Infirmary. HENRY HERBERT DONALDSON, Ph. D.... Balti- more, Md. Johns Hopkins University. HAROLD C. ERNST, M.D. Boston, Mass. Assistant Pathologist to the Boston City Hospital. EDWARD ALLEN FAY, M.A., Pn.D ... .Washing- ton, D. C. Professor of History and Languages in the National Deaf-mute College ; Editor of " American Annals for the Deaf and Dumb." WILLIAM II. FLINT, M.D New York, N. Y. Attending Physician, Presbyterian Hospital; Assistant to the Chair of Principles and Practice of Medicine, Bellevue Hospital Medical College. LIST OF CONTRIBUTORS TO VOLUME II. F. FORCHHEIMER, M.D Cincinnati, O. Professor of Physiology and of Diseases of Children, Medical College of Ohio. FELIX FORMENTO, M.D New Orleans, La. President of the Cremation Society of New Orleans. EUGENE FOSTER, M.D Augusta, Ga. President of the Board of Health of Augusta. FRANK P. FOSTER, M.D New York, N. Y. Assistant Surgeon, Woman's Hospital in the State of New York. GEORGE B. FOWLER, M.D New York, N. Y. Professor of Physiological Chemistry, New York Poly- clinic ; Physician to the New York Infant Asylum. JAMES M. FRENCH, M.D Cincinnati, O. Assistant Demonstrator of Pathology and Instructor in Physical Diagnosis, Medical College of Ohio ; Mi- croscopist and Pathologist to St. Mary's Hospital. E. M. GALLAUDET, Pu.D., LL.D Washington, D. C. President of National Deaf-mute College, Washington. JAMES McF. GASTON, M.D Atlanta, Ga. Professor of Principles and Practice of Surgery, South- ern Medical College. GEORGE W. GAY, M.D Boston, Mass. Surgeon to the Boston City Hospital. WALTER R. GILLETTE, M.D... .New York, N. Y. Professor of Obstetrics, New York Polyclinic ; Visit- ing Physician to Bellevue and St. Francis' Hospi- tals. JOHN GREEN, M.D St. Louis, Mo. Lecturer on Ophthalmology, St. Louis Medical College. J. ORNE GREEN, M.D Boston, Mass. Aural Surgeon, Boston City Hospital; Clinical In- structor in Otology, Harvard University. CHARLES R. GREENLEAF, M.D Columbus Barracks, O. Surgeon, United States Army. CHARLES E. HACKLEY, M.D... .New York, N. Y. Attending Physician, New York Hospital. ALLAN McLANE HAMILTON, M.D... .New York, N. Y. Professor of Diseases of the Mind and Nervous System, New York Polyclinic. FREDERICK P. HENRY, M.D.. .Philadelphia, Pa. Professor of Pathology and Microscopy, Philadelphia Polyclinic and College for Graduates in Medicine; Physician to the Hospital of the Protestant Episco- pal Church. S S. HERRICK, M.D New Orleans, La. Secretary of the State Board of Health, Louisiana. WILLIAM B. HILLS, M.D Boston, Mass. Assistant Professor of Chemistry, Harvard University. JOSEPH W. HOWE, M.D. New York, N. Y. Visiting Surgeon to the Charity and St. Vincent's Hos- pitals. GEORGE S. HUNTINGTON, M.D. .New York, N. Y. Member of the Resident Surgical Staff, Roosevelt Hos- pital. B. JOY JEFFRIES, M.D Boston, Mass. Ophthalmic Surgeon to the Massachusetts Charitable Eye and Ear Infirmary, the Carney Hospital, and the New England Hospital for Women and Children. LAWRENCE JOHNSON, M.D New York, N. Y. Professor of Medical Botany, Medical Department of the University of the City of New York. W. W. JOHNSTON, M.D..! Washington, D. C. Professor of Theory and Practice of Medicine in the National Medical College, Washington. SAMUEL KETCH, M.D New York, N. Y. Senior Assistant Surgeon, New York Orthopaedic Dis- pensary and Hospital. WILLIAM G. LeBOUTILLIER, M.D New York, N. Y. EDWARD SYDNEY McKEE, M.D. . .Cincinnati, 0. Clinical Assistant to the Chair of Gynaecology, Medi- cal College of Ohio ; Late Clinical Assistant to the Hospital for Sick Children, London, England. JULIAN A. MEAD, M.D Watertown, Mass. Medical Examiner for Middlesex County, Massachu- setts. T. WESLEY MILLS, M.D Montreal, Canada. Lecturer on Physiology, McGill University. CHARLES SEDGWICK MINOT, M.D Boston, Mass. Instructor in Histology and Lecturer on Embryology, Harvard University. E. M. MOORE, M.D Rochester, N. Y. Attending Surgeon, St. Mary's Hospital, Rochester; formerly Professor of Surgery, University of Buf- falo, N. Y. ROBERT B. MORISON, M.D Baltimore, Md. Professor of Dermatology and Syphilis, Baltimore Polyclinic and Post-Graduate Medical School. WILLIAM II. MURRAY, M.D. .. ..New York, N. Y. Late House Surgeon, New York Hospital House of Relief. SAMUEL NICKLES, M.D Cincinnati, O. Professor of Materia Medica, Medical College of Ohio. ROSWELL PARK, M.D Buffalo, N. Y. Professor of the Principles and Practice of Surgery, University of Buffalo, N. Y. F. PEYRE PORCHER, M.D Charleston, S. C. Professor of Materia Medica and Therapeutics, Medical College in the State of South Carolina; one of the Physicians to the City Hospital, Charleston. T. MITCHELL PRUDDEN, M.D..New York, N. Y Lecturer on Normal Histology, Yale College ; Director of the Physiological and Pathological Laboratory of the Alumni Association, College of Physicians and Surgeons, New York City. EDWARD T. REICHERT, M.D..Philadelphia, Pa. Demonstrator of Experimental Physiology and Exper- imental Therapeutics, University of Pennsylvania. HUNTINGTON RICHARDS, M.D New York, N. Y. Assistant Aural Surgeon, New York Eye and Ear In- firmary. HENRY A. RILEY New York, N. Y. Attorney and Counsellor at Law. A. SYDNEY ROBERTS, M.D... .Philadelphia, Pa. Visiting Surgeon to the Philadelphia Hospital and to the Orthopaedic Dispensary of the University Hos- pital ; Instructor in Orthopaedic Surgery in the Uni- versity of Pennsylvania. A. D. ROCKWELL, M.D New York, N. Y. D. B. St. JOHN ROOSA, M.D New York, N. Y. Professor of Diseases of the Eye and Ear, New York Post-Graduate Medical School; Surgeon to the Man hattan Eye and Ear Hospital. IRVING C. ROSSE, M.D Washington, D. C. WILLIAM B. SCOTT, Pu.D. (Heidelberg)... .Prince- ton, N. J. Professor of Geology, Princeton University. WILLIAM T. SEDGWICK, Ph D Boston, Mass. Assistant Professor of Biology, Massachusetts Institute of Technology. LIST OF CONTRIBUTORS TO VOLUME II. BENJAMIN SHARP, M.D., Ph.D... Philadelphia, Pa. Professor at the Academy of Natural Sciences of Phila- delphia, at the University of Pennsylvania, and at the Wagner Institute. H. N. SPENCER, M.D St. Louis, Mo. Professor of Diseases of the Ear, St. Louis Post-Gradu- ate School of Medicine, Polyclinic and Hospital As- sociation ; Aural Surgeon to the St. Louis Free Hos- pital for Children. THOMAS L. STEDMAN, M.D New York, N.Y. Assistant Surgeon, New York Orthopaedic Dispensary and Hospital. HENRY W STELWAGON, M.D... .Philadelphia, Pa. Physician to the Philadelphia Dispensary for Skin Dis- eases ; Chief of the Skin Dispensary of the Hospital, and Instructor in Dermatology, University of Penn- sylvania. GEORGE M. STERNBERG, M.D Washington, D.C. Surgeon, United States Army. JAMES M. STEWART, M.D... .Montreal, Canada. Professor of Materia Medica and Therapeutics, McGill University. SAMUEL THEOBALD, M.D Baltimore, Md. Professor of Diseases of the Eye and Ear, Baltimore Polyclinic and Post-Graduate Medical School; Sur- geon to the Baltimore Eye, Ear, and Throat Charity Hospital. WILLIAM GILMAN THOMPSON, M.D New York, N. Y. Assistant Physician to the New York Hospital, Out- Patient Department ; Physician to Roosevelt Hospi- tal, Out-Patient Department. WILLIAM H. THOMSON, M.D... .New York, N. Y. Professor of Materia Medica and Therapeutics and Dis- eases of the Nervous System, Medical Department of the University of the City of New York ; Visiting Physician to Bellevue and Roosevelt Hospitals. A. VANDER VEER, M.D Albany, N.Y. Professor of the Principles and Practice of Surgery and Clinical Surgery, Albany Medical College ; At- tending Surgeon, Albany Hospital. ARTHUR VAN HARLINGEN, M.D. .Philadelphia, Pa. Professor of Diseases of the Skin in the Philadelphia Polyclinic and College for Graduates in Medicine ; Consulting Physician to the Dispensary for Skin Dis- eases. SAMUEL B. WARD. M.D Albany, N. Y. Professor of Pathology, Practice, Clinical Medicine and Hygiene, Albany Medical College; Attending Surgeon, Albany Hospital. WILLIAM L. WARD WELL, M.D New York, N. Y. Surgeon to the Eastern Dispensary ; Assistant Surgeon, New York Polyclinic. J. COLLINS WAKREN, M.D Boston, Mass. Assistant Professor of Surgery, Harvard University ; Surgeon to the Massachusetts General Hospital. LEONARD WEBER, M.D New York, N. Y. BENJAMIN F. WESTBROOK, M.D Brooklyn, N. Y. Physician-in-Chief to the Department for Diseases of the Chest, St. Mary's Hospital. JAMES C. WHITE, M.D Boston, Mass. Professor of Dermatology, Harvard University. JAMES T. WHITTAKER, M.D Cincinnati, O. Professor of Theory and Practice of Medicine, Medical College of Ohio, Cincinnati. EDWARD WIGGLESWORTH, M.D Boston, Mass. President of the American Dermatological Association ; Physician to the Skin Department, Boston City Hos- pital. GEORGE WILKINS, M.D Montreal, Canada. Professor of Medical Jurisprudence, McGill Univer- sity. CHARLES FRANCIS WITHINGTON, M.D Bos- ton, Mass. EDWARD S. WOOD, M.D Boston, Mass. Professor of Chemistry, Harvard Medical School. PHILIP ZENNER, M.D Cincinnati, O. Clinical Lecturer on Diseases of the Nervous System, Medical College of Ohio, Cincinnati. A REFERENCE HANDBOOK OF THE M EPIC A L S CIE N C E S. Catarrh. Catarrh. CATARRH, NASAL. Acute Nasal Catarrh; Acute Rhinitis, Coryza, Cold in the Head. An acute catarrhal inflammation of the mucous membrane of the nose, and sometimes of the adjacent sinuses, manifested by hyper- femia and hypersecretion, sneezing, and obstruction to the passage of air. It is most commonly caused by "taking cold," but may arise from exposure to extreme heat, or from the inhalation of irritating dust or vapors. Acute rhinitis occurring in apparent epidemics is probably due to the exposure of a number of individuals to the same exciting causes. Experiments intended to prove its con- tagiousness have resulted negatively. It is a frequent complication of the exanthemata, especially measles, small-pox, scarlatina, and typhus fever. It often accom- panies facial erysipelas, or may occur as one of the mani- festations of syphilis ; it is a familiar symptom of iodism, and may be due to the action of other mineral poi- sons. It may also be caused by sexual irritation. The symptoms are at first those of general, more or less severe, pyrexia, accompanied with a feeling of fulness and some- times of throbbing or pain in the frontal region, and soon succeeded by paroxysms of sneezing. The mucous mem- brane, at first dry, soon begins to secrete a copious, thin, watery discharge. This in turn becomes saline and acrid in character, and later, muco-purulent. Finally, the dis- charge becomes thin again, loses its irritating quality, and gradually ceases altogether. In severe attacks the Eu- stachian tube may be involved, causing tinnitus and deaf- ness, while implication of the adjacent sinuses intensifies the headache and general discomfort. In infants the symptoms produced by acute coryza are sometimes dan- gerous. The diagnosis, generally easy, can only be doubtful when the attack is premonitory of some acute specific disease, such as measles, or in the early stages of ' ' hay fever," before a positive diagnosis of that affection has been established. The duration of the disease is very indefinite. Although it is attended with danger to life only at the extremes of youth and old age, it may nevertheless result in chronic hypertrophic rhinitis or in the development of polypi. The treatment should be both preventive and abortive. The former consists in the careful avoidance of known causes, which causes can generally be recognized by the patient himself. For the latter, many methods have been recommended, few of which, however, can be re- lied upon. Among the most useful formulae may be men- tioned the following : R. Ext. belladonna, camphoric, quin, sulph., taraxaci, aa gr. j. (0.065 Gm.). M. Ft. pil. No. 1. One such pill to be taken every four hours until the effect of the belladonna is felt. The old-time treatment of administering a ten-grain Dover's powder at night, followed by a saline laxative in the morning, will often be found valuable. Morell Mackenzie, however, believes that the effect of opium is much greater if ad- ministered during the day, and he advises the administra- tion of five to seven drops of laudanum, taken on an empty stomach, the dose to be repeated in six or eight hours if the first be not effective. He also suggests de- rivative treatment, by the administration of diaphoretics, diuretics, or purgatives. Of these the Turkish bath an- swers particularly well with some patients. Total ab- stinence from liquids has also been recommended. The following are also recommended by Dr. B. Robin- son : B- Sp. ammoniae aromat., § j. Sig.: One tea- spoonful in sweetened water ( § j.) every two hours. B. Ammonii carb., liq. morph, sulph. (U. S.), aa 3 j. (4 Gm.); mist, amygdalae, adj iij. (90 Gm.). M. Sig. : A teaspoonful in water ( § j.) every hour for six hours, and then every hour and a half. Dr. Robinson also recom- mends : B- Pulv. fol. belladonnas, gr. xx. (1.3 Gm.); pulv. morph, sulph., gr. ij. (0.13 Gm.); pulv. gum. acaciae, ad ? ss. (15 Gm.). M. Sig. : To be applied with a powder-blower in sufficient quantity to thoroughly coat the nasal mucous membrane. A spray consisting of a four per cent, solution of the hydrochlorate of cocaine has also been used with good effect. Owing to the relative smallness of the nasal cavity in infancy, acute rhinitis becomes to the young child a mat- ter of serious importance, as a slight swelling of the pituitary membrane may suffice to cause occlusion. This may in extreme cases result in paroxysms of dyspnoea, followed by pulmonary engorgement, or may even ex- pose the child to the danger of starvation through inabil- ity to suckle. These cases, although unusual, should be treated with careful attention, upon the principles sug- gested above ; the use of opium, however, being omitted. The child should be fed with a spoon or through a tube. Purulent nasal catarrh may result from traumatism, as in the case of injury or the prolonged presence of a foreign body ; or from direct infection, as from a leucor- rhoeal or gonorrhoeal discharge ; or simply as an aggrava- tion of an ordinary acute catarrh. The treatment should consist in cleansing alkaline sprays, followed by mild astringent solutions. Certain substances also, such as bichromate of potash, arsenic, and mercury, produce a specific effect upon the nasal mucous membrane, characterized by irritation, watery, followed later by thick and greenish, discharge, the formation of crusts, epistaxis, and, finally, partial ne- crosis of the cartilage of the septum. Chronic Catarrh.-This affection is usually, for con- venience of classification, divided into three varieties. 1. Simple chronic catarrh, or rhinitis. 2. Hypertrophic rhinitis. 3. Atrophic rhinitis. The first form is, like chronic catarrhal conditions in other mucous membranes, simply a chronic inflammation of the pituitary membrane, uncomplicated by serious structural changes. It is attended with an increased dis- charge of mucus or muco-pus. Chronic pharyngitis may be, and usually is, present. The continuance for any con- siderable length of time of this condition is likely to be fol- lowed by certain changes in the mucous membrane, which result in the second, or hypertrophic variety. In this the normal elements of the nasal mucous mem- brane, together with the underlying erectile tissue, be- come permanently hypertrophied. As a rule, enlarge- ment of the adenoid elements in the adjacent parts of the pharynx coexists. There is usually an excessive secre- 1 Catarrh. Catecli n. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion of thick, tenacious mucus, with more or less occlusion of the nasal passages and obstruction to normal respi- ration. Although the middle turbinated body and the septum are commonly affected, it is the inferior turbinated body which suffers most frequently and to the greatest extent. This may be enlarged throughout its whole extent, or the hypertrophy may be principally confined to its anterior, or else to its posterior parts. In the former case it may act as a serious hindrance to respiration ; in the latter it sometimes attains such proportions as to constitute an ac- tual tumor, irritating by its presence the neighboring pharyngeal parts, and leading to chronic pharyngitis, ca- tarrh of the Eustachian tube, and even chronic laryngitis. The third, or atrophic form of rhinitis is less common than the preceding, but far more unpleasant in its results and more difficult to deal with. It occurs as a sequence of the hypertrophic form, either early in its course or as a late consequence, and is the result of a hyperplasia of the normal fibrous tissue of the mucous membrane. When occurring early, it is due to the presence of so great an amount of fibrous tissue that the normal elements of the mucous membrane are literally crowded out, or, more commonly, it results from the contraction of fibrous tis- sue previously deposited upon the vessels and glandular structures of the membrane, -and their consequent ob- literation. So great may be the effects thus produced that not only the mucous membrane but even the under- lying turbinated bones may be markedly reduced in vol- ume. The calibre of the nasal passages is thus rendered abnormally large, and the erectility of the soft parts is lost; the discharge is scanty and the mucous membrane becomes dry and covered with crusts of inspissated mu- co-pus, which become more offensive and abundant as the disease progresses. And finally, the olfactory sense is impaired or wholly lost. The condition is apt to ex- tend to the pharynx, and the discomfort of the patient is further increased by his susceptibility to atmospheric changes. Treatment.-It is, of course, in the first, or simple form of chronic rhinitis that the best results from treatment are to be obtained. But this, to be effective, must be carried out with great persistence and regularity. Con- stitutional diatheses, such as the rheumatic, the syphi- litic, or the so-called strumous, must be recognized, if present, and dealt with by appropriate general treatment. Obedience to proper hygienic rules must be required as an aid to both prophylaxis and cure. Among these the securing of a state of healthy activity on the part of the skin is particularly important. The action of in- ternal remedies directed immediately to the local condi- tion has, thus far, proved of questionable value. The value of the sulphur mineral waters, however, has of late been urged both in this country and in Europe, while cubebs and muriate of ammonia are still regarded with favor by many. These measures should be used, of course, in connection with local treatment, the latter be- ing alike necessary whether the disease depend upon general causes or whether it be a purely local affection. The local treatment consists in a thorough cleansing of the parts and the application of the remedy selected. For the mechanical accomplishment of this first object many methods have been suggested and many instru- ments devised. Of these none can compare in general utility with that by which an atomized solution is applied by means of some form of the spray douche, as now commonly practised in this country. If the secretions cannot be removed by simply blowing the nose, the nasal passages and naso-pharynx should be sprayed with a solution at once alkaline and antiseptic in its composi- tion. Dobell's solution, or a weak solution of borax and salicylic acid, will be found useful. More elegant than these, however, are the following: B • Acidi carbolici (or acid, salicylic.), 9j. (1.3 Gm.) (or less if necessary); sodii boratis, sodii bicarbonatis, aa 3 j. (4 Gm.); glycerinae, aquae resorum, aa § j. (30 Gm.); aquae, q. s. ad Oj. (500 Gm.). Or: B ■ Sodii bicarb., sodii biboratis, aa 3 ss. (2 Gm.); " Listerine," § j. (30 Gm.); aquae ad § iv. (125 Gm.). M. In some cases a solution of bichloride of mercury, gr. j. to Oj., will give unusual relief, while in others it will be found too irritating to be endured. Solutions of chloride of sodium are not recommended. Should the secretions be too abundant or tenacious to be removed by the spray, some form of syringe or douche may be substituted, and the application be made of one of the above solutions properly diluted. The parts hav- ing been cleansed, the medicament should be applied. This application is made usually in the form, either of atomized spray or of powder. Of these two methods the former is decidedly to be preferred. Mild astringent or alterative solutions will generally prove most efficacious. Among these are the iodide or the sulphate of zinc, the sulpho-carbolate of zinc, the sulphate of iron and am- monium, or the sulphate of iron, any one of which may be used in the strength of gr. v.-^j. (0.3-30 Gm.). Tannic acid, gr. v.-xx.-^ j. (0.3-1.3-30 Gm.) ; and chlo- rate of potassium, 3 j.- 3 j. (1.3-30 Gm.), are also valuable. Persistent treatment is absolutely necessary for the ac- complishment of permanent relief. In the treatment of chronic hypertrophic rhinitis, in addition to the measures employed to meet the indica- tions which exist in the simple chronic form, we must use those which are designed to check the further prog- ress of the pathological changes which may have taken place, and to restore the mucous membrane as nearly as possible to its normal condition. For this, more active measures than those above described will be necessary, although at the present time much controversy exists as to the comparative merits of the mild and the more severe systems of treatment. In general it may be said that great care should be taken to avoid irritating the parts by excessive treatment and thus causing the ap- plication to defeat its own object. As patients diifer widely in their susceptibility to certain applications, a preliminary trial of the strength of a solution should be made, and its effects carefully noticed. The following has been highly recommended : 1^. lodini cryst., gr. iv. (0.26 Gm.); potass, iodid., gr. x. (0.65 Gm.); zinci iodid., Bj. (1.3 Gm.); zinci carbolatis, 3 j. (1.3 Gm.); "Listerine," § j. (30 Gm.); aqu® ad § iv. (125. Gm.). M. S.: To be used as a spray. In the later stages local applications will be found to be of little value. The causes of occlusion, if present, must be removed by surgical means. In case the mucous membrane is hypertrophied anteriorly, or along the course of the inferior turbinated body, its reduction may be effected by means of nitric, of mono-chloracetic, or of chromic acid. The galvano-cautery is also warmly recom- mended by some writers for this purpose. The desired re- sult, however, may generally be obtained by the less severe methods. In using the acids mentioned, the application should be made as follows : A very small bit of absorbent cotton is wrapped around the end of a probe and dipped into the acid ; then, the nostril being held open by a speculum, and the excess of acid having been removed, the cotton is applied directly to the diseased part and re- tained there for a few seconds, the patient in the mean- while breathing out gently in order to avoid inhaling the fumes. As soon as possible after the application the nostril should be thoroughly sprayed with an alkaline solution. The separation of the resulting slough, and sub- sequent cicatrization, together with the results of the in- flammatory process, will generally cause a marked dimi- nution in the volume of the mucous membrane. If one operation be not sufficient, it may be repeated. It is highly objectionable to cauterize a large extent of surface, and the acid should therefore be applied in a narrow line across the points of greatest convexity. When the hy- pertrophy exists at the posterior extremity of the inferior turbinated body it may attain the size of a veritable tumor, and by its presence cause great annoyance and mischief. Here brilliant results are obtained by the use of the in- strument known as Jarvis' snare, a small ecraseur carry- ing a fine loop of steel wire, in which the tumor is engaged, and, by means of a powerful screw, slowly cut through and thus removed. Should hypertrophy at the vault of the pharynx exist, the hypertrophied tissues must be removed either by a modified Jarvis ecraseur or by a suitable for- ceps. Although iu atrophic rhinitis the prognosis is gen- 2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Catarrh. Catechu. erally unfavorable, much, nevertheless, may be done to re- move the most annoying features of the disease, and, in some instances, especially if not of too long standing, a cure may be effected. By the persistent use of one of the disinfectant solutions mentioned above, the dry surface of the mucous membrane will be kept in a more or less nor- mal condition of moisture, and the inspissated and fetid crusts removed. Following this the application should be made of some remedy which shall stimulate the mucous membrane, or rather such of its secreting glands as remain intact, to a degree of activity sufficient to pre- serve its natural moisture and pliability. For this the following powders have been recommended : Sanguin- aria, 3 ij-- 1 j- (8-30 Gm.); galanga, §ss.-|ss. (15-15 Gm.); salicylic acid, 3j.-§ss. (1.3-15 Gm.); iodine, gr. j.-ij.-§ss. (0.065-0.130-15 Gm.); bromide of po- tassium, 3j.-^ ss. (1.3-15 Gm.) ; and, finally, nitrate of silver, gr. ij.-x.-§ss. (0.13-0.65-15 Gm.). Powdered starch, gum acacia, or sugar of milk will be found con- venient menstrua for the dilution of powders for insuffla- tion. In using these drugs in the above proportion they will often be found too irritating. Their strength should, therefore, be varied according to special indications. There is a form of chronic rhinitis which, although unusual, should not be lost sight of. In this the dis- charges have a peculiar and exceedingly unpleasant odor, due apparently to some individual idiosyncrasy, just as in the case of certain individuals whose perspiration is offen- sive. It is particularly intractable, but may be relieved by the disinfectant methods already explained. In closing this subject it is but fair to state that gratify- ing advances have of late years been made in the success- ful treatment of catarrh. ' At present, however, so many different therapeutic methods are proposed and strongly advocated by good authorities, that it is impossible to re- fer to any one as established. The above, however, is believed to be a fair resume of the views generally held in regard to this wide topic. D. Bryson Delavan. is from five to ten centimetres long (two to five inches), shaped like a bean-pod, and contains six or eight seeds. The tree is a native of most parts of both India and Bur- mah, extending high into the Himalaya valleys. It also grows in Ceylon, and has been transplanted to the West Indies. Acacia suma Kurtz, a larger tree with red wood and a white bark, growing in India as well as tropical Asia, is also a source of this drug. It has been trans- planted to South America. Catechu was not fairly in- troduced into European commerce until the middle of the seventeenth century, when it was considered to be a min- eral product {Terra Japonica). It was used in medicine shortly after its introduction into Europe. It has always been in use in India. Preparation.-The tree is selected when of suitable size, say thirty centimetres or so in diameter, felled, the alburnum cut away; and only the dark heart-wood used ; * this is cut into chips, which are filled into earthern boil- ing-pots arranged over a primitive furnace; water is added, and the whole boiled until the catechu is boiled out. The liquid is then strained or poured off into other pots, and the evaporation kept up until the extract is thick enough to harden upon cooling. It is poured into moulds or boxes. In Northern India the boiling is stopped earlier, and the "catechu" induced to crystallize upon sticks and branches laid in for this purpose ; this form of catechu never reaches'us. Catechu is a dark brown extract, solid and brittle when old and dry, often softish in the middle of freshly im- ported masses. It is apt to be covered with leaves, and contains also leaves, sticks, and frequently other impu- rities in the middle ; it breaks easily, displaying a bubbly surface. It is of a lighter brown color within when soft, but soon becomes almost black upon exposure. It has an astringent and sweetish taste, with but very little odor. When moistened and examined with a lens it appears to consist of an abundance of minute crystals (catechin). Composition.-The principal ingredient, both as to quantity and interest, in catechu is the crystalline body catechin, first prepared by Nees von Essenbeck and von Dobereiner. It exists not only in the article under con- sideration, but also in Gambir, Areca Catechu, and perhaps in Kino. It crystallizes in long, fine-pointed, clustered needles, which are white and perfectly transparent. It is permanent in the air, and very insoluble (n^u) in cold water. ■ Boiling water dissolves, however, about one third of its weight of catechu. It is slightly acid in reaction, and tastes bitter and astringent. Catechu-tannic acid, a second proximate principal of catechu, is a reddish-yel- low, transparent, uncrystalline form of tannin; besides these it contains a number of other products in minute proportions, which are mostly decomposition products of the above, probably produced by the boiling. Catechu is the most popular vegetable astringent for internal use, and is in constant demand for relaxed and chronic diarrhoeas. It may be also used with good advantage whenever tannic or gallic acid is indicated, as in uterine and other haemorrhages, flabby ulcerations, subacute pharyngitis, etc. The medical demand requires but a very small por- tion of the catechu imported, most of which is used in dyeing and for other technical purposes. Dose of ca- techu, from one-half to two or three grams (gr. viij. ad xxx.). The officinal Tincture {Tinctura Catechu Com- posita) - Catechu, Cinnamon, in diluted alcohol- is the usual form for administration. Dose, from one to two grams (7T^ xv. ad xxx.) or more. Allied Plants.-The genus Acacia numbers four hundred and fifty species, a large number of which yield astringent products ; of several the bark is used for tan- ning, several others yield the different varieties of Gum Arabic. For the order, see Senna. • Allied Drugs.-Gambir {Catechu Pollidum, Br. Ph. ; Catechu, Ph. G. ; the latter including also an extract from Areca Catechu) is obtained by boiling the leaves of Uncaria, Gambir Roxb., Order Rubiacea of India, and crystalliz- ing. It is a yellow-bro wrn solid, becoming quite dark with age, hard, brittle, and opaque ; it consists mostly of a solid CATECHU, U. S. Ph. (Cachou de Pegu, ou Cashcuttie, Codex Med.), Cutch; Terra Japonica; Black Catechu, etc. ; the Catechu of the British and German Pharmaco- poeias is from a differ- ent source (see below). An extract obtained by boiling the wood of Acacia Catechu Willd., Order Leguminoscs, Mi- mosea, in water and evaporating. The Catechu Acacia is a medium-sized, ir- regularly branching tree from eight to twelve metres (twenty to forty feet) high. The leaves are-alter- nate, petiolate, twice abruptly pinnate, and provided with a pair of recurved prickles at the insertion of the petiole upon the stem ; they are from ten to twenty centimetres long and have about a dozen pinnae. The leaflets are very small, three to five millime- tres long (one or two lines), and crowded so as to overlap each other. The small yel- low flowers are nu- merous, in axillary spikes, which usually grow in pairs ; they consist of an inconspicuous calyx, a small corolla, each five-lobed and regular, very numerous stamens, and a single, curved, several-seeded carpel. The ripened pod Fig. 587.-Catechu; Flowering Branch and Enlarged Flower and Section. (Baillon.) * Other accounts state that all the wood is utilized. 3 Catechu. Caustics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mass of Catechin crystals. The Catechu of the Areca nuts is of a similar composition. For further information concerning Astringents and Tannin, see Galls. W. P. Bolles. ically on the tissue, and forming new compounds with its elements. Potential cauteries, caustics, or escharotics, comprise a. great variety of substances. When placed on animal tis- sues they produce at first redness and a sensation of warmth, which is rapidly succeeded by pain. The pain produced by some caustics is transient and not very severe, but others are followed by intense pain that may even continue for hours after the caustic has ceased to act. When allowed to remain on the tissues, caustics de- stroy life to a greater or less depth, and produce sloughs or eschars. The slough is either moist or dry, and if left ex- posed to the air usually grows firmer and drier. Its color varies with the caustic employed, and it is surrounded by a zone of inflammation and congestion, which is broad or narrow, according to the greater or less diffusion of the action of the particular caustic. At the end of a few days, or perhaps weeks, the eschar is separated from the adjoining tissues by suppuration, and when it comes, away leaves a healthy ulcer that advances gradually to complete cicatrization. It is claimed that if the eschar be aseptic, and subsequent treatment prevent the access of germs, no suppuration will occur, and the slough will be separated by the development of granulations without inflammation (Hueter : " Chirurgie"). Caustics were used formerly to a great extent to arrest haemorrhage, and to destroy pathological new for- mations and hypertrophies. They have been much em- ployed also, in the treatment of abscess, hydrocele, cysts, fistulae, strictures, ulcers and skin diseases, poisoned wounds, and diseases of the eyelids and cornea. As hae- mostatics, caustics are now rarely employed. Their use always necessitates the formation of a slough, and thus prevents primary union, while many more efficient agents-torsion, the various materials for ligature, acu- pressure, even the actual cautery-are in many respects superior. In general, in the removal of tumors, the knife is much less painful, more rapid, and accurate than caustics, but there are some cases in which there are advantages in employing a properly selected caustic. In malignant tumors, in which the disease has advanced too far for complete eradication by the knife, or in which the general system has become infected, haemorrhage, excessive secre- tion, and disagreeable odors maybe prevented or much di- minished by the use of caustics. In other cases, in which the patient will not consent to the use of the knife, caus- tics may properly be employed ; and it is held by some au- thorities that no treatment is so efficient in certain varie- ties of superficial epithelial carcinoma as destruction by caustics. Caustics are rarely employed to open abscesses. For abscesses of the liver the use of the aspirator is bet- ter ; and cold abscesses are less liable to give rise to septic absorption if evacuated and drained antiseptically, or emptied with the aspirator under antiseptic precautions, than if opened by the action of caustics. The use of caustics at present is chiefly to destroy virus and prevent its absorption, as in poisoned wounds (the bites of snakes and animals, anthrax, dissection and post- mortem wounds); to destroy unhealthy granulations, ex- uberant or malignant growths, as cancer, condylomata, warts, lupus ; to coagulate the blood, as in haemorrhoids or superficial naevi, and occasionally in haamorrhage : and finally, to produce issues for purposes of counter-irrita- tion. For the removal of small pedunculated tumors the ligature, ecraseur, or galvano-cautery is preferable to the use of caustics, but small polypi with broad bases may be successfully treated in this way. Caustics are sometimes used to supplement the action of the knife where small particles of diseased tissue are left behind, which the caustic is better able to reach and destroy. The principal caustics employed have been found to fall naturally into two classes, caustic acids and caustic alkalies, besides which a third class is generally recog- nized whose members are allied to acids in their action. This group is known as the caustic metals or metallic salts. This name, however, is ill-chosen, as many of these substances resemble very slightly the metals. The points to be chiefly observed about the action of caustics are whether they are weak or strong (the former CATOOSA SPRINGS. Location and Post-office, Ca- toosa Springs, Catoosa County, Ga. Access.-By Western & Atlantic Railroad to Catoosa Station, thence by carriage to the Springs, two miles dis- tant. The East Tennessee & Georgia Railroad passes within seven miles of the springs. Analysis.-There are fifty-two distinct springs in this group, differing in composition, within a space of about two acres. The following is the analysis of No. 10, or ' ' Buffalo " Spring, which is distinguished from the others in that it contains more sulphate of magnesia. Like all the rest, it shows a small amount of lithia. One gallon contains : Grains. Sniphate of lime 45.0000 Sulphate of magnesia 33.0210 Sulphate of strontia 0.2900 Sulphate of soda 1.6720 Sulphate of potassa 2.3120 Sulphate of alumina 2.3850 Carbonate of lime 3.8560 Carbonate of magnesia 8.7010 Carbonate of iron 0.2790 Carbonate of manganese 0.0210 Carbonate of lithia 0.0030 Carbonate of strontia 0.0400 Carbonate of potassa 0.0120 Carbonate of soda 0.0280 Nitrate of calcium 0.0340 Nitrate of ammonia 0.9100 Bromide of calcium 0.1520 Bromide of magnesium 0.3310 Fluoride of calcium 0.0140 Chloride of sodium 0.1150 Crenic and apocrenic acids 0.0120 Free sulphuric acid 0.1290 Free carbonic acid 4.6220 Hydrosulphuric acid 0.0010 Total ingredients 103.9400 Total solid residue upon evaporation at 212° F.. 100.1090 Note.-This Spring contains more saline matter than either of the other Springs. The ordinary drinking-water is a pure limestone. Therapeutic Properties.-These waters may be de- scribed as purgative-calcic, combined with an active pro- portion of alkaline carbonates. They are valuable in cases of dyspepsia accompanied with constipation. They have also proved beneficial in hypersemia of the liver, enlarge- ment of the spleen, and catarrh of the bladder. The springs are located on each side of a small stream, in an elevated basin surrounded by mountains, and issue from a bed of black slate and marble of various colors on the side of the mountain. The air is that of the moun- tainous region of Northern Georgia and Eastern Tennes- see, the Blue Ridge range ; pure and bracing. The tem- perature seldom rises above 80° F. in summer during the day. The nights are always pleasantly cool. Hotels.-Accommodation is supplied by two hotels and twenty-one cottages, arranged on three sides of a rec- tangle, with a capacity for six hundred guests. These buildings are situated in enclosed grounds of about forty acres, shaded by magnificent forest trees. The scenery of this region is celebrated for its beauty and grandeur. Mountain streams and the beautiful Chickinauga River furnish good fishing. History.-The curative qualities of these springs were known to and used by the Indians. They have always been a favorite resort for the people of the Southern States up to the breaking out of the war, and are now re- gaining their former popularity. G. B. F. CAUSTICS. Synonyms : Lat., Causticum; GeY.,Aetz- mittel; Fr., Gaustique. Agents which burn, corrode, or disorganize the animal tissues upon which they act, are termed caustics or cauteries. They are usually classified as actual cauteries, those that destroy life by the action of a high degree of heat (see article Cauterization), and po- tential cauteries, those that disorganize by acting chem- 4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Catecli u. Caustic*. are sometimes called corrosives, the latter escharotics); the depth of action, amount of diffusion, character of eschar, and peculiarities of the solutions of continuity to which they give rise. The eschar may be deep or super- ficial, moist and semifluid or firm and dry, and the de- gree of surrounding inflammation depends largely on the extent to which the caustic has been diffused. Deeply acting caustics produce always loss of substance and scar formation, and the ulcers made by the,acid and metallic caustics usually cicatrize more rapidly and with less sub- sequent contraction than those of the alkalies. The corrosive acids, nitric, hydrochloric, sulphuric, chromic, acetic, bichloracetic, monobromacetic, destroy tissues by dehydrating, or oxidizing, or coagulating the albumens, and then disintegrating and dissolving the fibrin. They form a firm, dry slough that is aseptic and has little tendency to decompose. The eschar does not extend much beyond the limits of the application of the acid ; it is of varying thickness, usually separating in about ten days, and leaves an ulcer that heals rapidly. As the strong acids do not diffuse themselves in the tis- sues, as a rule, there is little danger of poisoning from their absorption. For this reason, and because they pre- vent haemorrhage by coagulating the blood, they are some- what preferable to the alkalies. Moreover, their action takes place rapidly even on surfaces covered by epithe- lium, and although they cause pretty severe pain, it does not as a rule last very long, and the consecutive inflam- mation is moderate. Glacial acetic acid is an intense irritant, producing, when applied to the skin, redness, severe pain, and rapid vesication. But its caustic action may extend deeply and give rise to troublesome sores. It is little used ; chiefly to destroy corns and warts and to cauterize post-mortem and dissection wounds. Chloracetic acid is said to resemble nitric acid in its ac- tion. It penetrates deeply and is followed by little in- flammation. The eschar soon separates, and leaves a healthy ulcer that furnishes a smooth cicatrix with little contraction. It should be applied with a glass rod or asbestos brush. The similar compounds, dicldoracrtic and trichloracetic acids, are powerful escharotics, whose action is little dif- ferent from that of monobromacetic acid. This latter is very highly praised by Hueter (" Chirurgie"), who says that it causes on the whole but little pain. With this and zinc chloride, he says, all caustic operations pro- posed to the surgeon may be satisfactorily performed. From the deliquescent crystals, a saturated solution is ob- tained of pleasant odor and light brownish-yellow color. It eats deeply, and furnishes an aseptic dry eschar. Weaker solutions may be employed where a less intense action is desired. It may be applied in the same way as any of the caustic fluids, and there is no danger of poisoning from absorption. Carbolic acid in strong solutions is a rapid but not very powerful caustic. It has the advantage of producing a local anaesthesia, so that its action is comparatively pain- less. It produces a superficial dry, white, and aseptic eschar. It is chiefly used to cauterize chancroids, con- dylomata, haemorrhoids, and poisoned "wounds. The ninety-five per cent, solution should be employed and applied by a glass rod. Chromic acid is a very energetic caustic that quickly penetrates and melts down even solid tissues. If em- ployed in excess, small animals, mice, rats, may be com- pletely dissolved by it. It produces very intense and persistent pain, is apt to spread over surrounding parts, and may give rise by absorption to poisoning. In cases of poisoning, after vomiting and diarrhoea, collapse and even death have been observed. Its red, deliquescent crystals, or strong saturated solutions, may be used. If it is used with glycerine, one should remember that there may be an explosion when the two substances are mixed. When applied to the skin chromic acid oxidizes and de- hydrates. After a few minutes the skin is moist and brown, and finally becomes black. A dry eschar one or two lines thick separates in about twenty-four hours. It is used for the destruction of warty growths and condylo- mata, and on phagedenic and diphtheritic ulcers. The surrounding soft parts should be carefully protected. Hydrochloric acid has been employed by Bretonneau in hospital gangrene and diphtheria. In concentrated solu- tions it is caustic, but weaker than nitric and sulphuric acids, and produces a soft, superficial slough. Nitric acid in concentrated solutions is a very painful, rapid, and often diffuse caustic, producing a dry, yellow eschar. A few moments of action suffice to produce a rather thick slough, surrounded by a red line of conges- tion. The eschar separates in from fifteen to twrenty days, leaving a sore that heals well (Ch. Sarazin : " Diet, nouveau de Med. et Chir."). It should be used only when the extent of surface is small, for bites of animals, ulcers of the rectum, warts, condylomata, luemorrhoids, un- healthy sores, etc. It may be employed liquid or partly solid in the form of pastes. Rivallie mixed nitric acid with asbestos or charpie ; Canquoin with saffron ; Bour- din with flowers of sulphur. The advantage of these pastes is that the acid does not spread as readily over healthy tissues. It is advised to limit its action by the ap- plication of cerates, oil, or soap on the surrounding parts, and when sufficient cauterization has been achieved, to wash off any remaining acid with soap-suds. Acid nitrate of mercury may be employed in solution or ointment, the unguent, hydrargyri nitratis or citrine ointment. It is prepared by dissolving the red oxide of mercury in excess of nitric acid, and owes its caustic action to the acid. It is a colorless or yellowish liquid, and may be used in solutions of varying strength. The eschar is thinner and smaller than that of nitric acid. At first grayish, it becomes red or yellowish, and is dotted with black spots of coagulated blood. The eschar falls, after a brief inflammation, in from fifteen to twenty days. The application of the caustic produces severe but tran- sient pain, and may salivate. It is used chiefly for ulcers of the cervix uteri and skin, tubercles of the skin, and acne. Sulphuric acid is an energetic caustic. It dehydrates the animal tissues, forming water and ammonia, leaving the carbon untouched. The eschar is black, dry, sur- rounded by considerable inflammation. Pain is severe for three or four hours after its application, but there is very little diffusion, and no haemorrhages occur. Cicatri- zation takes place rapidly, and may be complete when the eschar falls at the end of about two weeks. It is used in solution and in various pastes. Ricord's paste consists of sulphuric acid and powdered charcoal; Michel's of con- centrated sulphuric acid, three parts, to one of powdered asbestos; Velpeau uses saffron powder with twice the quantity of acid ; Syme used sawdust and acid ; and it may be mixed with powdered sulphur or lampblack. The eschar will be twice the thickness of the paste. The alkaline caustics-ammonia, lime, soda, potash, and their preparations-unite with the water of the tissues and dissolve the albuminous substances. They form a cor- rosive fluid of soapy feel that sometimes spreads un- pleasantly ; they do not arrest haemorrhage, and produce moist eschars-black, gelatinous masses, that easily de- compose. The ulcers left after the separation of the eschars heal slowly. Caustic ammonia is rarely used, except when it is de- sired to produce a blister rapidly for purposes of counter- irritation. Caustic lime is used only in combinations with other alkalies to make the eschar drier. Alone it produces a tolerably dry, white slough, and causes much pain. The ulcer heals more rapidly than that made by caustic potash. Caustic potash occurs in cylindrical, gray, deliquescent sticks, and in this form is usually employed to produce issues. In use it liquefies, and forms a soft slough of dirty, ashen-gray color that dries to a tough, black eschar. It abstracts water, combines a little with the fats, neu- tralizes acids, and forms solutions of fibrin, gelatin, and albumin, and its action produces intense burning pain. To prevent its diffusion it is usually mixed with quick- lime in what is known as Vienna Paste, or Potassa cum Calce. This is a powder of equal parts of caustic lime and potassa, and should be kept in a wTell-stoppered 5 Caustics. Caustics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bottle, although it is less deliquescent than caustic potash. When applied it may be used in powder or a paste made with a little alcohol. In the former case it absorbs moist- ure from the skin and air, and partially deliquesces. Its action is mild, easily limited, and it is the least painful of all the caustics. The pain at first may be pretty severe, but never lasts more than half an hour, and there is scarcely any pain if the paste be prepared of three parts powder and one of muriate of morphia with a little chloroform. In five minutes the eschar equals the paste in thickness, and if the action of the paste is not arrested, will double it in thickness. At first white, later brownish black, the eschar dries and hardens, and after moderate reaction drops off in ten or fifteen days, leaving an ulcer that cicatrizes slowly. It is used to destroy large tumors, warts, and other small dermal growths; to cauterize poisoned wounds, and ulcers, and to open hydatid cysts of the liver. Filho's caustic is similar to Vienna paste, but stronger. It is prepared by fusing three parts of caustic potash and two parts of quicklime, cooling in cylinders, and protecting from the air by wax-paper, varnish, seal- ing-wax, or gutta-percha. These two caustics are more rapid, energetic, less diffuse, and easier to manage than any other alkaline caustics. Caustic soda enters into the formation of London paste, is similar in properties and action to caustic potash, but less deliquescent, and more manageable. Dr. B. W. Richardson in 1870 introduced two new substances, sodium and potassium ethylates, both similar in action, and of which the former has been most used. Comparatively inert on dry parts, as soon as a little water is absorbed from the air or tissues, caustic sodium or potassium is produced, and a gradual destruction follows, which may be increased or diminished. Sodium ethylate is easily managed, very potent, less painful than one would ex- pect, sure, rapid, and has powerful antiseptic properties. Its action may be arrested by a drop of chloroform, which decomposes it and arrests the action. It may be applied in alcoholic solution with a glass rod. The addition of a little opium in alcoholic solution lessens the pain. A half-saturated solution is recommended for removal of tumors and the treatment of poisoned wounds, cutaneous naevus, lupus, and malignant ulcers (see Lancet, Novem- ber 9, 1878, p. 654). The class of metallic caustics includes the very ener- getic chlorides of zinc and antimony, and arsenic and mercury compounds, as well as a number of mild agents, some of which are hardly more than irritants or astrin- gents, as nitrate of silver, sulphate of zinc, and sulphate of copper. Some other substances, also, as bromine and iodine, are more appropriately considered here than with the acids or alkalies. In general this group of escharotics destroy the albumin compounds of the tissues, and exert an action similar to that of the acids, but they are far more liable to be absorbed and produce poisonous effects. They have little or no action on tissues protected by healthy epithelium, but elsewhere produce firm, dry, deep eschars. They coagulate blood and are haemostatic, and rarely spread much beyond the limits of the spot to which they are applied. The pain is severe, and lasts from four to six or eight hours, and the solution of con- tinuity heals rapidly. They destroy cancerous formations more rapidly than healthy tissues and it has been claimed that some of them possess a selective action and destroy cancer cells, leaving neighboring normal tissues uninjured. Alumen exsiccatum, dried alum, is little more than a powerful astringent to mucous membranes, but may act as a caustic on open surfaces by dehydrating growing tissues. Iodine is a weak caustic that is used principally on mucous membranes in strong solution. Perchloride of iron is a powerful haemostatic that produces a blackish, firm, but very superficial eschar, by coagulating albumin and arresting the capillary circulation. It causes little pain, and probably owes its use as a caustic to hydro- chloric acid. It has been used to some extent in hos- pital gangrene and purulent infection of wounds. Sul- phate of zinc and sulphate of copper, like dried alum, do not act through normal skin, nor do they destroy sound tissues. They are chiefly used to produce a superficial slough on unhealthy granulations. Sir J. Simpson ad- vised the employment of sulphate of zinc to ulcerations, particularly of the os uteri, and to warts and condylo- mata. It produces a firm, white, dry slough that is odorless and separates on about the fifth day. The pain is moderate, and subsequent inflammation slight. How- ever, it has been but little used. Sulphate of copper is perhaps more energetic in action than nitrate of silver, but the bluish crystals spoil on exposure to air, and are less portable and manageable than the various forms of lunar caustic. Its chief uses are in the treatment of granular conjunctivitis and all forms of ulceration, and it may be employed in crystals or strong solutions. Sul- phate of zinc may be used as a fine powder ; as a paste, made in the strength of one part of glycerine to eight of the salt; or as an ointment, of four parts of the salt to one of lard or vaseline. Nitrate of silver is the best known and most frequently employed caustic. It is, however, weak, the action being only superficial, and very slight on healthy tissues. It acts chiefly by virtue of the nitric acid which it sets free in decomposing, and produces a thin, white, limited pel- licle of silver albuminate that blackens in the sunlight. It coagulates albumin and fibrin, and arrests haemor- rhage. If the action be prolonged, it does not penetrate the thin slough. On mucous membranes and raw sur- faces it' produces pretty severe smarting, which usually is of short duration. Its action may be arrested, and staining of the skin be prevented by having some satu- rated solution of common salt at hand and applying it on a pledget of lint or wad of cotton. The nitrate of silver is used in fused sticks that are apt to be brittle, in the form of the mitigated stick, and in solution, or it may be fused upon a probe of platinum or silver, for application to sinuses and fistulse. Solutions of the strength of sixty grains to the ounce are very strong caustics to mucous membranes and young tissues. The mitigated stick so much used by oculists is prepared by fusing one part of nitrate of silver and two of nitrate of potassium. Nitrate of silver has a very extended and well-known use as a caustic for granulations, mucous membranes, warts, condylomata, etc. It is claimed to be the most efficient means of destroying the hydrophobic poison in the bites of rabid dogs, and is much employed in the treatment of lupus and other skin diseases. For lupus the caustic point should be sharp, and should be thrust deeply into the dis- eased tissues. A black slough forms, and leaves, when it separates, a healthy enough ulcer, except in parts where the diseased tissues have not been entirely destroyed. Chloride of zinc may be used in dry powder, paste, or solution. Applied externally, it is a very powerful and painful corrosive, but acts more rapidly and with less pain on surfaces denuded of epidermis. The pain may last for some hours, but is less than arsenic produces, and there is no danger of poisoning. It coagulates al- bumin, and its action is limited in general to the point of contact. The slough is firm, dry, whitish, inodorous, and aseptic, and separates in a wreek or two. It is a powerful antiseptic, and arrests decomposition in the wound to which it is applied, and the subsequent inflam- mation is limited. It is particularly powerful in pene- trating deeply, although less rapid in this respect than caustic potash. According to Sarazin, it penetrates one- eighth of an inch an hour for the first three hours, but then more slowly, so that at the end of twenty-four hours the slough will be four-fifths of an inch deep ; at the end of seventy-two hours, one inch and three-fifths. Deeper than this, however, it never reaches (" Nouveau Diet, de Med. et de Chir. Prat,"). The powder deliquesces, but may be mixed with equal parts of zinc oxide or anhy- drous sulphate of lime. It should be applied only to ul- cerated surfaces. The solution should be applied on a piece of lint smaller than the desired slough, and the cuticle should first be removed. Sir W. Burnett's solution is of the strength of one to seven of water. Cooke's method was to saturate lint with the deliquesced salt, which when dried he kept in a wooden or pasteboard box. When needed for use a pair of old scissors should be used to cut the lint into cou- 6 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Caustics. Caustics. venient strips. But in the form of paste, zinc chloride is most easily managed. Plaster of-Paris, gluten, rye- or wheat-flour are usually mixed with the chloride in vary- ing proportions, and a few drops of water, chloroform, or some preparation of opium aTe added. Mayet's paste is composed of zinc chloride eight parts, zinc oxide one, wheat-flour seven, and water one; Bonnet's, of equal parts of zinc chloride and flour ; Robiquet's, of the same, with gutta-percha, and is firm and tenacious ; Canquoin's paste, of one part of the chloride to two, three, four, or five parts by weight of flour or plaster-of-Paris, to which a few drops of water are added. Various modifications of this paste are employed ; glycerine, solutions of opium, or preparations of stramonium and sanguinaria replace the water ; and instead of flour or plaster-of-Paris, nitrate of potassium is employed, in order to make a firmer and more solid material. In using Canquoin's paste, the epi- dermis should first be removed with nitric or sulphuric acid. Having removed the slough of the acid caustic, apply the paste directly to the part on leather or heavy plaster, and cover by a compress and bandage. In twelve hours the slough will generally be one-half the thickness of the paste employed. This is by far the most useful caustic for destroying large tumors, and may be repeat- edly applied. When the action of the first layer of paste has ceased, cut through the slough and push in fresh paste on lint, and repeat the process at intervals of two or three days. Maisonneuve in 1858 proposed a method of removing large tumors with caustics, to which he gave the name of cauterization en fleches. For this purpose he prepared small arrow-shaped or conical flat wedges, and inserted them deeply into the tissues to be destroyed. A flat cake of one part of zinc chloride, and three of flour or plaster-of-Paris, is prepared with a little water and cut into these arrows, which are then dried and kept in a bottle ; or, a mixture of zinc chloride and nitrate of po- tassium is fused and run into suitable moulds. Sir J. Paget has suggested the use of slips of wood dipped in fused chloride of zinc. There are three methods of using these caustic arrows, and in many cases their use is fa- cilitated by making an incision into which to thrust them. The fleches may be applied in parallel rows extending deeply into the tumor from the most superficial part, or a row of arrows in the same plane at the base may be so applied as to cut off circulation in the rest of the tumor and cause it to slough out. Another method is to thrust several arrows into the tumor near its centre, and when the slough has separated, to attack various parts of the tumor through the cavity thus made. It is hoped in this way to have a smaller cicatrix. Bonnet, of Lyon, em- ployed Canquoin's paste to make caustic ligatures where- with to cauterize and destroy fistulous tracts and pedun- culated tumors. Landolphi's paste is composed of equal parts of the chlorides of zinc, antimony, bromine, and gold, and is used pure, or weakened by mixing with basilicon oint- ment in varying proportions. It should be spread on the surface with a spatula or applied on charpie, and allowed to remain for twenty-four or forty-eight hours. Chloride of gold is rarely used alone, being expensive and possessing no special advantages. Terchloride of antimony, or butter of antimony, is a deliquescent white salt. It is similar, in its properties, to zinc chloride, in conjunction with which it is often em- ployed in the form of Landolphi's paste, and of a modi- fication of Canquoin's paste, in which equal parts of zinc and antimony chlorides are mixed with one and a half part of flour and a few drops of water. It possesses powerful caustic properties, and is recommended by the European surgeons for the destruction of poisoned wounds, syphilitic warts, condylomata, etc. It is usu- ally employed in solution with hydrochloric acid, which should be applied with a camel's-hair brush, and pro- duces a whitish slough. When sufficient cauterization has been accomplished, the remainder of the caustic should be washed off, or it may spread and diffuse its action to a considerable distance. There is also some risk of poisoning. The compounds of mercury, when used for caustic purposes, are all attended by the danger of absorption and poisoning. The acid nitrate has been already men- tioned. The red oxide is sufficiently well known. It is more irritant than caustic, but has been used and re- commended as an application, in the form of a powder, to syphilitic ulcers, condylomata, and even granular con- junctivitis and corneal opacities. The bichloride is a moderately powerful caustic, that may be used in the form of paste or alcoholic solution, or in saturated solu- tion with collodion. It is chiefly employed in syphilitic ulcers, venereal warts, and onychia maligna. For the latter, Professor G. B. Wood advises to sprinkle thickly, on the part to be cauterized, a powder of equal parts of bichloride of mercury and sulphate of zinc. This should be covered with lint dipped in laudanum, and allowed to remain for eight or ten hours. It produces severe pain for half an hour or an hour, and when the slough separ- ates leaves a healthy granulating surface. The biniodide of mercury is similar to the bichloride. The eschar is superficial and black, but there may be haemorrhage. It is a usefid caustic in lupus, scrofula, and syphilitic ulcers. Arsenic and its compounds produce on animal tissues an intense irritation, resulting in the granular and fatty degeneration of the part, and death. The eschar falls in from eight to ten days, and the action extends deeper in unhealthy than in healthy tissues. It has been at all times a common application for cancer, but is less effec- tive and more dangerous than zinc chloride. If the ap- plication is of considerable strength, there is less danger of absorption, but even then it should never be applied to a large surface. The pain and subsequent inflammation are intense. Arsenious acid, or white arsenic, is the preparation usually employed, and is applied as a paste or powder. Arsenic sulphide is a weak caustic. Esmarch's paste is composed of one part each of white arsenic and sulphate of morphine, eight parts of calomel, and forty-eight of gum-arabic. Frere Cosme and Rous- selot used one part of white arsenic and two each of dragon's-blood and porphyrized cinnabar, made into a paste with mucilage when about to be applied. Dupuy- tren's paste was made of from six to ten parts by weight of arsenic, and one hundred of calomel, made into paste with water or mucilage, and was applied on lint or blot- ting-paper. Sir Astley Cooper's arsenious ointment con- sists of white arsenic, 3 j. ; sulphur, 3 j. ; and spermaceti cerate, 5 j., and should be left on the part for twenty-four hours. Marsden's mucilage consists of one part of white arsenic to two of gum-arabic. The great danger of poi- soning, however, and the fact that we have in chloride of zinc a less dangerous and easier-managed caustic, should prevent the use of arsenical preparations. If they are employed, they should not be diluted with more than four or six parts of the inert material chosen. Bromine is a very powerful caustic, rapidly oxidizing organic matter. The pain is so severe, and the fumes of the red volatile liquid so offensive and irritating, that it has been but little used. As an application for hospital gangrene it was found to be of great service in the Civil War. The patient was anaesthetized, and after cleansing the part, the caustic was applied on a cotton or lint swab attached to a long handle. In the application of caustics there are certain precau- tions that should always be observed. The part to which they are to be applied should be thoroughly cleansed of all discharges, mucus, pus, etc., and be dried. If this is not done the caustic action is partly expended on the se- cretions, and is more apt to spread over the adjacent tis- sues. The surrounding healthy parts should be covered with collodion, oil, cerate, ointment, soap, or heavy plaster or leather, if there is any danger of the spread of corrosive fluid. Syme protected the skin by covering it for some distance with gutta-percha, having a central aperture through which the caustic was to act. This was fastened to the skin by a solution of gutta-percha in chloroform, and on it was built up a wall of gutta-percha and lint, so as to form a well. In this well he placed the mixture of sulphuric acid and sawdust of the consistency of thin por- ridge. The action was complete in from ten to twelve 7 Caustics. Cauterization. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hours. The wall thus built up may be either of some impervious material, or of cotton soaked in some fluid that will neutralize the action of the caustic employed. The strong acids are best neutralized by a solution of car- bonate of potassium, the alkalies by vinegar, and nitrate of silver by olive oil or common salt. Caustics may be employed in the form of solids, liquids, and as pastes, plasters, and ointments. Where the appli- cation is to be short and very painful, it is often necessary to place the patient under the influence of ether. Ip other cases, the pain may be controlled or diminished by the use of some form of opium, either locally or internally. Freezing the part to be cauterized is sometimes advan- tageous, and the use of hydrochlorate of cocaine is worth trying, although no definite results have yet been obtained from its use in this connection. Wm. G. Le Boutillier. agents are known as potential cauteries. (See article Caustics.) The oldest actual cautery employed was the hot iron, ferrum candens, or cauterium actuale, and it had great re- pute and was generally employed even as early as the time of Hippocrates, as the following often-quoted remark of his shows: " Quaecunque non sanant medicamenta, ea ferrum sanat; qum ferrum non sanat, ea ignis sanat; qua? vero ignis non sanat, ea insanabilia existimare oportet." Heat has been made to act on the tissues in a great variety of ways. Metals, of all substances, possessing the greatest capacity for caloric, have been most often employed, but hot liquids also have been found of ser- vice. Sometimes the heat of the sun's rays has been con- densed on the part by a double convex lens, or various substances have been burned directly on the body, or a flame of tire has been directed against it. The various measures are employed in the belief that by destroying a part it is possible to produce a change of tone or an in- crease of vitality. It is thought that the increased heat induces greater conductivity of the nerves, contractility of the muscles, and activity in plastic processes. They excite a superficial inflammation that withdraws from deeper parts a portion of the irritation and inflammation, and thus limits the deep process. Such artificial metastases act by antagonism, and are chiefly employed in chronic inflammations of bones and joints, epilepsy, chorea, hy- pochondria, neuralgia, paralysis, gout, rheumatism, re- laxation of muscles or ligaments. The use of the cautery allays pain in many of these diseases, perhaps by adding a new pain on the surface, in the presence of which the old deep-seated pain is forgotten. The cautery is also indicated for the destruction of tis- sues, carbuncle, carcinomatous ulcers, poisoned Wounds, hospital gangrene, and for the opening of abscesses and occasionally of joints, and the refreshing of fistula: and sinuses. It is also a useful haemostatic, particularly in haemorrhages from bone and from the tongue, and in parenchymatous haemorrhage. In destroying tissues its use is generally confined to such small masses as may escape a knife or sharp spoon, to superficial destruction of any part, and to the removal of pedunculated tumors. There are certain situations recommended for the ap- plication of counter-irritation by the cautery, as in dis- eases of the bones of the skull and of the brain, to the nape of the neck, to the mastoid processes, or to the sole of the foot; in epilepsy, between the origin of the aura and the centre ; in spinal cord diseases, on both sides of the spinous processes ; in sciatica, behind the great trochanter, or at the back of the leg or thigh. Cauterization may be accomplished by the use of the water-hammer, ignipuncture, or the application of moxae, as well as by the application of some form of cautery iron. Ignipuncture generally consists of thrusting hot iron points into the diseased tissue so as to destroy it. Slough- ing and reactive inflammation follow. The water-hammer may be applied with satisfactory results in some forms of rheumatism, neuralgia, and spinal weakness. The skin is tapped for a few seconds with a hammer or small flat-iron heated in a spirit-lamp or boiling water, thereby causing the rapid formation of a blister. Moxse produce eschars by the heat of substances burned on the body. The action is very painful, and they are now little used, although they are said to produce good results in spinal affections, and some paralyses of motor and sensory nerves. European moxm are composed of cotton-wool soaked in a solution of nitrate of potassium, dried, and packed into metallic cylinders, or of the pith of various plants. A wet cloth, with a central aperture, is placed on the skin, and the moxa is applied lighted and is allowed to burn down to the skin. The action is due to the direct and the radiated heat, so that the eschar is larger than the moxa. Various other substances have been burned on the skin, as powder, phosphorus, and pieces of camphor. Burning charcoal, or slips of wood soaked in solution of nitrate of potassium and ignited, is some- times used. Nelaton's gas cautery consists of an india-rubber bag CAUTERETS. A thermal station, one of the most elevated in Europe, situated in the Department of Hautes- Pyrenees, France, at an altitude of three thousand and fifty-eight feet. The climate is rather mild and equable, arid the air is remarkable for'its purity, has a balsamic odor, and is not bracing but rather sedative in its effects upon those who breathe it. There are upward of twenty mineral springs, varying in temperature from 61.5° to 134.5° F., and in their solid constituents from 0.219 Gm. (3.285 grs.) to 0.307 Gm. (4.605 grs.) per litre (1.76 pint). They are classed among the thermal sulphur waters. Among the principal springs are the Cesar (tem- perature, 119°), the Rieumiset (61.5°), the Railliere (99° to 100°), the Petit-Saint-Sauveur (93°), and the Oeufs ; under the last name are grouped six springs, the waters of which have a temperature ranging from 119° to 134.5°. The composition of the water of the Cesar, as given in Jaccoud's " Nouveau Dictionnaire de Medecine et de Chi- rurgie," after the analyses of Filhol and Reveil, is as fol- lows : Each litre contains, of sulphide of sodium, 0.0239 Gm. (.3585 gr.) ; sulphide of iron, 0.0004 Gm. (.006 gr.) ; chloride of sodium, 0.0718 Gm. (1.077 gr.); sulphate of sodium, 0.008 Gm. (.12 gr.); silicate of sodium, 0.0656 Gm. (.984 gr.); silicate of calcium, 0.0451 Gm. (.6765 gr.); silicate of magnesium, 0.0007 Gm. (.0105 gr.); chloride of potassium, carbonate of sodium, phosphate of calcium, phosphate of magnesium, borate of sodium, fluoride of calcium, traces; organic matters, 0.045 Gm. (.675 gr.). The proportion of sulphate of sodium in some of the other springs is considerably greater, the water of the Railliere containing 0.0596 Gm. (.894 gr.) per litre ; while, on the other hand, that of sulphide of sodium is in many springs much less, some of the Oeufs group containing only 0.0109 Gm. (.1635 gr.) per litre, or a little less than half the quantity in the Cesar. The waters are taken internally and employed in baths of various kinds, such as hot, cold, sitz, douche, needle, etc. The season embraces the months of June, July, August, and Sep- tember. The Cauterets is frequented by patients suffer- ing from scrofulous and other forms of skin affections, notably certain varieties of eczema, from syphilis, rheu- matism, incipient tuberculosis, and chronic catarrh of the respiratory passages and digestive tract. The waters en- joy some reputation also in the treatment of certain uterine disorders of a congestive type. At the commencement of a course of the waters patients often suffer from conges- tion, or even from a low grade of inflammation, of the external mucous membranes. Pharyngitis and tonsilli- tis are common, and there is often considerable irritation of the rectum and anus. These troubles are slight, how- ever, and do not usually necessitate a discontinuance of the treatment. Sometimes the respiratory mucous mem- brane becomes the seat of congestive disturbances, and even haemoptysis is not very rare as a result of a pos- sibly rather excessive use of the waters in the early part of the course. • Thomas L. Stedman. CAUTERIZATION. Cauterization is an intentional destruction of animal tissue for therapeutical purposes by heat or by substances which act chemically on its ele- ments. Actual cauteries are those agents or measures which depend on the action of heat, while the chemical 8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Caustics. Cauterization. containing illuminating gas, which is conducted by a flexible tube, furnished with a stop-cock, to a burner pro- tected from draughts by a cylinder of wire gauze. Press- ure on the bag must be made to drive the gas forward. The flame may be directed to any part where its action is required. The apparatus is useful for haemostatic pur- poses, and to destroy animal tissues rapidly. Its disad- vantages are that it is not always possible to procure the gas when needed, and that the flame is less easily man- ageable in some situations than the hot iron. Hot water and boiling oil are not now employed, but the latter had an extensive use till Ambroise Pare showed its inutility in the treatment of gunshot wounds. Cauteries have been made of iron, steel, copper, gold, silver, platinum, and lead ; and at different times one or another of these substances has been considered of espe- cial value on account of the possession of some real or imaginary peculiar properties. For example, the hot iron was supposed to coagulate blood and arrest haemorrhage more rapidly than any other metal. Iron, steel, and pla- tinum are the only metals now usually employed ; and to these may be added the use of porcelain in the galvano- cautery. They vary in action, according to the amount of caloric with which they are charged. When of a red heat, acting for a short time at a little distance by radia- tion, they produce burns of the first and second degrees. Moderate pain and pallor are soon succeeded by diffuse redness, accompanied by a little swelling. The redness soon becomes limited to tile part acted on, and then dis- appears. If the part be acted on longer or more in- tensely, the pain is pretty severe and persistent, and ves- icles appear that may suppurate. Applied in this way the cautery dries and hardens the surface of solutions of con- tinuity and increases the inflammation. If the cautery is put on soft parts when it is at a red heat, it dries, hardens, and kills them. The eschar is firm, brownish, with black specks of coagulated blood, and in the deeper parts white. It is never thicker than about one-eighth of an inch, but may be as much as one-quarter inch larger than the cau- tery. It soon becomes surrounded by a red circle, where the radiated heat has produced a burn of the first degree. The pain is severe at first, but soon becomes supportable, and is almost entirely gone in a few hours. It may be much relieved by the application of ^old. The eschar is aseptic, depressed, and apt to contract. When detached at about the end of a week it leaves a healthy granulating surface. The cautery at a white heat destroys animal tissues rapidly and deeply. Applied by radiation, it pro- duces less pain than does the red heat. It has less ten- dency to adhere to the tissues, but does not prevent haemorrhage as well. The fat of the body cools the cautery almost like water, and its action rarely goes be- yond the subcutaneous connective-tissue, and less deeply on moist wounds than on the dry skin. Bone conducts the heat better than the soft parts, and this is particu- larly true of the compact tissue of bone. The actual cautery was usually made of steel or iron. Tips of various sizes and shapes were used-cylindrical, olive-shaped, conical, discs, spheres, rings, hatchet- shapes, etc. A non-conducting universal wooden handle was employed, with various contrivances to prevent the cautery iron from slipping from the handle when in use. A basin of coals, or a blow-pipe alcohol lamp was em- ployed to heat the irons, of which two or three were em- ployed, as they cooled rapidly when in use, and a pair of bellows was added to fan the flame. The galvano-caustic loop and burner replaced the ac- tual cautery or hot iron for many purposes. The loop acts more as a knife than as a ligature, for as it is pulled upon it burns through a thin layer of tissue, which it di- vides quickly and smoothly. " It is made of platinum wire, and is heated by an electric current (see article Elec- tricity). As a haemostatic the loop acts by coagulating the blood, more than by crushing the vascular walls. The wounds made by it are aseptic, on account of the high degree of heat employed. For the destruction of diseased tissues and for purposes of counter-irritation the porcelain tip may be employed. This is a cup of thin porcelain, on which the platinum wire is wound spirally, so that when heated by the current it soon renders the porcelain incandescent. It replaces in many cases the hot iron and even the Paquelin cautery. Other tips of course may be constructed for special purposes. A special advan- tage of the galvano-caustic apparatus is that the instru- ment employed may be placed, while cold, in any of the cavities of the body-the vagina, larynx, nose, or pharynx -and heated in an instant by closing the current. Its ac- tion may be as rapidly arrested. Its disadvantages are the complication and high price of the apparatus, which re- quires frequent repairs ; the inconvenience of a large bat- tery ; the possibility that the platinum wire may be melted by too great heat or broken against solid tissues ; the oc- casional haemorrhage from deep parts and from burned tissues, where its arrest by mechanical means is difficult; the impossibility of securing primary union of the wounds which it inflicts. Still it remains the most efficient means, in many cases, of removing pedunculated tumors from the nose, pharynx, etc. It is very often necessary to anaesthetize the patient in using it, to permit more readily the manipulations neces- sary in properly adjusting the loop, or to prevent the ex- treme pain that its action causes. This is also the case in the use of the thermo-cautery when employed to destroy tissues. The thermo-cautery, invented by Paquelin in 1876, can in many cases replace the galvano-cautery, and in all cases is a more convenient agent than the hot iron, and Fig. 588.-Paquelin's Thermo-cautery Ready for Use. Consisting of bulbs of Richardson's spray apparatus, glass receptacle for fluid, and movable platinum burner in non-conducting wooden handle. equally effective. It is simple, comparatively cheap, compact, portable, and in use less terrifying to the patient than the old hot iron. The construction of this cautery is based on the property of platinum, and some other metals, of becoming immediately incandescent, when raised to a certain degree of heat in contact with a mixt- ure of air and the vapor of some volatile hydrocarbons, and of maintaining this incandescence as long as the con- tact of the mixture exists. It furnishes a ready and efficient means of applying heat for the destruction of tissues and it is particularly useful as a counter-irritant. Its application for this pur- pose has already an extended field, for it acts rapidly and surely. It consists of three principal parts-a chamber for com- bustion furnished with a non-conducting handle of wood, a receptacle for the volatile hydrocarbon, and a pair of elastic bulbs. The receptacle is usually of glass, and is provided with a hook by which to hang it from a pocket or button-hole. Sometimes the receptacle is of metal, con- taining a sponge saturated with the fluid employed, and made small enough to be placed in the pocket. The best fluid is benzine, but if this cannot be obtained alcohol or wood alcohol may be used. Their combustion is defective, however, and produces disagreeable, irritating vapors, aldehydes, formic acid, etc. The bottle is closed by a rubber cork perforated by two metallic tubes ; one of these receives atmospheric air from a pair of india-rubber bulbs, the other transmits the air mixed with the vapor of 9 Cauterization. Cedar Keys. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in a small box which also contains an alcohol lamp (Fig. 591). The advantages claimed for this cautery are that it ad- mits of the employirient of a great range of temperature, from a dark red to a white heat, and may be maintained at any degree of temperature as long as desired, or quickly put out or rekindled ; that it requires but small quanti- ties of the hydrocarbon (two hundred grams of benzine furnish fuel for five hours of continuous action) ; that it is not very liable to get out of order, and maybe managed by the operator, without the aid of an assistant; and, finally, that the radiation of heat from the instrument is so slight that a hand may easily be employed in close proximity to the parts operated upon. The cauterizing point may be used in a great variety of shapes adapted to special purposes. In using the cautery the several parts should be con- nected and the point heated for half a minute, or a minute, in the white part of the flame of an alcohol lamp. Now, when a few short strokes on the bulbs have been made, a peculiar noise will be heard ; it indicates that combustion is taking place in the chamber. Under vigorous man- agement it becomes incandescent very rapidly. To pro- long the incandescence it is only necessary to keep up the current of air and vapor, and the degree of heat may be increased or diminished by forcing the current through more or less quickly. It is most easily controlled by mak- ing long, slow strokes on the bulbs. One should avoid in general a white heat, as there is some danger, if it is con- the benzine. The bulbs are the same as those of Richard- son's spray apparatus. The burner consists of a platinum chamber and two inner tubes. The chamber is of little volume and large surface, and forms the actual cauterizing agent, and is made of various shapes, the most common of which are the mushroom, Fig. 589, No. 2, and the smaller flatter burner, Fig. 590, No. 7. Inside this chamber are two concentric tubes, Fig. 589.-Movable Platinum Burners. 2, " Mushroom," for arrest of haemorrhage, for cauterizing surfaces and for counter-irritation ; 3 and 5, coarser and finer points, for use on smaller surfaces ; 4 and 6, curved points, coarser and finer, very useful in cavities and in arresting haemor- rhage in less accessible parts, and to use as knives or for ignipuncture. 0 3 4 5 e the inner transmitting the mixture of gas and air to the burner, the outer carrying away the products of combus- tion. The latter is fastened to a hollow wooden tube or handle. These three parts are connected by two india-rubber tubes, which should have thick walls, so that they may not twist on themselves and interfere with the proper action of Fig. 591.-Paquelin Cautery, packed in Box provided with Handle. tinned, that the inner tube may be melted or loosened from its attachment. Besides this, a red heat is proper for counter-irritation as well as for the arrest of haemorrhage. When one desires to use the knife-shaped points, a white heat is often necessary, and as their chambers are small, the insufflation should be rapid and the strokes short. During the continued application of the cautery, and in traversing liquids, the heat is maintained by continuing the insufflation. The modification of the receptacle for benzine (Fig. 592) is very convenient. The reservoir is of metal lined with sponge, and provided with a stop-cock After saturating the sponge with benzine the excess is poured off and the parts adjusted in the usual way. The stop-cock makes it more easy to regulate the heat, and allows the interrup- tion of the insufflation from time to time. Care must, however, be taken not to break the second bulb covered by the net. A few simple precautions are to be observed in using the thermo-cautery, otherwise it may act imperfectly, or be ruined by carelessness. Never fill the recipient more than half-full of fluid, and use fresh benzine each time the cautery is to be employed. If the benzine is new, do not heat it by placing it in the pocket, or holding it in the hand, or too much benzine vapor may pass over and the com- bustion be imperfect from lack of sufficient oxygen. If, however, the benzine has been used before, the volatile vapors may have been almost entirely used up, and it is then advantageous to heat the fluid. Never try to use more than two-thirds of the fresh benzine, the remainder 11 Fig. 590.-Additional Forms of Platinum Burners. 7, Broad burner for counter-irritation ; 8, fine point; 9, still finer point for destroying small particles of tissue, or for ignipuncture, or to use as a knife ; 10, straight scissors; 11, curved scissors, seldom used, but possessing ad- vantages in dividing superficial tissues, opening abscesses, etc. the cautery by interrupting the current of air and va- por. The several parts of the cautery are neatly packed 10 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cauterization. Cedar Keys, is useless. Do not let the fluid dissolve any of the rubber cork, for it gives rise to a disagreeable odor and clogs the chamber. Do not use impure alcohol in the lamp over which the cautery is heated or it may leave deposits on the platinum. Do not insufflate until the burner is hot enough to produce combustion of the vapor, or you may retard the heating of the chamber by the rapid current of air, and cover its inner surface with a deposit of hydro- carbons that will interfere with its proper action. Never cool the cautery in water ; but stop the insufflation and the vapors burn without flame, yet the heat of the cau- tery is sufficient to ignite ether vapor, and as many of the applications of the cautery are made while the patient is under the influence of ether, carelessness may result in an explosion, which may severely burn the face or air-pas- sages of the patient. In very vascular regions one should cut the vessels through slowly with one sweep of the cautery at a red heat, in order to coagulate the blood. (See " Bulletin G6n. de Therapie," vol. xc., 1876.) Wm. G. Le Boutillier. CAXTON SPRINGS are situated about twenty miles north of Three Rivers, Quebec, Canada. The water is a saline, containing also a considerable proportion of carbonate of magnesium. It is useful in chronic catarrh of the respiratory passages, in certain anaemic conditions, and in other affections in which the muriated saline waters are of benefit (see article, Medicinal Springs). The following is the composition of these waters according to the analysis of T. Sperry Hunt. Each pint contains : Grains. Carbonate of magnesium 7.721 Carbonate of iron 0.039 Carbonate of calcium 1.574 Chloride of potassium 0.583 Chloride of sodium 85.828 Chloride of magnesium 2.661 Chloride of calcium 0.366 Iodine trace Bromide of magnesium 0.249 Alumina 0.036 Silica 0.349 Total solids 99.406 Carbonic acid gas 9.93 cub. in. T. L. S. Fig. 592.-Modification of Thermo-cautery. A metallic vessel lined with sponge receives the benzine, and is provided with a stop-cock to control the insufflation. CEDAR KEYS. The small town of Cedar Keys, Fla., is situated upon the north shore of Waccassassee Bay, one of the indentations of the coast on the western or Gulf of Mexico side of the State. As will be seen from an examination of the accompanying chart (a detailed description of which, and of other similar charts printed in this Handbook, may be found in the article on Climate), Cedar Keys possesses a milder winter climate than is to be found upon the eastern or Atlantic seaboard of Florida. Attention is also especially called to the very large number of "clear" and " fair" days occurring in allow it to cool by radiation. At the close of every opera- tion the cautery should be thoroughly cleansed of all de- posits on the outside, by wiping with a moist linen cloth after it has cooled. While still hot, the inside should be also thoroughly cleaned, by detaching the rubber tube from the insulating branch, and heating the burner in the flame of the alcohol lamp until whatever vapor remains in the chamber may have undergone combustion. In using the cautery one should remember that although Climate of Cedar Keys, Fla.-Latitude 29° 8', Longitude 83° 2'.-Period of Observations, November 7, 1879, to De- cember 31, 1883.-Elevation of Place of Observation above the Sea-level, 6 feet. Spring Summer.... Autumn.... Winter Year January.... February. . March April May June July August September.. October .... November.. December.. 7 A.M. Degrees. 56.4 58.2 59.9 67.5 72.1 79.2 80.7 78.9 75.2 70.3 60.4 55.8 Mean tern at 3 P.M. Degrees. 64.0 66.5 68.4 75.8 81.2 85.4 86.6 86.7 84.8 79.0 69.6 63.9 perature the hours 11 P.M. Degrees. 59.1 61.4 63.5 69.5 78.8 79.4 81.0 79.9 78.2 72.9 63.3 58.8 if months of 70.1 81.9 72.6 60.4 71.3 Degrees. 59.8 62.0 63.9 70.9 75.7 81.3 82.7 81.8 79.4 74.0 64.4 59.5 Average mean temperature de- duced from column A. 72.1 83.2 J 74.5 62.6 , 72.4 Oft i Mean temperature for period of ob- servation. - 67.0 81.0 i 70.4 1 58.1 1 705 Lowest. Degrees. 54.6 57.8 58.3 66.0 75.1 79.9 81.5 80.5 78.0 70.4 60.5 54.7 | Degrees. 1 64.4 68.8 71.0 1 77.0 1 83.2 87.0 89.3 88.8 86.8 80.5 71.1 65.6 Average maximum temperature for period. a Degrees. | 52.3 56.6 58.5 64.7 69.4 74.6 76.8 76.0 73.2 68.4 57.8 53.5 Average minimum temperature for period. = Highest. Degrees. 77.0 79.0 82.0 88.0 91.0 94.0 94.0 96.0 94.0 89.0 81.0 78.0 Absolute maximum j temperature for period. Lowest. Degrees. 68.9 74.0 74.0 84.0 87.0 90.8 92.5 92.0 ! 90.3 85.0 77.0 । 69.0 Highest. Degrees. 48.0 43.0 49.0 , 60.0 ' 66.0 1 70.3 , 71.0 72.2 69.0 59.0 45.0 !a | :::::: (Absolute tempera period. - Lowest. Degrees. 32.0 35.0 40.0 38.0 50.0 65.0 69.0 69.0 64.0 49.0 33.0 22.0 minimum .ture for • • • • • cC •-4 tC i'X'>-4 >-4 ■-4 >-• fC >-4 »-• . . . . . W o GC r- - -4 00 -Q -Q CO -4 GO * • • • • M M H W hJ M 7C (v W M CO cn -1 QO w r- GO O -4 Greatest number of days in any single month on which the tem- perature was below the mean monthly minimum temperature. Greatest number of days in any single month on which the tem- perature was above the mean monthly maximum temperature. - = 11 Cedar Keys. Cells. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. J K L« M N o II S h i - .o • 1L = $ • ity les. s'C S" 'go ® £ ean relative midity. ^erage num of fair days erage num of ciear day erage num L fair and cl ays. 1 Q I o evading di tion ot win< erage veloc wind, in mi :r hour. r s <1 <4 075 £ Av oi P« Inches. From Miles. January.... 45.0 81.0 14.7 8.5 23.2 5.31 N.E. 9.0 February .. 41.0 75.4 9.2 13.8 23.0 2.98 N.E. 9.6 March 42.0 71.5 12.2 14.0 26.2 3.58 S.W. 11.1 April May 50.0 74.1 10.5 15.8 26.3 2.82 S.W. 10.4 41.0 70.3 13.5 13.3 26.8 2.72 E. 9.8 June 20.0 74.0 18.0 8.2 26.2 6.02 W. 9.3 July 25.0 73.0 14.2 11.5 25.7 9.10 w. 8.4 August .... 27.0 74.8 14.5 11.7 26.2 9.80 N.E. 9.1 September. 30.0 75.2 12.5 15.5 28.0 5.99 N.E. 8.2 October.... 40.0 76.4 8.5 18.3 26.8 4.16 N.E. 9.2 November. 48.0 78.6 10.2 13.8 24.0 2.81 N.E. 7.8 December . 56.0 80.8 11.4 14.0 25.4 2.73 N.E. 8.5 Spring 53.0 72.0 36.2 43.1 79.3 9.12 S.W. 10.4 Summer... 31.0 73.9 46.7 31.4 78.1 24.92 W. 8.9 Autumn ... 61.0 76.7 31.2 47.6 78.8 12.96 N.E. 8.4 Winter 57.0 79.1 35.3 36.3 71.6 11.02 N.E. 9.0 Year 74.0 75.4 149.4 158.4 307.8 58.02 N.E. 9.2 pleasant to the taste, and has a temperature of 51° F. Large quantities can be taken without causing uneasiness. The flow is ample, about 10,000 barrels per day. " The Glycerine " furnishes hydraulic power to force its waters throughout the hotel. , The climate is that of Southern Ohio. The air is in- vigorating, the temperature ranging in summer from 60° to 75°, with cool mornings and evenings. Hotel accom- modations are first-class. The Haldeman's Water-cure Sanitarium Hotel has lately been refurnished. The surrounding country affords many beautiful and charming views. New Paris, distant about one mile, is a pretty village of 1,500 inhabitants, with churches and good schools. Richmond, Ind., 20,000 inhabitants, is only five miles distant. History.-The curative qualities of these springs were known to the Indians and early settlers. In later years attention was attracted to their medicinal qualities by the fact that the teachers and pupils of a school located near the springs improved in health and strength, the cause being traced to the use of the waters. George B. Fowler. the course of the year. " Appletons' Handbook of Win- ter Resorts" (1884-1885) pronounces the climate of Cedar Keys to be " blander than that of Jacksonville" and to be " beneficial to rheumatism as well as to consumption," and alludes to the good facilities for bathing, boating, fishing, and hunting which are presented to the visitor in search of amusement. As to the visitor in search of health, while the location and climate of the town would seem to promise equally great things for him also, it would nevertheless appear that in other respects Cedar Keys was as yet hardly in proper condition to receive him. Thus "Appletons' Handbook" states that "there are as yet no adequate or proper accommodations for in- valids," and that " only those who can ' rough it' should go there;" while a writer in the New York Medical Record (June 19, 1884) speaks very disparagingly of the drainage and water-supply of the town, and also makes allusion to other inconveniences attending a residence there. It would seem very desirable, in view of such climatic advantages as are indicated by the accompanying chart, that these drawbacks should be as speedily as pos- sible removed, and that either in or near the town ade- quate accommodations for the winter residence of inva- lids should be provided. Huntington Richards. CELANDINE (Chelidonium, U. S. Ph.), Chelidonium majus L.; Order, Papaveracew. This, the only species of the genus, is a perennial herb, with slender branching stem, bright-yellow delicate flowers, and an acrid, irritating, dis- agreeable-smell- ing yellow juice. The plant is sufficiently de- scribed by the Pharmacopoeia i n describing the dried herb, which consti- tutes the drug : " Root several - headed, branch- ing, red-brown; stem about twenty inches (50 centime- ters) long, light green, hairy ; leaves about six inches (15 centimeters) long, petiolate, the upper ones smaller and sessile, light green, on the lower side glaucous, lyrate-pin- natifid, the pinnae ovate-oblong, obtuse, coarsely crenate or incised and the terminal one often three-lobed ; flowers in small, long-peduncled umbels with two sepals and four yellow petals. The fresh plant contains a saffron-colored milk-juice and has an unpleasant odor and acrid taste." Celandine is a native of Europe, but abundantly nat- uralized in the United States, where it affects rich, shaded door-yards. It is an old-country medicine, and has been used to dissipate warts and as a dressing for ulcers. It contains the alkaloid sanguinarine (chelery- thrine) ; when pure, a colorless crystalline substance, forming, with acids, beautiful orange or yellow salts. It is insoluble in water and consequently tasteless, but its alcoholic solution is sharp and bitter. It is a depressing poison, often producing vomiting and diarrhoea with car- diac debility, but its action does not appear to be very uniform. Celandine also contains another crystalline alkaloid, chelidonine, of bitter and acrid taste, which forms colorless salts with acids. It does not appear to be a very active substance. Chelidonic acid, an interesting vegeta- ble acid something like malic acid, and chelidoxanthm are further constituents. Use.-The depressant, emetic, and irritant qualities of celandine are seldom sought for at the present time. In chronic scrofulous conditions, internally, and as a vulner- ary externally it is now and then used. Dose from two to five grams (2 to 5 Gm. = 3 j.). Allied Plants.-See Opium. Allied Drugs.-See Sangulnakia. W. P. Bolles. Fig. 593.-Celandine, slightly reduced. Seed en- larged about four times. (Baillon.) CEDAR SPRINGS. Location and Post-office, New Paris, Preble County, O. Access.-By Chicago, St. Louis & Pittsburg, and Cin- cinnati, Pittsburg & St. Louis Railroad to New Paris, and Cincinnati, Richmond & Chicago Railroad to West- ville, O., one and a half mile from springs. Analysis.-There are four principal springs, viz. : "Washington," " Seidlitz," "Glycerine," and "Chalyb- eate." The most prominent, "The Washington," is the only one whose analysis has apparently been published. One pint contains : Grains. Bicarbonate of magnesia 1.295 Bicarbonate of soda 0.408 Bicarbonate of iron 0.228 Bicarbonate of lime 0.712 Chloride of sodium ....0.121 Sulphate of soda 0.023 Alumina 0.027 Sulphate of lime 0.155 Phosphate of lime 0.266 Total 3.302 Therapeutic Properties.-"The Washington" is diuretic and has proved of benefit in diseases of the kid- neys, bladder, and stomach. "The Seidlitz" is a mild and pleasant aperient. "The Chalybeate" is a tonic. "The Glycerine," used only for bathing purposes, im- parts a soft, velvety feeling to the skin, and is beneficial in rheumatism and eruptive skin diseases. These springs are located in a ravine, and boil up through a fine, ash-colored substance, alumina. The water is 12 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cedar Keys. Cells. CELLS. Cells are minute structural elements which are variously associated together, and with other anatomi- cal units make up the various tissues and organs of the body. It is upon the separate or combined activities of cells that all the varied expressions of life which animals display ultimately depend, and by them or under their influence all other structural elements of the body are pro- duced. A typical animal cell consists of several distinct parts ; first, of a mass of protoplasm (see Protoplasm), making up in most cases a large part of the cell-the cell-body. Within the cell-body is enclosed, second, a sharply defined, variously shaped object, called the nucleus, which differs from the cell-body in structure, in its chemical proper- ties, and in the varied activities which characterize the life of the cell. While the cell-body and the nucleus are the most con- stant structural features, the nucleus is, in certain cells which are modified for the performance of special func- tions, entirely absent. It is probable, however, that at some period of their existence all cells possess a nucleus. On the other hand, in some cells the outer layers of the body become so changed as to form a denser and firmer investment of the cell, called the cell-membrane. Still further, the nucleus very frequently contains one or more minute vesicular structures, or more or less conspicuous solid particles, which are called nucleoli. The four prom- inent structural features, then, of a typical animal cell (see Fig. 594), are cell-body, nucleus, nucleolus, and cell- membrane ; but of these the body and nucleus are by far the most common, and the body alone is the only ab- solutely constant feature. Sometimes the cell-body is spoken of as the proto- plasm of the cell, in dis tinction from its nu cleus. The size of cells is ex- tremely variable ; they range in diameter from 0.006 mm., in some of the blood-cells, to 0.23 mm., in one of the largest cells of the hu- man body, the ovum. A large majority of cells, however, are in- termediate in size be- tween these extremes. The cell-body varies so much in shape, consistence, and minute structure, that it is difficult to give a very com- prehensive general description of it. Thus some cells, in fact most cells when in an active condition, are more or less soft and gelatinous, or viscid, but under varying con- ditions they may become entirely, or in part, converted into a hard and even horny substance, scarcely at all resem- bling the protoplasm in which they originated. Not less variable is the shape of cells, their form being determined largely, when the protoplasm is soft and plastic, by the conditions and directions of pressure to which they are exposed from one another, or from other adjacent struct- ures, or by their adaptability to the performance of special functions. Thus cells may be spheroidal, poly- hedral, cuboidal, fusiform, cylindrical, pyramidal, dis- coidal, flat, stellate, branching, winged, or may assume altogether bizarre and indescribable forms. Many cells are more or less constantly changing their shape ; thus the so-called wandering cells, when in an active condition, cannot be said to have any constant and characteristic shape, varying as they do with each progressive move- ment, and with the size and shape of the tissue spaces through which they pass. Some of the epithelial cells of the bladder also are constantly undergoing modifications of form, as the pressure of the urine changes against the walls of the organ which they line. The bodies of some animal cells in the living condition appear, even with high powers, to be quite homogeneous and structureless, others appear finely or coarsely granu- lar. In still others the body contains a delicate network of fibrils which cross and interlace, leaving meshes be- tween them filled with the so-called protoplasm fluid. Such structures are called intracellular networks, and it is assumed by some recent observers that such networks are almost if not quite constantly present. They are, however, much more easily seen in cells which are dead, and which have been treated with chemical agents ca- pable of coagulating proteid substances, than in living cells, and although they undoubtedly exist in some cases in living cells, their presence has not yet been proved to be universal. In addition to the granules and networks which cell- bodies usually contain, and which form an integral part of the protoplasm, in,many cells, pigment particles, drop- lets of fat, various forms of crystals, etc., are present either as adventitious or temporary deposits, or as con- stant and characteristic structural features. These may be formed by the cell itself, or may be taken up into its substance from without. Not infrequently under a va- riety of conditions rounded spaces, called vacuoles, ap- pear in the bodies of cells. These may remain for long periods or may soon disappear, or they may repeatedly disappear and return with considerable rapidity. The nucleus, varying greatly in size relatively to that of the cell-body, is usually a sharply outlined structure, often furnished with a narrow, strongly refractive, ho- mogeneous, peripheral zone or investment, and situated sometimes in the centre, sometimes near the side of the cell. Its most common form is oval or spheroidal, but it A B Fig. 594.-The Ovum of a Dog. Fig. 595.-Cells showing Intranuclear Networks. A, branched con- nective-tissue cell from frog's bladder, X 500 and reduced ; B, red blood-cell of Menobranchus, X 1,500 and reduced. is often elongated, and may present irregularities in shape almost as diverse as those of the cell-body itself. In mi- nute structure the nucleus presents considerable varia- tion, depending partly upon intrinsic differences in dif- ferent forms of cells, and partly upon whether it is in a resting condition or in the state of activity which its par- ticipation in cell-multiplication involves (see below). In, many cases in the resting condition during life the nu-' cleus is seen to be crossed in all directions by a coarse or fine network of interlacing and anastomosing fibrils, whose points of intersection are often considerably thick- ened (see Fig. 595). It is to the more prominent of these nodes or points of intersection of the fibrils of the intra- nuclear net that the term nucleoli is often applied. To these intranuclear fibrils the name nucleo-plasm is some- times applied, in distinction from the nuclear fluid, which is believed to fill their meshes. When viewed in optical section, the network frequently looks like a mass of scat- tered granules, with here and there a longer or shorter fibril lying among them, and hence for a long time the nucleus was considered to be simply a coarsely or finely granular structure. While the intranuclear network may be readily seen in some living cells, in others it is very difficult indeed to discover ; in still other cases it is only demonstrable, with the technique at present at our com- 13 Cells. Cells. DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mand, after tlie death of the cell and its hardening by some preservative agent; in others, finally, it appears to be entirely absent. The nucleus is more resistant than the cell-body to various chemical agencies which cause disintegration and destruction of the latter. It is, more- over, capable of absorbing and retaining in its structure various coloring materials which the cell-body does not retain, and by this quality it may be rendered visible after, or even in some cases before, the death of the cell. Cells usually contain one, but may contain many nuclei. In certain cells, such as the fully developed red blood- cells of man, the nucleus is absent. The cell-membrane was formerly supposed, largely on the ground of the similarity which was believed to exist between animal and vegetable cells, to be a very constant structural feature of the animal cell. It is now known, however, to be present in but few forms, and in these it is rather a differentiation of the protoplasm for some special functional purpose than a general structural feat- ure of the cell. When present, the membrane may be simply a hardened peripheral portion of the body, with- out sharp demarcation from the latter ; in other cases it is thin, structureless, and well defined ; in still others it is thick, distinct, and presents various special structural features. Turning now from the structural features of cells to the activities which characterize them as living organisms, or, in other words, to their physiology, we find that these activities are such as belong to living protoplasm in gen- eral. But sometimes one, sometimes another of the ac- tivities is brought into prominence as cells pass, in the course of the development of the individual, into the condition of specialized organisms. This is done for the better performance of particular functions which promote the welfare and higher activities of the body as a whole. Before considering the general and special activities of cells, however, it should be remarked that certain cells which at one period of their existence share in the general activities of living protoplasm, in large part lose these activities, and while retaining to a greater or less degree the structural features of cells, become dry, hard, and inert, and fitted, without more special activity than is involved in their nutrition, to serve as protective or subsidiary structures ; such cells are found covering the skin as epidermis, in the nails, and in hair. , The transformation of protoplasm which results in the production of these inert cells seems analogous to those changes in the periphery of cells by which the cell-mem- brane is produced in some of the few forms in which it occurs. The varied activities of living cells are most readily understood if we consider them first in their simplest expression as seen in those cells which have de- parted least from the type of undifferentiated protoplasm, in cells which maintain a measurably independent exist- ence on a low plane of organization. Such types are exemplified in the leucocytes or white blood-cells, and in certain forms of connective-tissue cells. Such cells are capable, in the first place, of converting certain substances of the nature of food, received from without, into new materia], a portion of which, at least, may become an in- tegral part of the cell protoplasm. The chemical changes which the protoplasm undergoes in this process are called metabolic, and as a result we may have nutrition and growth of the cells. There may be in connection with these changes a production of certain new materials which, as secretions or excretions, may pass out of the organism, either having been, or not having been, directly available for the purposes of the life of the cell. The metabolic changes in the cell protoplasm, one of whose results is the nutrition and growth of the cell, serve still further, in the second place, to render the potential energy resi- dent in the assimilated material available for the uses of the cell by the formation of new chemical combinations. The energy thus rendered available may express itself in contractility of the protoplasm, in virtue of which the entire cell, or a part of it, may undergo movements. The discharge of this energy may be induced by a variety of external agencies. Finally, the power of reproduction is one of the characteristic activities of the lower types of cells. Cells never originate spontaneously, but are al- ways derived from pre-existing cells. Nutrition and growth, then, with which are directly associated the functions of secretion and excretion ; con- tractility, with resulting movement; and reproduction, are the fundamental activities which characterize the lower forms of active living cells. The cell may thus be considered as a molecular machine, differing from other machines which are not alive in this important respect, that it is capable under favorable conditions, by reason of the metabolic changes which occur in its protoplasm, of constantly furnishing the energy displayed in the varied manifestations of its life. The quality of irrita- bility in living cells, in virtue of which they respond to external influences by motion or by increased chemical activity, is simply the condition of what may be called unstable equilibrium of their molecules ; a condition which is more or less constantly maintained, so long as life lasts, by the metabolic changes in their protoplasm. The capacity of the cell for rendering energy available by an incessant rebuilding of its substance out of inert non-living material, varies greatly, depending upon a variety of external conditions. Thus the presence of oxygen and water, and the maintenance of a certain de- gree of temperature are necessary for the continued life of cells ; and, within certain limits, an increase of the temperature facilitates its metabolic changes. Thus in cells capable of performing active movements, such as ciliated cells and white blood-cells, the movements un- dergo a marked acceleration under the influence of a moderate increase in temperature, and are subject to a diminution of their activities when the temperature is lowered. Beyond a certain point, however, either of in- crease or diminution of temperature, the protoplasm ceases to exhibit the phenomena of life, and if either ex- treme be long continued it dies. Moderate mechanical irritation, electrical and chemical stimuli, and direct nervous excitation, may be mentioned as some of the more important influences under which increased molecular changes and movements may be induced in cells. Dilute acids, carbolic acid, quinine, iodoform, and a variety of other substances, when applied to certain cells, are capable of producing a temporary suspension of their activities. The above-enumerated activities by which the life of cells is expressed are by no means uniform in all of the cells of the body. It is only among the lower types, such as carry on a more or less independent existence, that all of these activities find approximately equal expression. As the body develops from its primitive condition of a single cell in the ovum, by means of cell multiplication, some of the new' cells soon begin to depart from the primi- tive simplicity of the lowest types, and to assume the role of special workers. This they do not in virtue of the ac- quirement of new capacities not found in simpler forms, but by reason of the intensification or specialization of their activities in certain particular directions. Thus the muscle cells acquire the capacity of performing rapid and powerful movements. Their power of contractility is at the maximum, but some of the other capacities of proto- plasm suffer in them a corresponding diminution. The reproductive power, for example, is largely in abeyance, and their capacity for elaborating crude nutritive material into new compounds is greatly inferior to that of certain lower types of cells. It is in accordance with the prin- ciples of the physiological division of labor, into which subject the scope of this article does not permit us to en- ter, that the varied structural features and specialized activities of all the higher types of cells in the animal body are developed. It is a suggestive fact that in the changes which the cells undergo during the development of every individual among the more highly organized animals, the doctrine of evolution finds a most exquisite exemplification. For a consideration oLthe specialized structural feat- ures and physiological phenomena of the higher types of cells, and a detailed description of the activities of lower forms, the reader is referred to the separate headings un- der which the different kinds of cells are treated. It will suffice in this connection to notice briefly the two chief 14 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cells. Cells. ways in which the contractility of protoplasm manifests itself in lower types of cells. 1. Amoeboid Movements.-These are most marked in the white blood-cells, but may also be observed in certain forms of connective-tissue cells. The white blood-cell in the ordinary resting condition is spheroidal, if the space in which it lies is large enough to permit free play to the ordinary physical forces which control it in common with non-living matter in a similar physical condition. If, however, it finds itself under suitable conditions it ex- hibits a series of contractile phenomena which we call spontaneous, but which are really responses to external influences of one kind or another, some of which we do, others of which we do not, understand. These responses are made in virtue of the above-described self-formed and self-sustained condition of the cell protoplasm called irritability. Under these conditions the cell may protrude portions of its substance in the form of variously shaped processes called pseudopodia, which, constantly chang- ing in shape, may grow larger and larger until the whole cell-mass is drawn over into them, thus accomplishing a progressive movement. Or, the processes may be thrust out only to be immediately withdrawn, others appearing from other parts of the cell; or, several processes may be formed simultaneously from different parts. Not in- frequently the cell rolls over and over upon itself, or, so to say, flows along. Minute particles of foreign matter, with which the cell or its processes come in contact dur- ing these movements, maybe taken into its substance and either retained there, or, after the lapse of a longer or shorter period, thrust out again at any part of the sur- face. Similar movements confined to the processes of certain pigmented connective-tissue cells, which may be thrust out and withdrawn, give rise to the changes in color which are observed in some of the lower animals, such as the frog and chameleon. They have been also observed in the cornea and various other forms of con- nective-tissue cells in the warm-blooded animals, and are of most frequent occurrence in many embryonic cells. 2. Streaming movements of the protoplasm granules may be seen in the white blood-cells, either during the active amoeboid movement, or when the cell is apparently at rest. They may be most readily seen, however, in the processes which the cell thrusts out during its amoeboid movements, which, at first, may appear quite transparent until the granules from the remainder of the cell pour into them. Flemming, Stricker, Klein, and others have observed in certain blood - cells and in epithelium, Schleicher and the writer in cartilage, movements in the intranuclear granules and fibrils of living cells somewhat similar in character to those of the granules in the cell- body. Reproduction of Cells.-The recent painstaking and elaborate researches of Flemming, Strassburger, Arnold, Butschli, Schleicher, Klein, and others upon the changes which the nuclei of cells undergo during the process of cell-division, have already taught us to attri- bute to the nucleus an importance and specialized char- acter in the life of cells of which investigators before the last decade had no idea, and have wellnigh revolutionized our conception of the nature and details of cell-multipli- cation. It was formerly believed that cell-multiplication nMght occur by a direct constriction or separation into parts of body and nucleus, either simultaneously or sepa- rately, and in a variety of ways. Thus endogenous cell- multiplication, where several new-formed cells were en- closed in a common envelope ; direct division by fission and by gemmation or budding, were described as modes of cell-reproduction of approximately equal frequency and importance. At present, however, it is known that in a great many cases the changes which inaugurate the pro- cess of cell-multiplication commence in, and are for some time largely confined to, the nucleus : the cell-body not sharing until later, to any considerable degree, in the ac- tivities which this significant process involves. Already in a great number of different forms of cells, and under a variety of conditions, normal as well as pathological, the details of this process have been carefully studied. Al- though much more remains to be done, especially in de- termining the limitations as well as details of the nuclear, or, as it is commonly called, indirect mode of cell-divis- ion, enough has already been accomplished to lead us to the conjecture that as our knowledge increases this will be found to be by far the most important, if not the only mode of cell-division. The details of indirect cell-division seem to be some- what variable in different forms of cells, and the concep- tions of different observers as to the interpretation of vari- ous phenomena and appearances are still at variance in some particulars. The following is an epitomized state- ment of the more important phases of the process : In a cell about to divide, the intranuclear fibrils increase in number, and while at first usually very delicate, soon be- come enlarged and unusually distinct, forming a mass of contorted filaments; the nucleus becomes larger and its outlines less distinct (Fig. 596, b). The fibrils, still large and distorted, now arrange themselves into a series of loops, forming an irregular rosette, which encloses a more or less well-defined central space (Fig. 596, c). Either before or during this rosette stage the peripheral portion of these loops separate, and the whole filamentous mass becomes more closely crowded into the centre of the nucleus, and forms, depending upon whether one or more new nuclei are to be produced, an irregular single or double star (Fig. 596, d). This astral stage gives place to the so-called equatorial stage, in which the intranuclear Fig. 596.-Indirect Cell-division, showing Different Phases of Nuclear Change. (After Flemming.) fibrils arrange themselves in two groups of irregular rays, which diverge slightly from points at the opposite poles of the nucleus (Fig. 596, e). These groups gradu- ally draw apart toward their respective poles, forming barrel or spindle-shaped figures (Fig. 596, /). The bases of the new nuclei being thus definitely indicated, the further changes in the intranuclear fibrils are in general a reversal of those which have been experienced up to the equatorial stage. Stellate figures appear at opposite poles (Fig. 596, g), which pass into filamentous rosettes (Fig. 596,A); a nuclear membrane is formed ; the rosette resolves itself into an irregular mass of contorted fibrils (Fig. 596, i), and these finally give place to the usual intranuclear net- work of the resting cell (Fig. 596, j). Hand in hand with the transformations through which the new-formed nu- clei, called daughter-nuclei, pass in assuming their ma- ture features, go the changes in the cell-body by which the new separate cells are formed. In the earlier stages of the nuclear change the granules of the protoplasm are sometimes grouped at the sides of the cell; but it is not un- til the independence of the daughter-nuclei is established that marked changes in the cell-body occur. Then the protoplasm gathers itself about the maturing nuclei, and the constriction around the cell which this involves be- comes deeper and deeper, until the new cells have assumed • the character of independent structures. These may re- main attached to one another or may fall apart; and their nuclei may at once pass through the phases of a new di- 15 Cells. Cellular Tissue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vision with the formation of a new set of cells. Not in- frequently the nucleus of a cell divides, without a divis- ion of the protoplasm following, and thus may originate cells with two or more nuclei. The nuclear changes, as a whole, in indirect cell-division, are sometimes called karyokinesis, from the circumstance that in some phases of the division the nuclear fibrils exhibit well-defined movements. The maintenance of individuality in the structure and in the life of the cells in the bodies of the higher animals is a question upon which our knowledge is yet in many directions quite meagre. In the case of the blood cells, and of some forms of connective-tissue cells, there is no doubt but that in structure as in function they are inde- pendent organisms, except in so far as they are dependent upon the nutritive fluids of the body for food supply. In other cases, especially in the higher types of cells, such as muscle cells, certain epithelial and nerve cells, we know that there are well-marked and intimate connections be- tween them and other differing structures, connections which are essential to the performance of the special func- tion with which their evolution from lower forms has en- dowed them. But there are many forms of cells commonly regarded as leading independent existences, concerning which much uncertainty yet exists as to whether they may not really be more intimately associated with one another in struct- ure and function than we are apt to believe. Of course all the cells of the body, in one way or another, contribute at some time to the welfare of the or- ganism as a 'whole, and also derive individual benefit from it; but this may be done while the cell maintains, in the above sense, a measurably independent existence. Classification of Cells.-Any classification of cells which we may make at present must be imperfect and provisional, because there is so much about their struct- ure, functions, and mutual relations which we do not know. The classifications which are usually made de- pend either upon their physiological peculiarities, their genesis, or their morphological characteristics. In the physiological classification we have groups of cells which manifest, to a more or less marked degree, one or more of the fundamental vital qualities of protoplasm, the re- mainder being, to a greater or less extent, in abeyance; thus, the muscle-cell group, which displays the power of contractility at its maximum ; and certain epithelial cells in which metabolic changes leading to the formation of new chemical substances, as secretions or excretions. Under the influence of certain other cells, called the connective- tissue group, the supporting framework of the body- fibrous connective-tissue, cartilage, and bone-is formed. But such a classification as this can at present be only suggestive, not complete, because there are many cell groups of whose functions we know very little, others of whose functions we know nothing at all. The classification according to the origin of cells in one or other of the primitive embryonal layers is of little assistance, since cells developed in the same layer may differ greatly both in structure and function, and because, furthermore, cells which seem to be closely alike may be developed from quite different layers. The morphologi- cal basis of classification is probably the most satisfactory, since it has at least the negative value of not involving us in theoretical considerations to any great extent, and so far as it goes is measurably precise. Practically, for con- venience of study, we may combine the distinctions which the various systems of grouping suggest, and consider the cells of the body under the following headings (which •see): Muscle Cells, Nerve Cells, Epithelial Cells, Endo- thelial Cells, Blood Cells, Connective-tissue Cells. The name ' ' cell " was applied by the earlier anatomists to the spaces in the looser-textured varieties of connective- tissue which sometimes become filled with air after death, and which were supposed to be filled with fat in adipose tissue, and this application of the word " cell" is still to a certain extent in vogue in the too common and alto- gether incorrect expression, " cellular tissue," as applied to the above kind of tissue. The elementary organisms called "cells" were first studied in plants, and when analogous structures were discovered in animals, the same name was given to them, although not strictly suitable, because the character of a little bladder or chamber, which most vegetable cells ex- hibit, is not possessed as a rule by animal cells, and never in the' characteristic form which makes the term in its original use appropriate. For an epitomized history of the varied views which have existed in regard to cells, the advance of research, and the changes of opinion which have led to the present conception regarding them, the reader may refer to the "Cell Doctrine" (J. Tyson). For bibliography, consult the same work and the "Index Catalogue" of the Sur- geon-General's Office, U. S. Army, heading, "Cells." T. Mitchell Prudden. CELLULAR TISSUE, DISEASES OF THE. An "at- mosphere of cellular tissue " extends in one continuous subcutaneous layer from head to foot. It surrounds and supports the various organs of the body and sends in to them prolongations which give shape and consistency to every part. The diseases of the cellular tissue which come under the care of the surgeon I have classified as follows: Inflammation, which may be either simple or malignant, phlegmonous erysipelas, hypertrophy, atro- phy, tumors, and parasitic affections. Simple inflam- mation may be either diffused or circumscribed, while the malignant form is always diffused. Gangrenous cellulitis, or carbuncle, phlegmonous ery- sipelas, and tumors of the cellular tissue will be treated of in other parts of the Handbook. Diffused Simple Cellulitis.-This affection maybe acute or chronic. The former is the more common variety. The latter is found in connection with old ulcers and badly treated wounds, and it may follow the acute. Cel- lulitis simplex usually develops in the cellular tissue of the upper and lower extremities in persons who are badly nourished or who are in the habit of using alcohol to ex- cess. The most frequent exciting causes are traumatism and exposure to cold. When the inflammation begins there are deep-seated shooting pains through the affected part, with some stiff- ness of the limb, and more or less pain in every move- ment. As the disease progresses the tumefaction of the tissues becomes more marked ; the pain increases in in- tensity and assumes a throbbing character ; every move- ment of the limb gives rise to much pain, and the surface is apt to be smooth and glistening. There is little or no redness. When lymph coagulates in the vessels, as it often does, the surface may be hard, white, and roughened, and this condition may continue long after the acute symptoms have subsided. When suppuration occurs there are chills and rigors, and a portion of the tissue which was formerly hard and tense becomes soft and fluctuat- ing. The separate patches of softening and suppurating tissue finally blend and form long communicating subcu- taneous canals, very difficult to treat. If pus forms far from the surface it will be hard to detect fluctuation. But the rigors, the subsidence of pain, and the pitting made by pressure are sufficient evidence of the formation of pus. ' ' The anatomical changes culminate in a varicose dilatation of the capillary blood-vessels of the inflamed district, and in some positions in a breaking down of the walls. The adjacent parts of the still intact vessels are closed by coagulum and by pressure from without of the various exudates. The connective-tissue cells are found in various stages of proliferation, and wandering cells (white blood-cells) infiltrate the inflamed tissue through- out its whole extent. The intercellular substance is opaque and shreddy, filled with cells, and sometimes with minute extravasations of blood which have escaped through the softened wall of a capillary vessel. As in other inflammations the chlorides and phosphates are in excess. A large amount of lymph and serum is also pres- ent. At a later period collections of pus are scattered through the inflamed part, and shreds of necrotic tissue are interspersed with the various exudates." The temperature in these cases seldom reaches above 103° F. The pulse runs from 100 to 110 except in ner- 16 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cells. Cellular Tissue. vous persons, when it may rise as high as 130. In the early stages the tongue is coated with a yellowish-white fur. Headache and pain in the back are almost always present when the inflammation involves much of the cel- lular tissue. Chills occur when pus forms. In subacute or chronic cellulitis slight or no constitutional disturbances are present, and there is little pain except when the in- flamed member is pressed or moved. There is often in these cases more discoloration of the skin than in the acute form. It is necessary to diagnose cellulitis simplex from phlegmonous erysipelas. In the latter the integument is of a bright purple hue, and there is a burning, throbbing pain. In the former, the pain is throbbing in character and much less severe, and there is very little redness. In erysipelas the fever runs very high, and the general dis- tress is greater. In cellulitis the fever is usually of a mild character. In erysipelas the constitutional symp- toms precede the local. Jn cellulitis the local precede the constitutional. There is very little trouble in diagnosing cellulitis ma- ligna from cellulitis simplex. In the former the inflam- mation extends rapidly, with great tumefaction, lym- phangeitis and lymphadenitis, fever and delirium, due to the introduction of septic poison into the system. None of these things occur in cellulitis simplex. In considering the treatment in any given case it is always well to remember that ' ' what is one man's meat is another man's poison." . It will be well to learn whether the patient is benefited by hot or by cold applications ; sometimes one will soothe while the other irritates. At the onset of the inflammation, in the majority of cases, ice- bags will allay the pain, diminish the swelling, and lower the temperature. A towel folded once or twice should be placed between the ice-bag and the skin. If the pa- tient is anaemic and there seems to be lack of circulation, the cold applications must be dispensed with ; hot applica- tions will do more good. Pieces of blanket dipped in hot water should be frequently applied. The inflamed part may also be wet with linen or muslin cloths saturated with lotio plumbi et opii. Clay poultices are also highly recommended by some in all stages of the disease. Poul- tices made of slippery-elm, linseed, charcoal and bran, etc., are also used. The charcoal poultices are especially beneficial when pus has forced an exit through the in- tegument. As the products of the inflammatory process accumulate and cut off the nutrition by pressing on the blood-vessels, it is well to resort to free incisions in the early stages of the disease. The use of the knife in many cases is indicated before pus forms, in order to diminish the extent of the disease and prevent the forma- tion of sinuses. Some surgeons object to early incisions, because pus and poisonous germs may enter the severed capillaries and thus contaminate the blood. This objec- tion could be made at any period of the disease. Experi- ence has shown, however, that it is not valid, and that incisions early or late do no harm if the wound is prop- erly cleansed and disinfected. Carbolized water (1 to 40), a solution of the bichloride (1 to 1,000), and chloral hy- drate (2 grains to the ounce)-such are all useful as disin- fectants. When the washing has been done, a poultice made of equal parts of linseed-meal and charcoal should be applied. The poultices must be changed three or four times a day. When granulations commence the poultices may be discontinued, and balsam of Peru or glycerine pads, saturated with a solution of carbolic acid and glycerine (1 to 7), may be used. When the cellulitis is due to traumatism, great relief will be afforded by keep- ing the limb immersed in a warm-water bath at a temper- ature of 110° F. The constitutional treatment consists in promoting evacuations from the alimentary canal by the use of a mild mercurial cathartic or by salines. Five or ten grains of blue mass, or a teaspoonful or two of Rochelle salts, will be sufficient for this purpose. Quinine may be adminis- tered in large doses (10 to 20 grains), to cut short the in- flammatory action and to limit the extent of the suppura- tive process. If the stomach does not bear it well, it may be given by the rectum in solution or in the shape of a suppository. Ordinary tonic doses (1 to 2 grains) can always be given with impunity. When suppuration has commenced, iron may be added to the quinine, and cal- cium sulphide may also be given in half-grain doses to limit the formation of pus. Opiates are not advisable. Sponging the surface of the limb with tepid water and alcohol, together with gentle friction of the affected limb, away from the seat of the inflammation, will tend to re- lieve pain and promote sleep. Circumscribed Cellulitis.-The various forms of circumscribed cellulitis are: Peri-phalangeal cellulitis, peri-arthritic cellulitis, peri-rectal cellulitis, peri-urethral cellulitis, peri-venous cellulitis, peri-ccecal cellulitis, peri- ocular cellulitis, and 'peri-uterine cellulitis. Peri-phalangeal Cellulitis (Syn., Paronychia; felon; whitlow).-This disease may be located in the subcutane- ous cellular tissue, in the fascia that retains the tendons in position, or in the periosteum. The disease is usually due to traumatism. It commences on the palmar aspect of the finger, with a sharp intense pain, which is much worse at night, and with some swelling of the pulp of the finger. The pain increases in intensity and the swell- ing extends to the sides and back of the phalanx until the whole surface becomes exceedingly tense and painful on pressure. On the third or fourth day the pain assumes a throbbing character and is almost unbearable. There is also more or less febrile excitement. Pus forms in five or six days from the commencement of the attack. If allowed to burrow it soon destroys the fibrous bands which cross the tendons, the cellular tissue, and the periosteum. The disturbance of the periosteum leads to necrosis of the phalanx. Cases which terminate in necrosis arise usually from neglect on the part of the patient or the sur- geon. Treatment.-Hot poultices should be applied for the first day or two. An incision is then to be made down through all the inflamed structures on the palmar aspect of the finger to the bone. In nearly all cases the knife should be carried directly down to the bone. By this means all the tension produced by the exudates is re- moved and the pus finds a ready means of exit. When the incision has been made, hot poultices are again neces- sary, as well as thorough washings with antiseptic solu- tions. Peri-arthritic cellulitis is an inflammation of the cel- lular tissue around the joints. It also arises from trau- matism, scrofulosis, and extension of inflammation from a diseased articulation. The disease most frequently at- tacks the cellular tissue over the knee. It is ushered in with soreness about the joint, which is increased on every movement. The pain, on pressure, extends beyond the locality of the joints. Redness of the integument is not always present, but there is the same tension and hard- ness which are found in other forms of cellulitis. As a rule it is not difficult to differentiate between inflamma- tion of the joint and peri-arthritic cellulitis. In the latter the swelling is continuous over the joint, covering up the bony prominences around it. The swelling is not found in excess where the synovial membrane is uncovered by ligaments, as is the case in synovitis. There is no fluc- tuation in cellulitis until pus forms, and then it is not confined to the limits of the joint. There is usually dis- tinct fluctuation in synovitis. The joint surfaces may be forcibly approximated in cellulitis without occasioning any pain, while in inflammation of the joint this proced- ure always produces pain. The pain on pressure in sy- novitis is intense when the fingers press directly on the inflamed membrane between the ligaments. In arthritis the pain is diffused over the whole surface. Treatment.-A well-padded splint should be applied to the limb to keep it immovable, and either hot or cold ap- plications made over the seat of the inflammation. Free incisions, carefully made at a safe distance from the artic- ulation, are also necessary. When the disease is over the knee-joint, incisions are necessary on both sides of the joint. When pus burrows all around the joint, drainage- tubes and antiseptic dressings will be found impracti- cable. The constitutional treatment is the same as in dif- fused cellulitis. 17 Cellular Tissue. Cellular Tissue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Peri-rectal cellulitis (Syn., Ischio-rectal abscess) is an in- flammation of the cellular tissue surrounding the lower fifth of the rectum. It is an acute disease, and occurs from injury or from exposure to cold, such as sitting on the ice after skating, or on stone steps or pavements. It occasionally arises from an extension of ulceration through the gut into the cellular tissue. There is acute pain on the affected side near the anus, extending up the rectum or down the thigh. The pain is aggravated by pressure from the outside, or by pressure of the. finger on the rectum. As the disease advances, the inflammatory swelling in the fossa becomes hard and prominent. The pressure of the exudation on the rectal wall causes a sensation akin to that produced by the presence of faeces, and occasions frequent calls to stool. Chills and rigors indicate the formation of pus. The pus burrows under- neath the levator ani muscle, around the rectum, and up- ward, because in that direction there is the least resistance. Its presence may produce necrosis of a portion of the wall of the gut, and assist in establishing a fistulous tract through the integument. The pus may make an opening, externally, an inch or an inch and a half from the anus, posteriorly, or over the tuberosity of the ischium, or on the inner side of the thigh and perineum. As peri-rectal cellulitis is always liable to produce a fistula in ano, it demands active treatment. If the pa- tient is not debilitated, and is seen at the beginning of the disease, an active saline purgative should be given, and half-a-dozen leeches should be applied over the inflamed part and free bleeding kept up by hot fomentations. From twenty to thirty grains of quinine may be given at the same time. If the pain and swelling continue, a deep incision must be made without delay, whether pus has formed or not. If the disease has existed four or five days before the attention of the surgeon is called to it, no time should be lost with leeches and poultices. A few drops of the four-per cent, solution of cocaine should be injected into the inflamed part, and an incision made, sufficiently large, midway between the anus and the tu- berosity of the ischium, to prevent the burrowing of the pus and the formation of a fistula. Even in cases in which the cellulutis arises from ulceration of the bowel, an early incision will limit the destruction of tissue and hasten a favorable termination. After the incision, charcoal poultices are to be applied, and the parts cleansed thoroughly with carbolized water or a solution of the bichloride of mercury, niSnj. The wound should be packed from the bottom, after each washing, with charpie wet with carbolized water, carbol- ized glycerine, carbolized oil, or balsam of Peru. When the granulations are full and flabby, as they often are in this situation, chloral hydrate, or potassium permangan- ate may be advantageously substituted for the antiseptics previously mentioned. Peri-urethral cellulitis is not an uncommon complica- tion of gonorrhoea, but it also arises from injuries or operations on the urethra or perineum. The inflammation may occur in small areas on the penile portion of the urethra, or between the layers of the triangular ligament behind the bulb. In the former the inflammation occu- pies, in the majority of cases, the neighborhood of the glans penis. The symptoms are often obscure in the beginning, es- pecially when the affection results from a urethritis, be- cause the scalding and soreness from the urethritis obscure the pain of the cellulitis. There is noticed, first, a small, hard mass, in close proximity to the urethra, ranging in size from a pea to a hazel-nut, which is painful on press- ure. There is also pain on micturition and during erec- tion of the organ. The cellulitis may extend up and down the canal, in the median line, for an inch or two. Suppuration occurs in the majority of cases, though not as often as in cellulitis between the layers of the triangu- lar ligament. Sometimes a lump of exudation lasts two or three months, but is finally absorbed without doing any special injury to the urethral canal. The second form of peri-urethral cellulitis originates in the cellular tissue around Cowper's glands. It is more extensive than the first variety, on account of the greater amount of cellular tissue involved, and its loose connec- tions. The inflammation almost always ends in suppura- tion. Blows or falls on the perineum usually cause it, though it may be due to a small point of ulceration in a follicle behind an organic stricture. As the disease progresses there is pain on micturition, and pain also when pressure is made in the perineum. In a short time a well-defined swelling occurs, usually on the right side of the raphe. This may increase until a well-marked tumor distends the whole perineum. If the mouth of the ulcer in the urethra is unclosed, pressure on the perineum will, when pus is formed, force it out of the urethral canal. The pressure from the exudation may be sufficient to cause retention of urine. Treatment.-In all cases attention must be paid to the condition of the general system. Constipation must be relieved by appropriate remedies. If the patient is pleth- oric, an active calomel purge will be found efficacious. When the cellulitis is in the penile portion of the urethra the organ should be bathed in cold water half a dozen times a day. After each bath a towel, wrung out in cold water, is wound around the penis, and oil-silk placed over that. Cold sitz-baths at night are also beneficial. Appli- cations of tincture of iodine and oleate of mercury may also be made. The internal use of iodide of potassium, when the stomach will tolerate it, will produce good re- sults. It may be combined with tonics. Most cases of cellulitis are cured before pus has formed, and no incis- ions should be made until pus is unquestionably present. The incision should be only large enough to give exit to the pus and admit of washing. The treatment of the perineal variety is the same as that advised in ischio-rectal cellulitis, viz., cathartics and leeches, and early and free incisions, whether pus has formed or not. If the patient is anaemic, the leeches may be dispensed with, and only a mild laxative used for the evacuation of the bowels. The incision is usually made, as in other cases, over the centre of the swelling. If an opening into the urethra be discovered, the urethral walls, above and below the opening, as well as any stricture, should be divided at the same time. Peri-cacal cellulitis (Peri-typhlitis) arises usually from the impaction of a foreign body in the appendix vermi- formis or walls of the caecum, which causes ulceration and finally makes an opening, and is pushed into the cellular tissue outside. Faecal matter is apt to pass out also with the foreign body. In those cases the inflamma- tion is much more severe and dangerous than when caused simply by the presence of a cherry-stone, peach-pit, or other non-poisonous foreign material. The disease usually terminates in suppuration. Second attacks, lighter in character than the first, may arise from injury to the organized mass of lymph existing as a result of the first inflammation. The early symptoms are not very well defined. The patient may complain for a few days of colicky pains in tho bowels, not confined to the vicinity of the caecum, but occupying the whole lower part of the abdomen. There are also diminished digestion, loss of appetite, and flatulence. The passage of faecal mat- ter through the gut causes more or less pain. Pressure over the part also produces pain. After stool the pain is relieved, but again returns with increased severity. In seven or eight days from the commencement of the dis- ease careful examination of the iliac fossa will reveal a swelling, not well defined but deep seated and painful. The temperature at this period runs from 101° to 103° F., seldom running higher unless some complications exist. The pulse ranges from 100 to 120. The tongue is coated and often dry in the centre. Constipation may alternate with diarrhcea throughout the disease. There is great irri- tability of the bladder, and the act of micturition is some- what painful. In three or four days the inflamed spot may be ascertained by inspection. It is more defined and very painful. The swelling may also readily be felt by an examination through the rectum, high up and on the right side, and posteriorly. Rigors indicate the formation of pus. Owing to the depth of the tumor and the thick- ness of the abdominal walls, fluctuation will not, as a rule, be perceptible. The purulent matter may make its 18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cellular Tissue. Cellular Tissue. ■exit through the rectum, bladder, peritoneal cavity, or into the colon higher up. The most favorable course for the pus to take is through the rectum. The rupture into the peritoneum is regarded as fatal, though if the accident could be diagnosed at once there is no valid reason why the abdomen should not be opened and the purulent matter washed out, while drainage could be established in another direction. Treatment.-In the early stages free catharsis should be produced by large doses of castor-oil. An ice-bag may then be applied over the seat of inflammation, or half a dozen leeches may be put on, and the ice used subsequent- ly. A large dose of quinine, from twenty to thirty grains, is also useful in aborting the inflammation. If the in- flammatory symptoms continue despite this treatment, more active measures are called for. If the swelling in the iliac region is well defined and increasing, an incision must be made over the centre of the swelling parallel with Poupart's ligament. When the integument and aponeurosis of the external oblique muscle have been in- cised, a hypodermic needle may be introduced with ease and the exact location of the pus made known. The knife is then carried on through the remaining tissues until the cavity of the abscess is reached. The pus has often a faecal odor, and on examination it may show the foreign body that ulcerated through the gut and caused the inflam- mation. When the abscess has been thoroughly cleansed by a solution of carbolic acid (1 to 40), a glass or rubber drainage-tube is inserted and the edges of the wound brought together with sutures. The wound may be dressed with the carbolized glycerine pads, or any other of the antiseptic dressings previously mentioned. When the ab- scess ruptures into the peritoneal cavity, I believe the only thing to do is to follow the pus with the knife through the walls of the abdomen, wash the cavity out, and estab- lish free drainage. In all cases a full dose of opium, with ten grains of quinine, should be administered after the operation. Peri-venous cellulitis, erroneously called suppurative phlebitis, is an inflammation of the cellular tissue sur- rounding the veins. It usually occurs from traumatism in persons whose vitality has been lowered by excess or other causes. It often commences in the cellular tissues around the small veins, spreading and involving rapidly the large trunks. The great danger in this form of cel- lulitis arises from the fact that the small capillaries which supply the walls of the veins with blood are pressed upon by the exudates, the nutrition of the walls is cut off, ul- ceration takes place, and coagula form within the vein, rendering the patient liable to pyaemia. There is some pain and swelling during the first forty-eight hours, al- though the disease is not well defined until the fourth or fifth day. Then the redness is increased, as is also the tumefaction around the vein, which may be felt like a tense cord under the finger. Pus rapidly forms, either in isolated masses or in a continuous tract along the course of the vein. If the walls of the vein remain in- tact, and none of the products of degeneration enter the circulation, the symptoms will resemble those of other forms of cellulitis. Should the suppuration be extensive, and the products of degeneration enter the circulation through the broken veins, the symptoms of pyaemia will manifest themselves. Rigors, followed by excessive sweating, appear, the temperature rises to 105° or even 107° F., and the pulse increases to from 120 to 140, or even higher, and is very compressible. The tongue is dry and brown, the face wears an anxious expression, delirium supervenes, and in a few days the case is apt to reach a fatal termination. Treatment.-In this form of cellulitis, more than in any other, are early incisions necessary. The inflamed tis- sues must be freely incised, and the parts thoroughly cleansed with carbolized water or other antiseptic solu- tion. Charcoal poultices applied two or three times during each day, with thorough cleansing and disinfection, will prevent the disease from spreading to any extent, and will do away with the danger of blood-poisoning. Oint- ments of mercury, belladonna, and opium, or applica- tions of iodine, are said to be beneficial in controlling the inflammation. Quinine and stimulants should not be omitted in the treatment, and nutritious materials, such as milk, etc., should be administered with the stimulants. Sulphide of calcium given in two-grain doses is said to be useful in diminishing the amount of the suppuration. Carbonate of ammonium in ten-grain doses is said to pre- vent the formation of a coagulum in the veins. Peri-ocular cellulitis is a comparatively rare form of in- flammation, which involves, more or less, the structure of the eyeball, as well as the cellular tissue of the orbit. It occurs from external violence, and follows convalescence from fever and erysipelas. There is a deep-seated pain in the orbit, often throbbing in character, together with redness and tumefaction of the ocular and palpebral con- junctivae. . The exudation pushes the eyeball forward until it becomes very prominent and immovable. When the upper lid is lifted, fluctuation may be obtained over the distended conjunctiva. Treatment.-Four or five leeches should be applied to the temples, apd a mild cathartic given internally. It is best to wait until the pus points distinctly, before an in- cision is made in the conjunctiva. In the majority of cases stimulants and tonics are necessary. Malignant Cellulitis.-There are two varieties of this disease, one of which arises from a dissecting wound and the introduction of the products of decomposition into the circulation ; while the second is occasioned by poisonous serpents or insects. Physicians and students of medicine who are engaged in making post-mortem examinations and dissecting are usu- ally the class most often affected by the first variety. Some get the disease by handling putrid carcasses of the lower animals. Cases occur in which the poison enters behind a "hang-nail." Surgeons get it from operating on gan- grenous limbs and phagedenic ulcers. From twenty-four to forty-eight hours after the introduction of the poison the edges of the -wound assume a dark red hue, and be- come much swollen. The epidermis is raised by a brown- ish serum, which in a short time becomes opaque and purulent. There is an intense burning pain at the onset, and shooting pains in the course of the limb. Inflamma- tion of the lymphatics occurs, which is recognized by the appearance of red lines radiating from the wound as high as the junction of the limb with the trunk. The glands are enlarged and painful, and the whole limb swells from infiltration with serum, lymph, and pus. Irregular areas of suppuration soon develop, open on the surface, and discharge a fetid, sanious pus. The poison absorbed by the lymphatics is carried to the glands, exciting inflam- mation and suppuration, and finally destroying them. The entrance of septic matter into the circulation is indicated by chills and rigors, which are not usually re- peated as in pyaemia. A rapid rise in temperature fol- lows the chill, the thermometer registering from 104° F. to 107° F. There are intense headache, pains in the back and limbs, congestion of the conjunctiva, a dry, brown, furred tongue, and an anxious facial expression and deli- rium. The urine is scanty and contains albumen. Within a period ranging from three to ten days, the patient usu- ally sinks into a typhoid condition and dies. In some cases of malignant cellulitis the lymphatic glands intercept the most of the septic poison, and the constitutional disturbances are not very great, though the inflammation in the wounded limb is about as severe as in the cases which terminate fatally. A post-mortem ex- amination shows that the liver is softened and filled with blood ; the spleen is enlarged and easily broken down under the finger, and some infarctions exist. There are no collections of pus in the internal organs, such as are found in pyaemia. Treatment.-The dirt about the wound should be washed away and the poison be removed by sucking the wounded member. Pure nitric or carbolic acid should then be applied over the cut surface as well as on the in- tegument around. A charcoal poultice is then applied, and the limb suspended in a sling. A grain or two of opium, and ten or twenty grains of quinine, if given im- mediately, will assist in warding off dangerous symp- toms. When the wounded limb becomes swollen and 19 CephalhJma"oma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. painful, and the lymphangeitis well developed, free inci- sions should be made over the wound down to the bone, and through the integument and cellular tissue above the wound when these tissues are much distended. Other incisions are to be made as the disease progresses, in order to prevent the burrowing of pus and absorption of the poison. The charcoal poultice may envelop the whole limb. Stimulants are to be given pro re nata, but in the main freely. In the second form of malignant cellulitis the constitu- tional disturbances are of such magnitude that the ac- companying cellulitis is of comparatively little conse- quence. The poison spreads more rapidly, and the whole disease may run its course in a few hours. The wounded limb swells rapidly, and is infiltrated with bloody serum and lymph. The integument is mottled, and clots of bloody serum form under the epidermis. If the disease runs over a day or two, purulent masses form throughout the diseased limb, and gangrene may set in. (See article on Wounds.) The local treatment is the same as recom- mended in the former variety. Ammonia and whiskey in large quantities are employed in counter-acting the effects of the poison. Hypodermic injections of ammo- nia are also advised. Myxcedema (Syn., Hypertrophy of the cellular tis- sue ; Cretinoid disease ; Mucoid degeneration of the cel- lular tissue ; Polysarcia) is a rare affection first described by Sir William Gull. The symptoms of the disease are a thickening and enlargement of the whole integumentary cover of the body, especially that of the face. The skin is smooth and rose-colored. The face assumes a blotched look. The tongue is thick, the voice hard and guttural. Fat accumulates on the trunk and lower extremities, and the patient looks as if suffering from oedema. The dis- ease is chronic, lasting from ten to fifteen years, the ter- mination being marked by a decrease of temperature. According to Dr. Ord it is sometimes as low as 77° F. A microscopical examination shows that the connective- tissue cells and the fibrous and interstitial mucous sub- stance are all very much increased. No treatment has yet been found to reach the disease. Iodine, iron, and cod-liver oil, have been recommended. Turkish and Russian baths, frequent friction of the sur- face, and mercurial inunctions may be of some service. Atrophy of the cellular tissue may occur as an independent disease, though it most usually exists in con- nection with progressive muscular atrophy. It occurs sometimes in facial neuralgia of long standing, or when there is prolonged irritation of nerves in other parts of the body. When the disease occurs from irritation of the facial nerve, it is called facial trophoneurosis. Treatment.-If the cause is known it must be removed. In one case of facial neuralgia, of eighteen years' stand- ing, in which there was great atrophy of the tissue on the affected side, I removed the nerve together with Meckel's ganglion. The neuralgia was cured, and in a few months after the operation the flattened face had assumed its nor- mal aspect. Electricity, nux vomica, hypodermic injec- tions of strychnine (one-sixtieth of a grain), and cod-liver oil, are considered useful remedies. Parasites of the Cellular Tissue.-The subcuta- neous cellular tissue is subject to invasion from the Cys- ticercus cellulosae, the Guinea-worm or Dracunculus, and the Pulex penetrans or sand-flea. The cysticercus celluloses is found most frequently in the cellular tissue between the muscles. It has also been found under the conjunctiva and in the aqueous and vitreous humors. It consists of a vesicle two lines in diameter, which contains in its interior the embryonic worm, or undeveloped taenia. It occasions but few un- pleasant symptoms except when in the humors of the eye or in the internal organs. They are sometimes removed from the eye by incision. The Guinea-worm, or Filaria medinensis, flourishes in tropical climates. The parasite in its undeveloped state measures one-fortieth of an inch in diameter, and finds an entrance through the sweat follicles and lodges finally in the cellular tissue. Busk says it gives no evidence of its existence for about eighteen months. It then meas- ures about two feet in length when uncoiled, and begins to travel to the surface of the integument. This excites an inflammation which is easily recognized. An elevated spot of a reddened color appears immediately over the site of the parasite. It itches and is painful on pressure. It sometimes assumes the appearance of a boil. Pus forms and the head of the worm is extracted. If there are many worms making their way out there is much pain and stiffness in the limb, and some febrile excitement. Treatment.-The inflamed spot should be incised and the parasite extracted by grasping the centre of its body with a forceps. Busk recommends slow removal of the parasite in the same manner that the tape-worm is some- times removed, viz., by winding it slowly around a pipe- stem or twig, taking a small section each day until the whole parasite is removed. The Pulex penetrans (sand-flea, jigger) is also peculiar to southern climates. The female enters the skin after it becomes impregnated. It makes an entrance under the nails of the toes, between the toes, and in other parts of the feet. According to Busk, when the ova distend the abdomen of the flea a swelling appears, white in color, which grows rapidly and leads to the formation of ulcers which are very difficult to treat. Treatment.-The insect is removed by excision and the cavity occupied by it is washed with carbolic acid and tobacco-juice or turpentine. Joseph IF. Howe. CENTAURY (JIerba Centauri, Ph. G.; Centauree petite, Codex Med.). The herb of Erythrcea Centaurium Per- soon ; Order, Gentianacea, a bitter, slender, branching annual herb, related to the Gentians proper, but differing from them principally in having longer slender styles, apparently two-celled ovaries, and anthers which, after the discharge of pollen, twist into a spiral. Centaury haa squarish, slender, upright, generally simple stems, from fifteen to forty centimetres high (6 to 16 inches), arising from a rosette of three- to five-nerved obovate leaves, and bearing pairs of smaller and narrower lanceolate leaves above. Flowers terminal in corymbose cymes, one and a half centimetre (one-half inch) long regular, per- fect, with a five-parted cylindrical calyx, a pretty, deli- cate, rose-colored, five-lobed, salver-shaped corolla, five stamens, and an apparently two-celled ovary, whose car- pels split away from each other at maturity. It is a native of Europe, Asia, and Northern Africa. Our limited sup- ply comes from Europe. Centaury has been in use in Europe for hundreds of years ; it is called Lesser Cen- taury because a species of thistle, a much coarser plant, has also the same name. Composition.-Centaury contains a minute proportion of a tasteless and odorless neutral crystalline substance, which becomes rose-colored and red in the sunlight, but crystallizes, from solution, white and transparent again. It also contains a bitter resembling the bitter of Gentian, a little volatile oil, etc. It is a simple, bitter tonic, ap- plicable to all the purposes to which Gentian and others of its class may be put. It is extensively used in Europe to make a bitter " tea" as a domestic remedy, and also is said to be sometimes employed to give flavor to beer. Dose, from two to four or more grams (2 to 4 Gm. = 3 ss. ad j.) in decoction several times a day. Allied Plants.-This genus contains about thirty named species, all of which have the same bitter quali- ties, and many of which are probably only varieties of the present species. Sabbatia angulans Pursh, the Ameri- can Centaury, in the same family, as well as most other plants in the Order, have similar action. (See Gentian.) Allied Drugs.-See also Gentian. W. P. Bolles. CEPHALH/EMATOMA. The word is from the Greek, Ke<pa\-f), the head, afaa, blood, and i^a, morbid con- dition. A morbid condition of the head characterized by an effusion of blood. The Latins rendered it Cranii tumor sanguineus; the French, Cephalematome, or Tumeur san- guine de la tete; the Italians, Cefalhamatoma ; the Ger- mans, Kephalamatom, or Kopfblutgeschwulst. Synonyms. - Cephalaematoma ; ecchymoma capitis; ecchymoma capitis recens natorum; thrombus neona- 20 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, cephalhJmZtoma. torum ; abscessus capitis sanguineus neonatorum ; tu- mor capitis sanguineus neonatorum; cephalophyma; cranio-haematoncus. Definition.-An effusion of blood upon or within the cranii of newly born infants. Varieties.-Subaponeurotic, the simplest, but not the most common form-a bloody effusion immediately under- neath the cranial muscles. Subpericranial, situated between the pericranium and cranial bone-the most common form. Diploic, situated within the diploe-a rare form, and dif- fering from others in that it continues to bleed when laid open. (This is explained by the abundant supply of ar- teries and veins in the reticulated structure of the diploe.) Subcranial, generally situated between the skull and dura mater, and sometimes in the cavity of the arachnoid. Pathological. Anatomy. - The scalp generally re- tains its natural aspect. Exceptionally its appearance be- comes red and livid. Its substance remains uninjured, and the pericranium preserves its transparency. The effused blood is contained in a sac of fine membrane, having all the characteristics of condensed cellular tissue. It rests on the bone, from which it can be easily de- tached, and underneath the pericranium, to which it adheres more firmly. Points of ossification can be ob- served on the under surface of this membrane. The earlier writers thought that the outer table of the skull was necrosed, carious, and destroyed, and that the ruptured vessels of the diploe gave rise to the haemorrhage. A bony ring forms in the majority of cases. It begins as soon as the separation of the pericranium is arrested, which is about the second day. This has been said to be only a delusion of the sense of touch, but its presence has been demonstrated by numerous post-mortem examina- tions. It is not, however, always present, being absent in tumors situated near a suture. There are many theories as to its causation. The following, by Virchow, is probably not only the most beautiful, but also the most plausible: The healthy cranium grows by proliferation of the inner layers of the periosteum. If, then, the peri- cranium, through the blood which is poured out, is held apart from the cranium, the bone-forming layers of the periosteum being still thrown off, they cannot reach that part of the bone for which they are intended, on account of the presence of the blood. Eager, however, to fulfil their office, they join themselves to the bone at the border of the tumor where the bone is still attached. Etiology.-The etiology has occasioned much dis- cussion. The reception of some injury by the child during parturition was long thought to be the cause. A number of observers failed to note that it succeeded difficult labors. The tumor occurred on parts not liable to pressure. Cases are reported after breech presentations, after Caesarean section, and after painless labor, and it has been observed that a narrow pelvis in the mother is an infrequent accompaniment. It occurs in premature births. These tumors form on children of advanced age and on adults ; sixty-six and two-thirds per cent, of the cases are males. While it is very easy to imagine how pressure during parturition might cause the tumors, yet it is very evident that in a large proportion this is not the cause. Hence, we may look for another cause. This must be some fault of the blood-vessels. Intracranial haemorrhage is in reality a form of apoplexy, and it is quite probable that the tendency is inherited. One case is on record in which the same mother gave birth to three children successively who had cephalhaematoma. In a case reported by the author, the mother said : " Three of my other children died of convulsions, and I gave this one up as soon as they came on." These other children, too, might have had cephalhaematomas, and there might have been an in- herited tendency; or an unusual friability or thinness of the vessels, or incomplete development of the outer layer of the skull, might have been the cause. If cephalhaematomas are caused by pressure in breech presentations, this must be due to the action of the cervix on the cord or neck of the child. Pressure during delivery undoubtedly has some- thing to do with the causation of a considerable number of these tumors, yet there are many others which must result from a diseased condition of the blood-vessels in- herited or acquired. Frequency.-The average, so far as it can be learned from the statements of authors, is 1 in every 235 children born. Location.-It is most frequently situated on the right parietal bone, then on the left, occasionally on the frontal, more rarely on the occipital and in the temporal regions. Diagnosis.-It is a disease of the newly-born. There are exceptions to this. One case has been reported in a child of six months, another in one of twelve months, a third in a man of twenty-six years, a fourth in one of thirty-six, and a fifth in a woman of forty-nine. These, however, are anomalies. One notices a tumefaction, usually one, two, or three days after birth. It develops gradually ; it is of fluid character. It pulsates forcibly at the beginning, if connected with an artery ; it loses this later, but fluctuation is always present. In size the tumor ranges from that of a hazel-nut to that of a mass involving the whole surface of the parietal bone. The tumor is limited by the sutures in the three varieties situated between the pericranium and the dura mater; in the subaponeurotic and arachnoid varieties this is not so. The scalp is natural in appearance in the subapo- neurotic variety. The bony ring is almost pathognomo- nic in the subpericranial variety, but is not so often present in those situated between the cranium and dura mater; in the other varieties it is absent. The diag- nosis of internal cephalhaematoma must be made from the symptoms of brain pressure, twitchings, convulsions, stupor, or paralysis which it may produce. The caput succedaneum occurs in the first twelve to thirty-six hours. Cephalhaematoma is at birth either absent or scarcely noticeable, grows from day to day, till on the eighth day it attains its full size, and then, perhaps, the bony ring can be felt. The caput succedaneum pits on pressure, while the cephalhaematoma does not. From hernia cere- bri congenita it may be distinguished by the fact that this pulsates, while cephalhaematoma simply fluctuates; hernia cerebri, furthermore, is not found on the parietal bones, but on the sutures and fontanelles ; it protrudes during the acts of coughing and crying, is partly reduci- ble, and then causes slight convulsions. The rim of bone resembles somewhat the elevated ring, but pressure of the finger on the tumor does not find a bony floor as in cephalhaematoma. The skin over hernia cerebri is thin and hairless, in cephalhaematoma it is normal. Fungus of the dura mater does not contain fluid, doesnot fluctu- ate, nor feel doughy, has no bony ring, and the overlying skin is thick and blue. This form of tumor becomes smaller under pressure, and, besides, it seldom occurs in children. Atheroma and fatty tumors occur rarely at such a tender age. They can be differentiated by the trocar, but one must be careful to exclude hernia cerebri before using this instrument. There is no danger of con- founding cephalhaematoma with hydrocephalus externus, and the osseous circle will distinguish the former from aqueous cysts. Telangioma occupies the favorite seat of haematoma, but is not covered with hair, pulsates weakly, and is somewhat diminished in size by pressure. Prognosis.-For the extracranial tumors the prognosis is good, for the intracranial it is bad. Death takes place mostly from exhaustion, brain pressure, and secondary haemorrhage ; from rupture of the tumor ; from necrosis or caries of the bone leading to perforation ; from throm- bosis of the cerebral sinus ; from extension of the inflam- mation into the meninges and brain itself ; from absorp- tion of ichorous discharge, and from pyaemia. Arthritis, phlebitis umbilicalis, pleuritis, scleroderma, intestinal haemorrhage, caries of the skull, and, in the internal variety, idiocy are among the results which may follow cephalhaematoma. Treatment.-Authors are divided ; some follow the expectant, others the active plan. Some of those who use the knife wait till the eighth to twelfth day ; a few make the incision earlier. The artificial evacuation of the blood is usually unnecessary, and may do harm ; as a rule, non-interference is best. If pus forms it should be evacuated. For the external varieties, warm aromatic 21 Cephalometry. Cephalometry. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fomentations, cold spirit lotions, pressure, and setons have all had their day. As treatment in intracranial cephal- hematoma has not yet been attempted ; as the internal is almost always associated with the external variety, the latter being situated directly over the former, in the writer's opinion it would be advisable to trephine the skull to evacuate the tumor. anthropometric characters of the head and face, with a view to determine the form, volume, and proportion, and to establish their differential characters in human groups. The positive character of this new method of study is based upon two kinds of measurement; the one dealing with lines, curves, surfaces, and angles ; the other with the volume of the cubic mensuration or cranial stereo- metry. These measurements should not be confounded with craniography, which is that part of descriptive craniology whose object is to describe or reproduce by the help of special processes, as written language or graphic representation, by drawings, tracings, projec- tions, photographs, mouldings, and impressions, the parts or regions of the skull or the bones of the face upon which comparison is to be made. Craniometrical meas- urements and comparisons may apply to different parts of the skull, or they may apply to it collectively. They may deal with the entire bones of the head and face, as the cranium; with the same bones without the lower maxilla, the calvarium; or with the bones of the skull alone, the calvaria. Among the oldest operations of cephalometry, as well as the most incomplete, is the measurement of the facial angle, which has given rise to the supposed importance of angular measures applied to the head, and to the in- troduction of numerous goniometers and cephalometers variously modified and simplified, but having for their object the measure of the facial angle, the length of the facial line, that of the side and base of the facial angle, and finally the distance expressing the degree of protuberance of the face in advance of the cranium, or the prognathism. The mensuration of the ence- phalic angles and of their sides, as well as the deter- mination of the degree of prognathism in its relations with the plane of the frontal, was accomplished by the cephalometer of Anthelme as early as 1838. This in- strument is composed essentially of two circles of copper or brass, the one fixed, which surrounds the head almost horizontally, the other a movable half-circle, which moves fore-and-aft upon the first. The instrument, highly es- teemed in cephalometric researches, was recommended to travellers and anatomists, and was simplified by Broca, whose instrument is so constructed as to measure the facial angle on a quadrant. The linear measurements next in importance are the diameters longitudinal and latitudinal, and the height. The greatest longitudinal diameter is measured from the glabella to the most prominent part of the occiput; the latitudinal is found in the breadth between the points of the parietal bones widest apart; while the height is ascertained by measuring with calipers from the middle of the anterior border of the foramen magnum to the most elevated point on the sagittal suture. The deter- mination of the zygomatic diameter and the measure- ment for ascertaining the index of the foramen magnum and of the nasal index may also be included in this cate- gory. The surface and its parts are measured in a variety of ways. One of these is by means of a millimetre wheel, which is divided into thirty parts ; another is by a series of triangles and a calculation of their contents-an oper- ation that is extremely troublesome and unproductive in good results. For ordinary purposes the circumference may be taken with a tape measure on a' plane including the glabella, the occiput, and the most prominent lateral points. The longitudinal arch, as well as the arch of the occipital, the parietal, and the frontal bones may be as- certained in the same manner. The method of projection, generally speaking, is of no value ; and stereographic designs, being good only in de- scriptive craniology, are worth nothing for craniometrical purposes. The mensuration of the mandible is to be commended, because of the reciprocal connections of the head and face. This is done with a special goniometer composed of a graduated arc and two hinged planes. Happy re- sults are also furnished by the method of the indices, or a comparison of the absolute values obtained from the measurement of a number of skulls. A simple illustra- Abegg: Beideseitiges Cephaliimatom, Monatschr. fur Geburtskunde u. Frauenkr., Berlin, 1865, xxvi., S. 43-50. Adams : Sanguineous Tumor of the Head in Newly born Infants, North. Journal of Med., Edinburgh, 1844, 1845, ii., 78-93. Beiting: Heber Kopfblutgeschwulst der Neugeborenen. Wurzburg, 1851. Betscher : Kephaliimatom, Jahrbuch fiir Kinderk., Erlangen, 1863, xi.,i. Bierbaum: Cephalhaematoma Verum, Med. Zeit., Berlin, 1858, i., 185; Cephalhaematom, Jahrb. f. Kinderk., Erlangen, 1860, xxxv., 57; Ke- phalamatom, Ibid., 1861, xxxvii.,199; Cephalhaematoma, Ibid., 1863, xii., 165-167. Black: On Sanguineous Tumors of the Scalp in New-born Children, Edinburgh M. and S. Journal, 1841, iv., 112-125 ; also Reprint. Boucharcourt: Cephalematome, Diet. Encycl. d. M6d., Paris, 1873, xiv., 1-16. Burenlechner: Zur Behandlung des Cephalhaematoma Neonatorum, Allg. Wien. Med. Zeitung, 1876, xxi., 198-207. Charney : Du cephalhaematome chez les enfans Nouveau-n6s. Paris, 1864. Churchill: Diseases of Children. Dublin, 1850, p. 66. Cleveland : Internal and External Cephalhaematoma, Cincinnati Lancet and Clinic, vol. vi., p. 350, 1881. Depaul: Deux cas. de Cephalematome, Journal des sages femmes, Paris, 1875, iii., 17; Cephalematome, Ibid., 1877, v., 313; Cephalematome, Gaz. des Hop., Paris, 1879, iii., 857. D'ipp : Zwei hundert zwei und sechzig Faile von Cephalhaematoma Neo- natorum, Journal de Chir. und Augenheilk., Berlin, 1843, u. f. ii., 99- 108; Zur Cephalematome, Annales de la Chir., Fran^aise et ktrang., Paris, 1844, x„ 176-186. Dubois : Cephalhaematome, Nouveau dictionnaire de Medecine, tome vii. Earle: Cephalhaematoma of the Newly-born, Journal of the American Medical Association, Chicago, i., 549, 1883. Feist: Heber die Kopfblutgeschwiilste der Neugeborenen. Mainz, 1839, Firon : Treatment of Cephalhaematoma from Early Puncture, American Practitioner, Louisville, 1870, i., 214-218. Garceau : Cephalhaematoma, Boston Medical and Surgical Journal, 1873, x., 47. Gosselin: Bemerkungen ueber die Entstehung des Split Cephaliimatom in Folge von rarefleirinde Osteitis des Scheitelbeins, Arch. Gen., 7 Ser., x., p. 513, November, 1883 ; also, Schmidt's Jahrbiicher, vol. 200, No. 2, p. 151, 1883. Geddings: Observations on Sanguineous Tumors of the Head, which form Spontaneously, sometimes designated Cephalhaematoma and Ab- scessus Capitis Sanguineus Neonatorum, N. Am. Arch. M. and S. Sci- ences, Baltimore, 1835; On Sang. Tumors of the Head, Amer. Jour. Med. Sc., Phila., 1839, xxiii. Gibb : Double Subpericranial Cephalhaematoma, Tr. Path. Soc., London, 1857-1858, ix., 380-382; also. Lancet, London, 1857, ii., 550. Godson : Cephalhaematoma, Quain's Dictionary of Medicine, p. 224,1883. Hennig: Kopfblutgeschwiilste, Gerhardt's Handbuch der Kinderkrank- heiten, Bd. ii., S. 49, 71, Tubingen, 1877, u. Jahresbericht der Poli- klinik fiir Kinder, Leipzig, 1856. Henderson: Treatment of Cephalhaematoma, or Bloody Tumors of the Cra- nium in Newly-born Children,North. J. Med.,Edinburgh, 1845, iii., 395. Hoere: De tumore cranii recens natorum sanguineo et externo et interno. Berlin, 1824. Homans: Double Cephalhaematoma, Extr. Rec. Boston Soc. of Med. Im- provement, 1856, ii., 149; also, American Journal Med. Set, Philadel- phia, 1855, N. S., xxix., p. 67. Jackson : Internal Cephalhaematoma, Amer. Journ. of the Med. Sc., 1855, N. S., xxix., p. 67. Jacobi: Cephalhaematoma, Phila. Med. Times, 1875. v., 507; Kephalii- matom, Med. Chir. Centralblatt, Wien, 1876, xi., 507. Keating : Archives of Pediatrics, ii., 11-20, 1885. Kleinwachter: Cephalhaematoma, Real Encyclopadie der Gesammten Heilkunde, iii., p. 119, 1880. Lefour: Un cas de Cephalaematome double avec epanchement sanguine sous-epicranien, Gaz. Hebdomadaire d. Sc. Med. de Bordeaux, 1880-81, L, 433. Metz: Bilateral Cephalhaematoma, Med. and Surg. Reporter, Philadel- phia. 1863, x., 183. McKee: External and Internal Cephalhaematoma, Cincinnati Lancet and Clinic, N. S., vol. xi., pp. 317-324, 1883. Monti: Jahrbuch fiir Kinderheilkunde, N. F., 1875, 407. Pigne: M6moire sur les Cephalhaematomes ou tumeurs sanguines des En- fans Nouveau-nez, Journal Universe! et hebdomadaire de Mddecine et de Chirurgie, etc., September, 1883. Ruge : Cephalhaematoma Verhandl. d. Gesellschaft f. Geburtsh., Berlin, 53, 7, Heft ii., u. Berliner Klinische Wochenschrift, No. 5, 1876. Tordeus; Cephalematome chez un enfant de dix sept, moir., J. de M6d., Chir. et Pharmacol., Brux., 1882, Ixxv., 523-25, and Arch, de Toxicol., Par., 1883, x„ 337-340. West: External and Internal Cephalhaematoma, Med. and Chir. Trans., London, 1845, xxviii., 397, 411. Virchow: Die Krankhaften Geschwiilste, i., 135, 1863 ; also, Monat- schrift fiir Geburtskunde, Bd. 20, 24, 26, pp. 43, 173, 174. Edward Sydney McKee. Bibliography. CEPHALOMETRY, CRANIOMETRY. These terms mean simply the application of instruments of precision to the study of the skull. The operations are used in studying the descriptive and 22 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cephalometry. Cephalometry. tion of the method is furnished on comparing the antero- posterior and the transverse diameters of a skull. The length of the cranium being represented by 100, its breadth is equal or superior to 80 ; the skull is then said to be brachycephalic. When the breadth is below that is to say, when the cephalic index is inferior to 77.7 in the hundred, the skull is dolichocephalic; finally the skull is mesaticephalic when the index is comprised be- tween J and -fa, that is to say, 77.7 and 80 in 100. But of all craniometrical methods the most important, from a practical point of view, as well as the oldest, and the one concerning which the greatest craniological interest at- taches, is stereometry or cubic mensuration, by means of which we arrive at the capacity of the cranium. Notwithstanding the newness of craniometry as a study, almost an arsenal of special instruments have been devised for taking the foregoing measures, and in spite of the inevitable causes of error, the imperfection in the results obtained, and the difficulties and illusions with which craniometry is beset, it is believed that important conclusions have been drawn from the study, especially in regard to the determination of human types, and in the relations that exist between the volume of the head and the degree of mental energy. To describe the colossal number of measurements ex- tolled by some craniologists, and to examine even sum- marily the various instruments used in cephalometry, cannot be done in a general epitome, which aims only at outlining the principal general methods. As a matter of prime necessity, the intending cranio- metrist should be in possession of good and well-made instruments, a certain amount of elementary mathemat- ical knowledge, a tolerable familiarity with the osteo- logical details both of the endocranium and the exocra- nium, and what is perhaps of considerable importance, a knowledge of the nomenclature not only of anthropo- logical but of zoological and comparative craniology. It has been remarked that one may become a well-informed craniologist without charging the mind with the osteo- logical details of the skull, and that, on the other hand, the most learned anatomist may be entirely ignorant of craniology. In reality, the latter science requires but a general knowledge of osteological details in order to dis- tinguish the special points that serve as guides for meas- urement, or for the morphological elements, the develop- ment of which is not the same in different types. The creation of a particular nomenclature, besides preventing circumlocutions, simplifies and facilitates cephalometry ; and the possession of mathematical knowledge united to intimate anatomical knowledge can certainly be no draw- back to a study which has been heretofore obscured by anatomists who knew little or nothing about mathemati- cal language. The fixity of craniometric points being indispensable in the comparison of results and their verification, it is im- portant, when proceeding to cranial mensuration, to begin by tracing with a pencil the auxiliary lines and the ana- tomical guiding points. The lines are the biauricular, the supraorbital, and infraorbital; and the points are the bregma, the lambda, and the inion, or external occi- pital protuberance of anatomists, etc. The biauricular line, which may be traced with the help of a cord extend- ing over the vertex from one auditory foramen to the other, separates the anterior from the posterior portion of the skull. The supraorbital line, dividing the facial from the cerebral region, passes the orbital apophyses, the arches and superciliary eminences, and the glabella. It should be marked at the point where it meets the median line, the ophryon, which is generally near the superior part of the glabella. The infraorbital line passes the in- ferior point of the orbits, and is useful in measuring Daubenton's angle, which, by the way, is the oldest of all the craniometric angles, and though of considerable an- thropological value, has lost the zoological importance it formerly had. The bregma is the point at which the coronal and sagittal sutures meet. Its position may some- times be uncertain, owing to asymmetry or deep denticula- tion of the coronal suture, or when the sutures are ob- literated, as in old skulls. The point where the sagittal and lambdoidal sutures meet, the lambda, is also rendered uncertain in consequence of ossification, and the presence of the Wormian, or, as they are called by many craniolo- gists, the ossa intercalaria, or epactal bones. The inion marks the base of the external occipital protuberance, also the limit of the cerebral region and the cerebellar re- gions. It is often wanting in female skulls. Such words as basion, that is, the anterior border of the foramen magnum ; opisthion, the posterior border of the same ; stephanion, the point where the coronal suture crosses the temporal crest; or asterion, the point at which meet the three sutures, temporo-parietal, parieto-occipital, and oc- cipito-temporal, illustrate what a special word will do to express clearly what otherwise would require several lines. Comparatively few know that a metopic cranium is one having a medio-frontal suture ; fewer still that eurycephalic signifies large-skulled, chamoecephalic a flat and receding skull; that eurygnathous is large-jawed, and that chamaprosopic is applied to a short, squat, thick- set face. Space does not permit even a rapid description of other singular points, both upon the head and face, many of which the study of craniometry has rendered almost indispensable. The ones just mentioned are, how- ever, among those most useful to know by way of pre- liminary before proceeding to practice. As cranioscopy gives no results beyond determining in an empirical way something of the ethnic physiognomy, as the oval, pyramidal, or prognathous character of* a head, we are obliged to apply instruments of precision to the skull, and unless these instruments are simple and easily applied at anatomical points established with mathemati- cal neatness and leaving nothing to personal interpretation, there will be a want of identity in the hands of different operators, and a consequent vitiation of results. The technical procedures of craniometry require first a standard skull for the purpose of controlling the exactitude of each operation. That used in the Army Medical Mu- seum is a bronze reproduction, and when measured with water at 60° F. contains 1,240 cubic centimetres. A mil- limetre rule, a pair of calipers, a metallic millimetre tape measure, Topinard's craniophore, a mandibular goniome- ter, an instrument for determining the index of the fora- men magnum, apparatus for taking photographic compo- sites, and appliances for measuring the cubic contents with water, comprise the necessary outfit. The calipers most used are those devised by Broca. For purposes of great precision they may be rendered micrometric. Calipers for this purpose have been devised with a vernier scale. Another useful instrument for obtaining linear measure- ment, and one of easy application, is the sliding compass, which resembles an aesthesiometer, or what is more familiar, a shoemaker's measure. It is of special value in small measurements, especially those of the face, and may also be used in cases of asymmetry and in studying the hygrometric properties of skulls. The former endo- metric procedure of multiplying the three internal diam- eters, the antero-posterior, the transverse, and the verti- cal, did not lead to satisfactory results. It is nowadays replaced by a different proceeding for obtaining the ca- pacity of the skull, which consists in filling the cranial cavity with some suitable substance, liquid or solid, and in measuring the volume introduced either by weight or quantity. The method of filling the skull and weighing the contained material is too tedious and troublesome. The better method is to fill the skull and measure the contained material, which may be done by converting the cubic contents into brain-weight by multiplying the num- ber of cubic centimetres by the weight of a cubic centi- metre of water (one gram), and deducting four per cent, for the difference between the specific gravities of brain and water. Various substances have been used with more or less ingenuity in the operation of determin- ing the volume of the skull, such as mustard-seed, peas, barley, sand, shot, and the like, which some writers on the subject mention as belonging to that branch of physics called granulistics. Two sources of error exist in all the granular methods. The first is caused by vari- able density ; the second results from unequal condensa- tion of the grains according as they are more or less 23 Cephalometry. Cephalometry. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. heaped and rammed in. Tiedetnann was a victim of this double error, finding the capacity of the negro skull to equal that of the whites, a result contradicted by all ulterior researches. Mercury has also been used, but it requires time, is troublesome, and mistakes amounting to fifty cubic centimetres frequently attend its use. Its great weight is another objection, fragile skulls being broken asunder. As a cubic measure of sand varies according to locality, it cannot be used as a constant quantity. Shot, although the lower strata become denser owing to press- ure, is the least objectionable of the substances under consideration. Results obtained with shot on the same skull vary not more than five cubic centimetres in the hands of the same or a different person, provided proper care be taken in the manipulation. The details of the operation are difficult and delicate-some of them even absurd, as ramming down the shot through the foramen magnum with a wooden spindle, the motions of which are to keep time with eighty or ninety beats of a metro- being 4.5 c.c. in a series of unvarnished, and 1.0 c.c. in the varnished skulls. Although the system is not a rapid one, it is claimed that it removes to a great extent the effect of varying muscular effort, which is a disturbing factor in other methods. The principal innovations of this method are the varnishing of the inside of the skull with thin shellac, applied with a reversible spray appa- ratus, and the use of putty. The varnishing prevents interstitial absorption of the water, as well as the undue measurement of a part of the fluid that does not represent the cavity proper, as that from the sinuses and vacuoles. Suppose a skull to have been weighed and varnished, the subsequent steps in the operation consist in closing all artificial or accidental openings with India-rubber ad- hesive plaster, and in filling the orbits and all other open ings except the foramen magnum with putty. The skull is made completely water-tight, by wrapping in a coating of putty about an inch in thickness. This coating is pre- pared on, a board, with a roller, after the manner of making nome. The oldest process for measuring the cubic capacity of skulls appears to be water, having been used by Virey, Palisot de Beauvois, Soemmering, and Tred- well, who filled the cranium with water through the fora- men magnum, after having stopped with wax all the other openings. The weight of the water indicated the volume. Water has the advantage of being a constant quantity, since any cubic measure can be determined with great accuracy ; but its employment has been condemned be- cause of the change brought about in the hygroscopic condition of the skull. The skull is affected by moisture from one season to another ; when wet, it increases rapidly in cubic capacity, especially if old ; and after pouring the water from a skull that has been filled, the water belong- ing to the cavity proper is unduly increased by the water from its sinuses and vacuoles. The chief difficulties with water have lately been over- come by Dr. Matthews, of the Army Medical Museum, who believes that his results, obtained by the hygrometric method, have not been excelled, the average variation Fig. 597.-Arrangements for Measuring the Cranial Capacity of Skulls. a pie-crust. By means of a special apparatus the skull is next tilled with water in forty-five seconds, and emptied in fifteen seconds, the water being finally poured into a measuring-glass of 2,000 c.c. capacity, when lycopodium is scattered on the water to prevent its rising on the glass and to insure correct reading. The putty is now taken from the skull, which is next cleaned and put away in a dry, uniform temperature, until by slow evaporation it has regained its former weight and capacity, when it is measured a second time for the purpose of comparison with the first measurement. Comparing the results furnished by measurements of the cranial capacity, it appears that the inferior races have less capacity than the superior, and the conclusions resulting therefrom are highly important, since the rela- tive value of the brain, not only in the human series, but in that of the mammalia, may be deduced on comparing the weight, mass, and stature with the stereometric re- sults. The cranial capacity of a male gorilla is three times less than that of an average white man, yet his 24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cephalometry. Cephalometry. mass almost equals that of a man. The average gorilla brain is 531 c.c., while that of a man is about 1,500 c.c. 1,650 to 1,715 c.c., and two eurycephalic Indian skulls in the anatomical section of the Army Medical Museum measure respectively 1,785 and 1,920 c.c. The object of the study of the capacity of the skull be- ing brain, not cranial measurements, there still remains another step, even though the exact measurement be taken. Brain alone does not fill the cranial cavity, a con- siderable portion of the cavity being taken up with its membranes, with the blood that nourishes it, and the se- rosity that bathes it. This space, which should be de- ducted from the general internal capacity, has been vari- ously estimated ; Weicker estimating from 11.6 to 14 per cent, of the whole ca,vity, according as the skull varies in size, and Davis makes a correction of 10 per cent. There are also certain modifying elements, as artificial com- pression, pathological deformities, posthumous distor- tions, and the hygrometric conditions that effect the sig- nificance of craniometry, and if due allowance be not made for these the study may lead to glaring absurdities. No longer ago than 1725 there was found in a quarry at CEningen the skull of a fossil batrachian compressed into rude resemblance of the human cranium, which was announced to the world as Scheuchzer's ' ' Homo dilumi tes- tis et theoscopos," and as the remains of one of the sinful antediluvians who perished in the Noachic deluge. Graphic representation of the skull, or stereography, is a branch of craniometry by which the forms of the di- verse curves of the head are traced, after measurement, on paper, or otherwise figured. The system of repro- ducing the cranial curves by sheets of lead has been found serviceable when applied to the skulls of idiots and imbeciles. A modification of the instrument used by Fig. 598.-Arrangements for taking Composite Negatives of Skulls. Skull accurately adjusted for photographing. In both, the volume of the female brain is smaller than that of the male ; this difference being almost 80 c.c. for the anthropoid female. It is also admitted that the cranial capacity may vary with the intellectual state, hydrocephalic skulls, of course, being excluded. Microcephalic adults give a figure inferior to that of gorillas, some being as low as 419 c.c. Andaman Islanders and autoch- thonous Australians appear, in respect to cranial capacity, to be most badly off. The capacity of an Andaman has been found as low as 1,094 c.c. ; while that of Australians (autochthons) and of some American tribes show an average capacity of 1,224 c.c. in their normal as well as in their deformed crania. The cranial capacity increases in the yellow races, and attains its maximum in the white races. In the middle European race, 1.500 c.c. may be ac- cepted as the average ; 1,750 c.c. is the maximum, and anything above is macrocephalous; while the minimum is 1,206 c.c., which is rather too low than too high. According to Topinard's nomenclature of the cranial capacity, macrocephalic skulls in the adult European male are those having a capacity of 1,950 c.c. and above ; a large skull is one of 1,950 to 1,650 c.c. ; average or ordinary, 1,650 to 1,450 c.c. ; small, 1,450 to 1,150 c.c. ; microcephalic, 1,150 c.c. and below. It would seem that the skulls of the insane are llelow the type, a measurement of sixteen male skulls giving an average of only 1,449 c.c. Scotchmen head the list with the most voluminous skulls, and according to a tabular statement made up from Weicker, Broca, Aitken, and Meigs, the English come next, with a capacity of 1,572 c.c. Then follow Eskimo, 1,483 c.c. ; Germans, 1,448 c.c. • French, 1,403 to 1,461 c.c. ; South African negroes, 1,372 c.c. ; Ancient Peruvians, 1,361 c.c. ; Malay, 1,328 c.c. ; Mexican, 1,296 c.c. ; Hottentot and Polynesian, each, 1,230 c.c. ; Australians, 1,364 c.c. ; Nubians, 1,313 c.c. The cranial capacity in man, like that of the anthropoid apes, varies accord- ing to sex, the difference being so great that it is necessary to measure separately. In the troglodyte skulls of prehistoric times the variation is not more than 99.5 c.c. ; but in the contemporaneous race the difference varies from 143 to 220 c.c. French cra- niologists usually speak of the Auvernats as possess- ing the highest cerebral capacity (1,523 c.c.), and mention the skull of a Parisian of 1,900 c.c. as the highest known. Some Eskimo skulls, however, measure from Fig. 59!).-Copied from a Composite Photograph of Seven Adult Male Eskimo Skulls. (Exposure, seventy seconds each.) hatters for obtaining conformations of the head, has been adapted to cephalometry under the name of kephalo- 25 Cephalometry. Cerebellum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. graph; but the results obtained with it are more curi- ous than correct. Particular methods of craniometric projections, diverse stereographic proceedings, and the principles to be observed in their employment, cannot here be mentioned in detail. Whatever be the method of reproduction, it should be subordinated to the visual plane under which the skull is to be examined, and it is highly important that the physiological attitude of the cranium be preserved, as the least change of attitude alters immediately its physiognomy. Photography, so useful in making anatomical reproductions, renders ser- vice to craniometry; but it has been objected to on the ground that it has no character of precision, and that photographs of the skull have the common defect of be- ing central, not orthogonal projections, such as anthro- pometry requires. Former methods have not really suc- ceeded in fixing the cranioscopic images by measurement and results ; but it is believed that some of the defects of photography have been remedied, or rather the art has been utilized in obtaining graphic representations of a series of skulls which point out not only the means, but the possible maxima of variations. Dr. Matthews has lately achieved considerable success by the method of composite photographs, in which the composites are made directly from skulls so adjusted in succession on an object-stand that the horizontal datum-plane, and the temporal; index of height; index of foramen magnum ; frontal, parietal, occipital, and longitudinal arches ; cir- cumference ; length of frontal, parietal, and occipital; zygomatic diameter ; facial angle ; nasal index ; remarks. The foregoing measures are, of course, those reserved for special work of trained craniologists. It is desirable to see adopted another category, consisting essentially of simple linear measures that may be easily and correctly applied by anybody at anatomical points concerning which there can be no mistake. The best category of measures seems to be that qualified as maximum and minimum, and of the anatomical or pivotal points, the bregma and the lambda are the ones concerning which there can be no possible misunderstanding. The basion, opisthion, and the asterion are equally excellent. The maximum bi-zygomatic diameter will be exactly the same for one hundred different observers, and the same is true for the two elements of the linear cephalic index, the frontal minimum diameter, and the breadth of the an- terior nares. It is generally admitted that if craniometry were lim- ited to taking measures, to adding them together, and to calculating averages, the proceeding would be easy, but when the object is to gain ideas, to create a principle, to deduce truths after the patient measurement of a series of crania, the task is one of great difficulty and perplexity. Anatomists know that salient differences in any collection of crania prevent methodical enumeration and constitute the stumbling-block of ethnic craniology. Cephalometry shows further, that dolichocephalic, mesoticephalic, and brachycephalic skulls do not belong exclusively to either the white, yellow, or black race, but exist among the three as a result of evolution. Aside from the question of races, queries arise as to the separation of diseases if the histories of skulls were known, and we are inclined to ask, Is man a free agent, or do his actions result from the conformation of his skull ? How far are criminals responsible for their actions ? These, and kindred ques- tions-medical, ethical, and judicial-present a nebulous view in the present state of knowledge, and still await satisfactory solution. Irving G. Rosse. CEREBELLUM, AFFECTIONS OF. The cerebellum, in man, comprises two lateral lobes or hemispheres, and a middle lobe, or vermiform process. It is connected with the remaining part of the cerebro-spinal axis by means of three large commissures-the superior, central, and inferior cerebellar peduncles. The superior peduncles, or crura cerebelli ad cerebrum, unite the cerebellum with the cerebral hemispheres, their exact relation with the latter being still undetermined. The middle peduncles, or crura cerebelli ad pontem, unite the cerebellum with the pons Varolii, and, perhaps, at a higher level, with the pyramidal tracts in the brain. The inferior peduncles, or restiform bodies, unite it with the posterior and lateral columns of the spinal cord. Functions.-Little has, as yet, been positively deter- mined as to the precise functions of the cerebellum. That it has important functions in man is known from its large size, and from the fact of the rapid increase in size, relative to the remaining part of the brain, as we ascend in the scale of animals. In lower animals, birds, fishes, etc., the middle lobe is the only part which exists. Our knowledge of its functions is gained from experi- ments on animals and the observations of the results of disease in man. The latter source of information is the more valuable, but the two are, in the main, consonant with one another. Nothnagel (Topische Diagnostik der Gehirnkrankheiten) has critically analyzed all the reported cases of disease of the cerebellum, and from them drawn careful conclu- sions as to its functions. Disease of the cerebellum may produce manifold symptoms, due to pressure on neigh- boring parts of the brain, to increased intracranial press- ure, and the like. The presence of such symptoms does not assist us to determine the functions of the cerebellum. For this purpose we must select cases in which the lesions do not involve neighboring parts, and do not produce Fig. 600.-Copied from a Composite Photograph of Seven Adult Hale Eskimo Skulls. (Wet process; exposure, seventy seconds each.) subnasal and maximum occipital points-or the supraau- ricular points in profile exposure-shall coincide. The skull is correctly adjusted by means of movable hinged frames, on which are stretched a series of vertical and horizontal threads. (See Fig. 598). A black velvet back- ground is lowered just before the lens is uncovered. It is suggested that one-half the natural size be agreed upon by craniologists as a unit of comparison for this rapid and convenient adjunct to the study of cranial measurements. In no study, perhaps, is the entire suppression of per- sonality of more importance than in craniometric re- searches. It is fully as requisite as skill and access to a large collection of crania. The measures should be taken sturdily, no matter what results they give, and, a rule hav- ing once been adopted, it should be unsparingly followed. If the work is to be done in .a laboratory or a museum, with a view to obtain systematic results, a table may be prepared with the following enumerations : Race or tribe, number, section, sex, age, weight, capacity, length ; breadth, interparietal and intertemporal; breadth of fron- tal ; height; index of breadth, interparietal and inter- 26 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cephalometry. Cerebellum. general symptoms-cases of circumscribed chronic soft- ening, atrophy, and the like. From the study of such cases Nothnagel concludes : (a) That lesions of the lateral lobes, or hemispheres need produce no appreciable symptoms, and that we can, therefore, as yet, assign to them no definite functions. (b) That the only symptom which is undoubtedly due to disease of the cerebellum is cerebellar ataxia, or reel- ing gait, which appears to depend upon a direct or indi- rect involvement of the middle lobe. This indicates a certain control of the cerebellum, par- ticularly its middle lobe, over locomotion, but its exact relationship to this function we do not know'. Hughlings- Jackson has supposed that the symptoms were due to paresis of muscles of the back. It is not probable that it is a common centre for the co-ordination of all volun- tary movements, for its disease generally affects only the ability to maintain the erect position and the power of locomotion. In cerebellar ataxia the upper extremities are usually not affected, the fingers remain as skilful as formerly, and even the various movements of the lower extremities can be made quite accurately and forcibly when the patient is in a supine position. The cerebellar ataxia is in these cases only a reeling gait. When the pa- tient walks, his body sways ; he is often unable to walk in a straight line ; in short, his gait resembles very nearly that of a drunken man. When the condition is very marked he is even unable to stand unsupported. It is true that cases of cerebellar disease have been re- ported in which the motor disturbances were more exten- sive, in which movements of the lower extremities were irregularly performed in the supine position, and in which there were also ataxic movements in the upper extremi- ties. But such symptoms are not usually found in these cases, and may be due to complications. Vertigo is a very common symptom of cerebellar dis- ease, perhaps is directly due to such disease. Vertigo and a reeling gait are often present at the same time, but the latter need not be dependent on the former, for it is often alone present. In other cases, though less rarely, vertigo is present while there is no reeling gait. Neither vertigo nor a reeling gait is a pathognomonic symptom of disease of the cerebellum, for both are often present where no disease of the cerebellum can be found. Indistinctness of articulation has been observed in a number of cases of atrophy of the cerebellum, and may have a direct relationship with disease of this part. Gall believed that sexual instinct was seated in the cerebellum, but there is no reasonable support of this view. The chief pathological changes found in the cerebellum are haemorrhage, softening, tumors, abscess, and atrophy. Haemorrhage.-The proportion of haemorrhages in the cerebellum to those in the cerebrum has been variously estimated as from 1:12 to 1: 35. It may occur in any part of the cerebellum. Small and circumscribed haemor- rhages are rare. More frequently they are large, involv- ing the larger part of a hemisphere, even bursting into the fourth ventricle, or appearing on the surface of a hemisphere under the meninges. For this reason haemor- rhage usually produces severe symptoms, and often leads to a rapidly fatal issue. Symptoms.-These vary according to the severity and locality of the haemorrhage. When the haemorrhage is large and sudden in its onset, the symptoms are like those produced by a large haemorrhage into the cerebrum, viz., coma, paralysis, etc., symptoms which are chiefly indirect in their origin (see article on Corpus Striatum). There is often in these cases retraction of the head, a symptom of some value in assisting to localize the haemor- rhage in the cerebellum. When the haemorrhage is less severe, the symptoms are more special. Frequently the onset is marked by re- peated attacks of syncope and vomiting. Vomiting some- times occurs with cerebral haemorrhage elsewhere, but it is especially frequent and violent with haemorrhages in the cerebellum, occurring in one-half af the reported cases, so that it acquires a certain value in diagnosis. Vertigo and a reeling gait, when the condition of the patient is such that they can be detected, are prominent symptoms. Many of the symptoms-the vomiting, immobility of the eyeballs, which is sometimes present, and often hemi- plegia, as well as other symptoms sometimes found-are to be attributed to pressure upon the medulla oblongata and pons Varolii. Softening.-On account of the direction of the ves- sels, emboli are very rarely found in the arteries supply- ing the cerebellum. Thrombosis also is not common in these vessels. Softening, therefore, occurs more rarely than haemorrhage into the cerebellum. The softening may be limited to the central part of a lateral lobe ; very rarely it involves almost an entire hemisphere. As the lesion is usually less extensive than in cases of haemorrhage, the symptoms are much milder. Otherwise they are about the same as those of haemorrhage. Tumors.-Tumors of the cerebellum are comparatively common. All varieties of brain tumors are found in this locality-tubercles, gummata, sarcoma, gliomata, etc. Symptoms.-The common symptoms of brain tumor, symptoms of increased intracranial pressure, headache, vomiting, convulsions, double optic neuritis, and, in ad- vanced cases, affections of consciousness, are found here as frequently as with coarse lesions in other parts of the brain. In addition to these we often find many special symptoms. The most characteristic symptom is cerebellar ataxia, though this is frequently absent, even when the tumor involves the middle lobe. The latter fact is to be ac- counted for by the slow growth of the neoplasm, which may merely press the tissues aside, instead of destroying them. Vertigo is a common symptom, much more frequently found than with tumors elsewhere. It is often distin- guished by the intensity of its paroxyms, or by its re- maining permanently. A long train of symptoms is produced by pressure in the neighboring parts-the medulla oblongata, cranial nerves, etc. Vomiting, attacks of syncope, and, perhaps, sudden death, which often occurs with tumor of the cere- bellum, are to be explained by pressure upon the medulla oblongata. Paralysis of the sixth nerve, with convergent strabis- mus, which is the most common form of paralysis of a cranial nerve in connection with cerebellar tumors, and paralysis of the other ocular muscles, or of the muscles supplied by the facial nerve, which occasionally occurs, are due to pressure on the affected cerebral nerves, while hemiplegia may be produced by pressure on some part of the pyramidal tract. Blindness at an early period is a common symptom of cerebellar tumor, so common that it has considerable value in local diagnosis. This is not due to the optic neuritis which is so often present, for the latter condition is often present without appreciable impairment of vision, and if it does terminate in blindness it does so only at a late period. The early blindness accompanying cerebellar tumor is duo to a complication, to an effusion of fluid into the ventricles. Tumors in this region often produce com- pression of the aqueduct of Sylvius, or of the veins of Galen, and a consequent accumulation of fluid in the third ventricle. As a result there is direct compression of the optic chiasma, frequently a perceptible flattening of the latter, to which the blindness is doubtless attribu- table. The same condition, effusion into the ventricles, often causes more marked general symptoms, a greater cloud- ing of consciousness, etc., than are usually found with brain tumors elsewhere situated. It also causes paralysis of other cranial nerves-of the olfactory with loss of smell, of the acoustic nerves with deafness. Either of these symptoms, anosmia or deafness, is often associated with blindness in cases of cerebellar tumor. The headache produced by cerebellar tumors is often in the occipital region, so that constant and severe pain in this locality has frequently a localizing value. Yet such tumors are often attended by pain in the frontal re- gion. 27 Cerebellum. Cerebral Cortex. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In some cases of tumor of the cerebellum rigidity of the muscles of the neck with retraction of the head, and paroxysms of tetanic convulsions without loss of con- sciousness, has been observed. Abscess.-Abscesses are occasionally found in the cere- bellum, usually the result of caries of the petrous portion of the temporal bone on its posterior aspect. The symptoms may be like those of tumor in the same locality, but they are usually more acute, and there are more marked symptoms of constitutional disease, fever, cachexia, etc. Atrophy.-A number of cases have been recorded in which there was atrophy of a large part of, or even the entire cerebellum. In some the condition was congen- ital, in others it was acquired after birth. These cases are of much importance in studying the physiology of the cerebellum, but they cannot be carefully analyzed in a brief article. There was generally more or less mental impairment, frequently epileptiform convulsions, while the cerebellar ataxia and some difficulty of articulation were seldom absent. Philip Zenner. In harmony with these results are those given by wide- spread removals of the cortex. An animal so treated be- comes dull and stupid, but in the lower vertebrates these results may be very transitory. The more important and highly developed the cerebrum becomes in the ascending scale of animals, the more permanent are such effects. Important in this connection is an experiment by Goltz. He removed in four successive operations nearly the en- tire cortex from both hemispheres of a dog (Fig. 610), in consequence of which the entire remaining mass of the brain shrank remarkably in size and did not nearly fill the cranial cavity. This animal, as would be naturally expected, was a canine idiot. lie went about slowly, snuffing the ground and paying no attention to the men or dogs around him. He was not entirely blind, though his visual perceptions were extremely dull, and the same was true as to his power of hearing, feeling, and the other senses. When pinched he became furious and bit blindly about him, and could be made to repeatedly bite his own foot. His motions were slow and clumsy, and he often fell. When food was put into the accustomed corner of his cage he could find it, though not when put in the open room. The difference between this mutilated animal and one from which the entire mass of the hemispheres has been removed should be emphasized. The former shows some spontaneity and volition, seeks his food and drink, howls when suffering from hunger or thirst, and moves about spontaneously ; the latter seems to be a delicately adjusted unconscious automaton, responding to stimuli, but mo- tionless when the stimuli are withdrawn. In man we find that any original deficiency or widespread injury of both hemispheres is always connected with a condition of idiocy. The hemispheres are the last links in the chains that connect the external world with the consciousness ; a break in any one of these chains, before it reaches the cortex, cuts that particular chain out of consciousness, or, in the case of motor functions, removes it from the con- trol of the will. All sensory and motor tracts not purely reflex begin and end here, and we have every reason to believe that in man, at least, only the activities of the cere- bral cortex can affect the consciousness. It is, therefore, clear that the organ most indispensable for the operation of the intellect and will is the cerebrum. It is, however, as Foster points out, a question whether volition and in- telligence depend upon the connection of the hemispheres with the other parts of the brain, or whether they arise in the former alone. When the connection is broken, they disappear. ' ' Our present knowledge will not allow us to decide between these two views." Having discussed the functions of the cerebrum as a whole, the question next arises whether the different func- tions of the cerebral cortex are localized in different regions of it. Till a short time ago the opinion of Flourens, that all parts of the cortex are functionally equivalent, was almost universally accepted ; a view which resulted largely from the reaction against the phrenological theories of Gall and Spurzheim. Still some pathological facts militated against Flourens' position. In 1825 Bouillaud localized the power of articulate speech in the frontal lobes; in 1836 M. Dax restricted this to the left frontal lobe, and in 1861 Broca made his celebrated observations, limiting still further the so-called "speech-centre" to the third left frontal convolution. Meynert showed, in 1869, that the motor and sensory nerve-tracts were distributed to different parts of the hemispheres ; but it was not till 1870 that a revolution was effected in the domain of ex- perimental physiology by the classical experiments of Fritsch and Hitzig. They showed that electrical stimu- lation of definite portions of the cortex caused contrac- tion of definite groups of muscles. At once a host of investigators attacked the problem, both from its experi- mental and its pathological sides, some answering it in one way, some in another, and a scientific warfare has been waged over it. The argument for the localization of cerebral function rests upon three classes of evidence : 1, that derived from anatomy and embryology; 2, that from physiological experiment; 3, that from pathological observation. Of CEREBRAL CORTEX, FUNCTIONS OF. The first step in the inquiry as to the functions of the cerebral cortex must be an attempt to understand its value as a whole. This may be made experimentally by observing an animal from which both hemispheres have been re- moved, though different classes of animals present us with somewhat divergent results. In general it may be said that such animals become reflex-machines, appar- ently without intelligence, volition, or memory, reacting with perfect regularity to appropriate stimuli and yet be- coming perfectly quiescent when undisturbed. They are, however, capable of exceedingly complex co-ordinations of movement. A frog so operated upon is at first sight scarcely distinguishable from a normal frog. When put into water it will swim until exhausted, placed on its back, it at once recovers its position, if pinched it will leap away, avoiding large obstacles in its path, when its flanks are stroked it croaks with entire regularity. Yet when left to itself such a frog never moves and will dry up to a mummy, though it may have food within reach. A pigeon deprived of its cerebrum will maintain its balance, can fly when thrown into the air, will follow a light with its eyes, will start back when ammonia is held to its nostrils, and will swallow food placed in its mouth. Yet, as in the case of the frog, it shows no spontaneity and will starve to death when surrounded by its food. Essentially the same results follow the extirpation of the hemispheres in one of the lower mammals, such as a rat or rabbit. When pinched it runs, avoiding obstacles that throw a strong shadow (Munk denies that sight impulses have any effect upon it); it will start at a loud noise, will chew and swallow substances placed in its mouth, though it endeavors to get rid of a disgusting taste. The muscles are weakened, and the limbs have a tendency to sprawl, though the animal can regain its feet when placed on its back. As in the other cases the animal remains quiescent except when stimulated; the sight of an enemy has no effect upon it, nor will it touch food except when placed in its mouth. In the higher animals the shock of the operation prostrates the victim and is soon followed by death. A dog without cerebrum will show apparent dis- gust when its tongue is painted with colocynth, yet one may open the dog's mouth and show the brush any num- ber of times without affecting him, whereas a sound dog soon learns to avoid the unpleasant sensation. Only when the stimulus is actually applied does the mutilated animal react. Veyssiere showed that severance of the posterior part of the internal capsule causes hemianaesthesia of the op- posite side, and when the anterior part is severed hemi- plegia results, likewise on the opposite side (Fig. 611). In man it seems quite certain that in order for sensory impressions to affect the consciousness, or for voluntary movements to be carried out, the cerebral cortex must be concerned. Lesion of the posterior part of the internal capsule causes hemianaesthesia, no matter how much the patient may strive to perceive the touch. 28 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebellum. Cerebral Cortex. these the first is dealt with elsewhere, we have here to do especially with the latter two. Physiological experiment as to cerebral localization proceeds in two wTays : 1, by stimulating different areas of the cortex ; 2, by removing various portions of the cor- tex and observing what disturbances of function follow. As it will be impossible in the limits of this short article to give an account of all the attempts that have been made to solve this problem, we shall confine ourselves to a few of the most important, using others only as they serve to give us additional light. The results of the investigations of Fritsch and Hitzig are briefly these. Part of the convexity of the cerebrum is motor, part is non-mo- tor. The motor part lies, in general terms, more in front, the non-motor be- hind. Electrical stimula- tion of the motor part causes combined muscular movements of the opposite half of the body. By weak currents these movements may be localized to defi- nite groups of muscles, while by stimulating the same or closely adjoining areas with stronger cur- rents, other muscles, or even muscles of the other half of the body, may take part in the contraction. The possibility of exciting an isolated group of mus- cles is limited to very small areas by the appli- cation of quite weak cur- rents. In this way they indicated areas for the muscles of the neck, for the exten- sion and adduction of the fore-limb, for the muscles of the hind-limb, the facial muscles, and the muscles of the eye (see Figs. 601 and 602). These experimenters next cut out the left cortical centre for the fore-limb, and ob- served that in running the dog used the right fore-limb unskilfully, and that the right foot, never the left, easily slipped out, so that the animal fell. No movement was quite destroyed, but the right foot was adducted some- what more weakly. Sometimes the foot was planted on the back instead of on the sole, without the dog's noticing it. When sitting up with both fore-feet on the ground, the right foot would slip gradually outward till the dog lay on his right side. He could, however, right him- self at once. Sensibility of the skin was not perceptibly changed. Fritsch and Hitzig consider it sure that "certain psychical functions, probably all, for their entrance into mat- ter, or their origin from it, are assigned to circumscript areas of the cerebral cortex." Later ex- periments showed that the faci- alis has two cortical areas (Fig. 602), one for the tongue and jaws, which operates bilaterally. Thte orbital region of the facialis is in the same area as that of the eye-muscles, and forms with this a centre for the move- ment and protection of the eye. This centre is unilateral in its operation, that for the neck and trunk is bilateral. Wernicke calls attention to two peculiarities of these results: (1) that in every movement branches of different nerves must co-operate ; (2) that only a part of the fibres of any nerve is called into action at the same time, with the possible exception of the eye-muscle nerves. Munk has made a much more extensive series of extir- pations of areas in the brains of dogs and monkeys. These have led him to the conclusion that the occipital lobes are connected with the sense of sight, the temporal lobes with hearing. On removal of the area Ai (Fig. 603) in a dog's brain on both sides, and examining the animal some days after the operation, he observed a peculiar disturbance of the sense of sight, without injury to any other sensory or Fig. 603.-Cortical Areas in the Dog. (After Munk.) A A, sight area; B, hearing ; C, feeling of hind-limb; D, of fore-limb ; E, of the head ; F, of protecting apparatus of eye; G, of the ear; H, of the neck; J, of the trunk. Fig. 601.-Cortical Areas in the Dog. (After Fritsch and Hitzig.) A. Muscles of the neck; -F, extension and adduction of the fore-limb; +, flexion and rotation of fore- limb ; ff, hind - limb; O *, facial area. motor function. The dog moves with perfect freedom without striking any obstacle, and when such are put around him, he eludes them by crawling under or jump- ing over them. But the sight of dogs or men, whom he had before greeted joyfully, now leaves him per- fectly cold. However hunger and thirst may cause him to move about, he no longer searches the accustomed place for his food, and will even pass it by as long as he does not smell it. A light held to his eye no longer causes him to blink, nor does the sight of the whip, which for- merly drove him into the corner, produce any ef- fect upon him. He had been trained to give his paw when a hand was held out, now he will not give it unless ordered to. " By the extirpation the dog has become psychi- cally blind, i.e., he has lost the sight-presenta- tions which he possessed, his memory-pictures of former sight-perceptions, so that he neither knows nor recognizes anything he sees." But the dog does see, and gradually forms a new store of sight-memories. Munk further states that no matter how long the dog is kept alive, he never re- gains any of his former sight - memories, except by renewal of the experi- ence. Extirpation of this area produces similar re- sults in the opposite eye. If the operation be performed in the left hemisphere, the dog recognizes everything that he sees with the left eye, but if this eye is bound up, the dog shows psychic blind- ness, from which Munk infers that the functions of the two hemispheres are so separated that the intact hemis- Fig. 602.-Cortical Areas in the Dog. (After Hitzig.) m, Rectus muscles of the eye and upper part of facia- lis; o, facialis; lower part of facialis ; Q, point of perforation to reach the nu- cleus lenticularis; a, sulcus cruciatus. Other areas as in Fig. 601. Fig. 604.-Brain of Dog after Removal of Cortex. The unshaded part is the part removed. (Goltz.) 29 Cerebral Cortex. Cerebral Cortex. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. phere cannot help the injured one. Complete removal of both sight areas, he asserts, causes total and permanent "cortical blindness : " if only one side be destroyed, hemi- opia results. He further maintains that different parts of the retina are, so to speak, projected on the cortical sight area, so that removals of small portions of the latter produce a corresponding series of blind spots in the retina. Fig. 608 shows very clearly the results which Munk de- rives from his experiments in the case of the dog. Each retina is assigned in its outermost lateral part to the outermost lateral part of the sight area of the same area (Fig. 603) are seven sub-areas, those for the fore and hind limbs, head, eyes, ears, neck, and body. The rapidity of restitution of function, when one of these areas is removed, depends upon the extent of the lesion ; if it is all removed the defect is a permanent one. In the monkey's brain Munk has obtained essentially the same results (compare Figs. 605 and 606), and he asserts that the retina is similarly projected upon the cortex, though with the differences that the lateral part of the retina which belongs to the hemisphere of the same side, is much larger than in the dog, and the macula lutea is assigned to the middle of the convexity of the occip- ital lobe. In this connection it will be of interest to compare Wernicke's diagram of the projection of the human re- tina (Fig. 609). The right half of each retina is pro- Figs. 605 and 606.-Cortical Areas in Monkey. (Munk.) Letters as in Fig. 603. side. The much larger remaining part of the retina be- longs to the much larger remaining part of the sight area of the opposite side. One may imagine the retina so pro- jected on the sight area that the lateral edge of the re- maining part of the retina corresponds to the remaining part of the sight area, the inner edge of the retina to the inner edge of the sight area, the upper edge of the retina to the anterior edge of the sight area, the lower edge of the retina to the posterior edge of the area. It will be plain that in this scheme the area (Ai Fig. 608), the re- moval of which causes psychic blindness, corresponds to the region of distinct vision in the retina. In the same manner extirpation of a limited area in each temporal lobe produced what Munk calls " psychic deafness," a condition much like the so-called " word deafness " in the human subject. The dog hears per- fectly ; but no longer understands words to which he had before been trained. Gradually, however, the dog learns how to hear. In the so-called motor zone the results are no less striking. In opposition to his predecessors, Munk maintains that the motor disturbances are always accom- jected on the right occipital lobe, the left on the left. While the macula lutea of the dog is represented only in the opposite hemisphere, in man this is connected with both hemispheres, and there is a point of clearest vision in the cortex as well as in the retina. Consequently every image, not too small, cast upon this part of the retina is seen in two halves, the left half by the left, the right by the right hemisphere. In Fig. 609, c is the centre of the macula lutea in each retina, a b and ax b^ the image ; its left half projected by the left eye a c to a 7, by the right eye ax c to ax 7 ; the right half passes from the left eye, c b to 7 3, from the right eye, c bi to 7 3i. Each point of the image here reaches the same hemisphere twice, on each side of the point 7. If the image is in the left half of each eye, x and xx, it passes to the left sight area, x and xx; if the point approaches c, the impulses approach 7 from each side. The position of identical points on the retina is therefore given by their distance from 7. That they are Fig. 608.-Projection of Dog's Retina on the Cortex. (Munk.) Fig. 607. -Cortical Areas in Monkey. (Ferrier.) 1, Forward movement of leg ; 2, the same, and toward middle line of body; 3, the same, with movement of the tail; 4, retraction and adduction of arm ; 5, exten- sion of arm ; a, &, c, d, movements of fingers ; 6, flexion and supina- tion of arm; 7, lifting and retraction of angle of mouth: 8, lifting of upper and sinking of lower lip ; 9, opening of mouth, with protrud- ing of tongue ; 10, the same, with retraction of tongue ; 11, retraction of angle of mouth and turning of head away from stimulated side; 12, opening of eyes, dilatation of pupils, head and eyes turned away from stimulated side; 13, turning eyes away from stimulated side and down; 13', the same, and up ; 14, the same, and same movement of head, expansion of pupils, pricking of opposite ear; 15, lifting of lips and corner of nostril on stimulated side. panied by sensory disturbances, which consist in the loss of the most complex feelings, the sense of position, of pressure, muscular sense, etc. He concludes that the paralysis is the result of the loss of motor memories, and calls the motor zone the area of feeling. Within this 30 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebral Cortex, Cerebral Cortex. seen as single must depend upon a native or acquired association of corresponding retinal portions. If for any cause corresponding retinal points are not touched by the image, the distances x 7 and x^ 7 will not be equal, and a double perception must result. It will be seen that this scheme differs fundamentally from that of Charcot. Ferrier's results are in many respects diametrically op- posed to those of Munk. According to his experiments no sensory or motor disturbance follows re- moval of the anterior part of the frontal lobes, which he con- siders the chief seat of intelligence. Munk, on the other hand, main- tains that the intel- ligence cannot be lo- calized, but depends upon the functions of the entire cortex, and suffers in proportion as the cortex is injured. Ferrier places the sense of sight in the angular gyrus, and states that he has repeatedly re- moved the entire oc- cipital lobes from mon- keys without in any way injuring vision (Fig. 607). Animals so mutilated continue to see, hear, touch, taste, and smell, and retain all their powers of voluntary motion. He is inclined to believe that the occipital lobes are the seat of visual sensations, and have to do with the feeling of hunger. Smell and taste he localizes in the region of the subiculum cornu ammonis, and tactile sensibility in the hippocampal re- gion, expressly stating that disturbances of tactile sensi- bility do not follow lesions in the so-called motor zone. Goltz's results again differ widely from those of both Munk and Ferrier. Goltz first experimented by washing away portions of the cortex by means of a jet of water, but as this method is open to grave objections he repeated the observations by removing large cortical areas in the usual manner. The case of the dog which had lost nearly all the cortex (Fig. 610) of both hemispheres has already been described. This animal had been deprived of all his motor areas, but showed no paralysis of any voluntary muscle, and in spite of the loss of the areas of sight and hear- ing, could both see and hear. Still more strikingly opposed to Munk's results is the case of a dog from whose brain both occipital lobes, including the sight area and part of the re- gion of feeling for the eyes, had been removed (Fig. 604). This dog was rather idiotic. He sprang merrily about the room, but fixed his eyes on nobody. He showed no loss of tactile sensibility, and no motor disturbance, and could see well with both eyes, avoiding all obstacles with ease and certainty. Food placed in a vessel he found immediately, scattered pieces only slowly. After the first operation he refused to eat dog-flesh, as all normal dogs do, except under pressure of severest hunger ; after the second he ate it readily. He showed no distaste to chloroform vapor, or tobacco-smoke. A dog which had lost the anterior part of both hemispheres showed no noticeable asymmetry of movement, and he could run and jump, though only clumsily. Tactile sensibility was everywhere dull, and his intelligence distinctly lowered. In another dog all the upper cortex of the left hemi- sphere, except part of the frontal lobe and a narrow strip along the longitudinal fissure, was cut out. His intelli- gence did not seem to be in the least affected, and his movements at first seemed perfectly normal, but his right fore-leg was somewhat weaker and less under control than his left, and he saw better with the left eye. Another experiment was the removal of the right posterior and left anterior portion of the cortex. At first there was a de- cided disturbance of vision, though he gradually learned to see better. He showed no fear when threatened, and the right fore-foot was less sensitive than the left. Goltz's latest paper on this subject (1884) leads to essentially the same results, though by a somewhat dif- ferent method. The anterior part of one hemisphere, including part of the corpus striatum and part of the internal capsule, was entirely removed. But this dog showed no paralysis of any muscles, nor was there any loss of feeling in any part. The dog felt it even when his hair was blown upon. When both motor zones were re- moved, the dog was clumsy, but did not lose the use of any muscle, nor was he insensible anywhere to touch. On the contrary, increased sensibility often results from the operation. As the outcome of his experiments Goltz lays down the following propositions : 1. The cerebral cortex is the or- gan of the higher psychical activities ; after removal of large parts of both hemispheres the intel- ligence is diminished. 2. It is not possible permanently to para- lyze any muscle by re- moval of any area of the cortex. The mu- tilated animal retains the voluntary use of all muscles. 3. It is likewise impossible to permanently e x t i n - guish any sense by re- moval of any cortical area. He finds, how- ever, a difference in the results depending on the part of the brain removed. " A dog de- prived of both posterior quadrants of the upper cortex is more silly than one op- erated on in front. Sight, hearing, smell, and taste are duller. In a dog which has lost both anterior quadrants, the higher senses are less dull, but, on the other hand, the tactile sensibility is duller. It is probably connected with this circumstance that his movements are more clumsy." Certain reflexes are more regular (less in- hibited) in dogs which have been operated upon than in sound ones, and curious changes in the animal's temper may take place in accordance with the part removed. Kriworotow and Hitzig have lately investigated the frontal lobes in the dog, and have obtained results directly opposed to those of Munk. The former observed circus- movements away from the wounded side, but these were not constant. In all cases the mobility of the trunk was intact, wlrether one lobe or both were destroyed. Sensi- bility was at first lowered on both sides of the trunk and in other regions, but after a week this effect passed away completely. After the healing of the wound all the ani- mals gave the impression of perfectly normal dogs with intact brains. Hitzig also finds that the motor disturbances are not constant, but he observed considerable injury to vision in the opposite eye, motor disturbances in the extremities, and considerable loss of intelligence. Trained dogs lost all their tricks after the operation, and could not be taught them again. The disturbances of sight Hitzig Fig. 6C9.-Projection of Human Retina on Cortex. (Wernicke.) Fig. 611.-Section of Anterior Part of In- ternal Capsule of Dog. (Carville and Duret.) i, nucleus lenticularis: ^cor- pus striatum; P, internal capsule. Fig. 610.-Dog's Brain, after Re- moval of Cortex. (Goltz.) The unshaded area is the part re- moved. 31 Cerebral Cortex. Cerebral Cortex. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. explains by referring them to direct connections between the frontal and occipital regions. Lob, a pupil of Goltz, has recently published some in- vestigations on the cortical area of vision which contra- dict the views of Munk. He removed the area Ai (Figs. 603 and 608) and the eye of the same side, and found, eigh- teen hours after the operation, that the dog could see with the macula lutea of the remaining eye as well as before. From a large number of experiments he concludes: 1, That every part of the occipital cortex may be removed without any disturbance of sight; 2, when an injury to vision results from removal of part of the occipital cor- tex, whatever part it be, it is always a lateral hemiam- blyopia opposite to the injured side ; 3, in all cases of single and double hemiamblyopia, the animals see best with the macula lutea. According to Lob, therefore, the only part of Munk's results which will stand the test is that each hemisphere supplies part of each eye; the left half being supplied by the left hemisphere, the right by the right. But this he does not consider constant, and ex- tends the area of sight over a great part of the cortex. Lob also observed after these operations motor disturb- ances and injury to hearing. He further produced am- blyopia, as others had observed before him, by removals of cortex in the parietal and temporal lobes, but these were of less intensity. With regard to the nature of the injury he never observed actual blindness, but only am- blyopia, and the animals acted as if they had lost the power of mentally utilizing the sight impressions. Von Monakow has made a series of experiments with new-born animals which show the connection between sight and the occipital lobes, and he reports changes in certain layers of the cortex resulting from removal of the eyeballs. Luciani agrees largely with Lbb. He gives up the theory of circumscript areas and adopts Exner's view of more and less intense areas. He produced dis- turbances of vision by lesions of the occipital, frontal, temporal, and parietal lobes, and the hippocampus. Le- sions in the frontal and temporal lobes produce transient results, those in the parietal and occipital regions persist in their effects, and lesions in the former do not affect vision so definitely as those in the latter. Luciani denies Munk's statement that blind spots may be produced in the retina by the removal of small areas. For the sense of hearing he places the most intense area in the tem- poral lobes, gradually diminishing in importance. as we pass from this area. The area of smell lies in front of the Sylvian fissure, gradually diminishing upward. Per- manent deafness or loss of smell could not be produced. He also finds that the area of feeling cannot be sharply divided into special regions, as Munk has done. The most important area is the special motor region, and from this it passes in all directions with diminishing intensity. According to Goltz, the results of the veterinary pathol- ogists of Saxony are likewise opposed to the views of Munk. It will thus be evident that the results of physiological experiment are by no means harmonious, there being great dispute as to the facts and still more as to the inter- pretation of them. As has been said of this question, scarcely two observers are of the same mind. Turning, however, to pathological observation, we find that the results gained are more satisfactory and concordant, in spite of wide differences of opinion, and even contradic- tory views. It has not yet been decided just what classes of cases can be accepted as evidence, and just what use is to be made of them. The preconceptions of clinical writers, and the more or less arbitrary limits or exclusion which they impose upon the evidence cause very consid- erable discrepancies in the resulting theories. Cases which militate against certain theories are often explained away by insisting that the examination of the patient or the autopsy was careless and incomplete. Wernicke, in fact, asserts that the observation and description of the cases in general medical literature is so imperfect that they are useless for the establishment of the theory of localization. No doubt this is very frequently true ; it is, however, rather an elastic and unsatisfactory explana- tion, and by skilful use of it any view whatever may be made plausible. Nothnagel uses the following limits: For the study of local diagnosis only such diseases can be used in which the affection is (1) chronically stable; (2) is quite limited and isolated, and (3) does not in any manner affect its surroundings, whether by pressure, dis- turbances of circulation, or inflammatory alterations. Exner adopts entirely different standards, requiring, be- sides an unambiguous description of the symptoms and the lesion, that no lesions in the brain or spinal cord, ex- cept those of the cerebral cortex, shall be present, and he rejects those cases in which a general meningitis was present. Other writers, such as Wernicke, Charcot, and Pitres, adopt somewhat different criteria, and with the criteria the results will vary. The effects of cerebral disease are largely dependent upon the character of the malady, as well as upon its sit- uation, and it becomes necessary to distinguish between the direct and the indirect effects of the lesion. For ex- ample, cerebral haemorrhage, which is caused by the rup- ture of a cerebral artery, may have effects extending far beyond its immediate neighborhood. The pressure of ar- terial blood in the brain is at least one hundred and fifty millimetres of mercury, that of the brain itself only ten millimetres of water, and when the blood is forced through a broken vessel, the result is a shock more or less violent, in accordance with the pressure of the blood and the size of the vessel. The effect may be limited to the region near the haemorrhage, or it may extend to the en- tire brain, causing loss of consciousness and coma. Such a shock, if sufficiently great, arising in any part of the hemisphere, may cause hemiplegia and aphasia, then later the effects may gradually be reduced to those result- ing from the destruction of tissue. In the case of a local- ized softening, the symptoms will depend upon whether the softening is acute or chronically progressive. In the former case the sudden embolism may have a widely ex- tended traumatic effect (to use Wernicke's phrase), and cause complex symptoms which gradually become re- duced to those of the actual lesion. If the shock does not occur the indirect effects do not follow. Tumors, again, exert a compressing effect, which may be general by narrowing the intracranial space, or may be local, limited to the area which they press upon and destroy Tumors may also cause very deceptive symptoms, by stretching the membranes, which thus compress and ren- der functionless certain cranial nerves. Tumors of the cerebellum frequently cause blindness, as they bring about hydrocephalus internus, which may so swell out the base of the third ventricle as to compress and flatten the optic chiasma. The same principles apply to trau- matic lesions and cerebral abscesses. These various mal- adies may have an irritative as well as a paralyzing influ- ence, giving rise to localized spasms of certain groups of muscles, or to general convulsions and epilepsy. At the outset of our investigation we are confronted with the fact that many cases are known in which there has been either an entire lack or a very great reduction in the mass of one hemisphere, without any apparent sen- sory or psychical defects, but only more or less partial paralysis of the opposite side of the body. One such case is that observed by Bell, and cited by Longet. A woman who was epileptic from her birth, had at the age of five or six years been partially paralyzed in the extremities of the left side. Bell observed her when she had nearly reached the age of forty, and found that she had ordinary strength and was very intelligent. The left arm was drawn back, but was of the same size as the right, and could perform some voluntary movements; sensibility was as marked as in the right arm, except in the hand, which could not so well estimate the form and size of ob- jects as its fellow, though this may have been due to lack of practice. The left leg was half bent, but could per- form some movements. The senses were equally acute on both sides. The patient died of inflammation of the lungs. The autopsy showed that the right hemisphere was by a half smaller than the left, and with extraordin- arily small convolutions ; the ventricle was greatly en- larged, so that the brain-wall was only a few lines thick, and the mass of the hemisphere was scarcely a fourth 32 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebral Cortex. Cerebral Cortex. that of the left hemisphere, which was well developed in all its parts with large and numerous convolutions. The left lobe of the cerebellum was perceptibly shrunken. Longet also gives a case from Quesnay, in which from an injury nearly the entire mass of one hemisphere was destroyed as far as the corpus callosum, without produc- ing any effect except hemiplegia of the opposite side. In a third case, an individual had had left-sided paralysis from his birth, but was entirely normal mentally; after death it appeared that the. place of the right hemisphere though not invariably, give rise to certain symptoms. Lesions of relative areas are not only more inconstant in their effects, but they are more transitory and less pro- nounced than those of absolute areas. In the right hemisphere the absolute areas are in the two central gyri (ascending frontal and parietal), and the lobulus para- centralis. Injury to these seems always to produce motor disturbances (see Figs. 614 and 615). In the left hemi- sphere the latent region is less extensive (Fig. 613), the parietal and most of the occipital lobes in this case be- Fig. 612.-Latent Areas in Right Hemisphere. (Exner.) The unshaded portion shows the region where lesions may be latent. Fig. 614.-Motor Region in Left Hemisphere, according to Charcot and Pitres. (Exner.) was filled by a serous fluid. These are only a few cases of a great number that might be cited, all of which go to show that motor disturbances always follow the destruc- tion or absence of one hemisphere, but that there need be no sensory or psychical effects. Exner points out that in these cases of the deficiency of one hemisphere the movements of the eyes are not af- fected and only rarely those of the eyelids. Though unilateral paralysis of the tongue is frequently the result of cortical lesions, these cases show that the tongue and larynx may be innervated from a single hemisphere, and the same is true of the voluntary respiratory muscles. longing to the non-latent portions. It should be stated, however, that there are some doubtful cases which seem to show the possibility of latent injury to even the central gyri, but these cannot be called satisfactory evidence. Cysticerci frequently cause no disturbance in whatever part of the brain they may be, as they do not seem to in- jure the tissue in any important degree. Exner's results from one hundred and sixty-seven cases are as follows: I. Motor Areas.-(1) Upper Extremity. - Lesions affecting the arm are much more frequent in the left than in the right hemisphere. In the latter we have the lobulus paracentralis, the anterior central gyrus, except some of its lower portions, and the upper half of Fig. 615.-Median Surface of Right Hemisphere. (Exner.) Exner's study of a large number of pathological cases has led him to the conclusion that the two hemispheres are different in regard to the effect following lesions of their cortex. Fig. 612 shows the field of latent lesions for the right hemisphere, the unshaded part being the area where lesions may occur without producing any ap- preciable effect, though it by no means follows that they always do so. On this ground Exner divides the areas into absolute and relative, the former being those areas injury to which always produces the characteristic effects, while the latter are those which, when injured, frequently, Fig. 613.-The Same, in Left Hemisphere. (Exner.) the posterior central gyrus ; the lobulus quadratus and part of the gyrus fornicatus may also belong to this region. This absolute area is surrounded by a much wider relative one, gradually diminishing in intensity. In the left hemisphere the absolute area is much larger, in- cluding the lobulus paracentralis, most of the central gyri, the greater part of the upper parietal lobe, and ap- parently some part of the occipital, especially its median surface. As in the right hemisphere there is a large relative area. 2. Lower Extremity.-In the right hemisphere the ab- solute area is in the lobulus paracentralis, the upper third of the anterior central and parts of the upper third of the 33 Cerebral Cortex. Cerebral Cortex. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. posterior central gyri, with perhaps parts of the lobulus quadratus. The absolute area of the lower extremity falls thus within that of the upper. In the left hemi- spheres it is the upper half of the posterior central gyrus and most of the upper parietal lobe. In spite of the co- incidence of the areas for the two extremities the arm is much more frequently the subject of monoplegia, and if Exner's results had been taken exclusively from very small lesions the area for the arm would have seemed much more important. 3. Facialis.-In the right hemisphere there is no abso- lute area ; the commonest place for lesions to affect the facialis is in the lower portion of the central gyri, though it occurs elsewhere. In the left hemisphere the absolute area is a narrow strip of the anterior central gyrus, be- tween the sulci frontales, superior and inferior. The rela- tive area extends backward from this. 4. For the hypoglossus the most frequent place of dis- turbance is in both hemispheres, the lower part of the central gyri, and the adjoining part of the inferior frontal. Two cases of complete paralysis of the tongue, given by Barlow and Rosenthal, presented a lesion at this point in each hemisphere. II. Area of Vision.-This region is much in dispute among pathologists ; the German authorities mostly agree in placing it in the occipital lobes. Exner states that there is no absolute sight-area, but that the most intense region is the upper end of the first occipital convolution. Lesions in one lobe, as would be expected from the dis- tribution of the fibres of the optic nerve, cause hemiopia, and not blindness of the opposite eye. Lesions in this region may also cause the condition which Munk has called psychic blindness, in which objects are seen, but not recognized. A case given by Fiirstner illustrates this. The patient showed disturbance of vision in both eyes, he could see objects on the table, but could not count them; could recognize separate letters, but could not point them out in a written word. Dissection showed a lesion of each occipital lobe. Wernicke records the case of a patient who, in consequence of a lesion in the left occipital lobe, had lost the power of reading, and showed some aphasia. Nothnagel, Exner, Wernicke, and Wundt all agree that the occipital lobes have to do with the sense of sight. On the other hand, lesions in these lobes may be without apparent effect, and it is strongly contended by Ferrier that they have nothing to do with vision. His experimental reasons for this view have already been given ; in addition he quotes some pathological evidence. In a case from Sestie there was a lesion in each occipital lobe, but without any objective symptoms ; ' ' although the patient's memory was some- what defective, there was nothing very remarkable in his mental condition." Leger gives an account of a tumor which invaded the substance of both occipital lobes, but without any apparent effects. Ferrier also gives cases in. support of his opinion that the centre of sight is situated in the gyrus angularis. The evidence is thus somewhat conflicting, though the preponderating weight of it is in favor of the connection of the occipital lobes with vision. III. Area of Hearing.-This is placed in the tem- poral lobe, and lesions of the left temporal very frequently give rise to sensory aphasia, or word-deafness, though such lesions may be latent on either side. The main dif- ference between pathologists is as to whether the area is connected with the ear of the same, or the opposite side. IV. Area of Tactile Sensations.-Exner finds that in spite of the greater frequency of lesions in the left hemisphere, disturbances of vision and tactile sensibility occur more frequently both proportionally and abso- lutely as results of lesions in the right hemisphere, and he is inclined to the opinion that the right hemisphere has a greater importance for sensation, and the left for motion. With regard to the position of the tactile areas, they in general coincide with the motor region for the same por- tion of the body. Munk's view of motor paralysis does not seem applicable to the human subject, as many cases of complete hemiplegia are not accompanied by hemian- aesthesia, or by the loss of the muscular sense. Nothna- gel gives an account of a patient who, though showing a monoplegia of the left arm, could readily distinguish small differences of weight with his left hand as well as with his right. Charcot and Pitres have also made great collections of pathological cases, the last of which, published in 1883, contains one hundred and eighty-five cases and deals with motor disturbances proceeding from cortical lesions. They find that the motor part of the cortex consists of the two central convolutions and the lobulus paracentralis (Figs. 614 and 615). Extended lesions of the central gyri cause hemiplegia of the opposite side of the body, less ex- tended lesions cause monoplegia. 1, Paralysis of the face and arm follow lesions in the lower half of both central convolutions ; 2, of the arm and leg, the upper half of both central gyri; 3, of the face and tongue, the lower end of the motor zone, especially of the anterior central gyrus ; 4, of the arm alone, limited lesions in the middle of the motor zone, especially the middle third of the an- terior central gyrus ; 5, of the leg alone, limited lesions of the lobulus paracentralis. Lesions within the motor zone always cause permanent paralysis, and, if the patient lives long enough, are followed by secondary degeneration of fibres that may be followed into the pyramids, and even beyond. If the lesion is outside the motor zone the de- generation does not follow. Starr, from an examination of ninety-nine American cases, concludes: 1, That the higher mental functions, reason, judgment, etc., depend upon the intact condition of the entire brain, but are especially connected with the frontal lobes ; 2, disturbances of vision follow lesions of the occipital lobes, while, 3, those of hearing result from injury to the first temporal convolution-this in the left hemisphere is the seat of the un- derstanding o f spoken words, the gyrus angularis that of written words ; 4, smell i s localized i n the basal surface of the temporal lobes ; 5, the mo- tor area is in the two central con- volutions, of which the lower third belongs to the face and tongue, the middle to the arm, and the up- per to the leg ; the tactile area coincides with the motor; 6, the normal use of speech is connected with the convo- lutions surrounding the Sylvian fissure. The subject of aphasia has been so carefully worked up, and is so widely understood, that it needs only a few words here. Aphasia is loss of, or injury to, speech, with- out paralysis of the tongue or other organs of speech. Wernicke distinguishes four forms of aphasia : 1. Motor (ataxic) aphasia, caused by lesion of Broca's area (Fig. 616). Spoken words are understood, but the patient can- not speak himself. 2. Aphasia of conduction, caused by interruption of the tract x, y. The vocabulary is exten- sive and the intelligence unimpaired, but words are con- founded in speaking. Lesions probably in the island of ReiL 3. Sensory aphasia (word-deafness), the vocabulary is not diminished, and the hearing unimpaired, but spoken words cannot be understood. Patients who have recov- ered from this disease state that they could hear distinctly, but that words were only a meaningless noise to them. Agraphia and ataxia are frequently associated with this form of aphasia, though not always, as in the cases re- corded by Wernicke, and in a particularly interesting case recently given by Burckhardt. The seat of lesion for this disease is in the first temporal convolution of the left side. 4. Total aphasia. The use and understanding of words are entirely lost; this is caused by destruction of both areas, x and y. There is, however, no absolute speech area, as any part of the brain may be injured with- out loss of speech resulting, and variations from Wer- nicke's scheme not unfrequently occur, as word-deafness Fig. 616.-Diagram of Speech-centres. (Wer- nicke.) x, Area of hearing; y, Broca's area; a, sensory tract; m, motor tract. 34 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebral Cortex. Cerebral Cortex. resulting from injury to the frontal lobes, aphasia and ataxia from injury to the occipital lobes. Again, cases of more or less perfect recovery are recorded, in spite of the permanent destruction of Broca's area. The evidence derived from atrophy of certain parts of the cortex, following the removal or loss of function of the organs with which these areas are especially con- nected, is not very satisfactory ; most so in the case of the motor area. In attempting to understand the evidence for the local- ization of cerebral function, a brief abstract of which is now before us, it is necessary to distinguish between the clinical and physiological bearings of the facts. In the former case the endeavor is made to establish a connec- tion between certain symptoms and the seat of a cerebral lesion, in the latter to establish the causes of certain ef- fects, and from these to deduce the normal function of jury to a certain cortical area produces an effect, however transient, which seldom or never follows an injury to an- other area, that is a fact which must not be left out of account. Exner's view of absolute and relative areas seems at present to best harmonize the apparently con- flicting facts, and nearly all of the most recent work, ex- perimental as well as pathological, goes to confirm this position. It would seem at present that the idea of small circumscript areas will have to be given up, and that the view most consistent with the evidence is that of more or less intense areas which overlap and embrace each other. In his latest article (1885) Exner accepts Goltz's facts with but little reserve, and shows how these make for the localization theory that he has defended, and in a late investigation from Munk's laboratory, the same idea is touched upon (Daniells, 1884) as an explanation of the fact that cramps of the extremities may proceed from the Arm. Leg. Facialis. Hypoglossus. Speech. Sight. Fig. 617.-Cortical Areas in Left Hemisphere. (Exner.) The scattered large circles indicate the absolute areas, the small circles the relative areas. The intensity of the latter is shown by the closeness of the small circles to each other. the area in question. It need hardly be said that the lat- ter is by far the more difficult problem. In the clinical aspect of the question a most important and valuable be- ginning has been made, which has already been utilized in surgery, and with very promising results. In the phy- siological side progress has not been so satisfactory, opin- ions as to the facts being very divergent, the explanation of them still more so. Nevertheless, recent series of ex- periments are beginning to bring together on a common ground observers whose views had differed most funda- mentally. The results of Goltz's experiments cannot be gainsaid or explained away, as they have been confirmed by special commissions of two medical congresses. His inferences from these facts belong in another category, and in some respects do not follow strictly from the ex- periments. On the other hand, the same must be said for the experiments of Hitzig and other defenders of the localization theory ; the facts are unquestionable. If in- occipital lobes, a fact which has also been observed in pathological cases. We have seen that there is every reason to believe that for any nervous impulse to affect the consciousness, the nerve-fibres must reach the cerebral cortex. The removal of the cortical cells with which these fibres are connected will necessarily affect the organ from which they come as surely as a severance of the fibres themselves, no mat- ter what the function of the cells may be. The strict- ness of the localization will therefore depend upon whether the fibres enter the cortex in compact or more or less scattered bundles. The former seems to be the case in the motor fibres passing to the central gyri and the lobulus paracentralis, the latter to be true of the other parts of the brain, though even in these we find more in- tense areas which receive the majority of the fibres. But the cortex is not a series of isolated ganglia like the nu- cleus lenticularis, for instance. All parts of it are con- 35 C^pUml Meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nected together by "associating fibres," both in the cor- tex itself and in the white matter : interruption to these may also cause more or less entire cessation of certain fundions, as in the injury to sight, which in Hitzig's ex- periments followed destruction to the frontal lobes, and in many other cases. Tuczek has shown that in de- mentia paralytica these associating fibres of the cortex degenerate in accordance with the degree of the disease, which would thus seem to consist, partly, at least, in a want of co-ordination between the different parts of the cortex. The same consideration may apply to the vari- ous complications of aphasia. In the same way lesions may effect certain memories, and only these. It is generally, and with good reason, be- lieved that memory depends upon the renewal of the sen- sation or volition by the same cortical mechanism that produced the original one, and that it requires the spe- cific association of a certain number of nervous elements. The injury of this association must affect the memory, and the position of the injury to have that effect must de- pend to a great degree upon the distribution of the " pro- jection-fibres," and the cortical cells with which they are connected. To use a very hackneyed comparison, the removal of a bolt from an engine may destroy the en- gine's functions, though the bolt cannot be said to per- form these functions. The importance of this principle cannot be too constantly borne in mind in speculations on cerebral physiology. No modern observer localizes the will or the intellect in the cerebellum, yet stimulation of its cortex will produce certain movements of voluntary muscles, diseases in its substance are frequently followed by profound mental disturbance, and its absence may be accompanied by idiocy. The nature of the cortical processes is entirely unknown to us, and while the great and increasing pathological value of the doctrine of local- ization is not to be doubted, it is only too apparent that we are very far as yet from a satisfactory physiology of the cerebral cortex. W. B. Scott. may explain the relations existing between these two organs, and lead us to regard the lesions of the visual organ as symptoms proper of brain affections, or at least as signs of these affections. It is not pretended that these new signs of cerebro- spinal diseases discovered in the eye have by themselves an absolute signification any more than a subcrepitant rale or a bronchial inspiration ; they are of importance only when taken collectively and associated with other symptoms furnished by the patient. Nor are they con- stantly the same in each of the cerebro-spinal or diathetic affections, being modified in nature and frequency by the age, constitution, and health of the subject. Yet we are enabled, in a great number of diseases, after having de- termined the area of the field of vision and inspected the size, texture, and conditions of the circulatory vessels within the fundus, to affirm the presence of an ocular lesion existing with a like lesion in the meninges, in the brain, or in the spinal cord, and sometimes to state with a reasonable degree of certainty which side of the brain or cord is the seat of the malady. The study of the func- tional troubles of the eye, comprising its exterior as well as the internal changes of circulation, motility, and nu- trition, also permit in many cases the diagnosis of an organic cerebro-spinal disease from a functional one, or even the recognition of serious material lesions, the pres- ence of which would not be suspected from other symp- toms. Thus are distinguished the convulsions and delir- ium of symptomatic paralysis from the convulsions and delirium of certain essential paralyses. The troubles of vision produced by diseases of the ner- vous system are those affecting the motility of the eye, as mydriasis, nystagmus, vicious accommodation, strabis- mus, and lateral deviation ; those affecting its sensibility, as photophobia, amaurosis, hemiopia, megascopy; those affecting its circulation, as papillary congestion ; and those affecting its nutrition, as pigmentary retinitis, atro- phy of the choroid, and the like ocular lesions of motion and of circulation, as hyperaemia, thrombosis, oedema, haemorrhage, and atrophy, which may be utilized in the diagnosis of acute or of chronic diseases of the brain, are brought about by the least obstacle to the circulation of the brain, just as a tumor of the stomach hinders the cir- culation of the lower extremities. In the same manner the circulation of the fundus of the eye is impeded by a cerebral inflammation, by a tumor, by a serous or san- guineous effusion, by a phlebitis of the sinus of the dura mater, or by any anomaly of the vessels which hinders the return of the venous blood of the retina into the cav- ernous sinus. By noting the intraocular changes, a more correct means is afforded to diagnose such conditions as contu- sion from compression of the brain following injuries of the head ; recent cerebral haemorrhage from softening ; and, in fact, all lesions, whether arising from inflamma- tion of the brain and its meninges, from mechanical lesions causing compression of the optic nerve on the sinuses of the dura mater, or from lesions symptomatic of a disease of the cord or of the vaso-motor nerves. The phenomena utilized by cerebroscopy are not al- ways pathognomonic ; but they lend to the diagnosis of cerebro-spinal diseases an additional source of correct- ness, and are at least very important complements to other symptoms. Among the phenomena most useful to the neurologist are those noticeable in irregularity of the pupil, and those caused by an interference with the sight, the area and acuteness of which may be affected either singly or in combination. Myosis often accompanies cerebral irrita- tion, as that following concussion. It is often indicative of pressure upon the sympathetic, as that caused by a. tu- mor or by an aneurism of the aorta ; it is often seen in such diseases of the cilio-spinal region as locomotor ataxy ; and is, moreover, often associated with the altered nerve influence that attends paretic dementia. Organic or toxic causes may give rise to scotomata, either central, marginal, or in patches ; and hemianopsia may result from hysteria and megrim, although it is usually of central origin. Unilateral scotoma is generally owing to organic causes. CEREBROSCOPY (cerebrum, brain; aKoirew, I ex- amine). Examination of the brain, made with a view to obtain a knowledge of its pathological state. The term applies more particularly to the method of diagnosing cerebro-spinal diseases by studying the alterations of the eye symptomatic of, or usually associated with, nervous diseases. This new science, though still incomplete, has done so much to advance the diagnosis of nervous diseases that the advocates of cerebroscopy place it in the first rank of the methods of exploration employed by physicians, and remark without exaggeration that it is for diseases of the brain and spinal cord what auscultation and percussion are for diseases of the chest; for it is now quite possible by this method to see in the eye what is taking place in the brain. By virtue of its anatomical relations the eye is the only organ of the body in which we can distinctly see nerves and vascular membranes in their normal disposition, and it is by observing the lesions in the arteries and veins at the fundus of the eye, when sufficiently lighted, that we are enabled to recognize not only lesions of the brain and cord, but different pathological states, such as the exist- ence of acute or of chronic general diseases, diseases of the blood, heart, kidneys, and other structures whose dis- organization reacts upon the brain. The object of cerebroscopy is to show, by means of perimetric records of the visual field, and by ophthal- mological images of the intraocular changes found at the posterior segment of the eye, that a co-relation exists be- tween neuro-retinal or choroidal lesions and such condi- tions as meningitis, encephalitis, cerebral haemorrhage, softening, contusion of the brain, and other acute or chronic cerebro-spinal maladies; and that the discovery of lesions of nutrition, of circulation, and of sensibility of the retina and of the optic nerve are not only symptomatic of morbid states of the general system, but even corre- spond with the cessation of life; so that it is now gen- erally admitted that certain cerebral affections are com- plicated with corresponding alterations in the eye, which 36 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebral Cortex. C.-Spinal Meningitis. such as haemorrhagic extravasations, inflammations, and degenerations ; when it attacks both eyes, the cause is toxic, as the excessive use of tobacco or alcohol; and when it appears in patches, embolism and retinal haemor- rhage are the usual accompaniments. Homonymous hemiopia may result from softening, tumors, or other causes that destroy the cortical visual centre. The changes in the^refraction of the eye, or those that take place in the vitreous humor and the lens, belonging more particularly to the domain of ocular pathology, do not come within the range of the subject under discus- sion ; nor do the morbid changes of the choroid, unless we exclude tubercles of the choroid, which announce tu- bercle of the meninges of the brain, of the cord, and sometimes of the other viscera. The situation of the nodules in tubercular choroiditis is near the posterior pole of the eye. They resemble small spots of choroidal exudation, and when accompanied by sensory, motor, and mental troubles, their presence announces tubercu- lar meningitis or meningo-encephalitis. There may also be mentioned, in connection with the changes in the choroid, anaemia and discoloration, characteristic of the stoppage of circulation in the brain, and preceding death by cholera, typhoid fever, and some cases of meningitis. It is, however, the morbid condition of the optic nerve and its retinal expansion that most interests the physician, and claims attention as a clinical fact of great impor- tance. Whenever the ophthalmoscopic image is altered, it may be affirmed, without fear of deception, that there exists at some point or another of the meninges of the brain, or upon the spine, a modification of the normal state of these organs. On the other hand, it is never proved by the ophthalmoscope that any change occurs either in the papilla or the retinal vessels in acute febrile delirium, in convulsions, essential paralyses, or any ner- vous affection unaccompanied by organic lesion of the brain. The alterations of the retina following injuries and syphilitic inflammations do not come within the province of the subject in question, and less closely connected with it are albuminuric and leucocythaemic retinitis, and the extravasations common to pernicious anaemia. The most common alteration of the fundus is from op- tic neuritis or papillitis, which is produced by all the conditions that increase the intracranial pressure, such as abscess, tumor, aneurism, hydatid growth, haemor- rhagic effusion, and it may occur, though rarely, in con- nection with acute myelitis and spinal meningitis. Partial sclerosis of the brain or of the cord is often in- dicated by optic atrophy or sclerosis of the optic nerve ; the lesion in the nerve structure of the eye presumably corresponding to what is taking place in other parts of the nervous system. Thromboses of the venous canals of the cranium or of the meningeal veins is often accompanied by thrombosis of the retinal veins ; while varices or retinal ha;mostases indicate either an obstruction of the venous circulation of the encephalon, a thrombosis of the sinuses and of the meningeal veins, compression by a strong meningeal haemorrhage, an intracranial tumor pressing on the sinus, cerebral haemorrhage, or an acute or chronic hydrocepha- lus. The forementioned are a few only of the salient morbid changes of the fundus usually associated with nervous diseases. The correlation, now generally admitted by competent observers, is found in the following intraocu- lar lesions, which are of cerebroscopic importance in neurological diagnosis : Papillary and peri-papillary con- gestion ; papillary anaemia, partial or general, including angioplany or errors of the situation of the vessels of the pupil; retinal phlebectasis ; phlebo-retinal tortuosities ; varices or retinal varicosities ; phlebo-retinal haemostasis; phlebo-retinal thrombosis ; phlebo-retinal aneurism ; ret- inal haemorrhage ; papillary oedema ; fibrinous and fatty exudations of the papilla and of the retina ; tubercles of the choroid and of the retina ; aneurisms of the retinal arteries ; pigmentary retinitis; atrophy or deformity of the papilla; arterial throbbing of the papilla; venous pulsations of the veins of the retina ; pupillary contrac- tion or dilatation ; nystagmus ; trembling or papillary ataxy ; strabismus ; exophthalmia, and the like. Cerebroscopy is important to the neurologist as a means of diagnosis in chronic disease of the brain and cord gen- erally ; but it is of special value in meningitis, all doubts regarding the diagnosis of which may be dispelled when, after one or several vomitings, with constipation and fever, there is found to exist at the fundus of the eye conges- tion and peri-papillary oedema and dilatation of the veins of the papilla and of the retina. When cerebral haemorrhage occurs, with the symptoms common to that condition, the diagnosis may be rendered certain if there be congestion of the papilla with dilatation of the veins of the retina or retinal haemorrhage ; in senile softening there is seldom or never cerebral congestion of the papilla or alteration or rupture of the retinal veins. Progressive general paralysis does not admit of a suitable cerebroscopic examination, for the reason that there is so often present a trembling of the pupil. Optic neuritis is present in a considerable number of cases of abscess and of tumor of the brain, and it may coexist with growths in the meninges. In locomotor ataxy neuro-retinitis is present and leads almost always to atrophy of the papilla of the optic nerve. When the atrophy does take place it is an early symptom. Other changes of the fundus, of less importance, are noticeable in chronic myelitis, epi- lepsy, tetanus, essential convulsions, and various insane conditions of organic origin. In the arrest of the retino-choroidal circulation we have an indication of the arrest of the cardiac circulation and of the nervous functions, or, in other words, death. An- other sign of death is furnished by pneumatosis of the retinal veins, which indicates a pneumatosis of the veins of the meninges, a phenomenon resulting from the libera- tion of the gas of the venous blood on the occurrence of death. (See Blood, Air in the.) The march and duration of the lesions observed at the fundus of the eye consecutive to cerebro-spinal diseases, or correlative of these lesions, varies according to the original lesion of the nerve-centres, being transitory, and often disappearing without leaving traces, as in haemor- rhages ; while they are of prolonged duration in the secondary lesions of the eye produced by a previous acute malady, and designated by some oculists as ' ' varieties of the physiological state." Persistence is the rule in cerebro- spinal diseases, and there is no retrocession of the papil- lary and retinal lesion in such conditions as locomotor ataxy, certain cerebral haemorrhages, and in tumors of the brain, whose slow march may lead to disorganization of the optic nerve, and finally to atrophy of the papilla and to amaurosis. To establish still further these correlations it is recom- mended that an histological study of the diseased eye be made on the bodies of patients that have died from such general diseases as typhoid fever with delirium, rheuma- tism, or any primitive cerebro-spinal disease in which the characters of optic neuritis, neuro-retinitis, or choroiditis were present during life ; for by minutely searching the cadaver for the lesions which are formed in the mem- branes of the eye and the optic nerve one becomes better acquainted with the alterations revealed by cerebroscopy, and better enabled to understand that in the eye are re- flected not only many general diseases, but all the im- portant diseases of the nervous system. Irving C. Bosse. CEREBRO-SPINAL MENINGITIS. Definition.- Cerebro-spinal meningitis (Muti'S, a membrane), is an acute infectious disease, with its main local expression in, as the name indicates, the membranes of the brain and spinal cord. Two sets of symptoms distinguish this dis- ease : one common to all the acute infections, and charac- teristic of general poisoning of the blood; the other peculiar to the local lesion in the coverings of the brain and spinal cord: the combination of these two sets of symptoms and lesions individualizes the disease. Synonyms.-It is a fact which indicates the unsettled state of its pathology that no disease has received so many names, while there is not one against which valid ob- 37 Cerebro-Spinal Meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. jection may not be raised. Of Cerebrospinal Fever (Royal College of Physicians) it may be said that while it recog- nizes the general infection it fails to indicate the part of the brain and cord affected. Cerebro-spinal fever is neither clear nor classic. It is a term ' ' which may be pardoned when used by the laity, but which educated physicians ought not to tolerate " (Stille). More glaringly faulty, though with abundant recognition of the brain symptoms, are the designations of the older French authors : Fievre ciribrale, Phrenisie, Cephalalgie epidemique, Meningite purulente epidemique, with which may be cited also the German Hirnseuche, and the old English terms Malignant Meningitis and Epidemic Meningitis. The early erroneous view of the disease as a variety of typhus fever is per- petuated in the names Cerebrospinal Typhus, Typhus cere- bralis apoplecticus, Typhus syncopalis, Phrenitis typhodes, Typhoid Meningitis. The appearance of an haemorrhagic eruption, which characterizes the graver cases of nearly all the acute in- fections, has been more distinctly associated with this dis- ease in the names Spotted Fever (Gallup), Petechial Fever (Wood), Malignant Purpura (McSwinney), Malignant Purpuric Fever (Stokes), Pestilential Purpura (Banks), Fe- bris Nigra (Lyons), and in its association in this connec- tion again with typhus as a Typhus petechialis (North), and with a neurosis, as Neuro-purpuric Fever (Mapother). Moreover, cerebro-spinai meningitis, on account of its eruption, has not escaped inclusion under the all-embrac- ing title, Black Death (A. Smith). As was correctly re- marked by Minet, over half a century ago : "It is quite unfortunate that a single symptom-petechiae-and one that is wanting in a great majority of cases, should have been seized upon to give it the odious and deceptive name of spotted fever, as that name has been applied by Euro- pean writers to a very different kind of fever." The opisthotonos, perhaps the most striking single symptom of the disease, which is, however, by no means universally present, has been selected by the Germans to name the disease a Genickkrampf, Genickstarre, Nacken- starre; by the Swedes a Nacksjucka, Dragsjucka; and by the Italians a Torticollo. Fancy has exercised its ingenu- ity in the title Cerebrospinal A rachnitis (Mayne), a refine- ment totally unjustified in the morbid anatomy of the disease, and the limits of frenzy have been almost at- tained by the frantic efforts of Italian writers to cover the entire field of the disease with the names Tifo-apoplet- tico tetanico and Febbresoporoso-convrtlsivo. Terms as de- lusive and diffuse as spotted fever are the popular names Congestive Fever, Winter Epidemic, and Cold Plague. From this array of titles, which is by no means ex- hausted, may be appreciated the difficulty of securing a proper name for a disease from its symptomatology or pathology. The name cerebrospinal meningitis (Hughes, Law, Banks, Moore, and others), is at present the least? of all objectionable, and has, hence, in the course of time, come into common use, though it gives undue promi- nence to the local lesion to the exclusion of the infectious character of the disease. As was observed by Valleix, it is begotten of anatomical bias and an incomplete appreciation of the facts." Gordon attempted to cut the knot of difficulty by calling the disease cerebrospinal fever, with cerebrospinal meningitis, a combination too bulky for practical use. So long as the cause of a dis- ease, which with the right of parentage can alone give it a true name, remains unknown, some provisional title must be selected from its most distinctive characteristics, and in this case cerebro-spinal meningitis does the least violence to the signs and lesions of the disease. History.-Cerebro-spinal meningitis is a disease of modern origin ; perhaps it would be more strictly true to say of modern recognition, for previous to the present century there was no possible differentiation of this dis- ease and forms of typhus fever, pernicious malarial fever, tetanus, and the various inflammations of the brain and cord, diseases known to be as old as the history of medi- cine. Even within the period of the last twenty years Davis was justified in the statement that "in regard to the disease promiscuously styled ' spotted fever,' and ' cerebro-spinal meningitis,' as reported in our literature. no less than three or four diseases have been confounded together " (Trans. Amer. Med. Assn., xvii., 1866). Hence the possibility is not to be excluded that cases, or even epidemics, of cerebro-spinal meningitis occurred in ancient times. Medical historians (Ozanam, Alpin) have made repeated endeavor to identify this disease with the phre- nitis of Hippocrates, and with certain epidemics of an- cient Egypt, or (Tourdes, Boudinlat least to find its most essential features in the later writings of Forestus, Ignassias, Felix Plater, and Saalman ; but the references cited go further to show interest and assiduity in antiqua- rian research than to confirm their views. Frequent allusion is made in this connection to the quotation by Forestus, 1584, from a private letter of Livinus Baudrinus, concerning a pestilential fever : ' ' Gallis dicta trousse- galant qua in Sabaudia potissimum, aliusque locis finitis- simis in Gallia anno 1545, grassabatur . . . qua et fortiores juvenes pigulabat accidentia fere haec sunt; aut continua vigilia, quae aegrum ad phrenitidem tandem ducit, aut continuus sopor qui in lethargiam transit. Dolor plerumque capitis adest in principio et renum calor cum lassitudine totius corporis vermium maxime copia qui ex putredine generantur, quique sursum repentes vivi per os evomuntur . . . plerisque et exanthemata erumpunt. Morbus his plerumque quarto die termina- tur aut undecimo." The localization of a pestilential fever, the seizure by preference of vigorous youth, the coma vigil or sopor, and the pain in the back, together with the eruption, and termination on the fourth or eleventh days, are all points that might be interpreted to refer to almost any one of the grave acute infections ; while the discharge of living worms ' ' generated from putridity," or their regurgitation by the mouth, belongs to none, and must have been an accident observed in but very few cases. It is, however, not just to claim that there could have been no possible recognition of this disease before the fifteenth century, when the first dissections were made of the spinal cord, for diagnoses in ancient times were wholly based on symptoms; but it is unreasonable to assume the distinct recognition of a disease whose symptoms were not separated from other acute infections or from purely local lesions. At any rate, it is now generally conceded of ceiebro- spinal meningitis that it first attracted notice as a separate disease in Geneva, February, 1805. Perhaps this first no- tice is due to the fact that the cases occurred in the practice of Vieusseux, an observer as keen as he was frank. He called the malady a fi'evre cerebrate ataxique, and admitted that neither he nor his colleagues had ever seen a similar disease. These first victims were a woman and three children, two of whom died within twenty-four hours. The disease extended gradually to neighboring houses, in one of which four out of five children were attacked, and died within fifteen hours. It was characterized by sud- denness of attack, vomiting, excruciating headache, stiff- ness in the back of the neck, dysphagia, and convulsions (Laveran, 7 Diet. Encyclop. des Sc. Med.," 2d ser., 5 to 6, p. 648). A young man in an adjoining house died on the same night of the attack, showing a violet discoloration of the whole body. Thirty-three persons fell victims to this first outbreak of the disease, which lasted until spring. The post-mortem examinations made by Mathey upon some of these cases, revealed gelatinous exudation covering the convex surface of the brain, yellow pus pos- teriorly and about the optic commissure, cerebellum, and medulla oblongata. It is remarked of this first attack that it remained quite strictly localized. It is a characteristic feature of this disease to appear simultaneously at parts of the earth as widely separate from each other as its various continents, and this pe- culiarity is remarked of the cases first distinctly recog- nized. For the very next outbreak of the disease, with unmistakable signs, occurred in our own country, with the first cases at Medfield, Mass., in 1806. These cases formed the preface to a long chapter in the history of the disease, known then as "sinking typhus," ten years in duration, during which time it extended over, but re- mained confined to, the New England States. Meanwhile 38 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal meningitis. the disease made its first appearance in France, at Gren- oble, where it prevailed during the months of the spring of 1814, remaining confined to the soldiers lately arrived from the army of Mont Blanc. Comte describes it as a malady characterized by stiffness of the neck, with head- ache and delirium among its prominent symptoms, with traces of inflammation in the brain and cord observed on autopsy among its lesions. During the next year, Ram- pont described four cases at Metz, distinguished by the same array of symptoms and lesions. With the excep- tion of an extensive endemic in Vesoul, in 1822, which differed from previous attacks in its preference for the civil population, the disease did not show itself again in France until January, 1837, when it broke out in great virulence in the garrison at Bayonne, and rapidly ex- tended to invade the neighboring barracks at Dax, Meig- non, and Tartos, and to assume, later in the course of the year, epidemic proportions, reaching Bordeaux by Decem- ber of the same year ; Rochefort, January, 1838; and Nimes and Avignon, in the interior, by the end of the year. It is remarked of this outbreak, at a place appro- priately named Aigues-Mortes, where it first appeared in November, 1841, remaining confined to the civil popula- tion, and continuing until March, 1842, that it attacked 160 persons of whom 120 died. The same regiment of light infantry which transported the disease from Bayonne to Rochefort, conveyed it also to Versailles, where it appeared in February, 1839, six men inhabiting the same1 room being attacked within a period of a few days. Paris made its first acquaintance with the disease, after the lapse of several years, in Decem- ber, 1847. It continued to prevail in Paris up to May, 1849, confined exclusively to the inmates of the garrison, and the prisoners at La Force, in which latter place ten of the twelve persons attacked fell victims to the disease. After France, Italy was invaded, the disease first ap- pearing in the kingdom of Naples, in the winter of 1839- 40, and spreading thence, in the following winter, to the lands of the Church. In the same year (1839), the most eventful in the history of the disease, as that from which dates any exact knowledge concerning its nature and in- dividuality, cerebro-spinal meningitis first showed itself in Algiers, where it continued to number victims with annual recurrence in various parts of the land up to 1847. But it is not to be inferred from these statements that cerebro-spinal meningitis has pursued a regular course in any way, as anything like a linear transmission or direct irradiation is the exception and not the rule. It is rather characteristic of the disease to have appeared simultan- eously, as stated, at points so distant from each other as to have been without means or time for intercommunica- tion. Thus, after the first recognized appearance of the disease, from 1805 to 1816, accounts of it cease for six years, when, in 1822, it reappeared at Vesoul, in France, and at Middletown, Conn., to which remotely separated places it remained quite strictly confined. Then, after an additional five years, it again showed itself, in 1828, in Trumbull County, O. ; in 1830 in Sunderland, Eng- land, and in 1833 at Naples. So in 1842, when the dis- ease again visited the United States, it appeared almost at the same time in Louisville, Ken. ; Rutherford County, Tenn., and Montgomery County, Ala. Sweden wTas not reached by the disease until 1854, when it suddenly appeared in Gothenburg, extending thence in the course of the following year as far north as the city of Kalmar. Then, after a complete cessation of six months, it showed itself in a series of small epidemics extending a degree and a half further north, and with this fitful, almost freakish appearance and disappearance, it hovered about this country for seven years, striking lightly in one place and like lightning in another, until it had killed in all 4,138 of its inhabitants. It was only during the last two years of this visitation of Sweden that the disease first showed itself in Norway (March, 1859), in very limited extent, but in such severe degree as to have carried off in the county of Opdal 14 of the 29 persons attacked. Strange to relate, the first invasion of Germany did not occur until very late in the history of the disease. Dis- regarding as unauthentic the earlier communications of Wurtemberg physicians, Hirsch feels compelled to accept the statements of Rinecker, who reports with due detail cases occurring in Wurzburg, June, 1851, both in hospi- tal and private practice. But the first attack of any severity or extent was reserved for a later date and place, namely, for Silesia, Posen, and Pomerania, in 1864. Ex- cepting Bamberg, anything like alarming proportions were not reached anywhere in Germany, though the dis- ease prevailed with some severity at Erlangen, in July, 1864. The exemption of certain countries is another, and as yet inexplicable, feature of the disease, more especially of countries contiguous to and under the same general con- ditions as those severely visited. Thus while Ireland has suffered repeated attacks-a severe epidemic having oc- curred in Dublin, in 1866, wherein "the British forces suffered much in proportion to their average strength "- England has never had anything more than isolated cases, and Scotland, where the elements of crowd-poisoning are greatest, has never experienced an epidemic of the disease. And while epidemic proportions have been reached in Germany on the north, and in Italy on the south, Austria has remained almost entirely free from attack. Our own country seems to have offered from the start a fertile soil for the development and spread of cerebro- spinal meningitis, and since the year 1842, when the dis- ease began to make excursions over the various lands of Europe, it has become almost indigenous with us. Men- tion has been made already of the simultaneous occur- rence of the disease in Alabama and Pennsylvania, in 1848. In the following year it made its first appearance in New Orleans, and during the following decade spora- dic cases occurred over various parts of the country, a/ in North Carolina, in 1856, and Massachusetts, in 1857. Four years later (1861), more and more frequent cases are reported, from Connecticut, Indiana, Kentucky, and Missouri. Three years later still (1864), the disease again appeared in Pennsylvania, carrying off 400 children of the 6,000 inhabitants of Carbondale. It was during the winter of these early '60s that the disease began to prevail in both armies of the rebellion, assuming a very malignant type in North Carolina, where it affected citizens and soldiers equally in the Union and Confederate armies alike (Stille). From the time of the report of the first cases at Philadelphia, in 1863, the disease has existed con- tinuously, with a death-list footing over twenty-five hun- dred, up to the present time. The view that cerebro-spinal meningitis did not extend to or prevail in other continents than "North America and Europe, and the vicinity of the latter," has been quite abandoned of late, as epidemics have been authenti- cally reported by Kotsonopulos, at Nauplia, in Greece, in 1868 ; by Horschelman, in the Crimea, in 1868 ; by Dia- mantopulos, in Magnesia and Smyrna, in 1869-70; and by Sandreczky, in Jerusalem, in 1872. Without attempting to even mention all the epidemics that have prevailed in various parts of the world, it may be stated that, though doubtful cases prevailed before this time, cerebro-spinal meningitis belongs to the nine- teenth century, and that its history naturally falls into three periods, quite distinct: the first embracing the first cases of "ataxic cerebral fever," observed at Geneva, in 1805, and of "spotted fever," in Massachusetts, in 1806 ; the second commencing with the outbreak at Bayonne, in 1837, and extending over various parts of Europe and America up to the year 1866, gradually merging into the third or present period, when the disease has become more or less universal. Thus it may be said of this disease that it began in sporadic form, to become endemic in the course of the first observations ; that on its second appear- ance it assumed the proportions of an epidemic in various lands, to finally overleap all barriers as a true pandemic disease. General Remarks. - Cerebro-spinal meningitis be- longs among the rarest of epidemic diseases. Since the establishment of the disease as a pandemic affection, sporadic cases are of continual recurrence, but these cases remain isolated as a rule. The remark of a distinguished 39 Cerebro-Spinal meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. clinician in our own country, that "the disease very rarely occurs save when it prevails to a greater or less ex- tent as an epidemic," will not hold good at the present day. The practitioner is often surprised at being con- fronted with a pronounced case of this disease in a crowded tenement-house, in a palatial suburban resi- dence, in a barrack or jail, in the ward of a hospital, in a distant farm-house, when no similar case may have been reported, and probably no other case may show itself for years. Wide-spread epidemics constitute the great ex- ception in the history of this disease, the outbreak at Dantzic in 1864-5 being the only notable example. The endemics which do occur seem to consist of a series of separate outbreaks among small sections of population rather than of diffused irradiations from first cases. So that individual cases, not distinctly marked, are apt to be overlooked for a time, or erroneously diagnosticated, and numerous instances are recorded in which the diagnosis has been fully established only upon autopsy. The irregularity of occurrence of the disease ; its simul- taneous appearance at remote places; its seeming inde- pendence of every discoverable cause, as regards season, soil, or surroundings of any kind ; the difference in the character of its victims in different epidemics as regards age, sex, or social relation, and in type as regards its symptoms, have served in all times to invest cerebro- spinal meningitis with peculiar mystery and obscurity. The later as well as the older writers have not hesitated f o express these doubts. Holmes said, " It is easier to say what it is not than what it is." Armor declares that "no two cases are alike." Ziemssen admits that the statement of Chauffard, in his account of the epidemic at Avignon, 1840, " L'etiologie de cette affection est restee envelopee d'ombres impenetrables," has even to-day much signifi- cance, and Stille remarks upon a "specific poison abso- lutely unlike any other morbid poison known to path- ology." Cerebro-spinal meningitis "remains, in fact, as inscrutable in its origin as it is lawless and capricious in its development and signs. . . . There is the same ig- norance as to its nature, doubt as to its course, and per- plexity as to its treatment." These are extracts from an editorial comment by the writer of this paper in the Cincinnati Clinic, May, 1872, during the prevalence of a light epidemic in this city. Now, however, that the disease has made itself more familiar by frequent or constant appearance, much of the obscurity surrounding it begins to break away, and cere- bro-spinal meningitis is seen to take its orderly place among the various acute infections, with its own specific cause, characteristic signs, and peculiar lesions. It has been stated already that two sets of symptoms distin- guish this affection; one common to all the acute in- fections, and the other peculiar to the anatomical lesions of this particular disease. But as in all the acute infec- tions, either set of symptoms may assume prominence in an individual case. Niemeyer's statement, "I must again repeat that the symptoms and course of epidemic cerebro- spinal meningitis may be fully explained by the changes in the meninges of the brain and spine," covers only the cases of normal or protracted course, and will not apply to the foudroyante forms of " a disease in which," as Stille remarks, "the septic element sometimes so far overrides the inflammatory as to destroy life before the latter has developed characteristic change." Bearing this explanation in mind it is seen that-aside from its etiology -cerebro-spinal meningitis does not differ more widely from other acute infections than they do from each other. And regarding the cause of the disease it may be said that the many facts accumulated under the patient in- vestigation of the past few years bring us quite up to the verge of its satisfactory solution. The view that cerebro-spinal meningitis was a cerebral variety or form of typhus fever had advocacy enough in the earlier history of the disease to have fixed the name of typhus in connection with it. This view, which was ably supported by Boudin, Murchison, Upham, Baltzell, and others, was based upon a seeming analogy of symptoms -suddenness of attack, petechial eruption, brain symp- toms-in the two diseases, and an occasional coincident prevalence. But more extensive observation has proven beyond doubt that there is nothing more in common be- tween these diseases, to use the language of Burdon- Sanderson, " except, so far as each was due to a specific poison." Holmes writes graphically upon this question : " That a disease which is sometimes almost as sudden in its invasion as a stroke of lightning ; which is rarely sus- pected of being contagious ; which gives us a solitary case in a ship of war, a single case in a boarding-school, two cases only in an almshouse; which in civil practice af- fects the villages and isolated farm-houses of the interior (where typhus ' running the ordinary course ' is unknown) as much at least as the larger cities ; which in a great ma- jority of cases is fatal in a few days, or even hours; the mortality of which is very variable ; such a disease pre- sents so many points of difference, when compared with British typhus, that we should hesitate before pronouncing the two identical." Clymer quotes Tourdes, Levy, Lebert, Niemeyer, Stokes, Gordon, and Hirsch, in protest against this view, citing from Hirsch the statement : " Apart from its very obscure pathological essence there is hardly anything in its symptoms or lesions which brings epi- demic meningitis within that comprehensive and elastic term-typhus." Differing in all essential particulars, Radcliffe says, ' ' doubt can only arise when the two dis- eases prevail together." Any connection of this disease with malaria has been disproved in the same way. Such fluctuations occur in the course of certain cases of cerebro-spinal meningitis as to simulate to some extent the periodicities of malaria, and the ' ' intermittent " is recognized as one of the forms of the disease. But the geographical study of the two affections reveals the fact that cerebro-spinal meningitis does not visit malarious countries with special frequency or virulence ; that it attacks regions entirely exempt from malaria-the high, dry, and sandy plateaus of Cen- tral Franconia, for instance ; that it shows preference for the winter rather than the autumnal season ; that the two diseases have, in short, different spatial and temporal rela- tions, or if they should coincide, the symptoms of menin- gitis do not show increased virulence. Ziemssen quotes in this connection from Bonsaing, who noticed that the epi- demic of meningitis at Pola ' ' did not seek out the noto- riously malarious parts of the city ; " and that ' ' during the epidemic, and after its disappearance, malarial fevers were almost entirely absent." If further proof were wanting to establish the non-identity of these affections it could be found in the absence in meningitis of enlarge- ment of the spleen and liver, and of the melanaemia, so characteristic of malarial affections, in the age of the victims of the two diseases, and above all, in the total in- efficacy of quinine in controlling the disease. These ob- servations, which establish the independence of cerebro- spinal meningitis, meet with striking confirmation at the hands of Diamantopulos, in his account of the epidemic in Asia Minor in September, 1870. Any connection with typhus or malaria is, this author states, ' ' positively to be denied, as during the entire prevalence of meningitis in Magnesia, no case of either of these diseases occurred " (" Schmidt's Jahrbiicher," 196, p. 239, 1882). Lastly, it is claimed that cerebro-spinal meningitis is not confined to man, but that characteristic symptoms and lesions have been observed in some of the lower animals. Gallup observed of the epidemic in Vermont in 1811 that " even the foxes seemed to be affected, so that they were killed in numbers near the dwellings of the inhabitants ; " and Smith remarks of the outbreak in New York in 1871, that * ' it was common and fatal in the large stables of the city car and stage lines, while among the people the epi- demic did not properly commence until January, 1872 " (Stille). Clymer quotes from Law, of Dublin, who writes, in reporting several sporadic cases of the disease in 1865 : " It is a fact worthy of recording that at the time we were attending this lady, nine rabbits out of eleven, which her son had, died all in the same way; their limbs seemed to fail them, they fell on their sides, and then worked in convulsions, and died. Two hens fell lifeless from their roost." Statements of this kind must, however, be taken with much allowance, as the 40 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal Meningitis. symptoms cited by no means identify the disease, and the lesions found upon the bodies of three of the rabbits ex- amined-"congestion of the vessels at the base of the brain " in two, and in the other ' ' vascularity of the mem- branes of the spinal marrow "-are too vague and indefi- nite for a diagnosis. The same reservations must also be made in the case of the so-called epizootic of meningitis among the domestic fowl in Algeria in 1846, among the dogs and hogs preceding the epidemic in Ireland in 1868 (Collins and Ferguson), and more markedly still of the disease among the artillery-horses in Grenoble, 1814, and the livery-stable horses in Paris, 1844 (Villatte), where post-mortem examinations were not made at all. Etiology.-Every attempt to connect cerebro-spinal meningitis with any special climate has turned out a signal failure. The disease has ranged, almost at will, from Gibraltar in the south of Spain, and from Algiers in Africa, to the most northerly towns and villages in Norway and Sweden. And in our own country cases have been reported from Maine to Mexico. The inter- tropical regions proper have, as yet, remained exempt from the disease, but the prevalence of it elsewhere, in seasons of extreme heat and humidity, would indicate this exemption to be an accident of time rather than of space. Equally futile has been the endeavor to fix the disease in connection with any special soil. The coast of France, the valley of the Rhine, the hills and mountains of Cala- bria and Algiers, up to ah elevation of a thousand feet and more, the marshy banks of the Garonne at Bordeaux, the recently inundated fields at Avignon and Aigues- Mortes, the wet camping-grounds at Newbern, N. C., the rocky sides of Gibraltar, and the dry, sandy plateaus of Franconia, have all offered equally fertile soil for the development and dissemination of the disease. Subse- quent writers subscribe with unanimity to the statement of Hirsch that " conditions of the soil seem to be in every respect irrelevant to the occurrence of the disease. " But the season of the year has more to do with the dissemination of this disease. Perhaps the most striking fact apparent in the study of the etiology of this affection is the frequency of its occurrence during the colder months of the year. Thus, of 52 epidemics in France and Switzerland, 23 occurred in winter, 13 in winter and spring, and but 2 in the midst of summer ; while of 16 epidemics in our own country, 6 occurred in winter and 5 in winter and spring. The epidemics of Sweden and Norway, Denmark, Spain, and the Netherlands all oc- curred in winter. Various explanations have been offered to account for this preference of the colder season. That-cold alone, or mere reduction of temperature, will not account for the genesis of the disease is proven by the fact that epidemics have occurred in the midst of sum- mer, even in hot countries, as in Italy, the South of France, and the Southern States of our own country. Moreover, many cold countries-North Russia, Siberia- have never known the disease at all. Obernier attributes the preference for the colder months of the year to the fact that people are more confined to houses at this season, are subjected longer to the evils pertaining to the ' ' house climate." But this view meets with full refutation in the fact that ' ' crowd-poisoning " has never been an ele- ment in the production of the disease. Confinement to the house implies the congregation of people under cir- cumstances which multiply purely contagious diseases, but cerebro-spinal meningitis does not fall in this list. The cases which do excite suspicion of contagion are really more rationally explained by exposure to the same cause. Leaving for the present these extrinsic, some attention must now be paid to intrinsic considerations ; and first, concerning age. While it is acknowledged of cerebro- spinal meningitis that an almost freakish variation has occurred in its attack of individuals, it is generally con- ceded that it shows predilection for the period of youth. Thus, it is stated by Hirsch that of 1,267 fatal cases in Sweden in the years 1855-60, where the age was stated, 889 were under fifteen years, 328 from sixteen to forty years, and 50 over forty years of age. But some quali- fication must be made of these statistics, from the fact that cerebro-spinal meningitis is notoriously much more fatal in the early years of life. Stille quotes from Schweitzer to the effect that in 1866, in the Kronach dis- trict (Germany), of 115 cases, 75 occurred under the seventh year, 22 between the seventh and twelfth years, and 10 between the thirteenth and twentieth years ; and from J. L. Smith, from the " Reports of the Board of Health of the City of New York," who found that of 975 cases 771 occurred in persons under fifteen years of age, and 336 in children under five years of age. In some epidemics children have been the only victims of the dis- ease. This was the' case at Conshohocken, 1863 (Reid) ; Neustettin, 1865 (Litton) ; Westchester, N. Y., 1872 (Rodenstein); and at the Petitburg Colony, 1848 (Ferrus). In other cases the disease attacked children first and adults later, as at Polzin, 1864 (Lehmann) ; Forchheim, 1864-65 (Seggel); Hanover, 1865 (Neynaber), and Jeru- salem, 1872 (Sandrecky). Emminghaus, who reports these data in his article on this disease (" Handbuch der Kinderkrankheiten," 2, 483), makes the collective state- ment, from over fifty extensive observers, that of 1,435 cases 1,133 were under fifteen years of age. All authors agree concerning this, as of all the acute affections, that the period of earliest childhood (suckling) is not affected in like degree. Smith found the proportion of liability to attack at the ages of under five years, as 461 ; five to ten, 204 ; ten to fifteen, 106. Niemeyer's figures for the first two quinquennial periods are as 54 and 40, and Mende's as 47 and 29. On the other hand, in Berlin, the disease was wholly confined to adults. It is definitely ascertained, regarding the period of childhood, that sex makes no difference whatever, and though different results have been reported in different epidemics affecting adults, it is probable that the average number of each sex attacked remains about the same. It is commonly stated that individuals of robust, vigor- ous constitution furnish the greatest contingent of cases. Hirsch remarks that statements to this effect were made to him by relatives and medical men, and Pfeiffer and Heiberg corroborate these statements from their own ob- servations. Yet all such statements of individual obser- vations must be taken with some allowance. We may recall how universally prevalent was this same idea re- garding pneumonia but a few years ago, whereas it is now conceded that the very reverse is true. At any rate it has been remarked by Leyden, of cerebro-spinal men- ingitis, how often weakly children are attacked, and by Ziemssen how frequently the victims of this disease were subjects of chronic brain-affections. Individual epidemics have been frequently noticed to have been distinctly connected with different social states. The selection of soldiers as exclusive victims has made this disease a familiar guest in army life. The recent conscripts and new recruits have been often the sole victims of the disease. Pfeiffer says the disease ' ' prefers winter, soldiers, and children." At times the disease has remained strictly confined to certain corps or companies. On the other hand, other epidemics have spared the gar- risons and camps to attack, as at Leipsic, the civil popula- tion. During the War of the Rebellion citizens and sol- diers suffered alike, and the colored race was not spared, whereas during the outbreak in Texas there was not an instance of the disease occurring among negroes. The same caprice has been exhibited in different epi- demics with regard to the inhabitants of cities and towns. As a rule the rural population has suffered most. In this connection Stille says of the disease : " It has passed by large cities reeking with all the corruptions of a soil sat- urated with ordure and populations begrimed with filth, as Vienna, Berlin, Paris, London, and New York, to de- vastate clean and salubrious villages and the families of substantial farmers inhabiting isolated spots." Roth re- marks of the 42 deaf-mutes attacked at Bamberg that 38 were from rural districts, while only 4 were from the city itself. What made this circumstance the more remark- able was the fact that the disease prevailed in Bamberg in unusual severity. A strict localization of the disease to certain houses, 41 Cerebro-Spinal Meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. flats, or stories has often been observed. Prisons, work- houses, orphan asylums, constitute at times breeding- places of cerebro-spinal meningitis. The epidemic in Ireland,. 1846, was strictly confined to the prisons, and the disease broke out with the same seclusion in the orphan asylums in Philadelphia and Vienna in 1863, Washington in 1869, and Jerusalem in 1872. Keene re- ports a similar outbreak in the Naval School at Newport in 1863. Fatigue of the body (Bollet), exposure to cold and rain (Mannkopf), traumata (Leyden), sunstroke (Schweitzer), the pre-existence of other acute infectious disease (Im- merman and Heller) have all been cited as accidental pre- disposing causes in individual cases, but no one now would claim that any of these factors stand in any direct relation to the disease. The same remarks apply to the alleged psychical causes of the disease, as fright from a peal of thunder (Ziemssen), mental strain, etc. The fre- quency with which the disease has broken out in school has the same significance as attacks at night in bed. Thus it must be confessed that a critical survey of the etiology of meningitis leaves the field as obscure as be- fore. The preference for the colder season, and the pre- dilection for the age of childhood are the sole factors which are universally acknowledged, but so many excep- tions have been noticed to these rules as to deprive them of the force of laws governing the disease. Moreover, the acceptance of these facts furnishes no clue to the nature of the cause of the disease. The fact that the disease oc- curs at the same time in places so remote from each other speaks decidedly against the theory of contagion. Iso- lated examples of infection by contagion have been re- ported by Ziemssen, Prew, Neynaber, and others, and instances have been reported by Niemeyer and Fraentzel of transportation of the disease by detached troops, but in no case has it been apparent that the disease was dis- tinctly contracted by contact with a case. Whether the affection was transmitted in these cases by the clothing or by so-called fomites cannot be definitely decided as yet, but it is everywhere acknowledged that the dis- charges, secretions, or emanations from patients them- selves are not at all infectious. Ziemssen intimates that there may occur some intermediate development of the poison or germs of the disease, which may with the lapse of time become infectious, but this view remains as yet a pure hypothesis. Certain it is that the air about recently dead bodies, more especially of the foudroyant cases, is more poisonous than the air of the sick-room itself. The mode of onset of the disease, the symptoms pre- sented during its course, and the characteristic lesions encountered in the internal organs, assign the disease un- mistakably, in its nosological relations, with the acute in- fections. Hence search was made for something charac- teristic in the way of micro-organisms. But the mycology of cerebro-spinal meningitis is as unsatisfactory as any other chapter in the history of the disease, as the forms thus far encountered indicate nothing special or peculiar to the disease. Thus Leyden found in the exudation and in the tissue of the pia mater of a sporadic case the diplo- cocci, formerly described by Eberth and Klebs, of oval form, united in short chains of two or three members, and assuming color with fuchsin and methylene blue. Marchiafava and Celli (Gaz. degli Ospital., 8, 1884) made the same examination in two cases of epidemic meningitis, discovering constantly in preparations colored with a weak alcoholic solution of methylene blue, oval micro- cocci isolated or united as in diplococci. The micrococci were partly free and partly embedded in the protoplasm of the white blood-corpuscles, rarely in the endothelial cells. Anything approaching chain-like formations were not observed. The tissue of the pia mater contained the same structures as the exudation, but blood from the right heart and splenic pulp proved entirely free. Ughetti (Deutsche Med. yVochenschrift, June 19, 1884) reports also, of examinations made in one of twenty-one cases of the disease, at Ulsterbianco (Italy), the presence of numerous spherical micrococci, partly isolated and partly grouped in pairs, in the sero-purulent fluid from the ventricles of the brain. The author injected a syringeful of this fluid under the skin of the back or abdomen in four rabbits, with entirely negative results. In another case the blood drawn by cups along the spinal column contained "in- numerable micrococci " of exactly the same appearance as those from the ventricular fluid. This blood injected into three rabbits by the hypodermatic method, produced likewise no symptoms worthy of note. Lastly, Schwen- inger (Schmidt's Jahrbucher, cxcvi., p. 130, 1882) speaks of having found enormous accumulations of germs (massen- hafte Pilze) in the brain in cerebro-spinal meningitis. To account for the ingress of micro-organisms into the re- cesses of the brain and spinal cord Eichhorst invokes the action of the lymph-vessels in conveying the excitants of inflammation from neighboring structures, and Weigert calls attention to the destructive suppurative changes which he has encountered in the upper cavities of the nose. In this connection Strumpell calls attention to the remarkable loss of the sense of smell, and to the prefa- tory coryza or nasal catarrh which he has repeatedly seen in this disease. Of these various observations it may be said that they are not so unsatisfactory as incomplete. There is really remarkable coincidence in the character of the micro-organisms encountered, but they lack as yet the pathogenetic proof of culture and successful inocula- tion. After all other possible theories, hypotheses, and de- ductions had been exhausted in the etiology of cerebro- spinal meningitis, quite a new field of inquiry was almost suddenly sprung in the. character of the food-supply. This subject was presented almost at the same time, in 1864, by two observers independently of each other, one in England and the other in Germany, and offering, as it does, a possible explanation of the simultaneousness of attack at distant places, and a plausible reconciliation of many discordant features of the disease in different epi- demics, it is strange that it has not received more con- sideration at the hands of modern writers. The first observer to call attention to the possible pro- duction of the disease by diseased grain was Richardson (B. W.), of London, who suggests in the Social Science Review, May, 1865 (quoted from " Reynolds' System," new edition, vol. i., p. 310), the possibility that epidemic cere- bro-spinal meningitis may arise from the consumption of diseased grain after the manner of ergotism and perhaps acrodynia. lie intimates that "the cause, in fact, is a dis- eased grain or fungus contained in some kinds of flour out of which the breadstuffs are made. This fungus may not be present in large quantities, and many persons may 'eat of the food without getting a poisonous part; but one will get it out of a number, and this without any com- munication beyond the breaking of bread together ; the disease may occur in one member of a family, leaving the rest free, and in this irregular way it may be distributed in an epidemic form over a large surface of country." Day, of Stafford, in making, subsequently, a number of experiments upon rabbits, feeding them with unsound grain (wheat, oats, ergot of rye, and mouldy bread), ob- served in all the animals the production of spasm, in two ' ' inflammatory changes in the right eye, proceeding in one case to ulceration of the cornea and evacuation of the contents of the globe." In all cases there was ob- served upon autopsy ' ' more or less congestion of the membranes of the spinal cord." Prestel, of Emden (Germany), commenced his observa- tions also in 1864, though his article on the subject( " Mo- mente welche bei der Aetiologie der Meningitis cerebro- spinalis in Betracht kommen diirften ") was not published until ten years later. An abstract of this paper is published in Schmidt'8 Jahrbucher, vol. clxiv., p. 243, 1874. In speaking of the colder temperature of the years in which the disease occurred, and endeavoring to account for the fact that the disease does not occur in all cold winters, the author is led to scrutinize closely the more marked symptoms of the disease ; the rapid onset, violent rigor, fever, delirium, unrest, pain on motion, headache, sopor, death ; and in the less acute cases, chilliness, vomiting, fever, excruciating pain in the head and neck, with opis- thotonos and hyperaesthesia ; whereby he is struck with the similarity of these symptoms to those exhibited in 42 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal Meningitis. poisoning by diseased grain, as from ergot {secale cornu- tum), dust fungus, Schmerbrand, or corn-rust (uredo sito- phila'), and the so-called dust-mould (ustilayo segetum). These moulds or rusts did not show themselves in the years 1864 and 1871, but in 1863 and 1870, in consequence of the cold, wet weather of these years, when they were unusually abundant, especially in low, marshy soils. In these seasons, the author thinks it more than probable that the outbreak of cerebro-spinal meningitis, which at- tacked especially the inhabitants of the wet, marshy soil of East Friesland, was caused by "the consumption of bread made from grain grossly adulterated by admixture with ergot of rye, dust-mould, and other entophitic germs." Thus the changes in the weather so often no- ticed in connection with the disease are only indirect causes, just as in the case of the potato disease, caused by the protomyces solani, pteronospera infestans. It is only in consequence of long-continued bad weather that these fungi develop to any great extent. The author describes in detail the seasons of 1863 and 1870, observing that in both years the unusual rainfall (sixteen and twenty-one days) coincided with the efflorescence of the rye, and was followed by a prolonged cold season in which the corn- rust and other fungi developed in luxuriance. The grain of the latest harvest does not come into general use until that of past years has been largely consumed, usually, therefore, not until the following spring. Hence, disease produced by unsound grain would not show itself until after an interval of six months or more from harvest time. The development of sporadic cases of the disease find in this fact a simple explanation, and the exemption of certain countries may be accounted for by the natural history of these fungi in these countries, and by the rigor of police inspection. Of these various forms of fungus or mycelia but one, ergot, has received as yet systematic scientific study, and of this agent it is known that it expends its chief effect in toxic doses upon the central nervous system. Any one familiar with the recent experiments of Dragendorff and Podwissotzky, Nikitin and Zweifel, will not fail to no- tice the striking similarity of its symptoms with those of cerebro-spinal meningitis. One attack of cerebro-spinal meningitis confers the im- munity common to most of the acute infections. At least up to the present time there is but one case of second attack authentically recorded. This was the case of an individual named Lacon, who left the hospital cured Feb- ruary, 1841, to return February 4, 1842, affected with the same disease, which proved fatal on the following day (Companyo : " Essai sur la Men. cerebro-spinale," p. 76). Paris, 1847. Pathology.-One of the shrewdest clinicians of mod- ern times, Niemeyer, whose views regarding this affec- tion met with much opposition at first, deciares in the last expression of his views that he has had no occasion with the lapse of time to change his opinion regarding the nature of the disease. He then repeats : ' ' But we may regard it as very probable that epidemic cerebro-spinal meningitis does not depend on atmospheric or telluric in- fluences, but is rather due to an infection of the body with a specific poison. " The disease begins with the aspect of an acute infec- tious malady, and maintains it throughout its course. As a rule the onset is sudden, with the impress of profound toxicaemia. A chill comes on in the midst of apparent health, with vomiting, excruciating headache, and rapid prostration. Tenderness and stiffness in the back of the neck supervene in the course of a few hours. The face is pale, the expression anxious and strange, the extremi- ties stiff and tremulous. The slightest motion intensifies the pain in the whole body, the act of vomiting makes it atrocious. A sense of formication with hyperaesthesia is felt first, as a rule, in the lower extremities, to which it may remain confined, or it may extend over the whole body. The special senses of sight and hearing become likewise supersensitive. A flare of light, the slam of a door, the rumble of wheels in the street, a touch of the bed, produce a condition of agony. Even the approach of an attendant with the gentlest ministrations is watched with apprehension. Temporary relief of this distress is secured during a state of sopor or stupor which may occur, from which the patient awakens or is aroused -children often with a cri hydrocephalique-with a re- newal of the same symptoms in greater or less degree. In the course of a few days, often during the same day of attack, the stiffness of the neck increases to rigidity, or extends to constitute the characteristic opisthotonos. Convulsive twitchings of the face, or clonic spasms in the muscles of the extremities, may now occur, with deli- rium or outbursts of maniacal excitement under the slightest provocation. Soon various eruptions, herpes and petechiae, begin to make their appearance, at first, as a rule, on the face, to extend later over large tracts of the body, or over the whole body (spotted fever). The temperature curve of the disease distinguishes it- self by its irregularity. As a rule, it rises quickly at first to 102° F., or even 104° F., to fall in the course of a few days, or to undergo fluctuations in extreme degree, sink- ing at times below the normal (Laveran). An extreme hy- perpyrexia not infrequently precedes a fatal termination, which is usually attended, however, with a reduction to correspond with the marble coldness of the skin. The pulse increases out of all proportion to the tem- perature, to experience, later on in the attack, greater fluctuation in frequency, volume, and tone than in almost any other disease. The same variations are noticed also in the acts of respiration, which are often quick and slow in the course of the same hour of the day. The tongue is usually dry and red, in bad cases fissured and fuliginous, and sordes in these cases covers the teeth and gums. The abdomen is sunken and retracted, often to such a degree as to show the outlines of the bodies of the vertebrae, or make distinctly apparent the crests and prominences of the iliac bones. Constipation is present, as a rule. The urine flows scantily and slowly from a paretic bladder, or in the worst cases is voided unconsciously in bed. Trismus, singultus, delirium, and coma, with ec- chymoses and meteorism of the abdomen, mark the speedy advent of the close of the disease ; or relaxation of the opisthotonos, relief of the pain in the head, with critical sweats or enuresis, indicate a favorable resolution. Although different epidemics exhibit great variations in the degree and number of the symptoms cited, cerebro- spinal meningitis usually shows itself besides, in the typ- ical cases mentioned, in one of three distinct forms or types, namely: the abortive, the intermittent, and the siderant or foudroyant. The abortive form exhibits all its symptoms in the lightest grade. The headache is slight, the stiffness of the neck trivial or temporary, and vomiting may not oc- cur, or may not recur after the first attack. Such cases often entirely escape recognition, or are diagnosticated only because of the prevalence of an epidemic of the disease. The intermittent form is noticed more especially in certain epidemics, though such cases are wont to occur in any .extensive outbreak of the disease. Not infre- quently isolated sporadic cases assume this form, to the great embarrassment of the practitioner. Quotidian and tertian intermissions or remissions occur in all the symp- toms of the disease, leading often for a time to erroneous prognostications. The intermissions are by no means as distinct, as a rule, as the periodicities of malarial disease, yet they prove exceedingly deceptive to superficial ob- servation. The exacerbations correspond undoubtedly to the irregular invasions or advances of the disease. The foudroyant is the fulminant form, in which the patient is often killed by the force of the poison before permanent local lesions have time to develop. These are the cases which destroy life in the course of from six to thirty-six hours. The patients in these cases are often suddenly stricken with unconsciousness and convulsions, sometimes preceded for an hour or two with vomiting and pain in the head, in which condition they are carried home, pallid, cold, or lightly cyanotic, showing no reac- tion to the most powerful stimulants, to sink into coma and speedily succumb. 43 Cerebro-Spinal Meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-spinal meningitis is particularly prone to a number of grave complications and sequelae, prominent among which may be mentioned paralyses and paresis of various organs and members, and profound, often per- manent lesions of the eye and ear. Morbid Anatomy.-The external appearance of the body in cerebro-spinal meningitis varies with the duration of the disease. Rapid or foudroyant cases exhibit no change, but cases of longer duration show an emaciation which in protracted illness simulates that of cancer and tuberculosis. No trace of eruption is discoverable, as a rule, though occasionally the surface remains covered with petechiae. Suggillations form quickly and in quan- tity over the body, and post-mortem rigidity sets in soon. Moreover, decomposition begins unusually early in rapid cases, as in other acute infections. In the most chronic forms, with extreme emaciation, bed-sores are common and extensive. The muscular tissue is in the foudroyant cases brown and fragile, in cases of average duration more pale from loss of blood. The molecular change of fatty de- generation invades its structure, and gives it the appear- ance, which is especially remarked of the heart, of being strewn with sand. The condition of the spleen varies greatly. It is usually found swollen, in fulminant forms, with deeply darkened pulp, but not infrequently it is shrunk to such degree as to show a wrinkled capsule. In average cases it is rather the rule to find this organ of diminished size. As might have been expected the intermittent forms show no en- largement of the spleen. The cloudy swelling, fatty and granular degeneration of the kidney and liver, ecchymotic state of the mucosae, oedema of the lungs, effusions in the serous sacs, post-mortem softening of the stomach, swollen condition of the mesenteric glands, dark color and altered consistence of the blood, are changes which belong to all the acute infections, and are especially marked in this disease. The characteristic lesions are encountered at the ana- tomical seat of the disease, in the membranes of the brain and cord. But, as already stated, in the fulminant forms these changes may be absent altogether, and Woodward claims that cases of even more protracted course may be marked in this way. There were two classes of cases observed, he says, in the army of the rebellion. " In the first the autopsy disclosed grave anatomical lesions of the cerebro-spinal axis, accumulations of serum, sero-pus, pus, or tough yellow lymph, especially in the ventricles about the base of the brain and in the upper part of the spinal canal. In the second class of cases no perceptible ana- tomical lesion in the cerebro-spinal axis was observable." The author further observes, " These two classes of cases rest upon equally reliable evidence, and are not to be dis- posed of on the supposition that the latter represent merely an early stage of the former, since it is to be re- marked that both anatomical conditions appear to have been found indifferently in protracted cases as well as in those which proved suddenly fatal " (Clymer, Aitkens : " Sc. and Bract.," 1872). Considering the difficulty of making sections of the vertebral column and of establish- ing an accurate diagnosis between this disease and per- nicious malaria without it, we may still look with some degree of scepticism upon the protracted cases without lesions. Most of us who form our own observations in civil practice with the greater leisure for investigation, will still agree with Valleix, who remarked long ago, ' ' that when there is more or less absence of the menin- geal changes, it is among those who have been struck down by the disease as by a thunderbolt." Light lesions are easily overlooked. Thus in the two rapid cases re- ported by Levick, with unappreciable change, Parks calls attention to the omission of stating whether or not there was opalescence or unnatural dryness of the membranes. We are not to forget, also, how quickly even intense hy- peraemias fade away entirely in the short interval between death and the autopsy. Leyden reports a case of this kind in which Recklinghausen made the examination. On opening the skull the membranes of the brain are revealed in a state of intense hypertemia. The sinus longitudinalis is distended to tension of its walls, and all visible vessels are filled to their utmost capacity. In ful- minant cases there may be no trace of exudation, but the pia mater is already opaque and lustreless, sometimes ecchymotic, from infiltration into its texture. The sub- stance of the brain and cord is cedematous and softened in the most superficial layers. In cases of longer duration the dura mater is stretched tense by the effusion beneath it, punctate haemorrhages are diffused over its surface, and the hyperaemia involves the porous substance of the bones of the spinal column, whose spongy structure appears saturated with blood. The pia mater is reddened with distended vessels, is opaque in some places, ecchymotic in others, and is softened in spots or more extensive surfaces. The first exudation is a light serum, which soon becomes an opaque milky fluid of semi-gelatinous or mucilaginous consistence, sticky, "drawing to a thread," which later becomes greenish, " leek-green," or yellowish with pus. It is effused first in the subarachnoid spaces and along the course of the vessels of the pia mater at the base and sides of the cerebrum, in the fissure of Sylvius and between the cerebrum and cere- bellum, or extends over the whole surface of the brain to form a veritable cap. Or the exudation, more limited to the base, surrounds the emerging nerves, dissecting up their investing sheaths and following them out in their course. In the spinal column the exudation is deposited first along the posterior aspect of the cord, as determined by gravity, but soon extends to its lateral surface and to affect or follow out the spinal nerves in the same manner as in the brain. The thickest masses of exudation are found in the cervical and lumbar regions of the cord, though effusion in spots, bands, or islands occurs irregu- larly throughout its course. In its advance the suppura- tive process invades the sheath of the optic nerve to travel along its course, infiltrate the orbital fat, to account in life for an iritis, choroiditis, or an all-destructive panoph- thalmitis. So, also, implication of and transit along the facial and auditory nerves lead to destructive changes in the ear. But the ravages of cerebro-spinal meningitis do not re- main confined to the membranes of the brain. Mention has been made already of oedema of the substance of the brain and cord in rapid cases, and more profound lesions are to be observed in cases of longer duration. 8triIm- pell has recently {Deutsch. Arch, fur klin. Med., xxx., 5 and 6, p. 505, 1882) described in detail these conditions, which have not received sufficient attention hitherto. His autopsies revealed in nearly all the cases such par- ticipation of the brain and cord as to justify him in nam- ing the disease a meningo-encephalitis and meningo- myelitis rather than meningitis alone. Beneath the inflamed membranes lies a border zone of hyperaemia and infiltration, composed of distended vessels, perivascular accumulations of round cells which dip deep into the substance of the brain, or more especially the spinal cord, with occasional punctate haemorrhages up to the size of millet seed. Disseminated depots of pus of various size, with even larger abscesses, more especially in the sub- stance of the brain (four cases), were noticed as a rule. But, aside from the effects of direct mechanical disturb- ance, there were few visible histological changes in the ganglion cells and fibres of issuing nerves. Although these exudative changes belong more espe- cially to the average or more protracted cases, they have been noticed also in the cases of short duration. Thus Fronmiiller reports the case of a girl, aged fourteen, who died in four days, when the central canal of the cord was found dilated and "filled with pure pus ;" and Gordon speaks of a case in which " purulent effusion was found, although the whole duration of the attack was under five hours (Hartshorne's "Reynolds," p. 306). More credible is the report by Ziemssen, of an "exquisite case," in which the cord was wholly embedded in pus in eleven days. A microscopic examination reveals the fact that the in- flammation affects the tissues through the blood-vessels. Numberless round cells infiltrate the intima and adventitia to collect on the external surface and form the lines and layers of pus-cells along their course. In the substance 44 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal Meningitis. of the brain and cord beneath and about the vessels " pro- liferation of the nuclei in the neuroglia takes place, with swelling of the ganglion cells and granulo-fatty degenera- tion of the nerve-fibres " (Eichhorst). The presence of micrococci in the exudation has been mentioned already. Aufrecht (Deutsch. Med. Wochenschrift, vi., 4, January 24, 1885) found them floating free in the serum, and em- bedded in the pus-corpuscles ; further, in miliary deposits in the liver, lung, and kidney, as well as in the splenic pulp and blood from the heart. They could be colored with fuchsin, and were endowed with active motion. Symptomatology.-The symptoms of cerebro-spinal meningitis naturally fall into two groups, those belonging to the general infection, and those belonging to the local lesion. 1. Our knowledge of the cause of the disease is still too uncertain, and the cases of alleged contagion too dubious to enable us to speak of a period of incubation. We recognize that the period of invasion is very short. The onset of the disease is, as stated in the majority of cases, sudden. Pro- dromal symptoms exist in but five per cent, of cases (Ziemssen), and the symptoms of this period are too vague, in the absence of an epidemic, to establish a diagnosis. Malaise, headache, anorexia, nausea, chilliness, wander- ing pains precede the outbreak of the disease in a few cases. These are symptoms which may mean nothing or may serve as forerunners of any one of the acute infections. The disease dates from the initial chill or chilliness, and subsequent fever, with vomiting, headache, and stiffness of the neck. This chill may repeat itself several times in the course of the disease, more especially in the inter- mittent forms, but it signifies always a new invasion or advance of the disease. During and subsequent to the chill the temperature begins to rise, reaching 100° to 102°, as a rule, by the second or third day of the disease. In foudroyant cases it may run up rapidly from the begin- ning of the disease, reaching a pre-agonal acme at even 108° F. (Wunderlich). Post-mortem elevations are not un- common in bad cases. On the other hand, some of the worst cases show little or no elevation of temperature at all (Hirsch and Ziemssen). In one case reported by Stokes the highest temperature recorded was 98.8° F. The characteristic of the temperature in this disease is irregu- larity. Cerebro-spinal meningitis shows an atypical tem- perature curve, a fact which distinguishes it at once from typhoid fever. Exacerbations and remissions occur so fre- quently in the course of the disease, even in the same day, as to baffle the most patient investigators. Ziemssen declares that few of the curves resemble each other, and Baumler confirms this statement from his own observations. Wun- derlich attempts to account for this irregularity by the successive complications on the part of the bronchi, lungs, intestines, serous membranes, etc., and Emminghaus ap- peals in explanation of it to the influence of oedema of the brain, basal lesions, affections of the cord, perhaps of a heat-regulating centre. The pulse is increased in frequency as a rule. It is usually more full and strong at the beginning of the dis- ease, and may number not more than eighty to one hun- dred beats to the minute throughout its course. But the pulse is subject to the same deviations as the temperature, to which at times it seems to bear no relation. Tourdes and Ziemssen mention variations of thirty to forty beats between observations at different times of the day, and every practitioner of experience has noticed fluctuations in the course of the same observation. In foudroyant cases the pulse may be increased to from one hundred and forty to one hundred and sixty per minute, to become thready and imperceptible before the end of the disease. Abnor- mal slowness, it may be stated here, is much less frequent than in basilar meningitis. The irritation of the pulse- regulating centres in the brain, the changes in the sub- stance of the heart, the poisoning of the blood, as well as the various complications of the disease have all been in- voked to account for the varying conditions of the pulse. The respiration is affected in the same way. Many cases show no especial disturbance in frequency or rhythm, while others are characterized by extreme irregu- larity. Sighing respiration is very frequent in childhood, and arythmia with dyspnoea is not uncommon at all ages. Leyden accounts for the Cheyne-Stokes respiration, some- times observed in the latter stages of the disease, by pressure on the medulla occasioned by oedema. This ex- planation is based upon the observation of this symptom in animals by Schiff, after the artificial induction of hae- morrhage in the vicinity of the medulla, Reference has already been made to a preparatory nasal catarrh in this disease, and in this connection may be mentioned the arrest of the nasal secretion, catarrhus sicca, noticed among the prodromal manifestations by Summerell and Schuchardt. The symptoms on .the part of the digestive system, be- long among the cardinal manifestations of the disease, as vomiting ranks in significance along with the chill, head- ache, and opisthotonos. It is only the mildest cases which show no disturbance of the stomach. It ceases frequently in a few days, to reappear in bad cases, and to remain at times, a more or less constant attendant of the disease. It is especially provoked by the ingestion of food, some- times even of water (Schilizzi), or by rising in bed. The contents of the stomach, then mucus in quantity are re- jected, and later a yellowish-green fluid is regurgitated from the duodenum through an incontinent pylorus. Hart says of his cases (" St. Barthol. Hosp. Rep.xii., p. 105, 1876), that it occurred without retching, was con- stant in bad cases, in which it was always an ominous manifestation. As a rule, however, it is preceded or at- tended by great effort, with such energetic contraction of the abdominal muscles at times as to eject worms from the intestinal canal. Loss of appetite is characteristic of the disease, even in the absence of fever, when it is de- pendent probably upon irritation of the vagus (Eulen- berg). Yet the very opposite condition, boulimia, has been noticed. Reich speaks of a case of progressive ema- ciation, notwithstanding a " voracious appetite" through- out, and Stille observes that "in no other disease is the return of a good appetite and digestion so prompt and complete. " Constipation is the rule in this disease, from inhibition of peristalsis through the influence of the sym- pathetic, and is obstinate to the action of laxatives; yet diarrhoea from gastric catarrh, or dysentery from catarrh of the colon, occurs exceptionally in the later course of the disease. In the worst cases stools are voided continu- ously from a paralyzed sphincter, while the abdomen loses its sunken shape to become tympanitic. Ordinarily the urine is passed freely, and in normal quantity and character ; exceptionally, there is difficulty in its discharge and alteration in its composition. Thus, pain may be experienced in evacuating the bladder, or there may be anaesthesia to such degree as to permit great distention of this organ. Emminghaus speaks of pear- shaped tumors above the symphysis, and Reeve ^Cincin- nati Clinic, vol. iii., p. 2, 1872) mentions the case of a lady who passed her urine " by time," having lost all sen- sation in the bladder. Any neglect on the part of the practitioner may lead thus to a troublesome cystitis. In the last stages of the disease there may be incontinence of urine as well as of faeces. With any reduction in the quantity, the color and specific gravity are naturally in- creased, but the most curious anomaly of the urine in this disease is an increased quantity in the face of fever. This paradoxical condition is accounted for by the pressure and destruction, from the exudation, of parts of the medulla. Resorption of these products during the stage of resolution may lead to irritation of the medulla, with polyuria or glycosuria. The skin shows the greatest variety of eruption of any one of the acute infections, with nothing peculiar or pathognomonic in any. A scarlatinous blush, more es- pecially of the face, is very frequent in the first days of the disease, and a roseolar exanthem, more especially upon the trunk and extremities, frequently follows later. Hirsch speaks of spots resembling measles, Ziemssen men- tions urticaria, Kamph erysipelatous maculae, Grimshaw pemphigus, and Jenks bullae, in individual cases. As to the petechiae which have falsely named the disease, they are most frequently distinguished by their absence. Davis states that they were present in but one-third of the cases 45 Cerebro-Spinal IWeiiingitiB. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seen by him; Tourdes saw only three cases in the epi- demic at Strasbourg, and Stille observed no eruption what- ever in thirty-seven out of ninety-eight cases, in the epidemic at Philadelphia. " Neither Burdon Sander- son nor Wunderlich mentions petechise or vibices as occurring during life ; and Hirsch, after noting their oc- casional presence, is obliged to draw upon American authors for an account of them" (Stille). Yet bloody eruptions or extravasations do occur in this disease as fre- quently, but not more so, as in any acute infectious mal- ady of equal gravity. Thus in the first New England epidemic, and later in the outbreaks at Geneva, Dublin, and Naples, they were frequently present. Stokes and Banas speak of spots which coalesced over some por- tions of the body, "so as to cover a large extent of the skin, and render it completely black, as though it were wrapped in some dark shroud " (Stille). Not infrequent- ly the petechiae or ecchymoses appear only post mortem (Day). The only eruption which has any real significance in this disease is herpes. It begins usually as early as the third day of the disease, and may continue in renewed eruption throughout its course, or, as Hirsch remarks, weeks after full recovery. It shows itself first, as a rule, about the face, on the lips, nose, forehead, and neck, or may extend to the chest, abdomen, back, nates, and even the extremities. Pneumonia is, perhaps, the only disease which shows her- pes in equal frequency, but the herpes of meningitis dif- fers from that of pneumonia, in having no prognostic value. In fact, Hirsch claims that a renewed outbreak rather signifies an exacerbation of the disease. Ziemssen is inclined to regard it as of tropho-neurotic origin. As in all the grave acute infections or septic maladies, cerebro-spinal meningitis is sometimes associated with af- fection of the joints. Jackson likens the articular swell- ings to attacks of gout, and Collins speaks of the swollen, red, and tender state of various joints, especially the knee, elbow, and wrist, and often also the smaller joints of the fingers and toes. Rinecker and Wunderlich observed this complication early in the disease, Salomon and Litten during its course, and Pfeiffer in the period of convales- cence. While articular affections are rather rare in this disease, some epidemics, notably that in Greece, 1869, have been distinguished by their frequency. 2. Of the symptoms produced by the local lesions, pain in the head is among the most prominent. Headache, crushing as if produced by a vice, or boring as from the penetration of nails or screws, is, as has been stated, one of the initial signs, and it constitutes always one of the most obstinate and distressing features of the disease. Strong men cry aloud in the agony of headache, and young children show, on account of it, the peculiar wild strange look, attending excruciating pain, which finds utterance at times in the " cri hydrocephalique." But the localization of the pain does not of necessity localize the seat of the disease, nor does its intensity bespeak its gravity, signs which prove it to be partly due to the sep- tic element. Fortunately, it is subject to intermissions or remissions in the course of the disease, and not infre- quently it disappears altogether. The other signs of the disease may then still remain in force, though cessation of headache may be usually regarded as one of the most favorable signs in prognosis. Wanting should be entered here, however, against that ominous arrest of headache, along with a general euphora, which sometimes immedi- ately precedes the end. Vertigo may Ve associated with the headache, to greatly aggravate the sufferings of the patient by compelling the continued observance of the re- cumbent posture. Tourdes speaks of cases in which the giddiness was so intense as to cause patients to whirl and fall, unable to rise again. Such cases excite suspicion of implication of the semicircular canals. Pain of a similar character, indescribable in its intensity, is also felt in other parts of the body, in the spinal column, rachialgia, in the extremities, or anywhere upon the sur- face in the course of the spinal nerves. Usually such pain is paroxysmal, stabbing, fulgurant, agonizing. It shoots out from the posterior nerve-roots of the spinal cord, where the local lesion, as determined by gravity, is most intense, and carries with it sickening sensations of praecordial depression. A more characteristic, though less frequent, sign of cere bro-spinal meningitis is hyperaesthesia of the surface. It is commonly absent altogether in the lighter or abortive forms, and may not show itself throughout the short course of the foudroyant forms, but it is quite constant, at least in the earlier days of the disease, in cases of aver- age intensity. It is first seen, as a rule, in the lower ex- tremities, to which it may remain confined ; next in the upper extremities, and lastly in the face and head. Like the pain described it may undergo remissions and exacer- bations, may disappear to recur later, or may last over, in regions, to the period of convalescence. When present it adds a peculiar poignancy to the suffering of the patient, who watches with anxious eyes every movement about the room. In aggravated cases it is manifest also during sleep, and even the stupor of coma does not entirely an- nul it. In such cases it interferes with, or even entirely prevents, an examination of the patient, which, however, may be unnecessary, as with the history and superficial inspection it frequently declares the disease. Hirsch, Fraentzel, and Ziemssen unite in saying that it is often absent throughout the whole course of the malady. Opisthotonos stands in the foreground in the semei- ology of this disease. It is rare that some degree of rigidity in the back of the neck is not present, though Burdon Sanderson declares that in the Prussian epidemic, 1864-5, there were many cases in which there was no stiffness or retraction of the muscles. In the lightest cases there is simply a sense of increased resistance on at- tempts at flexion of the head upon the chest-a valuable point in differential diagnosis-or a slight degree of ten- derness to pressure upon the cervical vertebrae. In most severe cases rigidity is marked, with retraction of the en- tire head, to such degree at times as to give rise to ex- treme mechanical dysphagia. Leyden speaks of cases in which the head was bent back at a right angle to the spine, and Gordon mentions an instance in which, in ad- dition to this deformity, the spine presented ' ' a most wonderful uniform curve concave backward." The most striking illustration of the degree to which this extension may occur was reported by Neville Hart (" St. Barthol. Hosp. Reports," xii., p. 105, 1876), in a case in which the pressure of the occiput caused a slough between the scap- ulae. In the experience of this author the degree of opisthotonos corresponded with the gravity of the dis- ease. Not infrequently the rigidity extends lower in the vertebral column, as in Gordon's case just mentioned. Thus Jansen mentions an instance where the whole body could be lifted rigid with the hand behind the occiput, and Ziemssen and Merkel report cases of "orthotonos" in which attempts to flex the head pushed the body like a statue to the foot of the bed. With the other symp- toms mentioned this condition may disappear, to reappear in greater or less degree, undergo fluctuations throughout the disease, continue to the fatal end-as long in one case as forty-nine days-or remain in some degree until full recovery. Ziemssen speaks of convalescents going about with rigid spines, and cases are reported in which the condition lasted throughout life. Usually the retraction is symmetrical, as pleurosthotonos is very rare. The rigidity is due to tonic contraction of the deep muscles of the neck, the splenii; the superficial muscles, the trapezii, remaining unaffected. It is easy to understand it in the presence of the abundant exudation about the medulla oblongata, but the absence of it in the presence of the same conditions remains as yet inexplicable. Besides these tonic, clonic spasms may occur in the muscles of the face, trunk, or extremities, as mere fibril- lar twitchings or veritable convulsions. Children are much more frequently affected in this way than adults, and the spasms occur more often in the graver than in the lighter cases. Sometimes the case begins with a well-marked epileptiform convulsion, and cases, as in the epidemic at Dublin, have been characterized by their persistence throughout the disease. Attempts at changing the posture, or agitation of the patient in any way, as by sounds, or the approach of light, are often the 46 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal Meningitis. exciting causes. Yet, grave as is this complication in adults, it is by no means fatal of necessity. Thus Stille records a case, cited from Vienna, in which "convulsions occurred repeatedly during the first two days, and less frequently during the two following days, but the patient ultimately recovered." In the case of a young lady, un- der the observation of the writer of this paper, clonic con- vulsions of the upper extremities existed continuously for three days and nights, and were only stilled finally by narcotic doses of opium. This patient escaped with life, but with lesions that left it of little value. As a sub-va- riety of convulsions may be mentioned tremor, which occurs exceptionally, more especially in children, and jactitation, which may occur at any time, more especially in the graver cases, and more frequently toward the end. The tonic and clonic spasms, expressions of the stage of ir- ritation, give place in time to paralyses as evidence of de- structive change. Ptosis, paralytic strabismus, and paral- ysis of the facial nerve, may be thus manifestations of the later period of the disease, or may be associated with hemiplegia as evidence of central lesion. Emminghaus quotes in this connection from Leyden, who saw in several cases paralysis supervene in the contracted muscles of the neck. Thus also hyperaesthesia may eventuate in anaes- thesia to such degree as to permit the penetration of a pin. Of the special senses, besides that of touch, the senses of vision and hearing suffer most. Corresponding to the hyperaesthesia or hyperalgesia of the surface of the body, is photophobia, to such degree, as a rule, as to necessitate the darkening of the chamber and the avoidance of arti- ficial light. Graver lesions than this functional disturb- ance, conjunctivitis, iritis, irido-choroiditis, neuritis, atro- phy of the optic nerve, even panophthalmitis, may occur in the course of the disease. The same exaltation of sen- sibility affects the ear with even greater distress, because offence in this regard is less preventable. Suppurative processes in the middle and internal ear, perforation of the membranes, atrophic changes, are among the graver affections of this organ, to be mentioned later among the complications and sequelae. Delirium is pretty uniformly present at some stage of this disease. It sets in, as a rule, on the second or third day, to vary in degree, coinciding often with the fever or the headache, or to be replaced by stupor, apathy, or coma at various periods of the disease. Low forms of delirium are constantly associated with sleeplessness, or incessant mutterings, the so-called coma vigil, alternate with outbreaks of maniacal excitement. Illusions and hallucinations are, though rare, sometimes encountered, and permanent impairment of the intellect may result. Yet long-continued stupor is quite exceptional in menin- gitis, though complete oblivion of every incident of the attack has been noticed not infrequently, even when the symptoms on the part of the nervous system have been of light degree. Complications and Sequelae.-With the elements of a general inflammation of the membranes of the brain and spinal cord, and the implication of the nerves irradi- ating thence over the body, together with affection also of the substance of these organs, superadded to a general poisoning of the blood, it is not to be wondered at that complications and sequelae of various kinds occur in this disease. Among the most frequent and serious of these complications are catarrhal and croupous pneumonia. Of these affections catarrhal pneumonia, or broncho-pneumo- nia, is most frequently encountered in children, and, if developed as a secondary affection, readily undergoes, ac- cording to Ziemssen, favorable resolution. But croupous pneumonia has a much more serious prognosis. It oc- curs more frequently in certain epidemics-fifteen times in the Erlangen epidemic of 1866 to 1872-and develops by predilection in the later periods of the outbreak of the disease. But Jurgensen reports of his cases that the re- lation of the two diseases was in three cases just the re- verse, as the meningitis supervened upon or followed the pneumonia. This author calls attention to the great dif- ficulty of diagnosis in these cases when opisthotonos hap- pens to be absent. In this connection Maurer points to the arching of the fontanelles in young infants as indica- tive of increased intracranial pressure, a sign of great value in a doubtful case. Schilizzi, at Aigues-Mortes; Tourdes, at Strasbourg; Levy, at Paris, and Laveran, at Metz, have all found serous and sero-purulent exudations in the pleural cavity as complications of this disease. Eichhorst emphasizes the frequency with which affec- tions of the throat occur as not sufficiently remarked hitherto, and Pfeiffer found parotitis present in a num- ber of his cases at Thiiringen. In the retrogressive changes which occur during and after the period of resolution various thickenings, throm- botic occlusions, or, permanent hyperaemias, may be left behind. Thus it is not surprising to learn that headaches sometimes remain for years, or for life, or that paralysis of various muscles, especially those supplied by cranial nerves, the abducent, oculo-motor, and facial, develop during the disease, or after it has run its course. Per- haps the most deplorable, if not the most dangerous damage, is done in this way to the organs of sight and hearing. Hypersemia of the conjunctivae, " redness of the eyes," with irregularity of the pupils, and photopho- bia, are to be noticed, as a rule, at the onset of the dis- ease, and affections of the cornea, synechiae, opacities of the lens, iridites, etc., have been mentioned in its course. Fish spoke of cases announced by blindness, to be fol- lowed later by symptoms on the part of the spine, and though the amaurosis was in his cases always temporary, examples of permanent loss of sight are abundantly re- corded. Rudnew claims that a microscopic examination reveals suppurative inflammation of the uveal tract, as a rule, in this disease. The affection begins in the capil- laries of the choroid and proceeds to invade its entire structure. The ear is affected, as stated, in both its middle and in- ternal parts. In a case reported by Ziemssen the pain of an otitis media began as late as the twenty-fifth day of the disease, and perforation with the discharge of pus did not occur until the thirty-sixth day. Heller and Lucae and Moos describe cases in which the trunk of the auditory nerve was embedded in pus, with hyperaemia of the neu- rilemma, suppurative inflammation of the cavity of the drum, haemorrhage and pus in the membranous labyrinth. Per contra, Ziemssen has seen cases in which the floor of the fourth ventricle was " macerated by pus, and the audi- tory nerve, together with the facial nerves, completely surrounded by the purulent exudation, without the oc- currence of deafness during life." But cerebro-spinal meningitis is one of the most common causes of deaf- ness, perhaps the most common cause of all diseases af- fecting the internal ear. For in the vast majority of cases the affection is bilateral and permanent. Knapp states that in every ohe of thirty-nine cases the deafness was bilateral, and, "with the exception of two cases of faint perception of sound, complete." Should this com- plication occur in the earliest years of life the patient is not only deaf but also dumb. The Bamberg Deaf and Dumb Asylum contained, April, 1874, forty-two pupils- deaf-mutes, without exception, from cerebro-spinal menin- gitis ; and of the thirty-two inmates of a similar institu- tion at Nuremberg, twenty-two were victims of this dis- ease. Moos mentions further that one-half of his cases that recovered from the disease with some impairment of hearing, showed also disorder in maintaining their equi- librium. That processes of cicatricial contraction, by thicken- ing and shrivelling the pia and obliterating its plex- uses of vessels, may lead eventually to chronic hydro- cephalus, or that these accidents with the deeper lesions in the substance of the brain and cord may beget aphasia, anarthria, impairment of memory or other faculties of the intellect up to complete imbecility may readily be in- ferred. One case illustrative of the.extent of damage that may be inflicted by this disease upon a patient who barely escaped with life may be cited from the graphic descriptions of Gordon. This was a case in which the patient recovered from all the acute symptoms, but gradually, in fifty-eight days after the invasion of the disease, passed into a state of almost organic life. " He 47 Cerebro-Spinal Meningitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ate, drank, and slept well; he passed solid faeces and urine without giving any notice, yet evidently not uncon- sciously ; he was excessively emaciated, and there was a peculiar mouse-like smell from him ; he seemed to understand what was said to him, but he could not an- swer ; he never called for anything ; his breathing was rather slow ; his pulse 120 ; his heart acting with a pecu- liar strong jerking motion ; his eye was quite well as also his knee (he had suffered from ulceration of the right cornea and immense effusion into the right knee-joint) ; he could draw his legs and arms up to him ; but he could not use his hands at all." Duration.-Cerebro-spinal meningitis has no definite duration. Hirsch says of it that it may last from a few hours to several months. The first period applies to the foudroyant cases, in which patients are killed as by a stroke, the last to the cases with complications or se- quelae, which may, indeed, prolong the disease indefi- nitely. Gordon's shortest case was five hours, and Jewell records a case of death in three hours and a half after seizure. These are, of course, most extreme and excep- tional cases. Clymer states that more than one-half the deaths happen as early as from the second to the fifth day. This author quotes also from Parkes, who found the dura- tion of the disease in 66 of 95 cases, five daysorless ; in 1, eight days; in 28, eight days or over. Abortive forms terminate in resolution in from three to five days, fou- droyant forms, with rare exceptions, in death within three days, and intermittent and average forms in one or the other way, barring complications and sequelae, in from one to three weeks. Diagnosis.-In the presence of an epidemic of the dis- ease the diagnosis of cerebro-spinal meningitis is suf- ficiently easy. The existence of cases in the vicinity prepares the practitioner for new attacks. Cases which are affected with, or more especially quickly succumb to, any disease with predominant nervous symptoms should excite the suspicion of the physician in this direction. Sporadic cases, however isolated in space or time, are likewise readily recognized in the presence, in sufficient number, of the symptoms peculiar to the disease. The sudden seizure, often in the midst of health, with chill, vomiting, and prostration, followed by opisthotonos, hyperesthesia, herpes, irregular pulse, constipation, con- stitute an array of symptoms that belong to no other disease. Unfortunately for the diagnosis many cases de- viate from the regular type in essential particulars, more especially in the absence of characteristic signs, to such degree as to make the diagnosis difficult or at times im- possible. Foudroyant cases differ most widely by the predominance of the symptoms of blood-poisoning which are common to all the grave acute affections. Light is sometimes thrown upon these cases by the considera- tion of the season of the year, the age of the patient, the existence of other cases more pronounced, or, if equally obscure, by the exclusion of simulating maladies or acci- dents. Thus a meningitis from trauma, insolation, or otitis, should be discovered by the history and inspection of a case ; or occurring in the course of scarlatina, pneu- monia, septicaemia, it should be eliminated by the pres- ence of signs characteristic of these affections. Typhoid fever distinguishes itself by the fact that it usually spares the period of earliest youth, that its onset is insidious, that it is attended with diarrhoea and disten- tion of the abdomen, that it often shows a rose-color erup- tion, has a constant high pulse, a typical temperature curve, and a definite duration. Moreover, typhoid fever almost never shows herpes, and almost always shows en- largement of the spleen. Malarial fever is marked by its preference for certain regions and certain seasons of the year. Periodicity is the criterion of malaria, and though this factor is simulated in the intermittent cases of menin- gitis it is never so. precise. Reeve says the early vomit- ing wras the key to the diagnosis of his first cases of men- ingitis. Whatever doubt may exist at first is quickly dissipated by the administration of quinine in sufficient dose. Tetanus is eliminated by its trismus, and hydro- phobia by its characteristic paroxysms of inspiratory spasm. Tubercular meningitis rarely shows symptoms on the part of the spinal cord, though opisthotonos and hy- peresthesia are not uncommon in this disease. Tubercu- lar meningitis is nearly confined to childhood. In the great majority of cases its victims are of tuberculous pa- rentage or stock. It is not affected by the season of the year. It distinguishes itself especially by its long prodro- mal stage, by its periods of reduction of temperature and retardation of pulse, by the occasional signs of tuber- culosis elsewhere, in the lungs or intestines, externally (scrofulosis) upon the skin, or possibly in the bottom of the eye. The extreme difficulty or impossibility of making a diagnosis in the absence of characteristic signs was well illustrated in a case reported by Jurgensen from the Polyclinic at Kiel, in May, 1872, in which the persistence of the fever, notwithstanding the use of quinine and cold baths, at last awakened the suspicion of brain disease, the exact character of which was only established upon autopsy. In this connection may be related a case re- ported by Jaffe (Deutsch. Archie, f. kiln. Med., xxx., 3 and 4, p. 332, January, 1882), which has also forensic interest. The patient, in consequence of fracture of the skull from a fall, was affected with vomiting, stiffness of the neck, convulsions, and coma. Death occurred on the third day, and the autopsy revealed, besides fracture of the skull, an extensive suppurative cerebro-spinal men- ingitis, with such characteristic signs as to compel the belief that the patient was suffering from latent menin- gitis at the time of the accident, which was the immediate cause of death. Prognosis and Mortality.-The prognosis of this disease is always grave. The factor of most importance in its determination is the type of the disease. Foudroy- ant cases perish with very rare exceptions; abortive forms recover with few exceptions, and average cases survive and succumb in about equal number. The char- acter of the epidemic is the next consideration. Certain outbreaks are distinguished by their mildness, as are others by malignancy. Thus Lowe and Wooley (London Lancet, June 26 and August 3, 1867) report that not a single case died in the outbreak at Bardney, in Lincoln- shire, England, in January and February, 1867, though the disease was characterized by " severe rigors, tetanic con- vulsions, intense neuralgic pain in the head and upper part of the trunk, increased sensitiveness of the surface, obstinate vomiting, restlessness, and in one instance, at least, by a dark purple eruption" (Hartshorne's " Rey- nolds," vol. L, p. 308). On the other hand, Wunderlich, Stonone, and others, give instances in which not a single case recovered. Young reports of the attack at Granada, Miss., that every one of the 35 cases perished, and the same fatality attended the first outbreak of the dis- ease at Memphis, Tenn. Between these extremes is every grade of gravity in different attacks. It is also true of this, as of most of the acute affections, that the first cases are most severe. The epidemic grows feebler, as a rule, with the gradual exhaustion of its most fertile soil. In- dividual considerations follow next. The prognosis is more grave in infancy and childhood than in adolescence and maturity. The ratio of mortality falls from 75 per cent, in children under one year of age, to 53.5 per cent, in later childhood, and 35 per cent, in adolescence. Not to burthen this section with a useless array of figures from different epidemics-useless because inapplicable to individual cases-the general statement of Hirsch may be given as indicating the average mortality of this disease. Of 15,632 cases analyzed by this indefatigable statistician, 5,734 terminated fatally. Thus the average ratio of mor- tality of this disease, under all conditions, is given at 37 per cent. The influence of "bad hygiene" in aggra- vating the prognosis is too patent to require mention. Of more importance are the signs which prognosticate the result in individual cases. It may be stated, as a rule of this, as of all the acute infections, that a severe onset indi- cates a grave case. Thus a high fever at the start, ob- stinate vomiting, marked opisthotonos, early convulsions, are signs of ominous import. As one-half the deaths happen before the fifth day (Clymer), a case which sur- vives the first week has a more favorable outlook. The 48 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cerebro-Spinal meningitis. an open fire, preferably in a grate. The physician and the necessary attendants should be the sole visitors. Quiet should reign supreme. In no other disease is con- tinuous or officious ministration so meddlesome and mis- chievous. Even cleanliness or apparent discomfort in posture must be sacrificed at times to peace of mind. The diet is to be simple and light at first, but as nutritious as possible with returning health. Beef-tea palatably made, soups of any kind, milk, if it do not increase constipation, scraped raw meat, with a little salt, gruels, if not distaste- ful, with water, seltzer water, Apollinaris, any simple car- bonated drink, should be proffered at proper intervals, without over-solicitation or any anxiety should everything be refused. With the beginning subsidence of the dis- ease an egg may be dropped into the soup, or sweet- breads, fish, the white meat of fowl may for a few days preface the more solid meats. Especial attention is to be paid to the bladder. The soft catheter, thoroughly cleansed, warmed above the heat of the body, and greased with pure vaseline, brings this organ, when refractory, under control. Constipation is overcome with calomel, two to ten grains, or castor-oil, in preference to an enema, which causes too much dis- turbance. The treatment proper is purely symptomatic, and has reference to the two sets of symptoms, general and local. Of these the symptoms produced by the local lesions- pain, opisthotonos, hyperaesthesia-assume prominence in the great majority of cases. For the relief of these symptoms no remedy equals in value opium. Opium is the "sheet-anchor" in the treatment of cerebrospinal meningitis. It acts solely by its anodyne influence. It protects, by obtunding, the nervous system until the force of the poison is spent. Surprising amounts of the drug may be given in this disease without narcotic effects. Thus Steiner often gave ten grains at a dose in cases of severe convulsions without producing stupor; Chauffard, three to fifteen grains ; and Boudin, seven to fifteen grains at first, and later, one to two grains every hour before soporific effects were produced. Stille was in the habit, he says, of prescribing one grain every hour in very severe, and every two hours in moderately severe cases, without inducing even an approach to narcotism in any case. " Under the influence of the medicine the pain and spasms subsided, the skin grew warmer and the pulse fuller, and the entire condition of the patient more hope- ful." When quick effects are to be had, or when the drug is rejected by the stomach, resort will be had, of course, to the hypodermatic use of morphia. Ziemssen gives expression to an experience made by every prac- titioner with this disease when he says that morphia is, without doubt, ' ' indispensable " in its treatment. But " medians systematicus periculosissimus vir ; " that would be indeed a routine physician who would prescribe opium indiscriminately in every case. There are other symptoms than those offered by the local lesions. In the foudroyant cases, and in all severe cases, the element of blood-poisoning is to be met. The best antiseptic we possess in this disease is alcohol, and what slender chance is offered in cases in which this element assumes promi- nence is favored most with this agent. The same toler- ance to alcohol as to opium exists in this disease. Arnell declares that he has given a quart of brandy within from six to eight hours with the happiest effect. It is almost impossible to produce with it toxic effects ; in fact, it is true of this as of all the grave acute infections, that when symptoms of intoxication supervene it is a sign that the disease has run its course. But alcohol indiscriminately used may do more harm than good. It is of value only in controlling a profound toxicaemia, as in puerperal sepsis, snake-bites, etc., when it should be given in the largest dose; or in milder form, as in wines, at longer intervals, in the stage of convalescence. Venesection in this disease belongs to history, or is only at most to be practised in relief of intracranial pressure, as in apoplexy, in the most sthenic cases, and in these cases the same results may often be effected by milder means, as by purgatives, calomel, and jalap. But local blood-letting by cups along the spine, or by leeches behind first three or four days are attended with the greatest anxiety. "Every day passed after the seventh day ren- ders recovery more and more probable " (Loomis). Ty- phoid symptoms at any stage of the disease imprint upon it an unfavorable prognosis. Arching of the great fon- tanelle, as indicative of intracranial oedema and exuda- tion, is a very bad sign. Almost all such cases end fatally (Maurer). A return of headache and vertigo which has disappeared, especially if associated with vom- iting and convulsions, evidences of consecutive hydro- cephalus, is likewise ominous (Ziemssen). Yet secondary hydrocephalus is not absolutely hopeless, as Ziemssen saw ' ' some cases in which a complete, and others in which an incomplete, recovery took place." Profuse sweats, with cold surface, are characteristic of a fatal issue (Hirsch). The persistence, after recovery from the •disease, of anorexia, debility, and emaciation, perhaps with diarrhoea, give a poor outlook, especially for chil- dren (Emminghaus). A sudden high elevation of tem- perature, or hyperpyrexia, after a chill in a previously apyretic case, means a complication and not a fatal issue, but a hyperpyrexia without chill, and with a profuse sweat, is pre-agonic (Immermann). Prophylaxis.-Although cerebro-spinal meningitis is not a contagious disease occasional instances are reported which would seem to prove infection in this way, as by Niemeyer, Fraentzel, Hirsch, Stokes, Simon, and Ziems- sen. Bristowe goes so far as to define the affection as a " specific contagious fever'," and so long as such a view may be entertained by any recognized authority, cases should be treated as if contagion were possible at least. Thus, as Flint suggests, though isolation be not necessary, ' ' removal of persons from without the area in which the disease prevails is desirable." Inasmuch as certain bar- racks, asylums, tenement-houses, schools, etc., become at times centres or depots of the disease, these institutions should be thoroughly cleansed and ventilated, or what is better still, vacated or closed. For while it is admitted that " crowd-poisoning," with all the defective hygiene the term implies, cannot develop the disease, it is as fully acknowledged that these circumstances eminently favor its spread. At least this was the condition, in aggravated degree, which attended its most extensive outbreak in Dantzic, 1865, when the disease prevailed, according to Hirsch, "exactly in that season of the year in which, on account of inclement weather, many individuals were crowded together into small and dirty rooms, kept con- stantly closed by their occupants, and from which all ventilation was excluded, and in which the before-men- tioned unfavorable hygienic conditions (dampness, great filth, and an atmosphere loaded with putrid emanations) were extremely perceptible." While it is not necessary that the physicians and attendants shall take the same precautions with their own personnel as in diseases emi- nently contagious, yet in the light of existing knowledge full disinfection should follow post-mortem examinations, and short and limited contact should be had with the bodies of the dead. During the prevalence of an epi- demic caution should be enjoined against excessive mus- cular effort, the unrestrained excesses of childhood for example, against exposure to cold and wet, or excessive mental labor. In the presence of this as in all acute in- fections, the source of the drinking-water should be studied, and in this disease, more than in almost any other, inspection should be made of the food supply. This factor of food demands more thorough investigation under the suspicions which have been expressed in the section on the etiology of the disease. It is a fact which ceases to be curious or strange, if these suspicions should ever be confirmed, that of Niemeyer's 28 cases among adults, 16 had to do-as farmers, butchers, waiters, tavern- keepers, clerks-with the dispensation of articles of food. Therapy.-A patient affected with this disease should lie upon a comfortable bed, not too hot, in a spacious, continuously ventilated room, whose windows can be darkened if necessary while they still admit the air, as remote from the street with its offensive sounds as may be. The temperature of the room should be regulated with a thermometer near the head of the bed at 65° F., by 49 CesStode"1.Me,,i,,SltlS* REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the ears, may often relieve the headache and unrest. Cold, in the form of bags of ice to the head or along the spine is of great value when the period of excitability, hyperaesthesia, and jactitation may have given place to the state of sopor and indifference. Radcliffe claims that " the application of cold to the head and spine either by means of ice or a freezing mixture in Esmarch's (or Chap- man's) india-rubber bags, has furnished by far the most satisfactory results of all direct treatment." Vomiting is best relieved by ice, champagne, efferves- cent drinks, milk and lime-water, bismuth, soda, carbolic acid, or creosote. No drug equals in efficacy sips of wrater excessively hot. Hiccough is often brought under control by the same means prescribed for vomiting, by the administration of a few drops of the oil of cajeput, or by clysters of sodium bromide. More obstinate cases of either vomiting or sin- gultus call for the subcutaneous use of morphine. It is useless to encumber space in a work of this kind with more than a mention of other remedies lauded in the treatment of this disease. As to quinia, which was recom- mended by the committee of the American Medical As- sociation, it is now admitted to be of no avail whatever, except in antipyresis, a call which is seldom made in this disease. But in the exceptional cases, in which high fever does occur, quinia in scruple dose, salicylic acid or anti- pyrin in double the quantity, are more valuable than the cold bath, because of the commotion created by the bath. Blisters, moxae, ferrum candens, are brutal assaults in the height of the disease, but may be justifiable in the treatment of sequelae. The same remarks apply to the use of electricity. Ergot, iodine, physostigma, mercury, the benzoates, the bromides (which may substitute opium in a very mild case), other anodynes, belladonna, with a host of other remedies, have been recommended on the- oretical grounds, or praised as specifics by practitioners of the "experience" school, who for the most part remain untrained to eliminate " the personal equation," but none of them stand the test of time. The various symptoms presented in the course of the disease are treated precisely as are the same symptoms in any acute infection, after methods mentioned in detail in this work in the history of diseases in which these symptoms assume especial prominence. There is as yet no radical or specific treat- ment of this affection, the therapy of which, unfortunately, has not advanced, except by exclusion, since the day of the declaration of Valleix, to the effect that hitherto " opium is the only drug which has appeared to exert any real influence over the disease." James T. Whittaker. CERVICO-BRACHIAL NEURALGIA. This term sig- nifies neuralgia affecting any of the nerves which ema- nate from the brachial plexus. This plexus is formed by the four lower cervical and the first dorsal nerves. The cervico-brachial nerves are distributed to the shoulder, the thoracic and scapular regions, to the arm, forearm, and hand. Pain, ofttimes of great severity and fluctuating in in- tensity, is the most prominent symptom. The pain fol- lows the course of one or more of the nerve-trunks. Its most frequent manifestations, however, are observed in the ulnar nerve, which is one of the largest and, in its situation, the most exposed of this group, though there is a constant tendency to implicate, simultaneously or successively, several of the branches of the plexus. In character, the pain is substantially the same as neuralgia experienced elsewhere. A conspicuous feature of this variety of neuralgia is the large number of painful points which have been observed -a fact doubtless accounted for by the exposed situation of the several nerves, and by the variety and extent of the muscular movements which the upper extremity is ordinarily required to perform. The principal painful points will be found in the axilla, near the inferior angle of the scapula, at the acromial end of the clavicle, in the bend of the elbow, above the inner condyle of the hu- merus, and at the wrist. Among the causes of cervico-brachial neuralgia, anae- mia, malaria, lead-poisoning, wounds, burns, bruises, and excessive muscular exertion are pre-eminent. The diagnosis may be made without difficulty. There is no reasonable probability of confounding this with any other affection. The prognosis for permanent relief is favorable, pro- vided the cause is amenable to treatment. The constitu- tion and age of the patient, however, are entitled to care- ful consideration. Imprudent use of the limb tends to hinder recovery, and to provoke a return of the pain after it has disappeared. The treatment must have reference to the relief of pain, and to the removal of the predisposing and exciting causes. Opium in some form, combined with belladonna or hyoscyamus internally, or morphine hypodermatically ; blisters, counter-irritants, and galvanism are all valuable remedies. Quinine and iron, and other vegetable and mineral tonics, are usually indicated. Malaria, while perhaps not so common a cause in the production of this variety of neuralgia as in some of the other forms, should, nevertheless, in the absence of other appreciable causes, always be suspected, whether the pa- tient lives in a malarial district or not, and even if no regular periodicity should be observed in the access of the paroxysms. Quinine and arsenic are here indispen- sable. Any constitutional infection should be appropriately met. Local rest should be prescribed, and the general system should be invigorated by change of air and scene, by generous diet, by stimulants and tonics, and by the observance of a hygienic mode of life. . James B. Baird. CERIUM. A single salt only of cerium is officinal in the U. S. Pharmacopoeia, namely, the cerous oxalate, en- titled Cerii Oxalas, Oxalate of Cerium : formula, Ce2 (C2 O4)s, 9 II2O. This salt is " a white, slightly granular powder, permanent in the air, odorless and tasteless, in- soluble in water or alcohol, but soluble in hydrochloric acid" (U. S. Ph.). In effect cerous oxalate most nearly resembles the insoluble bismuth compounds, being, from its insolubility, devoid of active properties, but yet, like many other insoluble metallic powders, having a power to allay local nervous irritability. This influence is availed of to combat reflex nausea and vomiting, espe- cfally the vomiting of pregnancy, and also to repress irri- tative dry coughs. In this latter application, when suc- cessful, the present drug has the advantage over the ordinary run of cough medicines of not disordering the stomach, but, on the contrary, of tending to quell any irri- tation of that organ. The oxalate may be given in doses of from 0.30 to 0.65 Gm. (five to ten grains) several times a day, best taken dry upon the tongue. Such doses may be kept up for a number of days in succession with no other effect than causing, at first, a little dryness of the mouth. For cough the medicine should be persisted in even if, as may happen, there be no benefit for the first two or three days ; and doses should particularly be given on the empty stomach early in the morning and late at night.1 Edward Curtis. 1 Report to New York Therapeutical Society, The Medical Record, June 12, 1880. CERVICO-OCCIPITAL NEURALGIA. A purely ner- vous pain affecting any of the posterior branches of the first four pairs of spinal nerves is called cervico-occipital neuralgia. It may be manifested in the great occipital, the superficial cervical, the auricular, the small occipital, or the superficial descending branches of the plexus. But the great occipital, which, it will be remembered, arises from the second pair and is distributed principally over the posterior portions of the neck and of the scalp as far as the vertex, is the nerve most commonly affected. The symptoms attending this variety of neuralgia are similar to those which pertain to neuralgia in other situa- tions. Pain of greater or less intensity is, of course, the essential feature of the attack, and, while it may not be so acute as in some other forms, it is frequently very severe. The pain may be dull or lancinating, boring or burning, tearing or cutting, and, as elsewhere, is inter- 50 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. C.-Spinal meningitis. Cestodes. mittent or remittent in character. Tenderness upon press- ure is observed over the region involved, more particu- larly at the points where tlie nerve is most superficial, and aggravation of the pain is occasioned by movements of the head. It is the commonly accepted opinion that exposure to cold is the most important and most frequent exciting cause of this form of neuralgia, and, no doubt, this pop- ular notion is well founded, for many cases are distinctly referable to sleeping in a draught, sitting by an open win- dow. riding in the wind, etc. ; but it should be borne in mind that conditions of bodily debility always favor and invite neuralgic developments, and, like other varieties of the disorder, this form is encountered most frequently in anaemic subjects, or in persons whose vital powers have been depressed by exhausting illness, or by the operation of any cause whereby the vigor of the system has been impaired, as haemorrhages, malarial infection, prolonged lactation, deficient nutrition, overwork, illy ventilated apartments, close confinement within doors, sedentary occupations, etc. The diagnosis is sufficiently easy, and can be readily reached by noting the features of the attack to which reference has been made. Discrimination may be made between this disorder and the so-called muscular rheuma- tism affecting the post-cervical muscles, by attention to the painful points-the points douloureux of Valleix- situated between the mastoid process and the cervical vertebrae, over the posterior cervical plexus, on the pari- etal portion of the head, on the mastoid process, and in the concha auris ; the tenderness is not so diffused, and the pain is more or less constant, and is not dependent upon muscular movements merely for its incitement. The prognosis depends upon the ability to correct the cause. Under proper management it is generally favor- able, especially for the relief of a given paroxysm, but the circumstances and conditions of the patient must be carefully considered in forming a judgment as to perma- nent cure. The treatment should be directed to the removal of the ascertained or suspected cause in each individual case, to invigorating the system, to the correction of any consti- tutional taint that may exist, and to the application of such topical and general remedies as experience has proven to be useful. Quinine holds an important place as a therapeutic re- source. It is often necessary to use it in full doses, though seldom, or never, in the fabulous quantities which fashion, these days, fearlessly prescribes. In the opinion of the writer, it is, at this time, one of the most grievously abused remedies in the whole range of the materia medica. Frequently the exhibition of the drug in tonic doses for a protracted period yields the best results. Arsenious acid is a remedy which holds a deservedly high place in the treatment of neuralgia. Unlike quinine, it is of doubtful utility in cases which are not of malarial origin. In order, however, to receive its full beneficial influence, it is often necessary to administer it in gradu- ally increasing doses until its toxic effects are obtained. Among the remedies classed as anodynes, opium and belladonna are specially valuable. Morphine hypoder- matically administered is not only palliative, but is often positively curative. It is immaterial into what part of the body the injection is made. Tonics are always indicated. Iron, nux vomica, cod- liver oil, etc., are important adjuncts to any specific medi- cation that may be employed. Of the local remedies of value, electricity and blisters come first, followed by sinapisms, heat, stimulating em- brocations, etc. Not infrequently the milder applications suffice. The constant galvanic current is the form of electricity to be recommended. Care should be taken not to use a current of too great strength, but to continue its applica- tion at each sitting for a considerable time-longer than is usually advised. It is sometimes more efficacious if the electrodes are gently moved over the skin, along the track of the offending nerve, than if the stabile method alone is employed. Hygienic measures are never amiss, and they are truly important. An abundant supply of nutritious food adapted to the digestive capacity of the individual, seasonable clothing, exercise in the open air ; and, in a word, the ob- servance of that mode of life which will foster and pro- mote bodily strength and vigor is of paramount consequence in the successful treatment of this affec- tion. James 13. Baird. CESTODES, or tape-worms, are flat worms without .mouths or in- testines. There .is simply the sco- lex, or head, following which are arranged in single file numerous links or segments, called also cu- curbitini, joints, or proglottides, the band-like colony being known as a strobile. The worm is nourished by ab- sorption through the skin, and per- haps through vascular canals (called the aquiferous system), one running down each side of the worm, ami connected by transverse vessels. The proglottides increase in size and development as they recede from the scolex ; the younger ones coming next to the head or nurse, and thus crowding the old ones away. The head, or scolex, is often sup- plied with hooks and suckers ar- ranged in a radiate manner, thus enabling the worm, in whatever position it may be placed, to cling to the intestines of its host. The back and belly of the worm are alike. The scolex is developed from a spherical embryo (cysticercus), which inhabits the most varied organs of different animals, whence, without effort of its own, it reaches the intestines of its permanent host. The scolex and attached proglottides form a colony which is usually spoken of as a tape-worm, and is often regarded as one individual; but the links or proglottides continue to live after being separated from their neigh- Fig. 618.-Strobile of Beef Tape-worm, with Occa- sional Interruptions, showing Head and Links of reduced Size. Fig. 619.-Pregnant Proglottid of Bothriocephalus Latus, Ventral Sur- face. a, Anterior border of link; b, b, nerve filaments; c. germ layer ; d, germ duct; e, e, yolk glands ; f, yolk canal; g, yolk duct; h, shell glands ; i, i, uterus ; k, opening of uterus on ventral surface ; I, vagina ; m, end of vagina; n, porus genitalis, showing end of vas deferens and vaginal opening of same; p, penis sheath. (After Sommer, " Real Encycl.") bors, and the head continues to throw out new links as long as it remains adherent to the intestines. The male and female sexual organs coexist in each 51 Cestodes. Cestodes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mature proglottid ; those near the scolex show no sexual organs ; further down the male organs become perceptible. In the more distant segments both male and female are when in the adult state they frequent the small intestine, but as bladder-worms they enter almost every part of the body. Of the bladder-worms the cysticer- cus cellulosae (of taenia solium) and hyda- tids (of taenia echinococcus) are especially well known. The most common varieties of tape-worm in man are the taenia medio- canellata (from beef), and the taenia solium (from pork). The latter, having booklets as well as suckers, is sometimes said to be more tenacious of its position in the bowels, but it is smaller and less muscular than the former. The development of a tape-worm to sexual maturity and detachment of the links requires from eight to twelve weeks, originating from bladder- worms introduced into the stomach along with raw or imperfectly cooked meat. It is said that in Abyssinia almost every one has tape-worm (taenia saginata or medio- canellata) from eating raw beef, still warm, called "brindo." It is not certain how long a tape-worm may live in the small intestine ; stories of their having infested the same host twenty or thirty years need confirmation. But Bremser saw in Vienna a Swiss who had a bothriocephalus (which worm is common in Switz- erland, but unknown in Austria), al- though he had been away from home thirteen years. Tape-worms usually are solitary, al- though several of the same, or even of different species, have been known to exist in the same person. Patients may have them for years without inconvenience, and only know of their presence by the occasional dis- charge of links ; but they often induce undefined disagreeable sensations, due to disturbances of digestion and nutri- tion, or of the nervous system. There may be severe colic when fasting or after the ingestion of certain articles of food, and flatulence with alternating diarrhoea and constipation. Nervous or cerebral symptoms in a patient with taenia solium may perhaps arise from self- infection with cysticercus, the eggs from the proglottides being hatched in the host • and working their way through the body. The only certain means of diagnosis is the discovery of the links, or eggs (see Figs. 622, 623, and 624). It is also important to distinguish taenia solium from the varieties having no hooks, as this form is said to be more difficult to dislodge. Its proglottides are less apt to pass off with the faeces, are not so strong or full of eggs, and are more transparent, showing the branches of the uterus (nine to twelve in number) (Fig. 625). These branches are less numerous in taenia solium than in taenia saginata, in which there are from fifteen to twenty (Fig. 626). The both- riocephalus shows a brownish uterine rosette (Fig. 627). Sometimes bits of undigested food have been mistaken for tape- worm segments, and the unhappy patients have been subjected to prolonged treatment for worms not present. Treatment. - The administra- tion of remedies should be pre- ceded by preparatory treatment. The large intestine should be emptied by some mild laxa Fig. 623.-Egg of Taenia Saginata. Magnified 350 times. (Heller.) Fig. 620.-Pregnant Proglottid of Bothriocephalus Latus, seen from the Back. a. Anterior border of link ; b, b, nerve filaments ; c, c, tes- ticle; d, vasa efferentia ; e, vas deferenssheath of penis; h, va- gina ; i, shell glands; k, k, uterus. (After Sommer, in " Real Encycl.") Fig. 624.-Fresh Egg of Bothriocephalus Latus. Highly magnified. (Hel- ler.) present, and with advancing maturity the female organs are more prominent. Hence Leuckart advises, in exam- ining the sexual organs, to take a young link for the male organ, but a mature one for the female. The male and female organs open into a cloaca in such a manner that during copula- tion or fructifica- tion the end of the male organ enters or comes against the fe- male. The individu- als, or proglot- tides, seem to be provided with longitudinal and transverse mus- cles, which may readily be distin- guished in longi- tudinal and trans- verse sections of the younger links, magnified twenty - five o r thirty times. The life his- tory of cestodes may be divided into : 1, spherical embryo ; 2, scolex, and 3, proglottid. These three forms represent as many generations. The spherical or six-hooked embryo, bladder-worm or cysti- cercus, may live for years ; perhaps the hydatid, or larva of taenia echinococcus, is the longest lived. Persons are said to have suffered from this parasite for many years ; but in the case of this animal there are sev- eral generations, the older dying off while the younger continue to live. The bladder-worm is not transformed into the scolex or tape-worm until it has entered the alimentary canal of a suitable animal. The proglottid is the only sexu- ally developed stage ; so it would seem to have two mothers-one, the scolex, coming directly from the other, the cysticercus. Leuckart and Van Beneden divide ces- todes into four families: 1, tetrarhynchidae ; 2, phylo- bothridae ; 3, taeniadae, and 4, bothriocephalidse. The last two are the ones which habitually infest human beings ; Fig. 625.-Mature Link of Taenia Solium. Magnified 6 times. (Heller.) Fig. 621.-Horizontal Section through the Margi- nal Layer of Bothriocephalus Latus. a, Cuti- cle ; b, muscular layer ; c, matrix of cuticle ; d, large-celled connective-tissue of marginal layer; e, obliquely cut longitudinal muscular layer ; f, circ. muscular layer ; g, middle layer; A, chalk granules; i, yolk layers; k, cut testicle; Z, cut nerves ; m, excretory apparatus. (After Sommer, in " Real Encycl."). Fig. 626.-Mature Link of Taenia Saginata. Magnified 6 times. (Heller.) Fig. 622.-Egg of Taenia Solium. Magnified 350 times. (Heller.) Fig. 627. - Bothriocephalus Latus. Mature Segment. Magnified6times. (Heller.) 52 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cestodes. Cestodes. tive and enemata, so that when the worm is detached it may pass away more rapidly and be more easily found in fhe dejecta. In searching for the worm, water should be added to the faeces, and after standing a few minutes the upper layer of the fluid should be poured off, the worm being heavier and sinking to the bottom of the vessel; if the faeces have not all been washed away, more water should be added, but one should avoid stirring with a stick, as it may break the worm. When the worm is found it is to be transferred carefully, loop by loop, into a vessel of clean water, careful search being made for the head. After evacuating the bowels gently (to avoid breaking the worm), feed the patient for two or three days on food which leaves little residue, such as meats, milk, coffee, etc., but avoid vegetables, berries, and eggs, as the latter render the discovery of the head more difficult. Some foods, such as salt herring and onions, are said to sicken the worm and diminish its resisting power. So, on the day be- fore the patient receives the remedies which he is to take, he may make his supper on such articles. The next morning he may have a cup of coffee with a little wheat bread, and in about an hour take an anthelmintic, such as koosso or brayera, half an ounce to an ounce (fifteen to thirty grams) being given in warm water (or in com- pressed tablets coated with sugar or gum), in divided doses during an hour. In a couple of hours after the last portion has been taken, an ounce of castor-oil may be given. Other remedies against tape-worms are aspi- dium or filix mas, cort. ra- dicis granati or pelleterine, kameela, oil of turpentine, oil of pinus punilis, chloro- form, etc., to be taken after fasting. With the progress of sani- tary precautions we shall probably be less exposed to these parasites ; animals will be more carefully fed, and when killed will be exam- ined for bladder - worms : and when served the meat will be so thoroughly cooked as to insure the death of any cysticerci present. T^eniad^e.-The follow- ing general description is taken from Rudolph Leuck- art's second edition of "Die Parasiten des Menschen." " The head, which is pear-shaped or spherical, has at a little distance from its crown four round suckers, at regu- lar intervals on the same circle, and having special mus- cles. Above these suckers there is usually one or more circles of booklets, which are moved by their special muscular apparatus (the rostellum), which projects or re- tracts them. ' ' The proglottides are distinctly separated ; when de- veloped, their length is usually greater than their breadth ; the sexual openings are situated laterally, sometimes only on one side of the animal, and sometimes irregularly on both sides. In some cases the porus is on each side of the proglottid. The number of proglottides varies from three to four thousand, the length of the animal depend- ing in great part upon the number of the segments. Their detachment occurs very regularly, but only after the em- bryos are completely developed. The uterus has no di- rect communication externally, so that the eggs remain within it until it is destroyed. The yolk (vitelligene) glands are not large. During development, as the em- bryos increase in size, they are covered with one or more envelopes of greater or less firmness." Tania Echinococcus is a tape-worm, especially in- festing the dog, and interesting to us from being the parent of the human parasite echinococcus, formerly called hydatid. It is quite small, only five millimetres or one-fifth inch long, and is formed of but three or four proglottides, of which, in the mature state, the last is larger than all the rest. The young echinococcus is a watery bladder, with thick elastic wall. On the inner surface of this wall a thick- ening occurs with a hollow in its centre. In this hollow a head forms, then the sides of the hollow close up over the head, forming a "brood-capsule." These may grow, have other brood-capsules, and give off " daughter " and "grand-daughter" vesicles, or the primary cysts may have no scolices and be "acephalocysts." The bladder may increase by sprouting outward or inward (exoge- nous or endogenous cysts). These parasites are found with especial frequency in the liver or lungs. The mature worm infests the intestines of the dog and allied species. The head of Taenia echinococcus is about 0.3 mm. broad, with a projecting rostellum carrying a double row of hooks, fourteen to twenty-five in each row, which are, however, seen only in fresh specimens. There are four suckers, and there is a thin neck ; after this comes the first segment which is a little broader, and then the sec- ond, twice as broad and four times as long as the first; it has male and female sexual organs. The last member may be two millimetres long by 0.6 mm. broad ; it contains eggs with shells which enclose six-hooked em- bryos ; of the eggs there may be five hundred. The uterus is a trunk with lateral branches ; the penis is usu- ally directed to the opposite side from that of the preceding member. A new proglottid forms next the head, before the last one is thrown off. There may be thousands of these worms in the small intestines ; they develop from the echinococcus heads in from two to seven weeks, as shown by experiments in feeding animals with mature proglottides. It is not known how long this taenia lives. It was formerly supposed that there were different species of echi- nococcus, but echinococcus hominis and echinococcus veterinorum are the same, with differences due to local causes; taenia echinococcus may be reared from echinococcus or hydatid, and hydatids from mature prog- lottides of taenia echinococcus. The latter, as well as the egg-shells, are digested by the animal fed, and the embryo being set free bores through the intestinal walls and other tissues until it enters a blood-vessel, in which it passes to the liver and other organs. Here it lodges and may become a hydatid, varying in diameter from the twenty-fifth of an inch to several inches. The form is that of a spherical vessel filled with non-albuminous fluid containing much chlo- ride of sodium, and of 1.007 to 1.015 specific gravity. The vesicle may be four or five months in attaining a diameter of fifteen to twenty millimetres, and years in reaching its largest size. The head, with its booklets and suckers, may project or it may be retracted, the vesicle looking like a bladder of water. It was formerly supposed that the connection between the head, or scolex, and the brood-capsule was only tempo- rary, and that at the end of their development the scolex was detached and floated free in the vesicle ; but Leuckart asserts that this is not true, and that they remain con- Fig. 629.-Echinococcus Head. A, head everted ; B, inverted pedicle. (Cobbold.) Fig. 630-Portion of Echi. nococcus Vesicle and Brood-capsule, a, En- velope ; 6, parenchyma; c, brood-capsule with scolices. (Cobbold.) Fig. 628.-Head of Taenia Saginata, outside; Taenia Solium within Dia- gram. (Heller.) Fig. 631.-Taenia Echinococcus from In- testine of a Dog. Magnified eight times. *, Mature link about being de- tached. (Cobbold.) 53 Cestodes. Cestodes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nected till their death. In a way not explained other vesi- cles with heads may develop inside of the first, forming daughter and granddaughter vesicles or "nurses" (en- dogenous development), or, in other cases, outside (exo- genous), forming multilocular cysts ; in man the latter is the usual mode of growth. The appearances vary with the host, location, etc. If the liver be the part attacked, one may find a tumor as large as a child's head, which, on being cut open, shows small cavities containing jelly- like substance (colloid tumors). There are two membranes, the ectocyst, a thick elastic layer, and the endocyst, which is the essential part, and is a " huge compound caudal vesicle ; " it is 20W" thick. The scolex begins as a slight prominence on the inner layer of the endocyst; as the brood-capsule grows, the number of scolices increases, as does also that of the brood-capsules, so that in large, old hydatids there may be some thousands of scolices. Echinococcus vesicles do not usually have brood-cap- sules and scolices until they attain the size of a hazel- nut, except in multilocular cases. The fluid in these vesicles is generally clear and watery looking, and is not coagulated by heat or acids, nor does it contain any cor- puscles when fresh, as at this time brood-capsules and heads are adherent to the inner surface. Where there is a single vesicle it is sometimes called E. simplex or granulosus ; where it contains daughter ves- icles, E. hydatidosus. These are the very large ones, and in one case of Luschka's the sac weighed thirty pounds, and contained several thousands of daughter vesicles, varying from the size of a pea to that of a man's fist. A third form, called E. multilocularis, which has many small vesicles lying close together, is found almost exclu- sively in the liver. It has been claimed that this multi- locular form was due to the echinococcus being located in the lymph-channels, blood-vessels, or gall-ducts. Of 327 cases of hydatids examined by Cobbold, there were in the liver 161 ; abdomen, 45 ; lungs, 22 ; kidney and bladder, 23 ; brain, 22 ; bones, 16 ; heart and lungs, 13 ; other parts, 25. Cobbold estimates that four hundred deaths occur yearly in Great Britain and Ireland from hydatids. In Iceland it is said that one-sixth of all deaths is due to this cause, and Australia ranks next in this respect. In Iceland, twenty-eight per cent, of dogs examined had sexually mature taenia echinococcus. Prophylaxis against this, as against so many other parasites, consists in filtering all water used for drinking or preparing food. The danger from echinococcus de- pends greatly on its location. Leuckart says Raynal operated on a woman who had an hydatid tumor the size of a child's head, covering the greater part of her face. The tumor had been growing for forty-three years, having appeared first in the neck. The same author states, on the authority of Barrier, that out of 20 cases death occurred within five years in more than half; 3 re- sulted fatally within less than two years ; 8 in from two to four years ; 4 from four to six years; 3 from six to eight years; 2 existed for over eight years ; and 4 for fifteen, eighteen, twenty, and thirty years, respec- tively. While small, the tumor manifests its presence by no signs unless it involve some portion of the nervous sys- tem or eye, but as it increases in size it gives rise to vari- ous symptoms. Pressure on the blood and lymph vessels may induce oedema, varicosities, and congestions of vari- ous sorts ; if the tumor be located within the chest dysp- noea is produced, and when in Douglas' cul-de-sac it may interfere with urination, defecation, or parturition. When hydatids are developed in bone they impair its firmness, so that it is readily broken. An echinococcus of the lungs may open into the bronchial tubes and empty itself in this way ; others may open externally, or be removed by the surgeon. There is no known internal remedy that can be relied on for the destruction of hyda- tids ; but when they occur within reach of the surgeon's knife they may be evacuated. When diagnosed in the liver, kidney, or peritoneum, irritation over them, to se- cure adhesion to the abdominal walls, may be resorted to prior to puncture or incision. For fuller information the reader may consult " Para- sites of Man and Animals," by T. S. Cobbold ; " Parasiten des Menschen," by Rudolph Leuckart; or Ziemssen's " Handbuch der Spec. Pathologic," vol. iii. Taenia mediocanaUata, T. saginata, or beef tape-worm, as it is variously termed, is derived from the measles or cysticercus of cattle, goats, etc. It has no crown of hooks like T. solium, but around the head are four suckers, and between them, in place of a rostellum, is a depression which is sometimes regarded as a fifth sucker. The strobile attains a length of over twenty feet. Behind the head, or sco- lex, the body is composed of members roughly resembling flat pieces of dough ; these increase in breadth as they recede from the scolex. The first sexually mature proglottides occur over four hundred removes from the scolex, and there may be three or four hundred of them. Mature links are from sixteen to twenty millimetres long, and from five to seven broad. They are bisexual, with the sexual openings on one side or the other, with- out regularity (see Fig. 633). The ute- rus has fifteen to twenty lateral ofl- shoots, terminating in a forked extrem- ity. The eggs are mostly oval, and the enclosed embryo has six hooks. The hosts of the young ones are the ruminants. After feeding calves with tape-worms, cysticerci or measles were found in the heart, lungs, and liver. These may undergo cal- careous degeneration and the infested animal survive. The beef measle is rarely seen, and is never found in man. It is especially frequent in India. It is a quarter or half an inch long. Dr. Fleming counted three hundred in a pound of beef. It is supposed to be shorter lived than other cysticerci. A question of great importance is, At what temperature will they die ? Pellitzari stated that a temperature of 140° F. (about 65° C.) for five minutes would kill them. Perroncito found that when warmed on a Shulze's table to 112° F. (50° C.) they died, as he determined by their lack of motion and by their imbibing carmine coloring, Fig. 632. - Head of Taenia Mediocanella- ta. Magnified. (For strobile, see above, page 51.) (Heller.) Fig. 633.-Trema Mediocanellata, Six Hundredth Link (diagrammatic). a, Lateral nerves ; b, excretorv tubes ; c, anastomes between them ; (I, papilla border; e, fossa gentalis ; f penis sheath : g, vulva ; h, ovary ; i, albumen glands; k, shell glands ; I, uterus. (Leuckart.) which live ones do not. It may, therefore, be assumed that beef which has been heated through to 150° F. may be eaten by man with impunity. In places where beef is eaten raw, and even before cooling after death, the beef tape-worm is almost universal. Some students ate of these cysticerci which had been heated, without developing tape-worm, while one who ate a live one began to pass links or proglottides in fifty- four days ; on the sixty-seventh day he took koosso and 54 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cestodes. Cestodes. castor-oil, and passed the strobile. In those passed spon- taneously, and after the medicine, there were about nine Imndred proglottides. It is claimed that measly meat is not necessarily injuri- ous if properly cooked and served in a cleanly manner, with clean knives, forks, and dishes. Cattle not infested may be kept so by stall-feeding and proper water. Mea- sles in cattle come from their swallowing eggs of T. me- diocanellata. Hence the faeces of persons having tape- worms should never be exposed in a barn-yard, but should preferably be burned. The larvae would die in a certain time, and if fresh infection can be prevented for six or eight months, eating the flesh would not be dangerous. After death, putrefaction of the meat destroys the cysti- cerci. T. mediocanellata or saginata inhabits the small in- testine of man, the head clinging to the upper part, while the strobile reaches in loops to the caecum. It is much more common than T. solium. For treatment and proph- ylaxis, refer to the section on Treatment, on page 52. Tania solium, or pork tape-worm, when stretched out, rarely measures over three or three and a half metres (ten or eleven feet) ; its width at the widest part, the mid- dle, is about eight millimetres (one-third inch). It may have eight or nine hundred proglottides, of which the last hundred may be mature, and being longer than the rest may constitute about one-third of the whole length. The scolex is about as large as a pin's head, rounded, with four suckers, and a double row of hooks, about twenty- eight in number, the outer row being composed of smaller hooks than the in- ner. It requires a lens to show the joints of the neck, which is about one centime- tre long. The segments gradually increase in length till at one metre from the scolex they become square. Mature proglottides are rare- ly evacuated spontaneously, but may pass off with the f.eces. The sexual opening is on the side, behind the middle of each segment (see Fig. 625). The uterus may be distinguished by pressing a segment between two pieces of glass and holding it up to the light. It has from seven to ten lateral branches on each side, and these again subdivide. The eggs are nearly round, hav- ing a thick shell, and containing a six-hooked embryo. If these eggs, or the proglottides containing them, be eaten by a suitable host, they hatch out a bladder-worm- Cysticercus cellulosse-which is found especially in swine, constituting " measly pork." It was the resemblance of the hooks and head in the cysticercus and Taenia solium which led Kuchenmeister to suspect the relationship of the two; this was proved by feeding the eggs of T. solium to young pigs (it has been claimed that only pigs under one year become infected) and finding in them the cysticerci; and the reverse has been proven by self-ex- perimenters who have eaten cysticerci and become in- fected with tape-worm. Like other parasites, these have immense numbers of eggs, of which one proglottid may contain several thou- sand, thus multiplying the chances of infection. It is said that cysticerci have been found in dogs, bears, rats, and goats. It is not certainly known how embryos pass from the intestines to the muscles and other organs where cysticerci are found. Mosier detected cysticerci about eight days after feeding the animal on eggs. He describes them at this period as oval vesicles, 0.033 mm. long, and 0.024 mm. broad, that is. slightly larger than the eggs were. The vesicles contain a clear fiuid, and their walls have a vascular system. It is not known how long a cysticercus may live; but it has been asserted that in the muscles they may live from three to six years. In the brain and eye they may live much longer, one in the vitreous body having been observed for twenty years. When cysticerci have been swallowed by man, they lodge in the small intestine, usually in the upper third. The scolex anchors itself by the booklets and suckers, the strobile hanging down in loops through the intestine. It does not begin to throw off any proglottides for fifty or sixty days. The worm may live many years, perhaps fifteen or twenty. The head may be distinguished from the other com- mon tape-worm (T. -saginata or mediocanellata) by its hooks and smaller size (see Fig. 629), and the proglot- tides by the form of the uterus, the lateral branches of which are less numerous, there being rarely over nine on each side ; the segments are much smaller than those of the other worms. The propagation of Taenia solium is effected by pigseat- ing the proglottides mixed with the faeces of man, and de- veloping cysticerci; the pork containing the cysticerci is then eaten by man, and a new tape-worm is formed. If previous to the consumption of the pork it have been ex- posed to a heat of 50° C., or more, the cysticerci do not develop. This tape-worm occurs wherever pigs are eaten, and is most frequent where the flesh is eaten raw or only partly cooked, or imperfectly smoked. Hence the meat should be cooked all through ; if the surround- ing albuminous tissue is coagulated and the bloody color disappears, the cysticerci die. They seem, furthermore, to survive the death of their host but a few weeks, and therefore smoked or salted pork and hams should be harmless. When cysticerci have lost their water and shrivelled up, they show' no signs of life. Decomposition of the meat also kills them. The bladder-worms in pork being more numerous than in beef, it is more common to find a number of Taenia solium than of Taenia mediocanel- lata ; there may even be from ten to forty. Jew's and others wflio eat no pork escape the infection. The symptoms are about the same as those from beef tape-worms, though perhaps less severe, by reason of the slower grow'th, smaller size, and greater sluggishness of the pork-worms, and the consequently smaller amount of ir- ritation of the intestines; but this may be counterbal- anced by the presence of numbers of worms, and still more by the chance of auto-infection from eggs of the worm, and development of cysticerci in various parts of the body. If these are few in number and limited to the muscles, there will be little disturbance, and their pres- ence will probably be overlooked during life, unless in the tongue or under the eyelids. When they are very numerous in pigs, the animals become quiet and dull, their snouts and mouths are pale, appetite is poor, they emaciate, but are oedematous about the neck and shoul- ders, and their bristles fall out. The only sure way of preventing infection in swine is by great cleanliness, and preventing their access to dung-heaps, etc. Statistics seem to show that cysticerci occur more frequently than trichinae in swine. It is said that more men than women are affected with cysticercus, but the reverse is true of T. solium. This may be due to their drinking water from streams, to having dirty hands, etc. As a patient with this tape-worm may infect himself or his neighbors, by carrying some of the eggs on his hands, great attention should be paid to cleanliness. Proglottides may pass back to the stomach from the small intestine ; then the gastric juice would digest the proglottid and the egg- shells and set free the embryo, unless they were expelled by vomiting. The cysticercus may become located in any part of the body. When seated in the brain, it is mostly in the mem- branes or cortex. It may be well observed in the eye, in which location it is reported to have been found in one .case per thousand of the eye-patients in the Berlin clinic, mostly in the deeper parts of the eye. It may cause de- tachment of the retina. Sometimes from their seat (as on the surface of the brain) cysticerci assume an irregular nodular shape, and are called C. racemosus. As the shape of the bladder- Fig. 634.-Cysticercus of T. Solium in Pork. (Heller.) 55 Cestodes. Chamomile. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. worm is determined by its surroundings, So its size de- pends on the nutritive conditions ; but generally the size will be that of a pea or small bean. When the worm dies, its fluid is absorbed and it decreases in size. The symptoms caused by cysticerci depend on their seat, where they act as foreign bodies. In the respiratory organs they may induce asthmatic attacks, in the abdomen, peritonitis, etc. In the brain they would induce the same symptoms as other cerebral tumors, and some- times these would give a clue to their location. In the United States cases of cysticercus must be much less frequent than in Germany, or else they are more overlooked, for they are rarely re- ported. For the treatment of T. solium, refer to what was said on pages 52 and 53. In the class of taeniae which may infest man, but which are not his peculiar parasites, may be mentioned (1) T. acanthrotias of Weinland, which, if it exist, is at present only known by its bladder-worm. This greatly resembles the Cysticercus cellulosae, except that it has three rows of hooks, each con- taining fourteen to sixteen hooks. Several of these cysticerci were re- ported to have been found in one cadaver, chiefly in the connective-tis- sue ; (2) T. marginata of Batsch, grow- ing in dogs to the length of four to six feet. This also has suckers and hooks (from thirty-two to forty-two). This tape-worm comes from Cysticercus tenuicollis, which sometimes grows to a large size in cattle and swine ; (3) T. serrata (from Cysticercus pisiformis), and (4) T. canurus (from Coenurus cerebralis). These two varieties infest the intestines of the dog; they also have suckers and hooks, and might be mistaken for T. solium. The coenurus cerebralis gives lambs "staggers" and proves very fatal; they derive their infection from the sheep-dogs. Where cysticerci are numerous they may quickly prove fatal to the bearer ; but when solitary or few in number, they may live for years and attain a large size. If fed to dogs, all except the head and neck disappear under diges- tion, and ripe proglottides appear in varying time, ac- cording to the variety of cysticercus experimented w'ith : C. tenuicollis in from ten to twelve weeks, C. pisiformis in about eight weeks, and Coenurus cerebralis in from three to four weeks. Tania nana of von Siebold, or dwarf tape-worm, was found by Bilharz in one case in Cairo ; great numbers being discovered in the duodenum of a boy who had died of meningitis. A very full account of this worm is given by R. Leuckart, in " Parasiten des Menschen." It is scarcely an inch long, and at its widest part measures only 0.5 mm. ; anteriorly it is thread-like. The head has four suckers, and a rostellum with about twenty-four minute hooks. The proglottides number about one hun- dred and fifty, of which the last twenty or thirty may be mature. Tania flavopunctata of Weinland also has very rarely been observed and described. A case was reported by Professor J. Leidy, in the American Journal of the Med- ical Sciences, July, 1884. R. Leuckart considers this very similar to T. nana, except in size, it being about thirty centimetres, or one foot, long, by two millimetres, or more, wide. The proglottides in the posterior half have each a yellow spot in the middle, which is supposed to be the testicle. The uterus is a simple cavity nearly filling the proglottid. The anatomy of the head is un- known, but it probably has a simple circle of hooks. Tania madagascariensis of Davaine is described from specimens passed by two children at Mayotta, one of the Comoro Islands. It is a tape-worm, perhaps eight centi- metres long, with about one hundred proglottides; the mature ones contain over one hundred small oval bodies, which are composed of minute eggs in an enveloping sub- stance. Tania cucumerina of Rudolphi, T. elliptica of Batsch, is the most common tape-worm of the dog and cat, and the proglottides have been frequently passed by babies from mouth or anus. The cysticercus inhabits the dog-louse (Trichodectes canis), whence it enters its host, and by the dog's tongue the eggs may be transferred to man. When mature this taenia is 180 to 250 mm. long, and the pos- terior links 1.5 to 2 mm. broad. The hooks are in four uneven rows, and number about sixty. In the posterior half the proglottides are rounded at the corners (elliptical), and the mature ones are reddish in color. The eggs are massed together, two or three dozen being in one group. The sexual openings are on both sides of each segment. Cobbold also gives Tania lophosoma (or ridged tape-worm) and 7'. marginata as of exceedingly rare, or, perhaps, doubtful occurrence in man. He gives the name of Tania tenella to a compa- ratively small human tape-worm, which, he thinks, is derived from cysticercus ovis (mut- ton measle). As sheep are thus affected, of course it is improper to use raw or under- done mutton, just as it is to eat insufficiently cooked beef or pork. Cobbold describes the measle as having a head one-thirtieth of an inch broad, armed with a double crown of hooks and having four suckers ; he has seen no perfect specimens of the worm, and so does not state its length, but describes the segments as measuring three-tenths of an inch in length by one-half that in breadth, with reproductive papillae al- ternating irregularly at the margin. Botiiriocepiialidje constitute the second family of Cestodes. They have the head rather egg-shaped, with the large end in front, and having two elongated suction fossae on opposite sides. Most of the species are not sup- plied with hooks. Segmentation is much less perfect than in the Taeniae. The proglottides are much wider than they are long, and are firmly united to each other, so that detached por- tions of the worm come away in long sections. The uterus is a simple tor- tuous canal, opening on the central line of the ventral surface. The male and female sexual organs are near together. The eggs have a firm shell, with a lid at one end for the escape of the embryo. (See Fig. 637.) The latter is covered with cilia, by the aid of which it can move around in water. The larvae probably de- velop in an intermediate host, but a bladder-worm state of Bothrioccpha- lus has not been discovered. Bothriocephalus latus is the largest tape-worm infesting man; it may reach a length of five to eight metres (fifteen to twenty-four feet). The head is about two millimetres long and half as broad ; the segments are three or four times as broad as they are long (ten to fifteen by three to four millimetres) ; they may number four thousand. The worm inhabits the small intes- tine of man and also of dogs. Its intermediate host is unknown, but is supposed to be a fish (salmon ?). Per- haps from the limitation of the habi- tat of this fish, the Bothriocephalus latus is only found in certain coun- tries, more particularly in Sweden, Russia, and Switzerland. Cobbold says it is rare in England, and when found it is imported ; but that it is indigenous in Ireland, and is some- times called Irish tape-worm. The symptoms induced by B. latus are the same as those from other tape-worms, viz., tumid abdomen, nausea, giddiness, hysterical symptoms at night, palpita- tions, faintness, etc. For treatment, see page 52. Fig. 635.- Cerebral Cysticer- cus, Nat- ural Size. (Heller.) Fig. 637.-Egg o f Bothrio- cephalus La- tus. I, Lid. (After Som- mer, in "Real Encycl.") Fig. 636.-The Same, Magnified. (Heller.) Fig. 038.- A, head and anterior end of stro- bile of Bothriocepha- lus latus; B, head of Bothriocephahis latus enlarged ; C, portion of pregnant links of Bothriocephahis 1 a - tus. (After Sommer, in " Real Encycl.") 56 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cestodes. Chamomile. garden plants, large amounts being produced in Germany and about Mitcham. It has been cultivated and used at least since the middle ages, and probably from an earlier date. The variety mostly selected for cultivation is that in which the majority, or all the disk flowers have be- come radiate, and the head is, in consequence, a convex or hemispherical rosette of white strap-shaped corollas, imbricated in many rows, and looking, at first glance, almost exactly like the Feverfew Howers of our gardens. Sometimes the transformation is less complete, and sev- eral rows of rays surround the then only diminished disk -these " half double " or "single " flowers are less prized than the fully " double although really fully as good or better. The "flowers " are prepared for use by pick- ing when in full bloom, and rapidly drying by the aid of moderate heat. They should be large, light-colored, bright-looking, and very fragrant, qualities which they lose by slow drying or overheating. Composition.-The principal ingredient of Chamomile is its essential oil (Oleum Anthemidis, Br. Ph.). This is contained mostly, so far as the flowers are concerned, in glands situated on the outside of the tubes of the corollas. It appears to be more abundant upon the disk than upon the ligulate blossoms, for which reason the "single" flow- ers are really more active than the favorite "double" ones. It is also found in the leaves and other parts of the plant, all of which are subjected to distillation for its production. The yield from the flowers is about six- or eight- tenths of one per cent. It is at first pale blue or green, but be- comes in a short time pale yellow- ish-brown. It is a transparent, mobile, very fragrant liquid, spe- cific gravity about 0.91. Oil of Chamomile is a complex sub- stance ; its composition has been the subject of several careful in- vestigations, each of which has shown it to be more complex than the preceding ones did. Isobutylic ethers, angelate of iso- butyl, tiglinate of isamyl, and other substances were obtained from it in recent analyses (Phar- macographia). Chamomile also contains a bitter principle which has not been isolated. Use.-Chamomile is an aro- matic bitter tonic, with antispas- modic qualities in addition. It is perhaps the best representative of its class. As a bitter its taste is clean and pure, and in small doses it quickens the appetite and stimulates digestion ; in large doses it is nauseant, and may produce emesis. It owes its carminative and soothing qualities to its oil, which is a useful adjunct to the bitter principle, and which itself is efficient in nervous or hysterical debility, accompanied as it usually is, with faulty digestion and accumulation of gas in the stomach or bowels. As a hy- dragogue diuretic in vesical catarrh, although occasion- ally given, Chamomile has no advantage over hot infu- sions of mints and other fragrant substances. The best mode of administration is in the form of infusion, or " tea," made by pouring boiling water upon the " flow- ers." Dose, from two to ten grams (2 to 10 Gm. = 3 ss. ad 3 iij.). . The oil is an elegant mode of obtaining its car- minative qualities, but is rare in this country, and very expensive. Dose, ten drops. Allied Plants.-The genus contains about eighty- species, and includes the common Mayweed (Anthemis Cotula Linn.). They are generally less agreeable than Chamomile, and although of similar qualities, not in use. Chrysanthemum Parthenium Pers. (Feverfew), is some- times used as a substitute or adulteration of this article. It can be told by its flatter and less chaffy receptacles. Bothriocephalus cordatus is a variety found in Green- land ; it is much smaller than the above (about one foot 'long). It is common in dogs, and has been observed in man. Bothriocephalus cristatus is very rarely met with. It grows to a length of nine or ten feet, and is about half an inch in width. It has prominences forming crests on its head. Chas. E. Hackley. CH ALLES lies among the foot-hills of the Alps, in Savoy, distant three miles from Chambery, at an eleva- tion of about eight hundred feet above the level of the sea. There are two medicinal springs, known as the source principale and the petite source, which, although similar in their composition, differ considerably in strength. The waters possess a peculiar value from the fact of their containing sulphur, bromine, and iodine, and Chalies is frequented by sufferers from syphilis, scrofula, goitre, ozama, mercurial cachexia, chronic eczema, and other rebellious dermatoses. The waters are used both internally and externally, and are not only taken at the springs but are also largely exported. The following table shows the composition of the two springs after the analysis of Wilm. Temperature 10.5° C. (50.5° F.). In 1,000 parts there are of : Source Petite principalc. source. Silicious earth 0227 i Argillaceous earth 0059 f Sulpho-hydrate of sodium 3594 .0059 Carbonate of calcium 5952 .1146 Sulphate of sodium 0638 .1557 Chloride of sodium 1554 .0232 Bromide of sodium 00376 Iodide of sodium 01235 .0080 1.21851 .3306 In commencing a course of these waters small quanti- ties are to be taken at first, otherwise there is danger of exciting gastric catarrh. T. L. S. CHAM/EPITYS {Ivette ou Chamapitys, Codex Med. ; Ground pine). The flowering herb of Ajuga Chama- pitys Linn. ; Order, Labiata. A little, yellow-flowered, annual herb, found in both Europe and America, re- ported to be antirheumatic and diuretic, but really of no value whatever. Ajuga Iva and Ajuga reptans have also been used, and are equally worthless. They are official in France. (See Bugle.) W. P. B. CHAMOMILE {Anthemis, U. S. Ph.; Anthemidis Flores, Br. Ph. ; Camomille Romaine, Codex Med. ; Roman Chamomile). The flowering heads of Anthemis nobilis Linn. ; Order, Composita, Anthemidea. The chamomile plant is a low perennial herb, with a branching rhizome, and rather numerous stems, most of which are short and bear leaves only. The flowering stems are long, slender, prostrate, often rooting at the base, but ascending and branched above. Leaves sessile, long and narrow', pinnate; pinnae once or twice incised-pinnatifled, with linear or awl-shaped pointed segments. Inflorescence solitary, at the ends of the branches. Whole plant more or less hairy. Flower- heads radiate, about two centimetres across (three-fourths inch) with, in the " single" (natural) form, a single row of white rays and a yellow disk. Involucre of two or three rows of blunt, appressed, scarious-margined scales. Receptacle scaly, conical, solid, longer than broad ; ray- flowers fertile, limb three-toothed ; disk flowers perfect, tubular below, bell-shaped above. Achenia obovate, slightly compressed, pappus none. The oil glands are mostly on the corolla tubes, and less abundant on the ray than on the disk flowers. Chamomile is a native of Europe, growing in open sandy places and waysides. It is abundant in the environs of "London, and elsewhere in the south of England, but is scarcely native in Scotland. On the Continent it is at home in France, Spain, Italy, and other parts of Western and Southern Europe. In cul- tivation or naturalized its range is more extensive, in- cluding Central and Eastern Europe, and North America. All the Chamomile for medicinal use is the product of Fig. 639.-Chamomile, Wild or Single-flowered Plant, one - third natural Size. (Bailion.) 57 Chamomile. Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The German Chamomile, Matricaria Chamomilla Linn., from a neighboring genus, consists of single heads and is never confounded with English or Roman Chamomile, except in name. Its qualities are similar. (See next ar- ticle.) The order Composita is the largest one in the natural classification of plants, numbering ten thousand species, arranged in over seven hundred and fifty genera-mostly herbs-and characterized by their daisy, or dandelion-like flower-heads. A remarkably small number are of any great economic value, either as food, medicine, poison, or iu the arts. The medical qualities of the order vary considerably, but a bitter principle, often nauseous, an essential oil, fre- quently of bitter and disagreeable odor, and a resinous substance are pretty widely present (Tansy, Grindelia). A milky juice, sometimes narcotic (Lettuce, Dandelion), rarely containing Caoutchouc, prevails in the chicory tribe. The following list comprises most of those in med- ical use from this order, and illustrates its general char- acter. It furnishes, besides, many beautiful and showy flowers, such as asters, chrysanthemums, dahlias, daisies, sunflowers, coreopsis, blue-bottles, etc. 1. Eupatorium perfoliatum Linn., etc., Bouesets; Bit- terprinciple, oil, resin, tonic, emetic. 2. Mikania Guaco H. B. K.; Guacin, bitter, diuretic. 3. Grindelia robusta Nutt; stimulant resin, expecto- rant. 4. Solidago odora Ait, Golden-rod; essential ail, diu- retic. 5. Erigeron canadensis Linn., Fleabaue ; essential oil, diuretic. 6. Inula Selenium Linn., Elecampane ; a camphor-like substance, oil, etc. 7. Speilanthus oleracea Jacq.; oil, sialagogue resin, and tannic acid. 8. Anacyclus Pyrethrum D. C., Pellitory ; sialagogue resins, etc. 9. Anacyclus officinarum Hayne, German Pellitory; oil, resin. 10. Achillaa millifolium Tourn., Milfoil; bitter, oil, etc. 11. Anthemis nobilis Linn. ; Chamomile. 12. Chrysanthemum Parthenium, Feverfew ; bitter, oil, etc. 13. Chrysanthemum {Pyrethrum) cinerariafolium, ro- seum and other species furnish insect-powders, oil, crys- talline substance {I), etc. 14. Matricaria Chamomilla Linn., German Chamomile; oil, bitter, etc. 15. Tanacetum vulgare, Tansy ; oil, bitter, etc. 16. Artemisia absinthium Linn., Wormwood; oil, bit- ter, etc. 17. Artemisia maritima, Levant "wormseed;" San- tonin, etc. 18. Tussilago farfara, Coltsfoot; inert. 19. Arnica montana, Arnica ; resin. 20. Calendula officinalis Linn., Marigold ; yellow color- ing matter. 21. Lappa officinalis All., etc., oil, etc., Burdocks; inert. 22. Cnicus benedictus Linn., The blessed thistle; bitter, crystalline substance, cnicin. 23. Carthamus tinctorius Tourn., Safflower ; red color- ing matter, Carthamin. 24. Cichorium Intybus Linn., Chiccory ; inert. 25. Cichorium endiva Linn., Endive ; edible. 26. Taraxacum vulgare Schrk., Dandelion ; Taraxacin, a bitter. 27. Lactuca sativa Linn., etc., Lettuce ; Lactucin, a hyp- notic. Allied Drugs.-The aromatic bitters in general, see Magnolia. Also, by virtue of its oil it may be com- pared to Valerian, Hops, and other soothing oil- and resin-yielding substances. German Chamomile and other plants in the same order are very similar in their action. W. P. Bolles. Feverfew). The flower-heads of Matricaria Chamomilla Linn. ; Order, Composita, an annual herb, somewhat re- sembling Anthemis, but with stouter, erect, smooth, branching stems, broader and more dissected leaves, and rather smaller flower-heads. Receptacle hollow. A com- mon weed throughout Europe. The dried " flowers" of Matricaria need never be con- founded with those of Chamomile, as they are always " single," of darker color, and stronger smell ; they are " about three-fourths of an inch (18 millimetres) broad, composed of a flatfish imbricate involucre, a conical, hollow, naked receptacle; about fifteen white, ligulate, reflexed ray-flowers, and numerous yellow, tubular, per- fect flowers without pappus ; strongly aromatic and bit- ter" (U. S. Ph.). German Chamomile contains a remarkable, rather thick, deep blue oil, of exceedingly penetrating odor. 'Similar blue oils are obtained from one or two umbelliferous resins. This is the common " Chamomile " of Germany and most of Europe. It has properties almost identical with those of the preceding Chamomile, and is put to similar uses. It is seldom employed in this country excepting among the German or other European immigrants. Dose and administration the same as of the above. Allied Plants, etc.-See preceding article. IE P. Bolles. CHANCRE. The word chancre (from Lat., cancer ; old English, shanker ; German, Schanker; Spanish, cancro') was originally used by the French to designate an ulcer or other lesion especially distinguished by its corroding character. Afterward it came to mean a corroding venereal ulcer upon the genitals. The introduction of syphilis into the study of venereal diseases was followed by another modification from the original signification of the term. As little as the initial lesion of syphilis answers to the definition of "a corrod- ing ulcer upon the genitals," it has not only still retained the original name, but has even been known as the " true chancre " in contradistinction to venereal ulcers that are not followed by syphilis, but, nevertheless, correspond in their clinical features much more accurately to the ety- mology of chancre than does the primary lesion of syphi- lis. The same term, then, is still applied to two entirely dissimilar affections, one the primary lesion of syphilis, the syphilitic chancre ; the other the simple venereal ulcer, the simple chancre. The Differentiation of Simple and Syphilitic Chancres.-Following the general outbreak of syphilis toward the end of the fifteenth century, it was natural that every venereal affection should be regarded as syphilitic. At an early period, however, medical writers sought to distinguish between the initial symptoms of the " new disease " and other genital affections that had been known from ancient times. Attention was soon directed to one of the chief distinguishing marks of the syphilitic initial lesion, namely, its indurated base. Thus John de Vigo, who wrote at this time, after describing the charac- ter of ' ' those ulcers of the genitals which were at all times known," proceeds to portray the appearances of the syphilitic disease, and states that " venereal pustules from infectious coition arise in the genitals, viz., in the vagina iu women and on the penis in men, and are sometimes of a livid color, sometimes black, and sometimes whitish, with a callosity surrounding them." Also Aloysius Lo- bera, physician to Charles V., about the year 1540, says ' ' that sometimes the patient is affected with ulcers on the penis, which are hard and callous, and that this appear- ance is a certain mark of the French disease." 1 The only chancre recognized by Hunter and his follow- ers was the " venereal sore characterized by the hardened edge and base." Other ulcers to which the genitals are subject were either not recognized as venereal at all, or were attributed to a variety of incidental causes, such as certain morbid tendencies inherent in the individual, or, if venereal, they did not constitute a disease sui generis. Carmichael2 refers to these affections as follows: "The organs of generation are subject to a variety of ulcers CHAMOMILE, GERMAN {Matricaria, U. S. Ph.; Flores Chamomilla, Ph. G.; Camomille commune ou d' Allemagne, Codex Med. ; " Matricaria " of the Codex Med. means 58 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chamomile* Chancre. destitute of the characteristics of chancre-the hardened edge and base " (p. 15). • " It should not be forgotten that the very organization, secretions, and functions of the genitals, dispose them to ulceration beyond all other parts of the body. They arc organized in the highest degree ; their secretions are vari- ous, their functions complicated with those of the urinary organs ; they are at one moment in a state of quiescence, and the next in a state of the highest excitement. Their secretions, particularly in the female sex, are liable to become vitiated, and consequently acrimonious and irri- tating, and the same effect may follow from inattention to cleanliness. The parts of generation must, therefore, be disposed more than others to derangement in their functions, and consequently more subject to the ravages of ulceration. "Since*Mr. Hunter's work upon the venereal disease, it is very generally admitted that not only certain modifi- cations of animal matter, but the healthy secretions of one animal applied to a susceptible or crude surface of another, is capable of exciting ulceration. It is unneces- sary to add how frequently this occurrence must take place during sexual intercourse " (pp. 17, 18). It was not until Ricord's time that the soft chancre was recognized as an independent form of disease. Ricord himself, at first, through failing to appreciate the impor- tance of the period of incubation in syphilis, though he admitted that at some period in its course the syphilitic chancre always became indurated, believed that all chan- cres were alike capable of producing syphilis, and re- garded the induration and subsequent general infection as matters of pure chance, or as dependent upon the spe- cial receptivity of the individual. Afterward forced to abandon his position by the convincing arguments of his illustrious pupil, Leon Bassereau, arguments based upon the results of artificial inoculations and numerous con- frontations, he became the greatest adherent and advocate of the new doctrine of duality-the doctrine that the sim- ple and syphilitic chancres were due to two entirely distinct poisons, the chancre poison and the syphilis poison. The one produced, always without incubation, only the non- infecting soft chancre ; the other, always with incubation, only the infecting hard chancre. It was implied, indeed, in this doctrine, that there are three independent venereal poisons-the gonorrhmal, the chancrous, and the syphi- litic. The independence of the first had already been es- tablished by Benjamin Bell and by Ricord. A parallel independence was claimed by Bassereau for the last two. It was assumed in his doctrine that the soft chancre had long antedated the first appearance of syphilis, and through a long series of uninterrupted inoculations from one individual to another, it had continued to propagate itself to the present time. Tested by the results of experimental inoculations, the correctness of Bassereau's conclusions appears amply cor- roborated. But there are a number of facts observed clinically with which they are not easily reconciled. Such facts are the following : 1. A soft chancre is sometimes followed by syphilis. In this case the sore usually becomes indurated at some period of its course, and its clinical features are exchanged for the characteristic physiognomy of the initial lesion of syphilis ; or, the soft chancre may heal and the indura- tion appear in the cicatrix. Again, it is maintained by some that a soft chancre, perhaps accompanied with a suppurating bubo, may sometimes run its course, no in- duration whatever occur, and yet syphilis follow. 2. A woman with only a soft chancre gives soft chan- cre to one man with whom she cohabits; to another, hard chancre and syphilis. , 3. The hard chancre is sometimes not followed by syphilis. 4. A woman with hard chancre gives the man with whom she cohabits only soft chancre, or conversely. 5. The hard chancre, when irritated and made to sup- purate, freely yields a pus, which, when inoculated upon the bearer or upon others, produces a sore which resem- bles the soft chancre, and is likewise inoculable in gen- erations. The existence of these clinical facts (as well as some others that will be referred to later), which are so at vari- ance with the natural history of the simple and syphilitic chancres as observed experimentally is unquestioned, but in the various explanations they have received there is a very wide divergence. First, the radical unicists, who still maintain that both forms of chancre are due to one and the same virus, claim that it is not unnatural that the clinical features of these lesions should be more or less interchangeable. Auspitz calls the soft chancre the acute form of the disease, while the hard chancre and syphilis constitute the chronic form. Kbbner explained the difference in the effects of the virus, by assuming that in the soft chancre the virus was more concentrated than in the others, in consequence of which a process of destruction was engendered so rapid that there was insufficient time for absorption, while in the milder grade of inflammation pertaining to the hard chancre, the virus was taken up into the general system. To these views is in the first place opposed the almost un- varying uniformity of the results obtained by experi- mental inoculations; for in these results the sources of error are vastly less than in any ordinary clinical observa- tions. In the latter we have to do, in most cases, with the complex effects of intercourse more or less promiscu- ous and with cases in which the complete history is rarely obtainable. It has been said that the syphilitic initial lesion begins, in the majority of cases, as a soft chancre, which in process of time may or may not become indur- ated, and syphilis follows. No such result, however, has ever been recorded after experimental inoculations of the secretion of a syphilitic lesion, unless the lesion had first been provoked to copious suppuration. Kobner's assump- tion vzith regard to the influence of concentration of the virus in determining the effect of the inoculation, is con- troverted by the experiments of Puche and Tarnowsky with artificially diluted chancre virus. So long as any effect whatever was produced, beyond an abortive pus- tule, it was invariably a soft chancre, but never syphilis. Rollet, as is well known, sought to account for the anomalous clinical cases to which allusion has been made, which seem to lead to conclusions adverse to the radical doctrine enunciated by Bassereau, by his ingenious hypo- thesis of " the mixed chancre." According to this hypo- thesis both the syphilitic viruses might be implanted, at the same spot, producing a lesion that partook of the characters both of the initial lesion of syphilis and of the simple venereal chancre, and that was capable of impart- ing to a healthy individual inoculated with its secretion either one or both poisons with their concomitant effects. The mixed chancre, it was said, might arise in either one of three ways: (1) Through simultaneous inoculation of the syphilitic and chancrous poisons, or, through succes- sive inoculations, either (2) of syphilitic poison upon a pre-existing simple chancre, or (3) of chancrous poison upon a pre-existing initial lesion of syphilis. All three cases had been demonstrated by confrontations or by ar- tificial inoculations. In the case whero there is but one exposure, followed by a mixed chancre, the source of the contagion may have been either another mixed chancre, or a soft chancre in a syphilitic subject. In the latter event the virus of the chancre must have been mingled with syphilitic blood, or the chancre may have been sit- uated upon a syphilitic secondary lesion, such as a mucous patch, but in this case the lesion would be equivalent to a mixed chancre. A modification of Rollet's hypothesis was proposed by von Barensprung,8 and is known as the German doctrine of duality. According to Rollet, when the poisons of syphilis and chancre are inoculated simultaneously, the result is a modified chancre, a sore with a dual character, that pertains partly to the simple and partly to the syph- ilitic chancre. On the other hand, Barensprung admitted the existence of but one chancre, the simple or soft ve- nereal sore. If at the same time the viruses both of syph- ilis and chancre were inoculated, the only immediate effect was a soft chancre, which continued only a simple chancre until after a period of incubation had elapsed, at the expiration of which syphilis developed, and the sore 59 Chancre. Chancre. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. became indurated, followed usually by a transformation of the chancre into the initial lesion of syphilis. In other words, there was no such thing properly as a "mixed" chancre, but simply chancre followed by syphilis. While according to the French doctrine there "were two forms of chancre, which in the mixed chancre were combined, according to the German view there were only two forms of contagion, one producing chancre, the other syphilis. By means of the hypothesis of the mixed chancre, or the German modification of it, it is clearly possible to ex- plain many clinical facts which otherwise, according to Bassereau's doctrine of duality, would be inexplicable. With Rollet's theory more can be explained than with the German doctrine of Barensprung, for according to the latter a double contagion could only result after the induration had developed. One of the most difficult cases for the advocates of dualism to explain is where a woman with soft chancre has connection with two men, neither of whom were be- fore syphilitic. To one she gives a soft, chancre, to the other hard chancre and syphilis. Occurrences of this kind are vouched for by Sigmund, Kaposi, and others. It may be presumed in this case, by the advocates of dual- ism, that the woman either had a mixed chancre, or else being already syphilitic had a soft chancre, the secretions of which were mingled with syphilitic blood or with secre- tions from secondary lesions. It seems scarcely possible, however, that the man contracting a hard chancre should escape contracting at the same time a soft chancre, though such is the case implied. It was admitted by Rollet, that in the mixed chancre either the chancrous or the syphi- litic element may be dominant, and either one may finally disappear while the other remains active. This, however, would hardly serve to account for the above case if both men, as the statement seems to indicate, had connection with the woman at about the same time. Indeed, in a clinical observation of this character, it is almost impos- sible to estimate all its complicated bearings. A case that is still more difficult to reconcile with the doctrine of duality is mentioned by Kaposi.4 A patient presents himself with a soft chancre ; from this chancre multiple chancres are produced by accidental auto-inocu- lation ; one of these secondary chancres in process of time becomes indurated and syphilis follows ; all the others, including the first sore, the result of the original exposure, run their entire course as simple chancres. This case-and Kaposi intimates that it is not an isolated one-would seem to imply a conversion in situ of the sim- ple chancre into the syphilitic, and so far as it goes is an argument for the unity of the two poisons. It is upon an argument somewhat similar to this that a theory has been based which is in the nature of a com- promise between the extreme doctrines of unity and duality. The theory rests upon the fact that in certain cases a lesion identical with, or closely resembling the soft chancre, has been produced from the initial lesion of syphilis. When the secretion from a hard chancre is inoculated upon the bearer the result in the great majority of cases is nil. In some instances, however, it has been followed without incubation by a sore having all the clinical ap- pearances of the simple chancre and inoculable in genera- tions both upon the bearer and upon others. Clerc, who reported two such cases, was led to believe that he had discovered the origin of the soft chancre ; that it was the offspring of the syphilitic virus modified by passing through a syphilitic soil. The result of this transplanta- tion was a virus with increased corrosive quality, but without infective power. It was a degraded chancre, but inasmuch as it retained some resemblance in its local ap- pearance to the " true " chancre, he termed it chancroid* The soft chancre or " chancroid," then, was a disease bearing a similar relation to syphilis that vaccinoid or varioloid does to vaccina or variola. According to Pro- fessor von Rinecker,5 of Wurzburg, who adopts the above view of the origin of the soft chancre, the tran- sition is analogous to what is known in zoology as hetero- genesis, where,under different conditions, the same animal occurs under different forms, under either of which it may continue to propagate its kind in the same form, or, under certain circumstances, may change to the other. Thus certain ascarides occur sometimes as parasites, sometimes in an independent form of life, and one mode of existence may be exchanged for the other. In like manner, it is maintained that syphilis or the syphilitic virus is capable of appearing under two forms, in one of which it requires a period of incubation before manifest- ing its presence, and afterward pervades the entire or- ganism, producing constitutional manifestations ; in the other, its development is precocious, its life brief, and the sphere of its action circumscribed within tlip vicinity of its first implantation. The production of the chancroid of Clerc under the simple conditions as first stated has not been found to be an easy matter. The auto-inoculation of the scanty se- rous secretion of the typical hard chancre is rarely fol- lowed by any effect whatever. Clerc described but two cases, one produced accidentally, the other designedly by way of experiment. Fournier, after numerous trials, succeeded but once, and some cases were reported by Bidenkap and Boeck in connection with their practice of syphilization. It was not long, however, before it was ascertained that, when the initial lesion of syphilis is irri- tated and made to suppurate freely, the chancroid could be produced more readily, and it now appears that it is not the syphilitic virus taken from the hard chancre that is essential to the production of the chancroid at all, but simply the artificially or accidentally excited purulent secretion which possesses irritant qualities sufficient to produce ulceration when inoculated upon a syphilitic soil. For by further investigations, which it is unneces- sary to cite in detail here, it has been shown that not only may the chancroid, or a lesion in all essential particulars corresponding to it, be produced by auto-inoculation of pus from a syphilitic chancre, but by a great variety of irritants ; that pus from the most diverse sources, cau- terizations and even traumatisms, are capable of produc- ing lesions in a syphilitic patient that in their destruc- tive course and inoculability in generations, both upon syphilitics and non-syphilitics, bear the closest resemblance to the typical soft chancre. But certain investigators, whose authority we have no right to question, have shown that sometimes the inoc- ulation of common pus-pus that is neither chancrous nor syphilitic-may produce also upon persons who are not syphilitic ulcers that are inoculable in generations. Tanturri produced such sores in a patient suffering from pityriasis rubra by auto-inoculation of matter taken from blistered surfaces that had been converted into ulcers by means of irritating ointments. These sores were inoc- ulated both upon syphilitics and non-syphilitics, and were reinoculated through fourteen generations. Kaposi, Wigglesworth, and others have reported similar experi- ences. That such occurrences, however, under any ordinary circumstances must be extremely rare ' ' goes without saying." Of fifty-seven successive inoculations of common pus derived from various sources, reported by Rieger,6 every one was a failure. Nevertheless the important fact remains that it is possible to produce de novo contagious sores, which, however faintly they may represent a typical chancre in their clinical appearances, yet evince that same property upon the presence of which the chancroid of Clerc has been declared identical with the soft chancre-namely, inoculability in generations. It is not unlikely, indeed we have much reason to believe, that the tissues of a person who is syphilitic are more vulnerable, more apt to take on ulcerative action under irritation than those of a healthy person. But the theory that the inoculable sores produced in such tissues owe their virulent properties to a modified syphilitic virus has been deprived of its chief support, the evidence as it now stands going to show that precisely similar sores may be produced under conditions which are entirely independent of syphilis. * Though Clerc's term for the simple non-infecting chancre has been generally adopted in this country, it can scarcely be because the author's views have been embraced at the same time. 60 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. The origin of the soft chancre still remains in ob- scurity. It is possible that under certain circumstances it may arise de novo, perhaps by the conversion of com- mon pus into virulent matter through peculiar reactions that it undergoes in certain tissues. The inoculable sores thus produced may at first stand as the connecting link between the simple ulcer and the typical soft chancre. A certain increase in intensity of the same virulence may suffice to convert such a sore into a chancre-a conver- sion similar to that which takes place when the chancre becomes a phagedenic ulcer ; or, on the other hand, the simple chancre may be the product of a virus as inde- pendent, as specific in its nature, and of an origin as re- mote as the virus of syphilis. But whatever its origin, the fact that there is a form of chancre distinct from syphilis, from which syphilis cannot be produced, and which there is no substantial evidence to suppose can be produced from syphilis, the results of both clinical and experimental experience leave no room to doubt. There is a simple chancre and a syphilitic chancre, which in the great majority of cases are distinguishable clinically, and in experimental researches have never been confounded. The clinical exceptions referred to above can fot the most part be rationally explained on the ground of accidental juxtaposition of two viruses or of two contagions, the chancrous and the syphilitic. The few anomalous cases that remain-anomalous because so at variance with the natural history of the two diseases-are as yet insufficient to destroy the great practical value of the doctrine of duality as a reasonable working theory. syphilization-a doctrine which was based upon an as- sumption of the identity of the chancrous and syphilitic poisons. It was defined by its originator, Auzias Turenne, in the following words : " When successive chancres are communicated to an animal by inoculation, at whatever intervals or however combined, the first chancre mani- fests itself more rapidly, becomes larger, furnishes more pus, is accompanied by a higher degree of inflammation, finally, lasts longer than the second. The second is to the third as the first to the second, and so on until the animal can no longer contract the disease. This animal is thus vaccinated [?] against syphilis. ... I de- signate this state by the word syphilization.'1" Unquestionably these chancres were not syphilitic, and in other respects the above views have been considerably modified by subsequent observations. Nevertheless it is beyond doubt that when the soft chancre is auto-inocu- lated in rapid succession, and especially if the inoculations are made in successive generations, each succeeding crop being produced from the last preceding, a gradual attenu- ation of the virus takes place, till, finally, its inoculability becomes extinct. But so gradual is this extinction that practically it has little importance, and so far as common experience of the disease is concerned, the inoculability of the simple chancre may be regarded as unlimited. Pathological Anatomy.-In its minute anatomy there is little that especially characterizes the soft chan- cre or that essentially distinguishes it from any ulcer of a simple inflammatory character. Examined microscop- ically the tissue just beneath the ulcer is found infiltrated with a dense mass of round cells which extends a certain distance beyond the external limits of the sore, and is limited both laterally and below by a sharply defined line bordered by a zone of oedematous tissue. Around and in the immediate vicinity of the chancre the papillae are seen to be swollen, those nearest the ulcer being con- siderably broadened. Above the enlarged papillae the rete mucosum is thickened and overhangs the surface of the sore at its periphery. The ulcerated surface is de- void both of papillae and epidermis. According to Ka- posi 8 the cells composing the infiltrated portion are partly of large size, resembling lymph corpuscles, and partly consist of small nucleated cells which are uniformly dis- tributed and in great number, all enclosed in a faintly outlined fibrous meshwork. Near the surface the cells are granular with indistinct nuclei, and are associated with many free nuclei and granules. The more deeply situated cells are larger, and have the character of ordin- ary inflammation cells, though many of them are smaller. The walls of the blood-vessels are greatly thickened through infiltration and hypertrophy of the adventitia, while their lumina are enlarged both in the infiltrated portion and also in the surrounding (edematous tissue. Clinical Features and History.-Whenever the chancrous virus is brought in contact with a cutaneous or mucous surface deprived of its epidermis or epithe- lium, an interval elapses before the contaminated tissue betrays any characteristic reactions. When the whole process is under observation from the beginning, as in the case of artificial inoculation, the first effect which immediately follows the introduction of the matter is a slight local irritation, consisting of an itching or burning sensation accompanied by the appearance of a little red spot. Within the first twelve hours the redness becomes more intense, and signs of inflammatory exudation ap- pear. In the course of twenty-four hours a papular ele- vation forms, which is surrounded by a red areola, and by the end of the second day the centre of the efflores- cence shows a pustule. The pustule soon dries, and a little crust is formed, underneath which is a small cup- shaped depression filled with pus, and, in from three to four days from the inoculation, the little lesion has be- come a round, excavated ulcer, with sharp-cut perpen- dicular edges, grayish-colored base, and purulent, highly contagious secretion-a characteristic chancre. When in- stead of a minute abrasion or scarification the inoculation occurs upon a raw surface of considerable extent, instead of beginning with the formation of a pustule, there is a gradual transformation of the surface into the character The Simple or Soft Chancre. Synonyms.-Lat., Ulcus simplex nA Venereum molle; Fr., Chancre simple, mou, venerien, ou d bubon suppure, chancrelie, chancro'ide, fausse syphilis; Ger., Schanker, weicher oder pseudo-syphilitischer Schanker ; It., Ulcero molle o cordayioso locale. Definition.-A foul, contagious ulcer, usually situ- ated upon the genitals, that is produced by inoculation of a virus derived from another ulcer of like character, and is unattended by constitutional infection. It is especially characterized by its frequent venereal origin, by its almost unlimited auto- and hetero-inocula- bility, by its peculiar clinical features and history, and by its tendency to give rise to suppurating and virulent buboes. Venereal, Origin.-Though not its only mode of origin, in the vast majority of cases the simple chancre is the result of sexual intercourse with an individual whose genitals are already affected with the disease. That the chancre arises in this way so frequently is chiefly due to the peculiar facilities for contagion afforded by sexual in- tercourse, and also implies, doubtless, that the conditions which obtain in the sexual organs are especially favorable to the development of the disease. Inoculability.-The contagiousness of the simple chancre is its most marked and constant characteristic. The only condition necessary to the production of the disease is the contact of an abraded or raw surface upon any portion of the body with the purulent chancrous secre- tion. The extent of its communicability in this manner from individual to individual (hetero-inoculability) in man is doubtless unlimited. The lower animals are prob- ably for the most part insusceptible to the poison, and in the comparatively few instances in which they have been inoculated successfully, the degree of susceptibility has been markedly inferior to that which is encountered in the human subject. Inasmuch as the simple chancre is strictly a local dis- ease, one successful inoculation affords no security to the rest of the body against subsequent exposures. When an individual with a soft chancre is inoculated at some other point with the secretion of this chancre (auto-inoculation), a second chancre results of the same character as the first $ from this second chancre another may be produced, and so on, often in hundreds of generations. It has been ascertained, however, that there is a limit to this inocula- bility of the chancrous virus upon the same individual, and upon this fact was founded the now obsolete doctrine 61 Chancre. Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of an unhealthy, corroding ulcer, commencing usually at some one point of the denuded surface, and gradually in- vading its entire extent. The above is what is commonly described as the stage of developmen t. Following this the ulcer slowly increases in size, and assumes a still more striking and characteristic appear- ance. As the ulceration advances, while preserving a general regularity of form, with a rounded or oval con- tour, and a comparatively level though depressed surface, certain places in its course succumb more readily than others. It dips deeply into follicular orifices, it creeps along folds of skin, it burrows underneath the surface. In the comparatively compact epidermis its progress en- counters a certain barrier, so that as it undermines the corium a more or less jagged fringe of epidermis over- hangs the ulcerated surface. The bottom of the sore is not smooth, but has a pitted or worm-eaten appearance, and is covered by a sticky, pultaceous, sloughy substance that cannot be wiped away without causing bleeding. The discharge is abundant, thick, purulent, of a dirty cream color, sometimes greenish or sanguinolent. The sore rests upon a more or less swollen base, which when pinched between the thumb and finger is felt to be soft, pliable, easily folded upon itself, and, though occasion- ally there is some sense of resistance due to the inflamma- tory exudation and engorgement, the hardness is inelastic, doughy, not sharply defined, but diffuse, merging gradu- ally into the surrounding tissue. Certain peculiar features are imparted to the simple chancre through its liability to inoculate its environment. Any abraded spot in its near vicinity, such as may easily result from maceration with the acrid and profuse secre- tion of the sore, or at a distance to which the matter may be accidentally conveyed, as, for example, by the finger- nails, is sure to be converted into another chancre. Such sores occurring as satellites about the original chancre, present a clinical picture that is striking and character- istic. The secondary chancres may approach so near to each other or to the parent sore as to coalesce and pro- duce irregularly shaped ulcers, with scolloped edges. Finally, through the medium of the lymphatics, the neigh- boring glands are liable to be inoculated and undergo sup- puration. Bubo.-The simple chancre of the genitals is usually accompanied with adenitis of the inguinal glands. Gen- erally a single gland on one or on either side is inflamed, and when attended with suppuration, as it commonly is, the pus may have the same virulent and contagious prop- erties as that of the chancre, and when opened, the edges of the aperture becoming inoculated, are converted into another chancre. Such is the ordinary course of the simple chancre dur- ing the period of its virulent activity, which continues from four to live weeks, when there begins the period of repair-a period that usually prolongs the affection for a fortnight more. First, the surface of the sore begins to assume a more healthy appearance ; the tenacious gray coating separates ; the discharge becomes creamier and more like healthy pus, gradually losing its virulence and inoculability. Red, easily bleeding granulations spring up, filling the excavated area of the chancre, and, finally, healing is completed, partly by cicatrization, partly by contraction of the edges. A permanent scar is left, which at first is red and pigmented, afterward becoming white. Varieties of the Simple Chancre.-Variations that arise in the course and clinical appearances of the chancre are never referable to the source from which the disease is derived. They may depend either upon morbid tenden- cies inherent in the individual, or else upon peculiarities pertaining to the location of the disease. To the former category belong cases in which the destructive process is extraordinarily rapid or extensive-phagedena. Why certain individuals should be subject to these severe forms of inflammation while others are not, is not easily explained. That it does not depend upon any special properties of the virus derived from the infecting chan- cre, has repeatedly been shown by confrontation. It seems rather to be owing to some indefinable quality per- taining to the individual attacked, a quality that may be associated with more or less obvious cachectic or dia- thetic conditions, but frequently enough it occurs where no such morbid conditions are present. The destructive inflammatory chancre occurs under two forms-the gan- grenous chancre and the serpiginous chancre. Gangrenous Chancre.-In this form, also known as sloughing phagedena, a dry, wrinkled, blackish or green- ish slough is formed, which is firmly adherent to the tis- sues beneath. It is attended with signs of severe inflam- mation, the surrounding surface becoming intensely red or livid, and cedematous, together with severe pain and high fever. After a time the edges of the slough become moist, and there escapes a dirty yellowish or greenish, thin, ichorous discharge. The slough finally separates, the inflammation subsides, normal pus appears, and a healthy healing surface may appear; or, on the other hand, the whole process may be repeated. The gangrene respects no tissue, and before its progress can be stayed its ravages may have caused most serious mutilation, or through the general constitutional disturbance it entails, may end by exhausting the vital powers and destroy life. t Serpiginous Chancre.-While the preceding may be characterized as the acute form of phagedena, this is es- sentially a chronic form. Compared with the former, its grade of inflammation is low, while its steady progress may continue unchecked for months, or even years. It begins from an ordinary chancre, which may pursue its usual course excepting at one point, whence it makes its invasion into the surrounding tissues. On one side is a healing surface, while upon the other the surface is gray, with undermined edges, and a thin, watery, or sanious and auto-inoculable secretion. Its favorite path lies through the connective-tissue. It is easily deflected from its course by the intervention of denser tissues, or even by a sudden change of tissue, such as from skin to mucous membrane. In this way blood-vessels and nerves may be dissected out, the skin is undermined, leaving bridges of tissue here and there with overhanging borders of integu- ment. As it gradually invades regions farther and farther removed from the point of departure, very extensive sur- faces may be traversed, involving not only the genitals, but extending also far over the thighs and trunk. Diphtheritic Chancre.-This name has been given to a variety in which, in connection with little or no evidences of inflammation, a yellowish-white, tough, firmly adher- ent membranous exudation forms on the surface of the sore. It is insensitive, secretes a thin ichor, or is per- fectly dry, and the secretion, when it exists, is not auto- inoculable. There is scarcely any destruction of tissue, and the disease may remain stationary for weeks in this condition without increasing either in area or depth. Finally, signs of a more active inflammation appear, the secretion becomes more abundant and purulent, the exu- dation disappears, and a healing ulcer is left (Kaposi, loc. cit., p. 33). Excoriated Chancre. Ulcus ambustiforme (Kaposi); Chancre exulcereux (Clerc).-A form that usually occurs upon mucous surfaces, as upon the glans penis, the inner surface of the prepuce, the introitus vaginae, etc., and is characterized by its superficial appearance, resembling a simple excoriation or a burn. Its edges are not elevated, though sharply defined, its surface is smooth and raw- looking, and its contour frequently irregular, and it va- ries greatly in size. It is often a rebellious form to treat, and leaves, on healing, thin glistening scars. Sometimes, in consequence of the growth of exuberant granulations, the surface of the chancre may be elevated above the surrounding skin or mucous membrane, and is then known as " ulcus elevatum." When the sore occurs upon the skin, as upon the sheath of the penis, the secretion often becomes dessicated and forms a thick, blackish crust, and is termed an ' ' ecthyma- tous chancre." Follicular Chancre.-When the chancrous matter hap- pens to be introduced into the interior of a follicle, a lesion results which at first bears some resemblance to acne in- durata. A red, elevated papule or tubercle is formed, in the centre of which appears a large and deeply seated pus- 62 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. tule, which breaks and leaves an excavated, conical, chan- crous ulcer. Peculiarities pertaining to Location.-The soft chancre, as it occurs clinically, being with few exceptions a venereal disease, its almost constant seat is the genital organs or their immediate vicinity. The parts that are most liable to injury and abrasion during intercourse are those most commonly affected. In the male the most usual seats of the disease are the inner surfaces of the foreskin, the sulcus coronas glandis, the frenum, and the preputial orifice; in the female, the introitus vaginae, the fossa navicularis, and the inner surfaces of the labia. In the Male.-Beneath the prepuce the chancre is ex- ceedingly apt to be multiple as the result of auto-inocula- tion, partly owing to the retention of the acrid discharge, and partly to the liability of the parts being torn during retraction of the prepuce. The frequent tension to which the frenum is subjected not only renders it a common seat of chancre ; but when once affected the repeated stretching of the part often produces little rents in the base and edges of the ulcer which tend both to promote its spread and protract its duration. The chancre is most commonly situated on one side, but usually gradually eats its way through to the other, leaving a little bridle of mucous membrane, which finally is ruptured or ulcerates away. When the sore first appears on the free border of the frenum it tends to spread in a linear form along the ridge to the insertion in the glans. The continual tearing of its base also tends to its gradual increase in depth, and thus it may bore its way into the urethra. Should the sore heal before the fibrous band in the frenum is entirely destroyed, the cicatrix is afterward liable to frequent fissures, ren- dering coitus painful. Upon the glans the chancres are apt at first to be small, but may afterward extend deeply, especially if compli- cated with phagedena, and cause extensive mutilation. They are usually accompanied with corresponding sores on the inner layer of the foreskin, and are often compli- cated with phymosis or paraphymosis. Chancre of the meatus may occur either on one side or at one of the commissures, or it may embrace the entire circumference. It frequently dips down into the urethra for a little distance, but seldom extends outward over the glans. On healing, the cicatrix leaves the meatus gaping and funnel-shaped, often without any obstruction of the orifice. Chancre of the urethra, beyond the fossa navicularis, is extremely rare. When it occurs it may be detected by the localized pain and tenderness corresponding to which an inflammatory thickening may be felt externally. It is succeded by an inodular stricture. In women, the chancre is apt to appear first at points where the parts are most liable to be stretched and torn during coitus. That the more deeply situated organs, the os and vagina, are less liable to inoculation than the ex- ternal parts, is probably chiefly due to the fact that they are less exposed to traumatism. Chancre of the vagina is one of the rarest of accidents, depending, probably, first upon the thickness and tough- ness of its epithelium ; second, upon its great distensibility, which renders it less liable to rents or abrasions during intercourse, and, finally, upon the copious secretions that bathe its sides, especially during coitus, which tend to shield it from contact with virus, or by acting as a con- duit serve to sweep the contagious materials away before they can effect a lodgement. Chancre of the vaginal portion of the uterus, though rare, is much more common than chancre of the vagina. It is said to be most apt to occur ^either when the womb is prolapsed, or when the tissues Ibf the os are rendered soft, relaxed (and, hence, more vulnerable) by the condi- tion of pregnancy. In rare cases the chancre invades the cavity of the cervix, or even that of the uterus. Extra genital Chancre.-While artificial inocula- tions have proved that no region of the body possesses an absolute immunity against the chancre poison, though certain parts are more favorable than others to its develop- ment, it is a notable fact that chancre has remained al- most exclusively a venereal disease, and, with rare excep- tions, is confined to the genital organs or their immediate vicinity. Indeed, it is this fact which furnishes the strongest presumptive evidence in favor of the indepen- dent or specific character of its virus, as against the theory which would derive it from simply depraved pus. Never- theless, extra-genital soft chancres are occasionally met with, both as a result of mediate and immediate contagion, and sometimes of auto-, sometimes of hetero-inoculation. Occasionally an abraded finger becomes the seat of the disease, and in very rare instances the region about the mouth. Chancre of the anus, though strictly speaking it be- longs to the extra-genital chancres, is not ordinarily classed with them because, usually, at least in women, in whom it is 'much more common than in men, it is associ- ated with chancre of the genitals. In men, chancre of the anus is presumptive evidence of sodomy, while in women it is usually due to contact with chancrous virus contained in the genital secretions, with which the anal orifice is often soiled. The chancre in this location usu- ally occurs in the folds of the margin both in front and behind, more rarely at the sides, and the sores are apt to be elongated from above downward. There are frequently multiple sores, and they may extend upward into the rec- tum, or sometimes, when due to coitus sodomiticus, they may occur there primarily. Chancre of the rectum may be the cause of serious stricture. Diagnosis of Simple Chancre.-The disease with which the soft chancre is most likely to be confounded is the initial lesion of syphilis, and the differential diag- nosis of these two affections will be considered later on under Syphilitic Chancre. The only other affection for which the simple chancre is liable to be mistaken is a modified lesion of herpes pro- genitalis. At the beginning of the latter affection the little clusters of perfectly clear vesicles, with their cres- centic or circular outline, and the decided itching or burning sensations attending them, are sufficiently char- acteristic. But it sometimes happens, after the herpes has lasted some time, that the little erosions left by the vesi- cles become superficially ulcerated ; they have a grayish- colored surface, with a more or less free discharge of pus, and may assume an appearance not unlike that of young chancres. Furthermore, it is quite possible that the le- sions of herpes may be the scat of chancrous inoculation. Hence when such superficial sores appear upon the geni- tals, occurring in the form either of a group or rounded isolated lesions, or of an irregularly shaped ulcer result- ing from the confluence of several lesions, the diagnosis may be at first difficult. But if, after a day or two, it is observed that the sores show no disposition to spread, and that under the application of some simple drying powder or astringent wash the surface becomes cleaner and the erosions begin to heal, and, especially, if the secretion is found not to be auto-inoculable, it is fair to conclude that the disease is not chancre. With a history of the com- mencement of the affection, and from the peculiar distri- bution of the efflorescences, we infer, furthermore, its herpetic character. Management of the Simple Chancre.-Prophy- laxis.-With our present imperfect knowledge of the origin of the soft chancre, the only sure means of pre- venting the disease consists in the avoidance of contagion. If the simple chancre, as maintained by many, can only be propagated from itself, and under no circum- stances can be generated de novo; if, while its virus is as independent and peculiar in its nature as the poison that causes cholera, or variola, or syphilis, yet in its effects it is as truly local, almost as circumscribed as the sting of a wasp or the burn of a caustic, it would seem no such impossible task to stamp the disease out entirely. For the ultimate extinction of an affection like this that is communicable only by its one lesion, and that, too, but for a short period of activity, should be vastly less diffi- cult than the control of diseases that may spread by ema- nations and by fomites, such as cholera and small-pox, or than that of a disease like syphilis, which a single indi- vidual is capable of communicating for years, and in a hundred ways. 63 Clianrre, Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The chancre, more than syphilis, is decidedly a disease •of filth. It flourishes best in the slums, in the lowest brothels, in the persons of the vilest prostitutes. Preva- lence of the simple chancre implies, more than does syphilis, promiscuousness of intercourse. While simple chancre is almost constantly a venereal disease, syphilis often is not. Since the chances of an individual who has syphilis of conveying the disease to others, considering its duration and the multiplicity of its lesions, are a hundred- fold greater than those of a person who has chancre of communicating that disease, therefore syphilis should be vastly more prevalent than simple chancre. Doubtless it usually is, but it has been repeatedly remarked in times of especial license and debauchery that the soft chancres greatly outnumbered the hard. Syphilis is much less influenced by venereal causes than is simple chancre. The time may come when the latter disease, with im- proved methods of control, may be eradicated from the race, provided only that there be no way of spontaneous origin, or of recreation out of another disease. Precautions.-The means of prevention, after exposure, consists in a thorough washing of the exposed surface, and afterward cauterizing any abraded spots with nitrate of silver, carbolic or chromic acid, care being taken to limit the caustic as much as possible by the extent of the abrasion, lest a troublesome sore be produced that would delay the diagnosis and prolong the patient's suspense. Abortive Treatment.-When the chancre has existed but a short time, and the infiltration and inflammatory en- gorgement are yet only slight and superficial, without doubt in a large proportion of cases it is possible by ener- getic measures to totally destroy the virulence and to con- vert the sore into a simple, benign, and healing ulcer. But if the disease has already lasted many days, has in- vaded the whole thickness of the skin, and shows a deeply excavated surface surrounded with a swollen inflamma- tory areola, while around it are clustered a number of secondary sores from auto-inoculation, it is very ques- tionable if more harm than good may not result from any attempts at ectrotic treatment. A cauterization de- signed to destroy all the virulence of the chancre at once will be very apt to leave a solution of continuity in sound tissue either at the borders or base of the sore, and should any virus be left undestroyed these spots will directly be infected, and the last condition will be worse than the first. Instead of limiting the disease its spread is only promoted. Deep cauterization, then, is only advisable when from the age and condition of the sore there is a fair prospect that every vestige of virus can be destroyed instantaneously. To accomplish this a powerful caustic is required- either a strong mineral acid (such as nitric acid or the acid nitrate of mercury), or the actual cautery (the hot iron or the thermo-cautery of Paquelin). The caustic pastes are seldom required. In using the acid, which is the most convenient agent for the majority of cases, the fol- lowing procedure is adopted : The sore must, in the first place, be thoroughly cleansed from all secretion, with a pledget of absorbent cotton, or for this purpose the per- oxide of hydrogen9 may be used, which has the property of destroying pus by oxidation and causes no irritation. The surface having been thus prepared it is held in a horizontal position while the chancrous cavity is cau- tiously filled, even to the brim, with the acid dropped either from the end of a slender glass rod or from the charred and pointed end of a match. In a few moments the cauterization is complete. The sore is dried with absorbent cotton or a bit of blotting-paper, and to relieve the sharp pain that follows, touch the cauterized surface with pure carbolic acid and the pain will almost instantly cease. In certain cases where the lesion is favorably situated it is possible to remove the chancre by excision. It has been done most successfully where the sore or sores were so situated that all the diseased parts could be removed by circumcision. The parts should be cleaned as above described, and all the sores should then be touched with carbolic acid, or, as recommended by Aubert,10 with the actual cautery. Circumcision may then be performed in the usual way. Aubert has thus operated successfully in a number of cases complicated with phymosis. But as a general rule it is unadvisable, except in cases in which it is possible to retract the prepuce and be sure that the glans, sulcus, and all other parts that cannot be excised are perfectly intact. In phymosis with irretractable foreskin it is safer to rely on subpreputial injections. In the larger proportion of cases the heroic methods of treatment above described are either impracticable, or if employed, are without avail. Many times they are inad- missible because of the danger of exposing more tissue to the spread of the disease. In some instances a less energetic cauterization than that by the mineral acids is of service; more particularly where the chancre has already gained considerable headway. Under these cir- cumstances, before retiring to simple palliative measures, it is proper to still continue efforts to destroy virulence by certain caustic agents, which, while they act more or less powerfully upon the surface of the sore, have little or no disposition to attack sound tissue. Such a caustic is pyrogallic acid. The application of this drug to the treatment of chancre was first proposed by Vidal,11 and more particularly for phagedena. It may be applied either in the form of a paste (pyrogallic acid, 20 ; starch, 40 ; vaseline, 40) or of a powder (pyrogallic acid, 20 ; starch, 80). The latter is better suited to cases of exten- sive phagedena, with undermined edges and sinuses, while the former answers for ordinary chancre of limited extent. The surface of the sore must first be carefully cleaned, and the paste or powder is applied fresh morning and night, and covered with gutta-percha tissue. The applications are continued till a red, healthy-looking sur- face appears and the base of the sore is level with the sur- rounding skin. The drug is then exchanged for some less irritating application, preferably iodoform, under which cicatrization usually proceeds rapidly. According to Ilans von Hebra,12 a similar effect may be produced by the application of pure salicylic acid in dry powder. Hebra claims that by this means a chancre whose ordinary course would be from six to eight weeks' duration may be entirely healed within a week. The powder is applied to the cleaned surface of the sore every day, or if there be much discharge, twice a day, till a slough is formed, which usually takes from two to three days. An emolient salve is then applied, underneath which the slough soon separates, leaving a healthy, heal- ing wound. Palliative Treatment.-In very many cases, however, all of the above methods of treatment will fail to abort the disease. The virulence is not annulled, and the chancre continues its course as before. Through what means the chancre finally limits itself spontaneously is unknown. It is not easy to see why the virus should not continue to poison the surrounding tissue and the disease spread in- definitely. When it is learned how nature inhibits its action, we may be better able to control the disease ; but, for the present, unless we can succeed by powerful agents in annihilating all the virus at a single stroke, the most we can do is to prevent to a certain extent the spread of the disease by auto-inoculation, and employ such means as may serve to temper the virulence we are unable to de- stroy. First among these in importance is cleanliness. The danger in the accumulation of the secretions of the sore is twofold. These secretions are not only the vehicle of the chancre poison, but, by macerating the surrounding mucous or cutaneous surface, they render the parts liable to excoriation, and to inoculation of new points of expos- ure. Moreover, the utmost care is requisite in handling the parts, in removing dressings, in retracting the prepuce, etc., to avoid all traumatism by tearing or abrasion of the surface, since every such solution of continuity is certain to become the site of fresh inoculation. Iodoform.-Among all of the remedies that have been used for the palliative treatment of chancre, none has so well borne the test of experience as this. There is no form of the disease in which it is contra-indicated, and scarcely any in which its beneficial effects are not decided. Its one objectionable feature, its penetrating and tell-tale 64 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. odor, should not condemn a remedy that has no equiva- lent, even were it not possible by proper precautions in a large degree to control this objectionable characteristic. The first of these precautions is to avoid scattering it about as far as possible ; to use only so much as is neces- sary to cover the ulcerated surface, and to apply it in such a way that not a particle shall be spilt. It is only by dif- fusion in the atmosphere that the odor becomes excessive, and extreme care in the dressing will, to a great extent, avoid this. In most cases it is sufficiently efficacious if used in the form of a paste, by means of which the dif- fusion is reduced to a minimum. Any attempt to dis- guise the odor by combining it with other substances is only partially successful. The best substance for this purpose is oil of peppermint, but even this is only of temporary advantage ; the iodoform soon reasserts itself, since the odor of the essential oil is much more rapidly dissipated. Combinations with balsam of Peru, with oil of eucalyptus, with tannin, etc., have been recommended, chiefly for the purpose of correcting the odor, but so far as this object is concerned they are of little avail. The following will be found a useful formula: R. Iodoform 60 parts. Glycerin, Mucilage aS 15 parts. Oil of peppermint 1 part. M. A paste is better than an ointment, for the reason that it does not prevent the escape of the discharge as does the latter. In place of iodoform, various powders, such as oxide of zinc, bismuth, or calomel may be used. When the in- flammation is considerable, lotions are preferable, such as black or yellow wash, aromatic wine and water (3 j.- iij. to 5 j-)> or aqueous solutions of sulphate of zinc or permanganate of potash (gr. j.-iij. to §j.), tartrate of iron and potash or nitrate of silver (grs. v.-xx. to 3 j.). When the course of the disease seems unduly protracted, the surface of the sore may be touched with the solid stick of nitrate of silver, with a solution of bromine (3 ij. to § j), or with pure carbolic acid. Treatment of Phagedena.-When the chancre be- comes phagedenic, whether in the gangrenous or serpigin- ous form, active measures are called for. The most efficacious of the local remedies are cauterization, either actual or potential, the prolonged hot-water bath, and powdered iodoform. Perhaps no remedy is equal to the actual cautery. The best form in which to employ it is either the thermo-cautery of Paquelin or the galvano- cautery. The surface having been previously prepared by slitting up all sinuses, paring away overhanging edges, etc., the entire ulcerated area should be thoroughly cleaned, and the parts afterward dressed with the cold- water dressing, to be exchanged later for a lead wash. The best potential caustics are the carbo-sulphuric paste of Ricord, made by mixing sulphuric acid with willow charcoal to form a paste ; Canquoin's paste, composed of equal parts of chloride of zinc and flour, with the addi- tion of a few drops of alcohol; or, the potassa cum calce. The first forms a dry scab, underneath which, in favor- able cases, the ulcer may completely cicatrize. The chloride-of-zinc paste is washed off after twelve to twenty- four hours and the surface dressed with simple water dressing or iodoform gauze. The Vienna paste (potassa cum calce) does its work in from five to fifteen minutes. When the gangrene is confined to a limited space, the nitric acid may be used, but for large, uneven surfaces it is less manageable than one of the caustic pastes. Vidal has highly recommended the pyrogallic acid for phagedena, ami, according to Baudoin,13 dry, powdered camphor, spread in a thick layer over the ulcerated sur- face four times a day, not only relieves pain, but is also efficient in checking the disease. The management of chancres in special locations some- times requires particular measures of treatment. In the subpreputial chancre, complicated by phymosis, any cut- ting operation, for the sake of exposing the disease, is en- tirely unwarranted, unless there be imminent danger of perforation of the urethra or foreskin. Ordinarily, with the aid of a syringe provided with a long, flattened nozzle, the surface can be cleansed and appropriate applications made with a sufficient degree of thoroughness, notwith- standing the chancres remain entirely concealed from view. Their location may usually be surmised with suf- ficient accuracy through the presence of local tenderness, together with a more or less circumscribed thickening, which can usually be felt externally through the prepuce. The syringe should be used every two or three hours, or oftener, depending upon the amount of discharge; first using simple water, or salt and water, and afterward throwing in a few drops of a saturated solution of iodo- form in ether, or a twenty-grain-to-the-ounce solution of the nitrate of silver. When the chancre is situated just within the orifice of the 'urethra, the iodoform paste may be packed into the meatus by means of a little wooden spatula. Chancre of the frenum requires the exercise of the greatest care when the foreskin is retracted, to avoid tear- ing the mucous membrane, and thus starting the disease at a fresh point. After the frenum has been perforated, leaving a bridle of tissue remaining, it is advisable to re- lease the part fro in tension by dividing the little bridge and then cauterizing (preferably with the hot iron) the cut edges ; or a good method, proposed by Diday, is to pass through the perforation one blade of a pair of scissors, the edges of which are blunted and rounded off so as to just meet without crossing, while the other blade is held in the flame of an alcohol-lamp, and then the two blades are slowly brought together, gradually burning their way through the little band of tissue. By this means ail danger of bleeding is obviated. Chancres of the anus and rectum, or of the vagina and vaginal portion of the uterus, are best treated by iodoform applications. In the latter regions the iodoform gauze may be used with advantage. The Syphilitic Chancre. Synonyms.-The Hard or Indurated Chancre, the Initial or Primary Lesion of Syphilis; Lat., Ulcus durum vel syphiliticum ; Fr., Chancre syphilitique, dur on inf ectant; Ger., Harter oder syphilitischer Schanker, Syphilitischer Primar-Affect; It., Ulcero indurato. Definition.-By the term "syphilitic chancre" we understand the local affection which follows the inocula- tion of syphilitic virus upon the skin or mucous mem- brane, appearing after a more or less protracted period of incubation. It is chiefly characterized by a circum- scribed, indurated growth, which may, or may not, be attended with ulceration. Incubation.-Between the inoculation of any tissue of the body with the virus of syphilis, and the appearance of the initial syphilitic lesion, there invariably intervenes a period of latency, a period during which the poison ap- parently lies dormant and inactive. Every trace of the little abrasion or solution of continuity at which the poi- son gained entrance disappears, and no sign, either local or constitutional, betrays the fact that the infection has taken place. In simple chancre the tissues react immedi- ately, as if to a corrosive poison. In syphilis the evi- dences of irritation are delayed. What processes of preparation may be taking place during this period of apparent quiescence are unknown. We may conceive them to be analogous to the germination of seed sown in a fertile soil, but in the former case the soil is a living body, and the only intimation we have of the grow th of the seed is in the morbid reactions that are superinduced in the soil. The period at which these reactions first be- come manifest varies in different individuals, depending partly, probably, upon the nature of the seed or virus, partly upon the quality of the tissues in which it is im- planted. It has been found, in the course of experimental inocu- lations, that virus taken directly from the primary lesion, or from mucous patches, is followed by a somewhat shorter period of incubation than is that derived from pustular secondary lesions, or from syphilitic blood. Some variation in the length of the incubation, therefore, 65 Chancre. Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. depends upon the source from which the virus is derived. Comparing the results of artificial inoculations from vari- ous sources, the mean duration of the period has been found to be about twenty-six days. The result thus ob- tained corresponds pretty nearly to what is observed in ordinary clinical practice. Julien collates the observa- tions of different authorities upon this point with the fol- lowing results: Diday found a mean of fourteen days; Clerc, fourteen to sixteen ; Chabalier, fifteen to eighteen ; Le Fort, nineteen ; Rollet, twenty-five ; Fournier, twenty- six ; Sigmund, twenty-eight to thirty-five ; Mauriac, forty. The mean obtained from these nine series of observations is twenty-three days. But great variations from this may occur. For example, Fournier reports a case in which the incubation was seventy days ; Limonet and Le Fort three cases in which it was ninety days. On the other hand, Diday declares that once he saw it last but twenty-four hours, and Le Fort saw three cases in which it did not exceed seventy-two hours. These last-mentioned cases, however, are so exceptional, so contrary to common ex- perience, that we must take them cum grano salis. It is highly probable either that the lesions were "mixed chancres," or that the date of exposure was misappre- hended. While bearing in mind the possibility of exceptionally long or short periods of incubation, we may pretty confi- dently look for the appearance of the initial lesion between a fortnight and a month from the date of exposure. Clinical Appearances.-The period of incubation having elapsed, there appears at the site of inoculation a spot of circumscribed redness, slightly elevated, and sur- mounting a small area of infiltration-a papule. This papule gradually increases in size without any marked evidences of inflammation, its surface after a time becomes abraded and slightly moist, and when the lesion is pressed between the thumb and finger it imparts to the touch a sense of firm resistance-it is indurated. The absence of decided inflammatory symptoms is in striking contrast with the condition met with in the sim- ple chancre. The latter lesion has essentially the charac- ter of an inflammatory ulcer ; the former that of a rather indolent neoplastic growth. In the syphilitic chancre the inflammatory signs of heat, redness, cedematous swelling, pain and tenderness, are rarely pronounced and often entirely lacking. Compared with the soft sore it is de- cidedly an inoffensive-looking affair. Its secretion is usually slight. From its somewhat eroded surface there exudes a scanty, sticky, serous, or sero-purulent discharge, not unlike that of an exuding eczema. The secretion is composed mainly of epithelial cells suspended in a serous fluid. The erosion is not a " solution of continuity " that in- volves the entire thickness of the epidermis, and hence can in no true sense be termed an ulcer. Though ulcera- tion may occur, it is not the rule, and is by no means a characteristic feature of the disease. The Dry Scaling Papule.-In some instances the syph- ilitic initial lesion runs its entire course without any further solution of continuity than consists in a slight desquamation of the cuticle. The surface remains dry, and the lesion in its course and appearance is not unlike a lenticular papule of the secondary stage of syphilis. It has been observed that this form usually follows a some- what prolonged period of incubation. It is the form commonly met with after artificial inoculations of syphi- litic blood. According to Diday it is generally followed by a mild grade of syphilis. The Superficially Eroded Chancre, however, represents the most usual form of the initial lesion. It is generally of a round or oval shape, and has a shining or glazed appear- ance. Sometimes it is simply red and raw-looking, or it may be covered by a gray, membrane-like film, which fre- quently, however, occupies only the central portion of the erosion. The edges of such a sore are perfectly level with the surrounding surface, the base is but slightly if at all depressed or cup-shaped, and sometimes may be raised like a dome above the niveau (ulcus elevatum). This elevated form is most commonly observed upon the borders of the prepuce, upon the frenum, the lips, tongue, or upon the vaginal portion of the womb. The centre of the little elevation is often slightly indented. The super- ficially eroded chancre is sometimes transformed into a mucous patch. The red, granular surface becomes cov- ered with a whitish membranous pellicle that extends from the circumference toward the centre, while usually the induration disappears or becomes less pronounced. Sometimes this lesion bears a resemblance to herpes progenitalis. A cluster of superficial erosions appears, with characteristic, though slight, induration of the base. In many cases, doubtless, this form of the chancre owes its origin to an inoculation of the lesion of herpes. Ulcerating Chancres. - As stated above, ulceration is not a typical feature of the syphilitic chancre. When it occurs it is often the consequence of irritation of the sore, converting what was naturally a simple erosion into an inflamed ulcer. Or the loss of substance may be the effect of a combination of the simple and syphilitic chancres (mixed chancre). But in most cases the loss of substance is more apparent than real. The mass of in- filtration may be attended with considerable central de- pression and with comparatively little destruction of normal tissue, and the resulting cicatrix is often insignifi- cant. But, in any event, the ulcer in a true syphilitic chancre is very different in appearance from that of the soft chancre. Its edges are never undermined nor jagged, and are sloping instead of perpendicular. Even in the deeply ulcerated or funnel-shaped sores the edges do not rise abruptly to the surrounding skin but by a gradual incline. Induration.-In all of these forms of chancre there is almost invariably a more or less distinctly perceptible in- duration of the base. Very rarely is it absent-according to Fournier, in not more than one per cent, of the cases. It varies greatly, however, in degree ; sometimes so slight as to be barely perceptible to the touch, and sometimes appearing in the form of a massive growth that feels, when held between the fingers, like a lump of cartilage or bit of wood. It varies also in form. It may be super- ficial, plate-like, lamellar, feeling as though a piece of parchment or thin leather had been mortised into the skin, or it may occur as a firm, rounded nodule, extending through and beneath the skin. It is in the ulcerative forms that the induration is most marked, and to these forms, more particularly, has been applied the term Hun- terian Chancre or Induration. For the detection of the slighter forms of induration, a delicate touch and con- siderable skill are requisite. In many cases it is as ob- vious to the eye as to the touch. The circumscribed, rounded tumor, extending to a considerable distance be- yond the seat of erosion or ulceration, is often in itself sufficiently characteristic. When subjected to pressure by the fingers, or if situated upon the prepuce and the latter be slowly retracted, the resistance offered by the hard tumor and its pressure against the superficial blood- vessels is obvious in the blanching of the superimposed skin or mucous membrane. The induration generally persists for some time after the ulceration or erosion has entirely disappeared, and often for a certain period after the appearance of secondary symptoms. So long as it lasts there is a liability that the ulceration may recur. A relapsing chancre, or chancre redux as termed by Four- nier, is most apt to occur in a massive induration, and especially if so situated as to be exposed to friction, trau- matism, or other mode of irritation. Sometimes under these circumstances the sore takes on a gangrenous char- acter. A moist, grayish, pultaceous slough forms, which, after separating, may be succeeded by another, and thus lead to a spreading phagedena. The induration may be- gin to break down interiorly, and open upon the surface by a number of apertures. Phagedena is less apt to at- tack the syphilitic than the simple chancre. When it occurs the induration usually melts away as it progresses ; though in some cases the ulceration and induration ad- vance pari passu. Under such circumstances the dis- ease is liable to be mistaken for epithelioma. Number of Lesions.-While multiplicity is the rule in the simple chancre, the initial lesion of syphilis is com- monly single, and for the reason that the simple chancre 66 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. is freely auto-inoculable, the other not. At the start the initial lesion is perhaps as apt to be multiple as the soft chancre. If the syphilitic virus is brought in contact with two or more abraded spots at the same time, all of these spots are liable to be infected, and each to develop a syphilitic chancre. Under these circumstances the lesions generally appear simultaneously. But it some- times happens that after the first inoculation the indi- vidual is again exposed to infection during the period of incubation. In such a case the local effect of the second inoculation will not appear till after the completion of its own period of incubation, which generally is subse- quent to the appearance of the first chancre, its delay corresponding to the interval between the two inocula- tions. There may be several of these so-called ' ' succes- sive chancres." They are most frequently observed upon the female breast, where the infection is received from a syphilitic nursling, since in this case the exposure is frequently repeated. The indurations de roisinage of French authors are probably often of a similar character, though sometimes they are better described as accessory than as successive chancres, and may be explained by the progress of the affection along the lymphatics, causing localized indura- tions that assume the form of chancres. Fournier14 has described certain indurations occurring near the site of primary infection, but at very late periods-in the tenth month, the second, third, or even as late as the seventh year. It is probable that they were secondary or ter- tiary lesions, which resembled the syphilitic chancres be- cause of their situation and of a certain hardness of the base. In some rare instances, where the primary indura- tion has lasted long beyond its usual duration, there may be a transformation of the lesion into a gummy tumor. An example of this sort is described by Urma.15 An in- duration of the prepuce of eight years' standing, which was the remains of an initial lesion followed by syphilis, was excised, and the microscopic examination revealed the characteristic structure of gumma. Usually when the induration is so protracted it is owing to the produc- tion of a knot of cicatricial tissue which is incapable of resolution. The duration of the initial lesion may vary between three or four weeks and several months. An invariable accompaniment of this syphilitic chancre is an enlargement and induration of the nearest lymphatic glands, or those with which the chancre is in most direct anatomical communication. When the chancre affects the genitals, indolent buboes occur in one, or usually both groins, consisting of a chain of enlarged and hardened glands (often three can be distinctly felt on either side), which remain discrete, are attended with no marked signs of inflammation, unless the chancre becomes irritated and inflamed, and often persist for months after the chancre has disappeared. Seat and Corresponding Variations of the Syph- ilitic Chancre.-We have no reason to suppose that the tissues of the body are not everywhere equally sus- ceptible to syphilitic infection ; the sole condition being that the virus be brought into sufficiently direct com- munication with the blood-vessels or lymphatics. Ex- cepting the instances of infection by inheritance or through the medium of the utero-placental circulation, the only parts ordinarily exposed to contagion are the cu- taneous surfaces or mucous membranes near the mucous orifices, and in these situations the incipient lesion is always a chancre. Inasmuch as in the great majority of cases the origin of the disease is venereal, most syphilitic chancres occur upon the genitals. In the male the most common situations are, first, the balano-preputial fold or sulcus coronas glandis, where rents or abrasions are most liable to occur, and following this, the mucous membrane of the inner surface of the pre- puce, the frenum, the preputial orifice, the outer surface of the foreskin, the glans, meatus, urethral canal, scrotum, and peno-scrotal angle. In the sulcus the chancre may be either in the form of the superficial erosion or of the variety known as Hunterian chancre. The tendency for secretions to accumulate here often provokes irritation and increased suppuration, and in this way gives rise to ulceration. According to Zeissl, when the orifice of a sebaceous gland, in this situation, is denuded of its epi- thelium it may become the seat of inoculation, the in- duration then dipping down into the follicle so as to produce the effect of a hard cylinder vertically placed in the mucous membrane. R. W. Taylor has recently de- scribed a similar lesion. When several such glands near together are thus affected, their indurations may coalesce and form a massive, thickened collar surrounding the glans. Upon the mucous membrane of the prepuce the indura- tion is usually well marked, and when the foreskin is slowly everted the blanching of the mucous membrane upon and at the borders of the chancre is especially char- acteristic. At the preputial orifice the chancre may appear in the form of the "dry scaling papule," or, especially in cases of congenital phymosis, as a massive cartilage-like induration, or sometimes it has the appear- ance of an indurated fissure. Upon the glans the appearances of the initial lesion vary according as the part is habitually covered by the foreskin or not. In the former case it usually takes the form of a superficial erosion, in the latter, often that of the simple desquamating papule. Upon the corona glandis the induration is usually pronounced. A peculiar modification of the initial lesion upon the glans penis occurred in a patient under my charge at the New York Dispensary, and was first reported by Mor- row.16 The patient had an unusually long and relaxed prepuce. The glans had an appearance as if some whitish substance like wax had been introduced just beneath the epithelium, so as to form a flat uniform coating, slightly elevated above the niveau, and terminating near the corona by an abrupt rounded edge, without any encircling areola or swelling. Above this the epithelium seemed to be per- fectly intact, and was firm and smooth, with a bright glisten- ing aspect entirely unlike the dull, moist, sodden appear- ance of a mucous patch, or an erosion covered by a membranous exudation, hence the term diphtheroid, as ap- plied to this lesion is hardly exact. To the touch there was a slight degree of resistance, but no marked induration. The lesion may, as suggested by Taylor,17 have been a peculiar modification of the dry papule, though there was no scaling or desquamation at any time. Its peculiar course was doubtless influenced by the presence of the elongated prepuce, which, by its pressure, may have tended to cause the infiltration to spread out in area while at the same time it protected the epithelium from injury or abrasion. The lesion gradually disappeared, leaving no traces behind, and was followed by syphilis. When the meatus is the seat of the primary lesion the induration usually encroaches upon the passage so as to cause more or less obstruction to the flow of urine ; but the constriction is usually only temporary, disappearing as the induration is absorbed. According to Bassereau, of 361 chancres 14 were in the urethra, but all at the meatus. Clerc found 33 in 404, and all at the meatus. Fournier found, out of 474 chancres, 32 at the meatus and 17 in the canal, so deeply situated that they could not be seen by stretching open the lips. Among 1,773 cases of Bassereau, Fournier, Clerc, and Leon le Fort, tabulated by Julien, there were 89 at the meatus, while only 17 oc- curred deeper in the urethra. Chancres concealed in the urethra or other mucous passages (chancres lanes) may, as taught by Ricord, account for a certain number of cases of syphilis in which the primary lesion is not discovered ; nevertheless chancres posterior to the fossa navicularis must be extremely rare. In the female, according to statistics furnished by Four- nier, the genital parts are liable to the syphilitic chancre in the following order: The labia majora, the labia minora, the fourchette, uterine neck, region of the cli- toris, vestibule of the vagina, meatus urinarius, upper commissure of the vulva, vagina. Upon the labia majora the chancre, besides occurring in the usual forms, is often ecthymatous. • Sometimes here it is attended with great oedematous infiltration, which often persists for a long time. It is due to a super- ficial lymphangitis. Syphilitic chancre in the fourchette 67 Chancre. Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is less common than the simple chancre, for the reason that the frequency of the latter lesion in this situation is due to auto-inoculation. Chancre of the uterus most commonly affects the an- terior lip. It usually appears as a smooth, flat, or some- times elevated lesion of a grayish color, as though covered by a false membrane, and surrounded by a red border. Sometimes it is attended with considerable hypertrophic enlargement of the cervix, but it is seldom easy to make out by the touch a distinct induration. Sometimes it is accompanied by inguinal adenopathus, but not always. The vagina is very rarely affected, and for the same reasons given above for the rarity of the simple chancre in this region. Extra-genital Chancres.-The syphilitic chancre is much more often extra-genital than the simple chancre. According to statistics collated from different authors by Julien, out of 3,956 simple chancres 66 were extra-genital (not including chancres of the anus), or about two per cent., while of 1,977 syphilitic chancres 126 wrere extra- genital, or over six per cent. Again, extra-genital chancres are much more common in women than in men. According to the same authority just referred to, they amount to about twenty-two per cent, of all syphilitic chancres in women, ami less than four per cent, of those in men. Moreover, chancres of the anus, which are not included as extra-genital in the above computations, are more common in women than in men, and the same is true of chancres of the mouth, while chancres of the breast occur almost exclusively in women. Chancre of the Anus.-According to Julien, its relative frequency in men is 1 to 119, while in women 1 to 12. In the former it is pretty sure evidence of sodomy, but in women it is possible for it to occur not only in this way, but it may also result from contact with secretions which contain syphilitic virus flowing down from the genitals over the anus in normal coitus. The lesion may either occur external to the sphincter-usually as an elongated erosion upon one of the radiating folds of integument- or more internally, when it commonly takes the form of a fissure. The syphilitic chancre of the anus is generally of rather long duration, is attended with but slight pain or discomfort, and on this account, as well as for the reason that it is difficult in this situation to appreciate by touch a moderate amount of induration, it is very liable to escape observation. It is attended with enlargement of the inguinal glands. The rectum is sometimes, though not often, the seat of the initial lesion. Chancre of the breast is most commonly situated just at the base of the nipple, in the furrow separating it from the areola ; next in frequency upon the nipple, then the areola, and finally upon the surface of the breast outside the areola (Fournier). As noted above, chancre of the breast is especially apt to be multiple. In its form it may either assume the appearance of an indurated fissure, or appear as a superficial erosion, or as an exuberant lesion {ulcus elevatum). If the patient is not nursing, the sore is commonly ecthymatous. The induration is usually well marked, and remaining, as it generally does, for a considerable time after the appearance of secondary manifestations, it becomes of the greatest value in de- termining the original site of infection. In this the en- largement of the axillary glands, together sometimes with a chain of swollen glands just below the border of the pectoral muscle, will materially assist. Cephalic Chancre.-About four percent, of all syphilitic chancres occur upon the head (87 to 2,043, according to Julien). Most of them are in the region of the mouth, and may be due either to mediate or immediate conta- gion ; the mediate sources of contagion consisting in the use of contaminated articles of various sorts, such as drinking or smoking utensils, unclean surgical instru- ments, etc. Immediate contagion, which is more com- mon, takes place from contact of an abraded spot in the mouth or other part with a lesional surface upon a syph- ilitic individual, wherever this surface may be situated. By far the most common situation of chancre of the mouth is the lips ; the next is the tongue, and, following these, the gums, the tonsils, etc. Upon the lips the site of infection is not infrequently a slight fissure, such as is very common either in the centre of the lower lip, a little to one side of the median line in the upper lip, or at the commissures. Originating in such a lesion, the chancre, at least in the beginning, will have the form of an indu- rated fissure or deep cleft, with reddish or gray base. Afterward the induration and ulceration usually extend so as to produce a massive Hunterian chancre, attended with considerable eversion of the lips, and bearing no little resemblance to an epithelioma. When the chancre occurs just within the lips, the induration is apt to be less marked. Chancres of the lip are always attended with marked en- largement of the submaxillary glands. Upon the tongue the lesion is flat, or slightly elevated, with a deep red color and a sharply defined induration. Occurring just at the tip, a common situation, it often has an appearance as though a bit of the end of the tongue had been sliced off. The accompanying adenopathy is in the suprahyoid glands. Chancre of the Tonsil.-Usually an indurated ulcer be- trays the presence of the lesion, but it is not always easy to discover. In a case very recently under my charge, I could only infer it with a fairly reasonable degree of prob- ability. I had been treating a woman for a recently con- tracted syphilis, when one day she brought her five-year- old child with her, who presented a well-marked roseola syphilitica and general adenopathies. No sign of a chan- cre was anywhere to be found, but under the ramus of the jaw, on the right side, was a marked glandular en- largement, and the right tonsil was somewhat swollen and hard. Other parts of the mouth were in perfectly normal condition. Diagnosis.-Comparing now the foregoing description of the initial lesion of syphilis with the account previously given of the simple chancre, the chief points of contrast in the two affections may be tabulated as follows : Syphilitic Chancre. Simple Chancre. Produced by contagion in the most various ways, from a primary or secondary lesion of syphilis, from syphilitic blood or its serum, and probably also from certain patho- logical secretions from the genitals, occurring in a syphilitic subject, though not proceeding from syphi- litic lesions. Origin. Produced by contagion, that if, almost invariably venereal, from a simple chancre, or from a chan- crous, virulent bubo. Incubation. Usually from three weeks to a month. Reaction begins within twenty- four hours. A papule or tubercle. First appearance. A pustule or ulcer. Often solitary, more rarely mul- tiple, and then usually all the lesions appear simultaneously, seldom de- veloping successively. Number of lesions. Rarely solitary. Multiple lesions often develop successively. Most commonly about the geni- tals or anus, very often upon the mouth in both sexes, and on the breast in the female. Seat. Almost exclusively on the geni- tals, or in their immediate vicinity, Usually round or oval, and regu- lar in outline. Form. At first round, later angular, with well-developed, irregular edges. Surface. Sometimes dry and scaling, more often moist, smooth, red, or gray- ish. Always moist or crusted over, with a grayish, uneven, pultaceous surface. Scanty and serous, except when irritated; then purulent. Secretion. Abundant, purulent, and often sanious. Pain. But slightly sensitive. Ulceration. Sensitive. Generally absent, nearly always superficial, flat or elevated, more rarely excavated, sometimes funnel- shaped. Deep, sinuous, with perpendicu- lar or undermined and jagged edges. 68 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. Syphilitic Chancre. Firm, elastic, circumscribed. Induration. Edges and base almost always soft and pliable. May be more or less indurated through inflamma- tion, but then the hardness is doughy, inelastic, and ill-defined. Simple Chancre. litic chancre, various hypotheses have been proposed. Robin and Marchal, as well as von Barensprung, regarded it as due to an amorphous connective substance, which Ricord characterized as plastic lymph. Michaelis at- tributed it to the production of newly formed connective- tissue at the periphery of the growth-a fibrous callus that served as a capsule to the cellular infiltration, simi- lar to that observed in gummy tumors. It is well known that Virchow represented the earliest manifestation of syphilis-the initial lesion-as histologically the counter- part of the latest product of the disease, the gumma. But for him the "morphological product" in a syphilitic growth had little significance. It was " only through its mode of evolution and involution, its life-history," that its distinctive characters were acquired. Kaposi also has declared that from its " histblogical relations alone the specific character of the sclerosis " could not be inferred. Von Biesiadecki sought to account for the induration partly by the fibrous growth in the oedematous tissue surrounding the lesion, but chiefly by alleging that the tissue constituting the chancre was ischaemic and " dry," and the cause of this was attributed to narrowing of the blood-vessels through the dense cellular infiltration in the adventitia. He did not explain, however, why the same infiltration in the walls of the blood-vessels in the soft chancre caused no such ischaemia and no induration. Though Biesiadecki admitted a new formation of con- nective-tissue about the vessels, he failed to attach to this any especial significance. He further found dilated lymph spaces in the sclerosis, which appears somewhat inconsistent with his theory of its dryness. They were explained upon the fact that in a section of the indurated cord upon the dorsum penis, leading from the induration, he found a vessel, presumed to be lymphatic, the lumen of which was occluded by a coagulum which, it was supposed, impeded the flow of lymph, and thus caused the dilatated lymph spaces in the initial lesion. On the other hand, Caspary 18 maintains that these spaces are due to the rigidity of the tissue which surrounds them and prevents them from collapsing. Moreover, cogent reasons are given by Unna for believing that the occluded vessel in the dorsum cord was not lymphatic, but prob- ably a vein. In an important contribution concerning the minute anatomy of the primary lesion, by Verson,19 the produc- tion of the induration is very clearly traced to the new- formed connective-tissue. The course of events is de- scribed as follows: "In the first stage, development of exudation corpuscles in at first normal tissue, which from their situation are undoubtedly derived from the interior of the blood-vessels. lu the second and third stages, the exudation-cells throw out processes that in part remain free and in part anastomose with each other. Thence there arises a meshwork that through the continual pro- liferation of new cells undergoing similar changes, be- comes more and more dense and intricate, and finally sclerosed." Cornil and Ranvier20 also believed that while the cells of the initial lesion resembled the simple product of inflammation, they were situated in a fundamental amorphous or fibrillar substance, and to this the chancre owed its induration. They regarded the presence of this substance as distinguishing the syphilitic chancre from simple- inflammatory tissue. Caspary21 believed that the fibrillar new growth which characterized the initial lesion did not occur in the soft chancre, because of the rapid de- struction that took place in the latter. He also attributed the narrowing of the blood-vessels to the contraction of this new tissue. But the most exhaustive study of the anatomical changes in the initial lesion has been made by Auspitz and Unna.22 By them the induration is also attributed mainly to the connective-tissue growth about the blood- vessels, which is- characterized as a true hypertrophy attended with sclerosis. But in addition to this, they describe certain important changes not heretofore men- tioned, as occurring in the epidermis, changes which do not occur in the soft chancre. In both the'simple and syphilitic chancres there is a moderate hypertrophy of the inter-papillary portion of the epidermis at the periphery of Inoculability. Essentially contagious, but rarely inoculable upon the bearer, and non-inoculable on a syphilitic per- son. Contagious and inoculable, both upon the bearer and others to an in- definite extent. Transmissibility to animals. Peculiar to man. Concomitant adenopathies. Transmissible to certain animals besides man. Polyadenitis; indolent and very rarely suppurating. Monadenitis; commonly acute, suppurating, and often virulent. By means of these clinical marks it will be easy in a large proportion of cases to distinguish the syphilitic from the simple chancre. But it should be borne in mind that the chancre is not always a typical one. In a large proportion of cases, the initial lesion, through irrita- tion, is excited to a free suppuration, and a more or less deep ulcer is formed, which may easily be mistaken for a simple chancre, especially where the inflammation has given rise to a boggy, oedematous infiltration about the sore, which may completely mask its characteristic indu- ration. Moreover, the lesion may be a " mixed chancre," and only by the course of future events is it possible to ascertain the syphilitic factor. It is not difficult, usually, to decide that a sore possesses the virus of the soft chancre ; that may easily be determined by the effect of auto-inoculation or by confrontation, but the more serious question to be determined is, was syphilis inoculated at the same time with the soft chancre ? In very many cases this can only be decided by awaiting after-effects. In certain rare cases where the history is vague, a doubt may arise in differentiating between the primary indura- tion of syphilis and an ulcerating gumma. The difficulty is most liable to arise when the lesion occurs upon the lip. In this situation the induration is apt to attain very large proportions, and assume something of the shape of a gummy tumor. With the history of a tumor breaking down first in the centre, opening by a small aperture and then ulcerating, the diagnosis of a gumma would be easy. When this is not obtainable, we may be guided by the condition of the neighboring glands; and afterward, if secondary symptoms appear, the case is plain. A phagedenic chancre upon the penis, of slow progress, and attended with a marked degree of induration, as it sometimes is, may occasionally be mistaken for epitheli- oma. In this case, also, the diagnosis must depend upon the history and future events. Pathological Anatomy.-Pathologists have found it no easy matter to discover, in the minute anatomy of the syphilitic chancre, a satisfactory explanation of its peculiar clinical characters. The microscope plainly re- veals a dense cellular infiltration, with round nucleated cells, such as are found in syphilitic lesions at all stages of the disease. These cells, however, do not differ ma- terially in character from the granulation cells of inflam- matory growths generally. Precisely such cells occur, also, as we have seen, in the infiltration of the simple chancre. In the initial lesion the cells are enclosed in a reticulated fibrous structure, and are especially accumu- lated about the walls of the blood-vessels, whose lumina are found contracted or entirely obliterated, differing in this respect from the simple chancre, in which the vessels remain patulous. At the circumference of the cellular infiltration the connective-tissue fibres form loose oedem- atous meshes, as they do also in the simple chancre. At the periphery of the eroded surface of the syphilitic lesion the papillae are enlarged and infiltrated, while upon the surface of the erosion are remains of epidermis to be seen, with here and there traces of papillae and prolonga- tions of the rete Malpighi. But there is nothing in this picture to account for the dense hardness of the growth. To explain this character- istic and well-nigh constant accompaniment of the syphi- 69 Chancre. Chancre. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the sores, but in the hard chancre the rete Malpighi was found enormously increased, far beyond anything that takes place in the other. From the under surface of this layer, prolongations descended into the cell-growths, and formed long processes either connected together in a re- ticulated form, or, here and there, completely detached from the stratum to which they belonged, forming isolated blocks of epidermic cells surrounded on all sides by the round cell-growth. As the latter increased, it gradually invaded the epidermic layer, and, breaking through the stratum lucidum, entered the corneous layer, and, finally, appeared upon the free surface, thus producing the eroded or ulcerated appearance of the sore. According to this explanation, the epidermis is not destroyed as in the sim- ple chancre, and, therefore, the lesion cannot properly be called an ulcer. The hypertrophy of the epidermis is regarded by Aus- pitz and Unna as contributing in a measure to the hard- ness of the chancre. The resistance which it offers to the increasing cell-growths would tend to render the tissue denser, and so augment the induration. The contraction of the blood-vessels is explained by Unna as sometimes due to an inflammatory proliferation of the endothelium, an endo-arteritis obliterans acuta, which is believed to de- pend upon a previous implication of the rasa rasorum. But more frequently Unna thinks it should be referred to the accumulation of cells in the adventitia and their subsequent sclerosis. The latter form, which he terms " Gefassverschluss durch Infiltration," is said to be more likely to affect the smaller vessels, while the endo-arteritis obliterans is commoner in the larger. Pathology of the Syphilitic Chancre.-The fol- lowing propositions are universally admitted: That syphilis can only result from the introduction into the body of a contagious principle derived mediately or im- mediately from an individual infected with the disease ; that this contagious principle, in order to cause infection, must be brought into direct relation with the interior of the bodily tissues, either through a local point of infection, a foramen contagiosum, through a general and immediate contamination of the blood, such as may take place through the medium of the utero-placental circulation, or through infection by inheritance ; that when the infec- tion takes place through a local inoculation, the first ap- preciable effect consists in the appearance at the foramen contagiosum, after a varying period of incubation, of a neoplastic lesion, attended sooner or later by an enlarge- ment and induration of the nearest lymphatic glands, which local manifestations remain for a considerable period the sole evidences of infection, and that, finally, at the expiration of this latter period, with a more or less sudden onset, the general symptoms of constitutional syphilis make their appearance. What especially concerns us here is the significance in this train of events of the initial lesion. Is it the first manifestation of constitutional syphilis, as maintained by many, or is it merely the starting-point of the disease ? Do it and the changes in its immediate vicinity fairly rep- resent the limits for the time being of the syphilitic in- fection ? At first sight the question would seem to ad- mit of but one rational answer. All the more obvious facts seem to point to the entirely local character of the primary lesion. The entire absence of all general symp- toms for six weeks after the appearance of the chancre, and then, all at once, an outbreak of constitutional dis- turbance with symmetrical mucous and cutaneous mani- festations, indicating a sudden change in the general economy, would seem clearly to imply that during a pri- mary period the progress of the infection is held in check by certain barriers, and that not until these barriers give way does it become general. To this view is opposed two alleged facts: first, that with the appearance of the primary lesion the bearer has already acquired immunity from sub- sequent infection, and second, that destruction of the local lesion is incapable of preventing the occurrence of con- stitutional symptoms. According to the first of these alleged facts, the tissues of a person who has a syphilitic chancre are in the same condition in respect to their susceptibility to the syphilitic virus as those of a person with well-marked constitutional syphilis. In one case, as in the other, reinoculation is fol- lowed by no specific reaction. It is inferred from this that the tissues of one who bears a syphilitic chancre are infected throughout the body, for we can conceive of no other way in which they could acquire their immunity except through preoccupation by the disease. It is admitted that, for a short period after the inocula- tion is first made, the immunity does not exist, for when a second or third inoculation takes place within a few days of the first, it is followed by successive or multiple chancres. But by the time the first chancre has made its appearance, it is claimed the general infection is an accomplished fact, and immunity from further inocula- tion complete. The proof of this assumption is said to be the impossibility of producing secondary syphilitic chancres upon the bearer of an initial lesion by auto-in- oculation. But in order that auto-inoculation should be a fair test of immunity, it is necessary that it should be made at an early period, sufficiently far removed from the period at which the disease becomes manifestly con- stitutional to enable the second implantation of virus to complete its incubation. Thus supposing the second period of incubation comprising the time between the appearance of the initial lesion and the outbreak of gen- eral symptoms to be forty days, and the incubation of the chancre to be twenty days, now if auto-inoculation be delayed for twenty days from the first appearance of the initial lesion, the development of the second chancre would surely be forestalled, and in all probability be pre- vented by the intervention of the constitutional disease, even though at the time of the auto-inoculation the tissue inoculated may have been free from any infection, and still susceptible to the poison. It is true, however, that auto-inoculations often fail, even when made at a com- paratively early period ; but in ordinary clinical cases it is rarely possible to determine the precise relations of the incubation periods. Nevertheless, auto-inoculation of the syphilitic chancre has in some cases been followed by a positive result. It must be admitted that a single well-authenticated case would outweigh many failures. Two such were recently reported by Bumm.23 In the first case the secretion of an indurated chancre was auto-inoculated three days from the appearance of the chancre, and sixteen days from the date of exposure, upon the upper right arm. Three days later every sign of the inoculation had disappeared, but at the expiration of ten days' incubation a little red spot ap- peared, which in ten days more had become a lenticular desquamating papule, with distinctly infiltrated base, which remained till the symptoms of general syphilis be- gan, when it rapidly disappeared. In a second case (loc. cit., p. 268) the auto-inoculation was practised twenty- three days after the first exposure. The patient, puella rulgwaga, had presented herself at the hospital fourteen days before with an indurated chancre, which had been excised with successful result. On her return with an- other affection (scabies), for the purpose of experiment, mainly to ascertain whether the previous excision had left her syphilitic or not, she was inoculated upon the left thigh, with secretion taken from an indurated chan- cre. There was no effect for eleven days, when an indu- ration appeared at the point of inoculation that gradually increased with ulceration, and was attended with enlarge- ment of the glands in the left groin. Twelve days after its appearance a reinoculation was performed upon the right thigh, that was followed, after an incubation of nine- teen days, by redness and infiltration at the site of inocu- lation. The infiltration gradually increased, was accom- panied with enlargement of the right femoral glands, and ten days later had become "the size of a mark piece," was " red, slightly elevated, partly excoriated, partly covered with scales, infiltrated, and hard." General symptoms of syphilis then appeared with roseola syphi- litica. A number of similar cases (five are reported in full), were previously observed by Bidenkap and Boeck.24 In all of these cases, with a single doubtful exception, the auto-inoculations were practised within six weeks from 70 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Chancre. the time of exposure and before there was any evidence of general saturation of the system with the disease. A noticeable fact in connection with these latter cases is that the papules resulting from the reinoculations con- tinued to develop, in several instances, after the second- ary symptoms had begun, while in Bumm's cases, simul- taneously with the appearance of constitutional symptoms the secondary sores began to subside. But, in the case of the initial lesion also, the advent of secondary symptoms is not always followed by an immediate disappearance of the chancre. Apparently, while in most cases the pres- ence of general infection precludes the development of irritative reactions following a fresh implantation of virus, it does not always hinder the progress of these re- actions when once set in full play. That successful auto- or re-inoculations during the stage of the initial lesion have been so rarely reported is proba- bly partly due to the fact that the period of observation has been too short. The few instances above referred to, however, suffice to show that between the time of the first inoculation with the syphilitic virus and the outbreak of general symptoms, there is no period when we can claim absolute immunity for the tissues from reinfection. Regarding immunity as the test of saturation with the syphilitic poison, the indications do not point to any gen- eral contamination of the system, either before or im- mediately following the appearance of the chancre, but rather to a slow, progressive infection. Reinoculations following the first exposure at a short interval are toler- ably sure of producing an effect. Auto-inoculations from the primary chancre are rarely successful, and probably only when performed at an early stage of the primary period of the disease. It is fair to suppose, from the materials thus far at command, that immunity in proba- bly the majority of cases precedes what is known as secondary syphilis. There is reason to believe that a comparatively slight degree of infection, insufficient to •cause outward and general manifestations of the disease, may yet suffice to secure immunity from reinoculation. Of this we have a notable illustration in the so-called "law of Colles." The mother who bears a child with inherited syphilis suckles her syphilitic infant with im- punity, notwithstanding she shows no sign of previous infection other than in the insusceptibility of her tissues when brought in contact with the syphilitic virus. The other assumption upon which the theory of the symptomatic character of the initial lesion is based is the failure of ectrotic methods of treatment, the inability to prevent the progress of the disease by means of destruc- tive agents employed at the site of inoculation. It is af- firmed to be the rule in infectious diseases generally, which take their origin from a local point of inoculation, that it is impossible to prevent general infection by local cauter- ization. After the inoculation of horses with glanders {Renault), of sheep with the rot, and of children (Martin) with vaccinia, the most thorough cauterizations have failed to prevent the virus from taking effect. Moreover, in syphilis, attempts have often been made to abort the dis- ease by ectrotic treatment of the initial lesion, or to avert the danger by cauterization at the site of inoculation with- in short periods of the exposure and, yet, without prevent- ing general infection. Certainly it is a natural enough inference from these experiments that as soon as the in- fectious matter finds its way into the tissues it passes al- most immediately beyond the reach of the caustic, but this does not prove that at the time of the cauterization the virus may not still have been confined to the vicinity of the point first inoculated, though extending beyond the area affected by the caustic. Furthermore, with re- gard to the results in other diseases than syphilis, we have no right to assume the existence of identical conditions in different infectious diseases as to the character of the virus, or its necessary period of incubation. But, on the other hand, it might with equal justice be objected that the non-occurrence of the infectious disease after ectrotic treatment at the seat of inoculation does not prove that infection was thereby prevented. But certain apparent successes of ectrotic treatment ob- tained in recent years invite further inquiry in this direc- tion. Ricord, in his " Lemons sur le Chancre" (2me edit., p. 286), says, "De tons les chancres que f ai vu cauterises ou que j'ai cauterises moi-meme du premier au quatri^me jour de la contagion, aucun n'a ete sulci des symptdmes pro- pres d I'infection constitutionnelle. " Among these chancres it is presumable that a certain number were syphilitic. Sigmund treated, out of 57 patients in whom he found abrasions following exposures to syphilitic contagion, 35 by cauterization at the points of exposure, and 22 were left alone. Of the 35 cases cauterized 10 became syphi- litic, while of the 22 not interfered with 11 became syphi- litic-a result clearly in favor of the abortive treatment. Of the 35 cases, 24 were cauterized from the first to the third day, and of these but 3 became syphilitic. Of 11 cauterized from the fifth to the tenth day, 7 became dis- eased, tending to show that after the first four days the cauterization ceased to have much effect. The results of these attempts (and numerous others might be cited) to avert the constitutional effects of the disease during its period of incubation, afford, it must be confessed, but little encouragement to any ectrotic treatment after the chancre has once made its appearance, If the materies morbi has spread so far from the foramen contagiosum, within five days from its inoculation, as to be inaccessible to local cauterization, there is still less chance of its being within reach at the expiration of from two to three weeks. Yet, what could not be done by caustics might, perhaps, be accomplished by a free exci- sion. In 1867 Hueter25 reported 7 cases of excision of the initial lesion, in 2 of which syphilis seemed to have been prevented, and only 1 was certainly followed by the dis- ease, while in 4 cases the result was uncertain. Thiry,2S in 1870, reported one case of excision of chancre in which the induration returned in the cicatrix, and was followed by syphilis. In 1871 Vogt21 reported a case of indurated chancre on the inner surface of the prepuce, that ap- peared two weeks after intercourse, and was excised eight days after its appearance. For three years following there was no sign of syphilis. In 1873 Lewin excised a chancre without preventing the disease. But little interest was taken in this method of treatment till after the publication of Auspitz's 33 carefully re- ported cases,28 extending over a period of several years. Auspitz, after eliminating from these 33 cases 10 which for various reasons furnished inconclusive results, states that of the remaining 23 fourteen were successful, no syphilis developing during the periods of observation, of not less than four months, and nine were followed by syphilis. In other words, in sixty per cent, of the 23 cases, syphilis seemed to have been prevented by excision of the initial lesion. Hundreds of cases have been re- ported since by more or less competent observers, but to draw any positive conclusions from the results thus far obtained is extremely difficult. The results show the greatest disparity, and the suspicion cannot be avoided that in the pursuit of these investigations the " personal equation " has been a disturbing factor of considerable moment. Among those who have reported successful cases, Paspelow reports 2 out of 3 ; Kblliker, 3 out of 8 ; Spellman, 2 out of 8 ; Holinea, 8 out of 19 ; Chadzynski, 7 out of 30 ; Lassar, 5 out of 45 ; Schiff, 5 out of 9 ; Oed- mansson, 2 out of 28 ; Ravogli, 3 out of 4; Angerer, 1 out of 12, and Julien, 1 out of 6 ; while Rydygier re- ports 3 cases, and Bevan 8, all successful. On the other hand, Klink reports 10 cases; Mauriac, 8; Gibier, 2; Lucca, 1; Zeissl, 5, and Tomanschewsky, 50, all consec- utive failures. Out of 318 reported cases of excision of the initial lesion which I have been able to collect, there were 75 successes, 204 failures, and 39 in which the re- sult was doubtful. But where there is so little uniformity in the individual results compiled, statistics are of com- paratively little value. The only thing of importance is that a number of good observers have excised indurated chancres, such as are usually followed by syphilis, and in a very considerable number all symptoms of the con- stitutional disease have remained absent. To say that because some of these observers are unicists, therefore they were likely to mistake simple for syphilitic chancres. 71 Chancre. Change of Life. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is a futile objection. For the unicist in claiming that syphilis may be conveyed in the form of the soft chancre, none the less admits the importance of the induration and of the accompanying adenopathies as the necessary precursors of general infection. Auspitz, though a uni- cist, differentiates in his article, above referred to, the two forms of chancre most carefully, and in each instance the lesion excised is described as " Sklerose.'' But, on the other hand, who can affirm that in the "successful cases" syphilis was prevented because it did not follow ? It is not every initial lesion that is followed by such symptoms of general infection that they can be positively recognized as syphilitic. Indeed, there is good reason to believe that in many instances the duration of syphilis is limited to what is known as the primary period. It must be within the experience of every one with oppor- tunities for seeing many cases of venereal disease, that a considerable number of chancres bearing the usual marks of the initial lesion of syphilis, are followed by no dis- coverable symptoms of geheral disease. What the pro- portion of these cases is, and how far they suffice to account for the apparently aborting effect of excision, it is yet impossible to determine. Hence the arguments drawn from the results of ectrotic methods of treatment to determine at what period the syphilitic virus becomes diffused throughout the system are in no sense decisive. For the present it cannot be denied that the successful re- sults reported by Auspitz and his followers, though far from conclusive, are sufficiently encouraging to warrant further investigation in the same direction. But even should further investigation ultimately show that excision of the chancre does not prevent general in- fection, it is not thereby demonstrated that the chancre is only a symptomatic manifestation of systemic disease. The position of those who maintain the symptomatic character of the initial lesion seems to be the following : Directly upon its inoculation the syphilitic virus passes into the general circulation. The apparent quiescence at the point of inoculation during the incubation period is real quiescence ; the incubation pertains not to virus im- planted and remaining at the foramen contagiosum, but to virus already circulating throughout the body, and the initial lesion is its first effective manifestation, reflected in some arbitrary and unexplained way to the point at which it originally entered. As objected by Auspitz, it is not easy to understand why such effects should be produced by a second transit of the virus through this region, when the first produces no reaction whatever. Nor is it clear why the lymphatic glands in the vicinity should escape disturbance at the first passage of the virus, when after- ward the poison that reaches them from the initial lesion produces such marked effects. Though the question is yet an open one, the indications still point to a probability that the disease is for a certain period mainly confined to the region first contaminated. During the forming stage of the local sclerosis, during the period of apparent quiescence, and before any changes at the point of inoculation are outwardly perceptible, certain alterations are doubtless in progress ; the round cells are accumulating, the walls of the blood-vessels are being in- filtrated and occluded, and, moreover, it may be presumed that the infection is slowly advancing. It is not unlikely that certain infectious elements find their way in small quantity into the general circulation. A few such germs of disease might possibly be at once destroyed or eliminated from the economy, while a larger number maintaining themselves and increasing would per- haps be supplied to the tissues in sufficient amount, or in some way so influence them, as to account for that modified infection which suffices to secure immunity from reinfec- tion in a certain proportion of cases during primary syph- ilis, but insufficient to elicit constitutional manifestations till reinforced by the larger incursion of infectious matter that takes place toward the end of the primary period. That the initial lesion, charged with infectious material as it is, serves as an important depot of supply to the general infection there is scarcely room for doubt. The most striking evidence of this is the participation of the nearest lymphatic glands. It is generally believed that this implication is due to the presence of virus absorbed directly from the initial lesion. Even by those who sup- pose the chancre to be but a symptom of pre-existing general infection, the indolent buboes have been regarded as evidence of reabsorption of its virus into the general circulation. This view of the function of the lymphatics, apparently so natural, and so entirely in analogy with what takes place in other diseases (as in the malignant tumors, lepra, and tuberculosis) is, however, disputed by Auspitz, chiefly because of the comparatively slight implication of the lymphatics within the initial sclerosis, and because of the lack of a continuous chain of affected lymphatics up to the receptaculum chyli. The so-called "lymphatic cord," often felt upon the dorsum penis, was found to be wholly due to thickening in the walls of the blood-ves- sels, and it was not continued uninterruptedly into the pleiad of enlarged glands in the groin. The three famous preparations of Fournier in the Musee de Lourcine, taken from patients who died while in the primary stage of syphilis, and which represent both the inguinal and iliac glands as enlarged, are regarded by Auspitz as indicating that the lymphatic implication is only partial, and not essential to tlie general infection. Moreover, it is ob- jected that the secretion of these glands has never been shown to be infectious. The last-mentioned objection is completely removed by the following experiment, reported by Bumm,29 and per- formed at the instigation of Professor von Rinecker : The enlarged inguinal glands were removed from a patient with recent constitutional syphilis, and in whom the initial lesion still remained. After being carefully cleaned, the glands were incised, and with the milky lymph serum exuding from the cut surface a patient who had never had syphilis was inoculated, twice upon both arms. The inoculations all took, with the production of indurated ulcers, accompanied with adenopathies in the axillae, and followed on the fifty-second day by a maculo- papular syphilide. The result of this experiment shows a perfect analogy between the indolent adenopathies of the initial lesion and the virulent bubo of the soft chancre. It is unfortunate, however, that the glands from which the secretion was taken for inoculation were not removed a little earlier, and before any constitutional symptoms had appeared. That the lymphatics within the primary induration are but slightly implicated is perhaps the very reason that their absorbent function is not disturbed. Through their patulous channels the virus might find an avenue of es- cape which is denied it by the occluded blood-vessels. It should be borne in mind that the more obvious formative elements in the syphilitic neoplasm are only the effects of the virus, the evidence of its presence, but yet not the virus itself. Whatever the latter may be, whether micro- scopic bacilli or degraded bioplasm, it is not that which we plainly see, and of its movements and mode of progress but little is yet known. Whether the lymphatic vessel leading from the chancre to the nearest lymphatic glands be infiltrated in its walls or not, whether every gland be- tween the chancre and the receptaculum chyli be affected or not, there still remains sufficient reason to believe that it is through the lymphatics that the virus finds its prin- cipal route to the general circulation. As each gland is in turn affected it becomes another depot for the genera- tion and supply of more virus to the economy, and when all the sources of supply, whether many or few, have de- livered more of the poison than the system can tolerate, then constitutional syphilis declares itself. From the above considerations the following conclu- sions seem to be justified : 1. That there is necessary to the production of syphilis a certain quantity of that specific virus to which the dis- ease is due. 2. That as soon as implanted in the tissues of a person susceptible to the disease, the poison begins directly to in- crease, and is slowly augmented till in sufficient quantity to excite irritative changes in the surrounding tissues, which changes finally becomes manifest in the form of a circumscribed indurated growth, the syphilitic chancre. 72 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chancre. Change of Life. 3. That during the period of its local increase the poison is continually escaping from its main focus of de- velopment, partly, perhaps, through the implicated blood- vessels, but chiefly through the lymphatics. 4. That the nearest lymphatic glands where the poison effects a lodgement become secondary depots for the fur- ther augmentation of the virus, whence the latter is finally discharged into the receptaculum chyli. 5. That from these multiple sources of supply, includ- ing the initial lesion and a certain number of the lym- phatic glands, partly by way of the blood-vessels, but chiefly through the receptaculum chyli, the blood is grad- ually contaminated; at first, probably to a limited de- gree, sufficient to afford immunity in some cases against further contagion, but insufficient to excite constitutional symptoms, and afterward in such excess that the system, unable to longer cope with it, finally reacts with manifes- tations of general disease. Treatment.-There are but two points in the manage- ment of the syphilitic chancre that require especial con- sideration here ; one concerning the question of the utility of ectrotic treatment, the other the advisability of begin- ning constitutional treatment during the chancre stage or primary period of the disease. The local palliative measures employed for the syphilitic chancre are essen- tially the same as those already described under simple chancre. Ectrotic Treatment.-The only method entitled to any consideration under this1 head is the excision. The futil- ity of any attempt to eradicate the disease by cauteriza- tion after the chancre has formed, has been pretty well established. Whether it is possible to prevent syphilitic infection by a thorough excision of the initial lesion, is still an open question, though, it must be said, the chances do not seem to be in its favor. Nevertheless, regarding the chancre as a nidus of infection from which syphilitic germs are continually being supplied to the organism, it is certainly a perfectly justifiable and rational procedure to remove it, if, as is often the case, it can be done with impunity. When the initial lesion is uncomplicated with soft chancre, and is so situated that its excision may be effected without serious mutilation, the operation is justi- fied on the score even of removing an annoying and pos- sibly (to others) dangerous lesion. The induration may return in the cicatrix, but not necessarily, and when it does it will very likely be unattended with ulceration, and a lesion less markedly developed than the first. Con- cerning the chances of thereby preventing the constitu- tional disease, enough has been said above in speaking of the pathology. The statement has been made, that even when the ex- cision did not wholly prevent syphilis, it has yet tended to modify the subsequent disease and render it milder. This view appears to me highly improbable. To the pro- duction of syphilis, it is only necessary that the germs of the disease find a lodgement somewhere in the tissues, where they can grow' and develop. The seed must be planted. Such an implantation or nidus, being once established, whether at the foramen contagiosum or in a lymphatic gland, is sure to increase and to go on in- fecting its environment and the blood till the latter is thoroughly poisoned, till constitutional syphilis re- sults, and the mildness or severity of the constitutional disease will then depend not on the quantity of the virus, but upon the susceptibility of the organism. If after the excision of the chancre syphilis follows, whether mild or severe, it is evidence sufficient that some source of supply of the poison was left remaining, to which would belong the same potentialities of infection as to the original chancre. When the chancre occurs upon the genitals, it has been proposed to include in the excision, besides the initial lesion, the indurated inguinal glands. It wmuld seem as though by this means the chances of preventing infection would be materially increased. Bumm,30 who reports several cases in which the inguinal glands were excised to- gether with the chancre, gives results which, though only partially successful, are such as to warrant further trial. General Treatment.-The remaining point to be con- sidered is the advisability of beginning antisypliilitic treat- ment for the primary lesion. Rollet, who is in favor of general treatment during the primary stage, claims that at this period the disease is most impressionable, most easily affected by mercury. For those who hold, as Rol- let does, that the initial lesion is but the first manifesta- tion of constitutional infection, it is not easy to see how any other view could consistently be maintained. Yet Mauriac, who also believes in its symptomatic character, asserts that mercury internally has no affect whatever upon the syphilitic chancre. Sigmund also was of this opinion. Diday gives the following statistics : Of 74 cases of syphilitic chancre, 49 were treated without mercury. In these secondary symptoms appeared after an average of 43.23 days. In 25 treated with mercury secondary symptoms appeared after an average of 49.08 days. In the first 49 cases the syphilis was slight in 17 cases, moderate in 27 cases, severe in 5 cases. In the 25 treated with mercury the syphilis was slight in 6 cases, moderate in 14 cases, severe in 5 cases. If these statistics prove anything, they as surely prove (as Diday himself admits) that mercury renders the subsequent syphilis severe as that it delays the period of secondary manifestations. Most authorities, however, are agreed that it is best to postpone mercurial treatment till constitutional symptoms are present; some for the reason that by delaying second- ary symptoms it leaves the diagnosis uncertain, but by most because it is admitted that it can have no appreciable influence upon the subsequent disease. In some cases, however, in which the induration is very marked, mer- cury seems to have some effect in promoting its resolu- tion. Edward B. Bronson. 1 Cited by Astruc, De morbis venereis, Book I., p. 97. 2 An Essay on Venei-eal Diseases. Philadelphia. 1825. 3 Die nicht syphilitische Natur des weichen Schankers, Charite An- nalen, ix., 1 Heft, 1860, p. 124. 4 Die Syphilis der Haut und der angrenzenden Schleimhaute, p. 50. Wien, 1882. 6 Sitzung der Physikalog. Med. Geselschaft vom November 15, 1879. Vierteljahrsch. f. Derm. u. Syph., 1880, p. 400. 6 Vierteljahrschr. f. Derm. u. Syph., 1881, p. 209. 7 Acad, des Sciences, November 18, 1850. 8 Loc. cit., p. 42. 9 Hydrogen Dioxide in the Treatment of Venereal Diseases and as a Test for Pus, by Robert W. Stiger, M.D., The Medical Record, 1884, xxv., p. 81. 19 Lyon Med., February 26, 1882. 11 Bulletin Gen6r. de Therapeut., January 30,1883. 12 Wiener Med. Presse, 1884, xxi., 425. 43 Gaz. des H6p., No. 110, 1871. 14 Arch. G6n. de Med., I. 12, vol. i., p. 640; vol. ii., p. 70. 15 Vierteljahrsch. f. Derm. u. Syph., 1878, p. 567. 46 On a Rare Form of Initial Lesion, Diphtheroid of the Glans Penis, Arch, of Dermatol., 1876, p. 383. 47 Venereal Diseases, Bumstead and Taylor, p. 451. Philadelphia, 1879. 18 Vierteljahrsch. f. Derm. u. Syph. 1873, p. 45. 49 Virchow's Archiv, Bd. xlv., p. 117. 20 Manuel d'Histologie Pathologique, Premiere Partic, p. 186. Paris, 1869. 24 Loc. cit. 22 Anatomie der Syphilitischen Initialsklerose, von Professor Hein- rich Auspitz und Dr. Paul Unna, Vierteljahrsch. f. Derm. u. Syph., 1877, p. 161; also, Ein Weiterer Beitrag zur Anatomie der Syphilitischen Initialsklerose, von Dr. P. Unna, ibid., 1878, p. 543. 23 Zur Frage der Schanker Excision, von Dr. Ernst Bumm, Viertel- jahrschr. f. Derm. u. Syph.. 1882, p. 259. 24 Cited by Baumler in Ziemssen's Cyclopaedia of the Practice of Medi- cine, vol. iii., Chronic Infectious Diseases, translation, p. 97. New York, 1875. 25 Berlin, klin. Wochensch., 1867, No. 27. 28 Presse med. beige, 1870, No. 38. 27 Berlin, klin. Wochensch., 1871, No. 38. 28 Vierteljahrsch. f. Derm. u. Syph., 1877, p. 107. 28 Loc. cit., p. 285. 30 Loc. cit. CHANGE OF LIFE, THE. The term Change of Life is meant to indicate those phenomena in the human female incident to ovarian involution. Its synonyms are : Climacteria, Climacteric, Turn of Life, Menopause, Critical Time, Temps Critique, Age de lietour. In Ger- man this condition is called Aufhoren der weiblichen Reinigung. It comprises all that time between the com- mencement of irregularity in the menstrual function and the complete cessation of the menstrual flow and the restoration of health. As usually manifested in the great majority of cases, it may be said to commence before menstrual disturbances are ushered in, having for its phenomena certain vague nervous symptoms which are not easily mistaken by the skilled observer. Women look upon this period of their lives as one fraught with danger. The profession, on the other hand, holds a 73 Change of Life. Charcoal. DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. divided opinion upon this subject. There can be no doubt that it is fraught with many perturbing conditions, and that it stands in its relation to adult life, in its dis- turbance in the female economy, somewhat as dentition and puberty do in their relation to infancy and youth. Its main significance to the practitioner is that it will need all his sympathy, and enlist his intelligent investigation and aid, in managing its protean forms of disturbance, as at this time organic changes of a destructive kind are liable to occur and be overlooked and slighted because of the popular belief that the change of life must necessarily be accompanied by physical ailments of some sort. The time of the cessation of the menses varies somewhat with the climate. In cold climates it terminates later than in warm climates. It varies very much with indi- viduals, some women ceasing at twenty-five years, and others continuing to sixty or even seventy years of age, with, as some authors relate, though this is extremely doubtful, the power of conception still retained. Prob- ably forty years is the age when most women cease to menstruate regularly. It is not to be inferred that be- cause a woman commences to menstruate early in life she will cease early. This is not the case : on the contrary, as a rule, a longer menstrual life is delegated to this class than to others. In the higher classes menstruation com- mences earlier and ceases later than in the lower classes. There seems to be a law of inheritance governing men- strual life, as women of the same family not infrequently cease to menstruate at about the same age. When the cessation of menstruation is long delayed, it is well to sus- pect some affection of the uterus or its appendages, such as granular endometritis, fibroid tumors, polypi, ulcera- tion, or cancerous masses. On the other hand, if the change of life is delayed without pathological causes, we may consider that the ovarian activity is simply the meas- ure of the constitutional vigor, indicating a continued ac- tivity in all the functions of vegetative life that together contribute to longevity of the individual. Sexual involution has only one fixed state, and that is cessation. Its beginning is frequently very vague and illy defined, and may have its origin in some functional, organic, or diathetic condition, which may cause it to cease prematurely. Fright, or mental or moral shock, has accomplished this through paralysis of ovarian nerve- centres, as have also intercurrent diseases, such as septic diseases of the uterus and tubes, the continued fevers, rheumatism, or gout. These latter operate by inflamma- tory implication of the ovaries, or tubes, or both. The process of involution in the reproductive organs produces precisely opposite effects in the generative re- gions to those presented in the stage of puberty, the ovaries being shrivelled and shrunken in every direction. Their external envelope is folded and wrinkled, and the ovaries sometimes seem to have disappeared altogether. The Graafian vesicles present wrinkled walls, containing grayish pouches from which the fluid has been absorbed. Sometimes the cavities, even, are effaced, and nothing is left but a small tubercular-like mass. The Fallopian tubes diminish in size, and even become obliterated. Similar changes extend to the uterus. Its walls atrophy, its cavity becomes smaller, and the cervix diminishes, at times almost disappearing. The dimensions of the vagina diminish markedly in some women, especially in those who have not borne children. The mammary glands, whose activity is always commensurate with ovarian ac- tivity, come under the same influence, and waste grad- ually away, becoming foreign to all the other vegetative functions of the body. Diagnosis.-The symptoms vary greatly, so that it is quite impossible to classify them in any order or regular- ity. In the perfectly typical woman, such as we may find in the agricultural classes, the changes may occur without any unusual phenomena whatever, except the cessation of the flow. This may occur abruptly and at once, after a life of perfect menstrual regularity, but more frequently the change occurs slowly, running through a period of many months, the catamenia being in the meantime irregular as to time, and scanty as to quantity. In the majority of women, however, it is only accom- plished through a sea of nervous and functional disturb- ances, which for a time, and from the popular superstition accompanying it, fill them with the direst apprehen- sion. The physiognomy of these cases is peculiar, in- dicating a suffering and a debility not to be accounted for by any discoverable disease. Some present a sallow, chlorotic look, others are plethoric, while another class may present a nervous appearance which is entirely opposed to any former habit or temperament. In some, a cessation of the menses may occur, lasting for months, leading them to think the change is over. A profuse flow of blood, accompanied with clots, will follow, having all the appearances of a miscarriage. These flows are fre- quently beneficial, as they relieve congestive states, which, otherwise might light up inflammatory conditions, or in- duce perturbed functional states. The most common of the latter are vertigo, faintness, and flushes. Flushes are the most common phenomena, and it is rare that women escape them. They depend on a partial paralysis of the vaso- motor nerves, and sometimes are ushered in by slight chills or creeping sensations. Following them is a gentle perspiration. These conditions are undoubtedly caused by sudden congestion of the nerve-centres, due to the ab- sence of the usual menstrual monthly flow, and are not infrequently relieved by vicarious haemorrhages from haemorrhoids or from the nasal mucous membrane, or by a diarrhoea, or a profuse leucorrhceal discharge. Leucor- rhoea is almost always present during the change of life, and is an undoubted relief to the congested organs. Con- sequently it ought not to be treated as a disease and checked. The nervous phenomena that may occur with this state are as varied as the location of congestive points in any part of the nervous tracts, or their sympathies. Irritability of temper, headaches, hypersensitiveness, neu- ralgia, loss of memory, tearfulness, fear, apprehensions, hysterical attacks or fancies, and the vagaries almost of insanity, may occur, while melancholia is not at all infrequent. Changes in the physique of the individual also occur. Women generally have a tendency to grow fat, and develop hair on their chins or faces. The breasts become enlarged from fatty deposit, and pendulous. The fat of the omentum and abdominal walls increases to such an extent that women frequently imagine that they are pregnant, and are further encouraged in their belief by the condition of flatus which coexists with digestive dis- orders, giving rise to supposed movements of the child. Simpson applied the term pseudocyesis to this imaginary form of pregnancy. It is a curious phenomenon that in some women sexual frigidity continues all through men- strual life, only to be broken down and awakened into activity at the change of life. Pruritus vulvae, colics, and lumbar and pelvic pains are apt to be present; and at times eruptive conditions of the skin appear, just as they do at the age of puberty. Succinctly, then, we may say, there is hardly a symptom associated with perturbed health that may not have a temporary awakening at this time. It is to be remembered that fecundity may occur, rarely, after the cessation of menstruation ; for it is quite agreed that ovulation may proceed independently of men- struation. Prognosis.-The prognosis is generally satisfactory, for all these troubles are, pathologically considered, trivial and evanescent. If, however, germs of disease exist in the sexual system, or organic affections are latent, they may become aggravated and developed at this time. This is especially true of cacoplastic growths. This, although infrequently occurring, has obtained for this time of life the term critical period, but that its dangers have been wonderfully exaggerated has been shown by statistical investigation. The organic diseases of the breasts, uterus, and ovaries are much more frequent during the active life of those organs, before the cessation of menstruation, while the mortality of women between the ages of forty and fifty is not greater than at any other period of life. The Differential Diagnosis between the so-called physiological phenomena of this state and the true or- ganic diseases that may be lighted up, is most important, and should claim the strictest attention of the physician. To this end the careless habit of ascribing all disease to 74 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Change of Life. Charcoal. the inevitable symptoms should be most carefully avoided. Women presenting themselves for investigation or treat- ment at this period should be most carefully studied and thoroughly examined. Nothing should be left to guess- work or chance. So far as professional knowledge is available, everything should be eliminated from the purely physiological condition of this period, as an error in diag- nosis, or failure in detecting the incipiency of pathologi- cal states which may be awakening, will only result in the fruition of disease and death. Treatment.-The treatment must necessarily be as varied as the indications. It is generally symptomatic, and we can do nothing more than to meet the phenomena, as they may arise, by special remedies applicable to them. As a general thing, women suffer at this time from habit- ual constipation. This must be corrected, and the daily movement of the bowels insisted upon. It is best ac- complished by the saline cathartics, as by their producing watery discharges they act as geiieral depletories. Ro- chelle salts, administered in teaspoonful doses in a tum- bler of hot water upon rising in the morning, is most ef- ficacious. The Hunyadi Janos water, Friedrichshall, Pullna, or Carlsbad salts, administered in hot water, are also beneficial, as they relieve portal congestion, which is generally associated with constipation. Aloes and blue pill occasionally give great relief, and should be pre- scribed from time to time. Indeed, cathartics are a sheet- anchor, as they produce vicarious discharges which re- lieve the congestion^ which almost invariably occur, and which fail of relief through the missed catamenial discharges. General or local depletion by blood-letting is also sometimes indicated, and, indeed, at times power- fully demanded. The ancient custom was to bleed all women at stated periods for this relief, and there can be little question that its abandonment of late years has been a great mistake. In the plethoric conditions that occur during this change there is nothing that will give such speedy and prolonged relief as venesection. Sometimes, in severe headaches, leeches behind the ears will accom- plish this purpose most admirably. Local depletion by leeches at the anus, or upon the cervix uteri, is some- times practised when there is congestion of the uterus or ovaries ; but the same, or a better effect, may be accom- plished by putting leeches over the region of the round ligament, where it escapes from the external abdominal ring. The food at this time should not be too stimulat- ing, especially if the patient is full-blooded or hearty. If, on the contrary, she is anaemic, tonics and iron should be given, and every attention paid to the improvement of the general nutrition. Turkish baths are especially beneficial, as they relieve local congestion and equalize the circulation. The skin, under all circumstances, should be kept free and pliant by frequent warm bath- ing. Freedom from care, anxiety, or excitement, should be enforced ; and amusement and occupation of all sorts encouraged in order to distract the attention of the indi- vidual from herself when her mood is introspective or de- pressed. For the further relief of headaches, and the general nervous phenomena that are almost always pres- ent in these cases, the bromides are almost specific and unqualifiedly called for. In addition to their action as sedatives, they diminish the blood supply to the uterus and ovaries, thus relieving congestions. The effects pro- duced by the bromides in these cases are marvellous, and it is remarkable what large doses of these drugs women can take under these circumstances. They relieve pain, they overcome depression and melancholia, and in those cases in which there is an increased and aggravating sexual im- pulse, they act as an anaphrodisiac. Women are apt to be tortured a great deal by sexual desire during the change of life, and will apply for treatment for its relief. The bro- mides, coupled with camphor, act most beneficially, and should never be withheld. All forms of narcotics are pre- scribed, such as Indian hemp, chloral, or opium. As a rule, it is unwise to administer these remedies unless the pain and distress are unendurable, inasmuch as at this impressionable period of a woman's life she very readily acquires the morphia or chloral habit. This is especially to be avoided in those cases in which the phenomena of the change run through a period of years, as in such cases it is almost unavoidable for them to escape the thraldom of the narcotic habit to which they may be, for so long a time, subjected. Regarding the thousand and one phenomena that may present themselves at this time, whether from profuse haemorrhagic, enteric or nervous conditions, they must be met, if of sufficient severity, by the proper topical remedies. It is manifestly impossible and unnecessary to lay down specific lines of treatment for all the disturbances that may present themselves. We can simply meet the indications as they appear from time to time. Walter li. Gillette. CHARCOAL. The essential constituent of charcoal is the element carbon, which in the condition in which it occurs in charcoal presents itself as a black substance, insoluble, infusible, odorless, and tasteless. The medi- cinal virtues of carbon reside solely in the singular absorb- ent property of this element. As represented by the substance charcoal, carbon tends strongly to absorb and hold fast gases and many organic principles, notably alkaloids and odorous and coloring matters. And in the case of such of these bodies as are oxidizable, the fact of their retention in the meshes of the charcoal mass leads to their ultimate chemical transformation by oxidation. Charcoal thus operates indirectly as an oxidizing agent, and thus is practically available as a decolorizer, deodori- zer, detergent, and, so far as noxious products of zymotic processes are concerned, also as a disinfectant. Charcoal is used by the pharmacist to decolorize and to separate organic principles, and by the physician to deodorize and hasten oxidation in the contents of receptacles for excreta, to deodorize foul discharges, and, given internally, to ab- sorb and hold the substance of vegetable poisons, such as, notably, alkaloids, until their evacuation can be de- termined, and, by absorption and secondary chemical conversion, to dispose of the noxious products, fluid and gaseous, of fermentation of the ingesta in a dyspeptic stomach. Charcoal is officinal in the U. S. Pharmacopoeia in the following forms: Carbo Animalis, Animal Charcoal. Under this title is recognized the common so-called animal charcoal or bone- black, that is derived as a black pulverulent residue from the heating of bone to redness in a closed vessel. Animal charcoal occurs in " dull black, granular fragments, or a dull black powder, odorless, and nearly tasteless, and in- soluble in water or alcohol. When ignited, it leaves a white ash, amounting to at least eighty-six per cent, of the original weight, which should be completely soluble in hydrochloric acid, with the aid of heat" (U. S. Ph.). Animal charcoal is officinal as the basis for the follow- ing preparation : Carbo Animalis Purificatus, Purified Animal Charcoal. Animal charcoal, in No. 60 powder, is digested with diluted hydrochloric acid on a water-bath for twenty-four hours, and the undissolved residue then freed from the acid by thorough washing with water, dried, heated to dull redness in a closely covered crucible, cooled, and put up in well-stopped bottles. By this procedure the calcic salts, which form so large a proportion of the w'eight of crude animal charcoal, are dissolved out, and the carbon, thereby, is obtained practically pure. Puri- fied animal charcoal is " a dull black powder, odorless and tasteless, and insoluble in water, alcohol, or other solvents. When ignited at a high temperature with a little red oxide of mercury and with free access of air, it leaves at most only a trace of residue" (U. S. Ph.). Probably because of a peculiarity of its texture, animal charcoal decidedly surpasses wood-charcoal in the prop- erty of decolorizing and of separating and holding vege- table principles. It is, therefore, the form of charcoal most used by the pharmacist, and should also be selected by the physician where the purpose is to hold swallowed vegetable poisons from absorption. But in this applica- tion it should be remembered that the action of the char- coal is, so to speak, mechanical only, and the use of the same should, therefore, be merely accessory to measures 75 Charcoal, Cbelold. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to secure evacuation. The charcoal should be given freely, by the spoonful, in suspension in water, until from half a tumblerful to a tumblerful shall have been taken. Carbo Ligni, Charcoal. Under this title is offlcinally recognized " charcoal prepared from soft wood." When well prepared, wood charcoal contains but a very small percentage of mineral matter, and may, therefore, be re- garded as practically all carbon. For medical purposes it is pulverized, and yields an exceedingly tine, light, black powder, odorless, tasteless, and insoluble. Upon expos- ure it attracts moisture, and it is in best condition, there- fore, when freshly made. Wood charcoal possesses in high degree the property of absorbing gases of certain kinds, and notably the foul- smelling products of zymotic processes. For deodorizing purposes it may be relied upon to absorb and effect the decomposition of from fifteen to twenty times its bulk of gas. It thus makes a good application to privy-vaults or cesspools, a pailful of powdered charcoal, as freshly made and as well preserved from damp as possible, being thrown into the receptacle once or twice a week. To wounds or sores yielding offensive discharges charcoal may be ap- plied by dusting upon the surface, by strewing upon the face of a poultice, or by quilting the powder between two layers of cotton wadding, such quilt being then used as the wound dressing. In dyspepsia, with acidity and flatulence, relief may often be secured by administering powdered charcoal in quantities ranging from half a tea- spoonful to a tablespoonful. It should be, if possible, freshly made, and is more effective if taken dry. Other- wise it is given mixed with water or milk. Charcoal should not be taken in large doses too frequently, since under such circumstances considerable mechanical irrita- tion has been known to follow. In mild dyspeptic caies, quite small doses, such as from 0.12 to 0.30 Gm. (two to five grains) may be all-sufficient, and such may be taken without objection. A sample of charcoal that has lost potency by keeping recovers the same on being recalcined. Edrcard Curtis. CHARLESTON. (For detailed explanation of the ac- companying chart, and for directions as to the best method of using it, see Climate.) The city of Charleston, S. C., situated upon a point of land between the mouths of the Ashley and Cooper Rivers (Lat. 32° 47' N., Long. 79° 56' W.), possesses, as may be seen by an examina- tion of the accompanying chart, a mild winter climate. The population of the city, according to the United States Census for 1880, was 49,984, and, as one of the chief sea- Climate, of Charleston, S. C.-Latitude 32° 47', Longitude 79° 56'.-Period of Observations, January 5, 1871, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, 13 Feet. A Mean temperature of months at the hours of Average mean temperature de- > duced from column A. | * B Mean temperature for period of ob-I servation. Average maximum temperature | - for period. Average minimum temperature ' _ for period. I " E Absolute maximum temperature for period. F Absolute minimum temperature for period. Greatest number of days in any single month on which the tern- perature was below the mean w monthly minimum temperature. Greatest number of days in any single month on which the tem- m perature was above the mean * monthly maximum temperature.1 January.... February... March April May 7 A.M. Degrees. 45.7 48.5 53.4 61.0 69.8 77.5 3 P.M. Degrees. 53.7 57.5 63.2 69.4 76.8 84.4 87.2 84.9 80.4 71.6 62.0 55.7 11 P.M. Degrees. 49.2 51.9 56.8 63.0 70.9 80i6 79.4 74.9 65.8 56.2 50.2 Degrees. 49.5 52.6 57.8 M.4 72.5 79.8 82.8 80.8 76.0 66.8 57.2 50.9 64.9 81.1 66.6 51.0 65.9 Highest. Degrees. 58.3 57.3 62.5 67.5 76.3 81.7 84.9 82.9 80.7 72.0 60.6 57.9 67.7 82.2 71.1 53.6 67.2 Lowest. Degrees.1 38.2 48.2 ' 52.1 I 60.4 68.8 78.1 ' 79.1 . 78.9 1 72.6 । 62.0 53.5 43.4 62.6 79.6 64.5 47.2 64.4 Degrees. 58.4 62.0 67.1 72.2 80.1 86.6 90.2 87.9 82.4 75.5 65.0 60.1 1 Degrees. 43.8 47.5 52.1 57.6 66.0 72.1 76.1 75.1 70.4 62.8 50.9 45.5 Highest. 1 Degrees. ' 80.0 , 78.0 I 85.0 87.0 94.0 100.0 104.0 97.5 94.0 93.0 82.0 । 76.0 Lowest. Degrees. 67.0 67.0 73.0 81.0 86.0 89.1 92.0 91.0 87.0 81.0 73.0 65.0 Highest. Degrees. 33.0 39.0 41.0 47.0 61.0 69.0 76.0 73.0 68.0 54.0 38.0 34.0 Lowest. Degrees. 23.0 26.0 28.0 32.0 47.0 60.0 K? 0 21 20 24 18 20 16 91 28 19 22 20 17 23 19 22 17 22 16 29 June J uly August September.. October November.. December.. Spring Summer.... Autumn.... Winter Year 78 72 63 13 46 2 7 2 4 9 62.0 54.0 39.0 28.0 13.0 23 29 20 27 22 January... February.. March April May June July August.... September. October.... November. December.. Spring Summer... Autumn... Winter .... Year J K M o Il S port towns of the Southern States, it is necessarily a com- mercial centre of no little importance, presenting, in this respect, to business men in search of a winter residence having a warmer climate than that of our northern cities, the same attraction already alluded to as existing at Augusta, Ga. The Charleston winter climate is, how- ever, rather warmer, and, at the same time, less bracing than is that of Augusta ; and, as might be expected from its immediate proximity to the sea, the relative humidity at Charleston is greater than it is at Augusta. The little town of Summerville, twenty-two miles from Charleston, is favorably spoken of by Appletons' " Hand- book of Winter Resorts," as a place of residence for those desiring a winter climate less variable than that of the city of Charleston itself, and for invalids wrho wish to escape from the easterly winds prevailing upon the coast. Summerville "is situated on a ridge which extends across from the Cooper to the Ashley River, which is covered with pine-woods, and is remarkable for its healthful- ness. . . . There is no hotel, but a number of good boarding-houses at which the charges are from 87 to 810 a week. Rents are cheap, there are several schools, and S' fl 57. 52. 57. 55. 47. 40. 37. 35. 40. 54. 51. 63. 66. 44. 66. 67. 91. 0 0 0 ) 0 0 0 5 ) 0 0 0 0 0 0 0 0 fl Q ■ <D rA 75.4 71.8 69.6 71.0 72.2 73.1 74.3 76.6 76.6 76.5 74.7 74.4 70.9 74.7 75.9 73.9 73.8 S£ 2 a O'C 10.5 9.1 10.8 11.3 13.5 14.3 14.6 14.5 10.5 10.0 10.5 10.7 35,6 43.4 31.0 30.3 140.3 Q c8 re $ 9.5 11.2 12.7 12.0 11.8 9.5 10.4 9.2 10.5 14.0 11.5 11.7 36.5 29.1 36.0 32.4 134.0 Is So be U . & 20.0 20.3 23.5 23.3 25.3 23.8 25.0 23.7 21.0 24.0 22.0 22.4 72.1 72.5 67.0 62.7 274.3 3 fl ■g CD u 0> <4 Inches. 3.77 3.65 4.47 5.03 4.70 5.05 7.18 7.46 6.44 5.00 3.51 3.64 14.20 19.69 14.95 11.06 59.90 $ Prevailingdirec. 3 tion of wind- tx of cd >.s . o'C g bes o Miles. 7.3 8.1 8.8 8.6 8.8 8.2 7.7 7.3 7.8 7.7 7.5 7.1 8.7 7.7 7.7 7.5 7.9 port towns of the Southern States, it is necessarily a com- mercial centre of no little importance, presenting, in this respect, to business men in search of a winter residence having a warmer climate than that of our northern cities, the same attraction already alluded to as existing at Augusta, Ga. The Charleston winter climate is, how- ever, rather warmer, and, at the same time, less bracing than is that of Augusta ; and, as might be expected from its immediate proximity to the sea, the relative humidity at Charleston is greater than it is at Augusta. The little town of Summerville, twenty-two miles from Charleston, is favorably spoken of by Appletons' " Hand- book of Winter Resorts," as a place of residence for those desiring a winter climate less variable than that of the city of Charleston itself, and for invalids who wish to escape from the easterly winds prevailing upon the coast. Summerville "is situated on a ridge which extends across from the Cooper to the Ashley River, which is covered with pine-woods, and is remarkable for its healthful- ness. . . . There is no hotel, but a number of good boarding-houses at which the charges are from $7 to $10 a week. Rents are cheap, there are several schools, and 76 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Charcoal. Cheloid. churches of nearly all the religious denominations, while the proximity of Charleston affords liberal supplies for the markets. The South Carolina Railroad runs special trains for the accommodation of residents, who are thus enabled to enjoy all the advantages and attractions of the adjacent city" (Appletons' " Handbook," 1884-1885, p. 49). The city of Charleston itself cannot be considered a desirable summer or autumn residence, especially for persons coming from the North. Huntington Richards. metres in diameter), globular, with a hard, gray peri- carp, and numerous irregularly ovoid or compressed seeds. The seeds, which are the source of the oil and are themselves occasionally imported, are about three centi- metres long ; they have a thin, brittle, dull gray testa, and a brown, oily, albuminous kernel. Chaulmugra is one of the many substances which have been employed in eastern countries for the cure of lep- rosy and other skin diseases for an unknown length of time. It has been only recently used by European prac- titioners, and although official in the Indian Pharma- copoeia, is but rarely used in Europe or America. The fixed oil, of which the seeds contain 51.5 per cent. (Fliickiger), is generally obtained by expression. It is a light-brown or yellow fat of about the consistence of butter, melting at about 100° F., and having but little odor or taste. It is soluble in benzin, carbon bisulphide, chloroform, and partially in ether and alcohol. Chaul- mugra is a compound fat, consisting of, according to Moss, 63.6 per cent, of palmitic acid ; 11.7 of gynocardic acid; 2.3 of cocinic acid, and 4 of hypogeeic acid (Huse- mann). Besides the fat the seeds contain nothing of note. Uses.-In India, as noticed above, both the seeds and the oil are extensively used. The former are given inter- nally as an " alterative" tonic in syphilis, and scrofulous and chronic skin diseases. They are also ground into a paste and mixed with lard for an external application. The oil is employed, chiefly externally, in leprosy, psoria- sis, and parasitic skin diseases ; for these affections it is now and then prescribed here, but does not promise to have any extended use. Dose of the seeds from one-third to one gram (gr. v. ad xv.); the latter dose may nauseate. Externally the oil itself, or gynocardic acid (which may be purchased), may be used clear or diluted, for inunction. Allied Plants.-There is but one species in the genus. The order is small and tropical, furnishing no familiar product, excepting the dye, Annatto. One or two species of Hydnocarpus in the same order supply seeds which are occasionally substituted for those of Gynocardia. Allied Drugs.-It is not probable that Chaulmugra has qualities very distinct from other vegetable fats, so far as its external use goes. A list of drugs which have been empirically employed for the above-mentioned dis- eases would be long and incongruous. IK P. Bolles. CHARLESTON ARTESIAN WELLS- Location and Post-Office.-Charleston, S. C. Access.-By steamer from New York, and by various lines of railway. Urged by the necessity of discovering a supply of good drinking water, the City of Charleston, in 1844, author- ized the boring of a well at Wentworth and Meeting Streets. After several failures and years of labor, a flow of water 30 gallons per minute, with a head of 24 feet 10 inches, and a temperature of 87° F., was struck at the depth of 1,260 feet. This meagre supply was owing to the small internal diameter of the tube, (three inches,) at the bottom. Encouraged by this result, another well of larger diameter was begun, but the war intervening, it was not completed. In 1876 another well was com- menced on Citadel Green. Water was struck at a depth of 1,970 feet, flowing at the rate of 250 gallons per minute, with a head of 103 feet, and a temperature of 99.5° F. Analysis. Meeting and Wentworth Streets. Grains to U. S. Gallon. Bicarbonate of soda 71.0603 Chloride of sodium 63.3843 Bicarbonate of lime 0.1185 Bicarbonate of magnesia 0.0175 Silica 0.0013 Oxide of iron and alumina 0.0005 Organic matter 0.0023 Free carbonic acid 0.7818 Total 135.3665 Citadel Green (Dr. S. T. Robinson, Jr., 1879). Grains to U. S. Gallon. Organic matter and water of crystallization 1.7337 Carbonate of iron 0.3350 Sulphate of lime 0.4424 Sulphate of magnesia 0.1653 Chloride of magnesium 0.2303 Chloride of sodium 11.3903 Carbonate of soda 47.2585 Nitrate of soda 0.5543 Silicate of soda 2.5248 Silica 0.3617 CHELOID (xv^, a claw). Synonyms : Keloid, Chel- oma, cheloides ; Germ., Keloid; Fr., Cheloide, Keloide. Definition.-A connective-tissue neoplasm, resem- bling an hypertrophied scar and developing spontaneously in the skin, or arising from the tissues of a cicatrix. History.-Cheloid is an affection of comparatively mod- ern recognition, the first genuine description of it being that of Retz, in 1790, under the name dartre de la graisse. To Alibert (1806) belongs the credit of having made the first careful study of the growth, describing it under the term kelis, with the synonyms, cheloide and cancroide. Later, however, he abandoned the term cancroid and classified the affection into two varieties, designated the true and the false. Since his time, a large number of widely different diseases have been improperly designated cheloid. Addison, for example, applied the term to a diffuse dermatitis (scleroderma), and Dieberg described a warty variety. The classification which is sanctioned by the majority is that originally proposed by Alibert, namely, the true or spontaneous, and the false or cicatricial cheloid. This, however, is not received by all. The dissimilarity be- tween both the clinical and histological features of the two varieties, and the uncertainty that has sometimes arisen in the differential diagnosis between cheloid and papilloma, sarcoma, carcinoma, and even certain syphi- litic lesions of the skin, has given rise to several conflict- ing statements with regard to the use of the term. Volk- mann, on the one hand, proposes to discard it, classifying all cases with the fibromata and sarcomata of the skin, according to their histological structure. Fremmer, on the other hand, thinks it more rational to restrict the Total 64.9963 The water from several other wells of varying depths, sunk by private enterprise in Charleston and vicinity, shows practically the same chemical composition. " The habitual use of the water of the Wentworth* Street well is said to have been very beneficial in dys- pepsia and kindred diseases." For a full and detailed account of the artesian wells at Charleston, we would refer to the Municipal Report, Ar- tesian Wells, 1881. G. B. F. CHAULMUGRA (Chaulmoogra, Gynocardia, etc., oil). A peculiar compound, fatty substance, expressed from the seeds of Gynocardia odorata, R. Br. Order, Bixacea (Bixinece). This is a large, fine, much-branched, East Indian tree, with large, oblong pointed leaves, slender grayish branches, and dioecious flowers. These latter are whitish-yellow, about five centimetres (two inches) across and regular; the calyx splits irregularly into three or four segments ; the' corolla consists of five oval, blunt petals, each having a large yellow scale at its base ; stamens very numerous ; pistil in the fertile flower large, ovoid, with five short styles, one-celled, with numerous ovules on five placentae. Fruit as large as a shaddock (ten centi- 77 Clielold. Clierry, Wild. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. term cheloid to the spontaneous variety, qualifying it by appropriate adjectives to designate the other varieties, as fibromatous or sarcomatous cheloid. Finally, the exist- ence of a spontaneous form of cheloid has been questioned, first, on the ground that in the supposed idiopathic cases the traumatism has been so trifling as to have escaped ob- servation ; and second, because of its close relationship, or identity with the fibromata. Description.-With respect to appearance, cheloid is of two varieties, the flat and the elevated. The former is a round or oval, smooth or furrowed mass, but little ele- vated, and sometimes circumscribed by a reddish border, with a depressed centre. The elevated variety is a firm, more or less cylindrical tumor, having slender bands of the same tissue extending from its sides and ends into the surrounding integument, giving it the appearance of being firmly secured. The growth stands prominently above the surface and varies in length between one and several inches ; it has even been observed to bridge across small tracts, as from one side of the sternum to the other, leaving the intervening skin unaffected. It was the re- semblance of this cicatricial form to the claw of a bird that suggested to Alibert the term cheloid ; whereas, Breschet (1825), observing the smooth variety, accepted the term, but as being more properly a derivative of the word a scar. This ety- mology is still retained in the orthography of Eras- mus Wilson, who desig- nates the smooth variety keloid, and the elevated cheloid. The growth be- gins as one or several small, slightly elevated nodules, pustules, "but- tons, hard to the touch," or granulations, which in the course of a few months coalesce to form a single tumor. The accompanying symptoms are a sense of itching or burning, tenderness to pressure, and occasion- ally some pain. In its earlier stages, sometimes throughout its entire history, the growth is of a deep-red color, owing to the vascularity of its surface ; later, how- ever, it usually becomes pale or of a yellowish hue in the Caucasian, but sometimes more pig- mented than the sur- rounding skin in the negro. The epidermis is tense and firmly united to the tumor, its surface glossy and usually smooth, though rarely studded with a few fine hairs. The growth is firm, but resilient and elastic. The spon- taneous variety develops almost exclusively in the skin of the trunk, notably that over the sternum and buttocks, and rarely invades the face, neck, back or extremities. The cicatricial variety is not so limited. The former, be- longing wholly to the integument, is freely movable with it; the latter follows the line of a cicatrix into deeper structures ; both have a strong tendency to recur after removal. The spontaneous variety is generally single, the cicatricial multiple rarely exceeding twenty in number ; yet Schwimmer reports a case in which he counted one hundred and five distinct tumors. Etiology.-Few positive statements can be made re- specting the etiology of this affection. Unless its origin can be explained, as has been attempted, on the ground of a peculiar diathesis in the affected individual, render; ing him predisposed to the development of a cheloid upon the receipt of any skin-wound, we have as yet no sufficient theory for its explanation. Transmission by heredity has been observed in some cases, and certain of the older au- thors have argued a special predilection for strumous sub- jects. The cicatricial cheloid shows no preference for major over minor injuries, but has been repeatedly ob- served to follow such trivial wounds as the opening of an abscess, blood-letting, the bite of a leech, piercing the ears, scraping for lupus, the action of escharotics and blisters, and the lesions of such diseases as acne, small-pox and syphilis. The disease is most frequently observed in early and middle life, is a little more frequent in women than in men, and attacks with special preference the negro race. The evidence fails, however, to prove anything more than a local cause for the traumatic variety at least, and there is no more reason to presume the existence of a dia- thesis to account for the spontaneous variety than to ex- plain such growths as the myomata, of which Virchow says ' ' each individual tumor is the product of a local influence, and their multiplicity signifies nothing with re- gard to the extent of that influence." Morbid Anatomy.-In microscopic appearances, che- loid is closely allied to the fibromata, if, indeed, it is not a species of them. The spontaneous variety springs from the fibrous tissue of the corium, and preserves in it all the elements of that layer. For some time its increase of size occasions an almost equal displacement of the structures above and below it, without doing injury to the papillary layer or forming connec- tion with underlying tis- sues. The structure is a regular net-work of 'white fibrous tissue arranged in parallel layers and con- taining a large proportion of yellow elastic fibres. The lymph and blood- vessels of the region are compressed, and toward the centre of the tumor the latter are oftentimes obliterated. In the trau- matic form the fibres are arranged more into bands and bundles, and the elements of the skin are replaced by those of the neoplasm, so that the papillary layer is oblite- rated (see Fig. 640). In the young tumor, the fibrous bands may be traced into dense bundles of spindle-cells, which of themselves compose a large part of the growth, and are especially nu- merous toward the pe- riphery, extending for a considerable distance outward along the course of the blood-vessels. As growth advances, the blood-vessels of •the periphery multiply, while those of the central zone become few and compressed. In the syphilitic subject cheloid is characterized by a great abundance of cellular elements and a decided tendency to the formation of granulations. In the tubercular subject, on the other hand, we find but few cells and pale fibrous tissue. In the multiple cheloid the cicatricial elements greatly pre- dominate. There is sometimes observed, in a cheloid, a network of large stellate or spindle cells in the outer zone of the tumor, particularly if a sclerotic or hyaline metamorphosis has occurred in the interior. Variations in the relative abundance of the several cellular elements sometimes occur, as well as certain other features pecul- iar to individual cases. Prognosis.-Cheloid has no influence upon longevity. With reference to cure, the prognosis is unfavorable. Spontaneous recovery has been observed, particularly in the idiopathic variety ; in other instances, the tumor, after attaining a certain size, has remained stationary for a time, or even throughout the remaining life of the indi- vidual. a b c a Fig. Ci-40.-Cicatricial Cheloid from the Gluteal Region, following a Burn, a, Epi- dermis : 6, Malpighian Layer; c, Remains of Papillary Layer near the Border of the Tumor ; d, Cheloid tissue. The cellular infiltration around the blood-ves- sels is also indicated at several points. (From an original drawing by the Author.) 78 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cheloid. Clierry, Wild. Treatment.-The treatment of cheloid is restricted almost exclusively to measures intended for the comfort of the patient, especially the application of suitable com- presses, which are reported to have exerted a curative in- fluence in a few cases, and salves or liniments containing hyoscyamus, belladonna, chloroform, or opium. Any attempt at removal, either by the knife, cautery, or caus- tics, so far from resulting in cure, will prove harmful, for the growth springs with renewed vigor from the wound. This tendency is explained by Warren, on the supposition that the cellular elements of the growth, which follow the course of the blood-vessels for some dis- tance beyond the limits of the tumor, are not removed in the operation. Of late several cases have been reported cured by multiple scarification, numerous crossed in- cisions having been made into the substance of the tumor. The good results in a few instances reported from the use of such mild remedies as iodine, mercurials, the acetate of lead, etc., have in all probability resulted from their use in cases in which spontaneous recovery would have occurred. James M. French. Therapeutic Properties. - These are excellent sulphur w'aters, and though long known, and situated in a historic region of New York State, have never been much improved. There is also an "acid phosphate" spring here. G B F CHERRY, WILD (Prunus Virginiana, U. S. Ph.). The officinal Wild Cherry Bark is obtained from Prunus serotina Ehrhart, and not, as might be supposed from the officinal name, from Prunus virginiana Linn., another "wild cherry," of smaller size, and like the other, a common American plant. P. serotina is a large, graceful tree, with spreading slender branches covered with red or purplish, smooth, shining bark ; that of the trunk, however, is dark and ex- foliating. Its wood is the valuable cherry, so extensively used for house-finishing and cabinet work. In general aspect it resembles the domestic cherry trees, but is much larger and has a rounder and more spreading top. The flowers are small (one centimetre across) and borne in long, slender, rather erect, terminal racemes. Calyx cup- shaped, five-toothed. Corolla, of five-reflexed, broadly- obovate white petals. Stamens, twenty or so perigymons. Ovary, simple, one-celled, two-ovuled. Fruit, a round black, mawkish-sweet drupe, about one centimetre in diameter. Stone, one-seeded. The wild cherry tree grows in nearly all parts of the United States and Canada. In the Middle States, and in some of the Western ones, it is very abundant and large ; in the extreme South it is less common, and in New Eng- land, although common, it does not attain its maximum size. Wild Cherry has been in use in the United States for about a hundred years, and has been recognized by each edition of the " Pharmacopoeia," from the first, in 1820, to the present. Although occasionally employed in Eu- rope, it is essentially a local drug. The bark should be collected in the autumn, when its hydrocyanic odor and taste are the most perceptible, and that of the root, moreover, is said to be preferable to that of aerial portions ; but it is an abundant and cheap drug, largely called for in domestic and other informal medi- cine, and apparently indiscriminately gathered. Much of it is nearly devoid of its proper odor. The "Phar- macopoeia " description is as follows : " In curved pieces or irregular fragments, one-twelfth of an inch (2 milli- metres) or more thick, outer surface greenish-brown, or yellowish-brown, smooth, and somewhat glossy, marked with transverse scars. If collected from old wood and deprived of the corky layer, tliQ outer surface is nut-brown and uneven ; inner surface somewhat striate or fissured. Upon maceration in water it develops a distinct bitter- almond odor ; its taste is astringent, aromatic, and bitter. The bark of the small branches is to be rejected. This bark contains substances analogous to the emul- sin and amygdalin of Bitter Almonds, but they have not been satisfactorily examined as yet. Upon being macer- ated in water and subjected to distillation it yields hydro- cyanic acid, and a volatile oil having the properties of that of almonds. It also contains tannic acid. Wild Cherry is used as a sedative bitter tonic ; the former property due to its hydrocyanic acid, the latter perhaps to its amygdalin only, although there is reason to believe that it contains another bitter substance. It is very slightly astringent. The above qualities express its entire value as at present understood. As a substitute for quinine it is entirely ob- solete. Dose from two to four grams (2 to 4 Gm. - 3 ss. ad j.). The Fluid Extract (Ertractum Pruni Virginiana, strength }) and the infusion (Infusum Pruni Virginiana, strength Tfo) are officinal, and represent it well. The syrup (Syrupus Pruni Virginiana, U. S. Ph., is frequently used as a basis of cough mixtures ; its taste is rather pleasant. Allied Plants.-See Almonds, Bitter and Sweet. Allied Drugs.-Cherry-laurel leaves, Peach meats, and also Almonds and Hydrocyanic Acid. IF. P. Bolles. CHELTENHAM, situated in a pleasant valley in Glou- cestershire, Efigland, and sheltered from the east and northeast winds by the Cotswold Hills, enjoys the reputa- tion of being one of the healthiest and cleanest towns in Great Britain. There are four mineral springs, three of which, Old Wells, Montpellier, and Pittville, are saline, while the fourth, Cambray, is chalybeate. The waters contain also a little sulphur. They are recommended in the treatment of dyspepsia and constipation, of the uric acid diathesis, mercurial cachexia, chlorosis, and the ' ' nervousness " of young females. The waters are taken by visitors at the springs, and are also largely exported. The following is the composition of the Cheltenham waters, after the analyses of Parkes and Brande. One pint contains : Carbonate of sodium Chalybeate Spring. Grains. 0.5 Saline Spring. Grains. Sulphate of sodium 22.7 15.0 Sulphate of magnesium 6.0 11.0 Sulphate of calcium 2.5 4.5 Chloride of sodium 41.3 50.0 Ferric oxide 0.8 Total 73.8 80.5 Carbonic acid gas T. L. S. CHERRY (Cerise, et queue de Cerise, Codex Med.). Cul- tivated cherries (Prunus Cerasus Linn.), are official in France as the source of a "juice" (sue) and syrup, used for flavoring. W P B CHERRY VALLEY SPRINGS. Location and Post- office, Cherry Valley, Otsego County, N. Y. Access.-By Delaware & Hudson Canal Co. Railroad, Susquehanna Division, to Cherry Valley. Analysis.-One pint contains : Bath House Spring. (J. B. Chilton, M.D.) Grains. Spring North of Bath House. (Prof. Perkins.) Grains. Carbonate of magnesia... 2.227 1.245 Carbonate of iron 0.306 Carbonate of lime 1.177 1.844 Chloride of potassium.... 0.311 Chloride of sodium 1.555 0.266 Chloride of magnesium... 0.460 Chloride of calcium 0.350 Sulphate of soda 1.385 Sulphate of magnesia . ... 3.070 Sulphate of lime 7.210 18.683 Hvdrosulphate of soda ... 0.075 Silica and alumina 0.045 Silex 0.455 Organic matter 0.035 17.589 23.110 79 Chervil. Chest. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. CHERVIL {Cerfeuil, Codex Med.), Anthriscus Cerefo- lium Hoffm. {Scandix Cerefolium Linn. ; C hoerophyllum Cerefolium Grantz); Order, Umbelliferoe. An annual plant, long cultivated in Europe, where it is also indigenous, for its agreeably spicy leaves and fruits. These are used for flavoring soups, somewhat as parsley and celery in the same family are with us. Chervil had formerly a reputa- tion in the treatment of " scurvy, dropsy, scrofula," etc. ; the bruised fresh leaves were also used as a poultice for inflamed breasts, haemorrhoids, etc. It has no more value as a medicine than the similar plants mentioned above. Dose, indefinite. Allied Plants and Drugs.-See Anise. W. P. Bolles. ration thereby produced. It may be accomplished, how- ever, while the bones are still soft, by well-regulated manual pressure, employed at frequent intervals and steadily persevered in. There are various other malformations of the chest, either unilateral or symmetrical, which, however, require no extended description in this connection. The unilateral deformities are due usually to intra-thoracic disease or are secondary to lateral curvature of the spine. The bilateral deviations from the normal, other than those above men- tioned, consist in a relative disproportion in the size of the thorax as compared with the rest of the body, and are dependent chiefly upon the volume of the lungs. When these are small the chest is diminished in size and the ribs are arranged more obliquely; when, on the other hand, the lungs are abnormally large, the volume of the thorax is increased and the ribs have a more horizontal direction. Thomas L. Stedman. CHEST, DEFORMITIES OF-1. Funnel-shaped Chest (Ger., Trichterbrust}.-This rare deformity is one which is characterized by a depression in the anterior thoracic wall, and is thus directly the reverse of that known as pigeon-breast. The condition, in marked de- gree at least, is but rarely met with, the literature of the last quarter of a century furnishing only some eight or nine cases. The depression in the anterior chest-wall is shaped somewhat like a truncated cone with an oval base, the long diameter of which is directed vertically. The depth of the excavation varied, in the cases reported, from one to three inches. When the depression was profound, there was usually noticed a slight secondary kyphosis of the corresponding dorsal vertebrae. The- deformity causes a great displacement of the thoracic viscera, yet it seems not to interfere with their function. In most of the re- ported instances the affection was congenital, but in a few it was said to have first appeared in early childhood. All of the subjects were males. The etiology of funnel-shaped chest is uncertain. Among the various hypotheses which have been advanced may be mentioned intra-uterine traumatism, strong pressure of the foetal chin against the thorax, rachitic or syphilitic softening of the bones, and arrest of development of the sternum. The latter is the theory advanced by Ebstein, and is the most plausible one. He states that the growth of the sternum being arrested, the development of the thorax in a vertical sense is re- stricted, and the ribs continuing to elongate, an incurva- tion of their sternal extremities results. The following list embraces, it is believed, all or nearly all of the hitherto recorded cases : " Une difformite thora- cique," editorial note in Gazette des Hopitaux, Paris, Janu- ary 7, 1860, p. 10. Eggel, " Eine seltene Missbildung des Thorax," Virchow's Archie., vol. xlix., 1870, p. 230. C. T. Williams, " Congenital Malformation of the Thorax," " Transactions of the London Pathological Society," 1872, p. 50. Maximilian Fleech, "Ueber eine seltene Missbil- dung des Thorax," Virchow's Archie., vol. Ivii., 1873, p. 289. "Eine merkwiirdige Difformitat, Wiener medizinische Blatter, No. 50, 1880, p. 1276. Nicolaus Hagmann, " Sel- ten vorkommende Abnormitat des Brustkastens," Jahr- buch der Kinderheilkunde, vol. xv., 1880, p. 454. Ebstein, " Ueber die Trichterbrust," Deutsches Archie fur klinische Medicin, April, 1882, p. 411. F. Percival, " Caso di To- race Imbutiforme," Ricista Clinica, May, 1884, p. 401. A case is mentioned by Luschka in his work, " Anatomic der Brustorgane," 1863, pp. 20-23, but this is probably the same one described in the Gazette des Hopitaux. In the discussion on Dr. C. T. Williams's case in the London Pathological Society, Dr. C. J. B. Williams referred to another one seen by himself, but the case is not reported in detail. 2. Chicken-Breast (or "Pigeon-Breast" {Pectus Ga- rinatum).-A deformity of the thorax dependent upon rickets ; sometimes produced, also, by angular curvature of the spine in the dorsal region. It is characterized by a projection forward of the sternum ; the ribs are some- what bulging laterally, while the costal cartilages assume an antero-posterior direction. The configuration of the chest thus produced resembles that of a chicken, or the keel of a ship (carina), whence its names. Attempts have been made to push the sternum back by elastic pressure, but they have been usually unsuccessful, owing to exco- riations of the integument, or to the impediment to respi- CHEST, PHYSICAL EXAMINATION OF.-For clini- cal convenience, the chest and root of the neck are subdi- vided into regions. The suprasternal region lies between the upper end of the sternum below, the lower border of the cricoid cartilage above, and the sterno-mastoid muscles at the sides. The upper sternal region extends from the upper border of the sternum to a level with the third rib. The lower sternal region covers the remainder of the sternum. The supra-clavicular region is that lying over the clavicles. The clavicular region covers the inner half of the clavi- cle. The infra- clavicular region is bounded by the clavicles above, the sternum with- in, a horizontal line crossing the chest at the level of the third rib below, and a ver- tical line dropped from the acromi- al process. The mammary region is bounded by the infra - clavicular region above, the sternum internal- ly, the acromial line externally, and below by an oblique straight line drawn along the middle of the sixth costal cartilage to meet the acromial line. The infra- mammary region consists of the remainder of the thorax below the mammary region. The posterior portion of the chest is subdivided into the scapular, the part covered by the scapula ; inter-scap- ular, lying between the scapulae ; alright and left infra- scapular regions. At the sides are the axillary, above the pectoral muscles, and infra-axillary below the muscle. The position of the structures lying in these regions, and their relations, should be carefully noted. In Physical Examination of the Lungs, patients may be placed in either a sitting or a recumbent posture ; only it should be remembered that the boundaries of the organs differ a little in the two positions. The pulse is also three or four beats faster in a sitting than in a re- cumbent posture, and three or four beats faster still, when a standing posture is assumed. The patient should be stripped to the waist, and care should be taken to see that he is placed in a symmetrical position-the face directed to the front, and not only the arms, but also the legs, placed in corresponding positions. It is often desirable to change the position of the patient during the examination. In pleurisy with effusion, for example, one of the most certain indications of the fluid is the alteration in the line of dulness when a change is made from the recum- bent to the sitting position. In the physical examination of the chest we are accus- Fig. 641.-Kegions of the Front of the Chest. 80 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chervil. Chest. tomed to use inspection, palpation, mensuration, percus- sion', and auscultation. To these may be added the use of the sphygmograph and the microscope. By inspection, we learn the shape of the chest and the character of its movements. By mensuration, we learn the size of the chest and the extent of its movements. The girth of the chest, for general purposes of compari- son, should be taken under the arms and above the nip- ples. For comparing the tw'o sides, measurements are taken low'er down. Several curious and complicated in- struments have been devised for measuring the chest, but a common tape-line will be all that is needed. The min- imum size of the chest in the healthy adult is eighty-one and a half centimetres (thirty-two inches), and the mini- mum expansion is five centimetres (two inches). The average expansion is about seven and a half centimetres (three inches). The bony walls of the chest aje conical and convex in every direction, except in the sternal region, and are alike on both sides. The infra-clavicular space is convex, even in emaciated persons, except as the tissues are raised by the clavicle. A cord drawn tightly from the nipple to the clavicle should touch the chest as far as to the upper border of the second rib. Distortion of the chest-walls occurs in many diseases. A depression under the clavicle is one of the most common and certain indications of phthisis. A depression at other parts of the chest, when not the result of deformity, may indicate an old pleurisy. Contraction often indicated bronchiectasis. The pigeon- breasted appearance of atrophy of the lung is quite char- acteristic. The chest is enlarged in many diseases. The barrel- shaped chest of emphysema, with its peculiar restricted motion, is a prominent example. Pleurisy with effusion, or emphysema, increases the girth of the chest and causes a bulging of the intercostal spaces, and pneumo-hydro- thorax often produces the same effect in a more marked degree. The movements of the upper part of the chest are a lit- tle greater in women than in men, but in both they should be smooth and uniform, and alike on both sides. An in- equality in the expansion of the two sides indicates some- thing abnormal. If it has existed for some time, is situated under the clavicle, and is combined with depres- sion on one or both sides, it probably indicates phthisis. In pleurisy, pneumonia, and pneumo-hydrothorax the affected side remains quiet w'hile the other side moves excessively. In double pneumonia the upper part of the chest moves excessively, as do also the abdominal mus- cles, while the lower part of the chest remains quiet. A labored attempt to breathe with the arms braced and the muscles of the neck and abdomen acting strongly while the chest-walls remain nearly motionless, is quite charac- teristic of bronchial asthma. Palpation is the study of the chest by the sense of touch. If the hand is laid upon the healthy chest, noth- ing of note is detected in quiet respiration. If the person speaks, a vibration is communicated to the fingers (vocal fremitus'). In disease, this condition of affairs is often much changed. In general terms, vocal fremitus is in- creased over consolidated lung or over cavities, and di- minished when the lung is withdrawn from the chest-wall, or a bronchial tube is plugged. Hence, in pneumonia and phthisis, the vocal fremitus is increased, and this is notably so over a cavity. In phthisis, however, a thick- ening of the pleura may push the lung away from the chest-wall and cause a diminution of the vocal fremitus. In bronchiectasis vocal fremitus is increased. In pneumo- thorax, and in pleurisy with effusion, vocal fremitus is ab- sent. Even in dry pleurisy the thickening of the pleura causes diminished vocal fremitus. In other diseases the vocal fremitus varies. In chronic bronchitis there may be no change, but if the bronchial tubes are thickened, the vocal fremitus is increased. In croupous bronchitis, plugging of the bronchi may give rise to diminished vocal fremitus over portions of the lung. In emphysema, vocal fremitus is usually less than normal ; but if the lung is much atrophied, as is often the case in the old, vocal fremitus is increased. The object of percussion is to discover the condition of the parts within, by light blows upon the surface. It is described as of two sorts-immediate and mediate. Im- mediate percussion consists of blows directly upon the chest-wall. In mediate percussion the blows are received upon some intervening substance. The first of these is of little use. The second is one of the most valuable means of diagnosis, and is what is ordinarily understood by percussion. The value of percussion depends upon the fact that a solid tissue gives out a high-pitched note, while a porous tissue gives out a lower note. When the lung is diseased its density, and consequently its percus- sion note, is changed. In practising percussion, a light hammer shod with rubber, or the hand alone, may be used. With the hammer, a hard, flat, oval plate, called a pleximeter, is used. There are two varieties of hammers. In one of these the head consists of a cone of soft rubber about four cen- timetres (one and a half inch) in length, and one and a half centimetre (five-eighths inch) thick. To this is at- tached the handle, which tapers near the head to a slender metallic stem, slightly elastic, in order to give a rebound after the blow' is struck. This form of hammer was de- vised by Prof. Austin Flint, of New York. In the other form, the head is of metal tipped with rubber. The handle is shorter than in the other variety, and is of wood flattened from side to side, but of some consider- able breadth from above downward. No attempt is made to secure elasticity, the rebound coming from the hand alone. Flint's hammer is excellent for general use, but is rather light for deep percussion. The pleximeter is a flat, oval plate of ivory or hard rubber, four centimetres (one and a half inch) long, by two and a half centimetres (one inch) wide, the ends being provided with flanges which serve the purpose of handles. One side is often made straight and divided into a scale. In percussing with the hand, the middle finger of the left hand is pressed upon the chest, care being taken to leave no space between it and the chest. The finger is then struck a sharp blow with one or more fingers of the opposite hand. The blow should be delivered from the wrist alone, the arm, elbow, and shoulder being kept im- movable. Care must be taken that the fingers of the per- cussing hand be held perpendicular to the chest-wall, and the finger of the left hand be struck squarely in the mid- dle, otherwise the resonance heard will not be from the parts immediately beneath, but from a distance, or the percussing finger will slip and give a muffled sound. It is better not to percuss over a bone, as the bony resonance will mask the sounds beneath. It is worth remembering that percussion in the neighborhood of any organ is liable to be influenced by that organ if the blows are directed toward it. A blow toward the heart may convey the impression of dulness when none exists. A blow' toward the trachea may give a normal resonance, vdien a blow aw'ay from the trachea would indicate dulness. The use of the hammer needs no explanation to one who has learned to percuss with the hand. In practising percussion, the hammer, unlike the hand, can be used for an indefinite length of time, and sometimes, in deep per- cussion or in demonstrating to a large number of persons, a more forcible blow is needed than can well be given by the hand alone. The hand, however, has the advantage of being always ready, and as it is of the same texture as the chest, it does not change the resonance of the tissue. With the hammer there is always more or less of a click w hich tends to mask the other sounds. We also lose in great part, with the hammer, the feeling of resistance given by solid tissue, by which a skilful diagnostician often feels more than he hears of the condition of the parts beneath. It is necessary, therefore, to give the time and attention necessary to learn to percuss readily with the hand, otherwise a correct diagnosis in diseases of the chest cannot be made. When the method of percussion has been learned, stud- ies should be made of healthy chests, beginning with an adult male. The typical resonance of the chest is found in the infra-clavicular spaces. Careful percussion will some- times show the left side to be a shade less resonant than 81 Chest. Chest. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the right. Passing downward from this point on the right side, we find, on light percussion, that the mam- mary region is less resonant than the infra-clavicular, on account of the thick tissues overlying the lung. Deep per- cussion shows the lung quite resonant down to a point be- tween the fourth and fifth ribs, where we reach the upper border of the liver. Deep percussion here shows dul- ness, which increases until we reach a point between the fifth and sixth ribs. We never have a complete flatness over the liver. The thin lower border of the lung should be detected, by careful percussion with one finger, lying just above the lower border of the ribs. On the left side we reach the dulness of the heart at the upper border of the third rib. This dulness occu- pies a triangular space, extending from the costo-sternal articulation of the second rib to the nipple, and thence horizontally to the sternum. Below, and to the left, we have, on deep percussion, the tympanitic resonance of the stomach. This varies considerably in extent, often reaching from the fifth rib to the epigastric region. The lung is deficient over a space which varies somewhat in size ; it corresponds in shape with the heart triangle, but is smaller. One should here also be able to mark out ac- curately the borders of the heart and the lung as it over- lies the heart and stomach. It must not be forgotten that above the clavicles there is a resonant spot, corre- sponding with the apex of the lung. The examination of the chest posteriorly should not be omitted. The position of the patient should be different in studying different parts of the back. For the supra- scapular regions he should sit erect. For the inter-scapu- lar and infra-scapular portions he should cross the arms upon the breast, clasp the points of the shoulders, and lean forward. The thick tissues of the back make deep per- cussion necessary. The two sides are nearly alike until we reach the liver, at the level of the twelfth dorsal vertebra on the right side, and the stomach, somewhat lower down on the left. The sounds obtained by percussion are divided into flat, when the sound is the dullest possible, as over the thigh ; dull, which is somewhat less resonant; normal; tympa- nitic, as over the abdomen; amphoric or cavernous, over a large cavity. The cracked-pot sound resembles, as its name implies, the sound produced by striking a cracked iron pot. It may be imitated by clasping the hands, with the palms together, so as to leave a small opening between the thumbs, and then striking the back of one hand on the knee. Dulness, varying in degree, is found in many diseases of the respiratory apparatus. Pleurisy, with effusion, affords a typical example of flatness below the level of the fluid; the line which bounds this flatness is horizontal, and changes with the position of the patient. The second stage of pneumonia, after the exudation has occurred, is the type of dulness. There is no intermediate stage be- tween flatness and dulness, but between the complete dulness of pneumonia and the normal resonance the de- grees are numerous. In phthisis there is always a cer- tain amount of pulmonary resonance. In oedema of the lung there is a certain amount of dulness. In bron- chitis there is sometimes slight dulness. The typical tympanitic sound is heard in pneumo-thorax, and, occa- sionally, over large cavities ; but in emphysema a char- acteristic sound, somewhat less resonant, is heard, which is called vesiculo-tympanitic. Occasionally tympanitic or vesiculo-tympanitic sounds are heard where we should hardly expect them. They are not uncommon just above the level of the fluid in pleurisy, and sometimes in croup- ous bronchitis the percussion note is extra-resonant. In pneumonia there is usually exaggerated resonance over the sound lung, and even over a part of the affected lung ; in front, especially, the resonance may be great. Cracked-pot resonance usually, but by no means al- ways, indicates a cavity. It may sometimes be produced in children even in health. It is often, of course, heard over dilated bronchi. Sometimes the cracked-pot sound is heard in pneumonia near, the consolidated portion of the lung, when no cavity exists. Auscultation is listening to the chest. It may be im- mediate or mediate. Immediate auscultation is performed by placing the ear over the naked chest, or the chest covered with a towel ; the towel, however, obstructs the transmission of the sound, and may lead to error by rus- tling. Mediate auscultation is performed by means of a stethoscope ; the stethoscope is used to intensify the sound and to locate the position accurately. Much can be done by a well-trained ear without the aid of a stetho- scope, but in difficult cases some form of stethoscope is essential. Stethoscopes are of two kinds-the wooden stetho- scope, so largely used in Europe, and the binaural, which is in general use in America. The wooden stethoscope is a trumpet-shaped tube of wood or hard rubber, or other material, to the top of which a round disk is at- tached. When the instrument is to be used, the trumpet- shaped extremity is placed upon the chest, and the ear is laid upon the disk, the meatus coinciding with the open- ing. The binaural stethoscope consists of two metal tubes, tipped with ivory bulbs, so as to fit the meatus of the ear. These tubes are connected by a joint, and are pressed together by a spring; below they are connected with a trumpet-shaped extremity by two flexible tubes. The stethoscope is used by placing the bulbs in the ears, where they are held by the elastic band, and the other extrem- ity on the part to be investigated. Two bells are usually provided, one large, perhaps four centimetres (one and a half inch) in diameter, for general use ; the other is one- half this size, for examinations of the heart. For emaci- ated patients, a soft-rubber bell has been devised. The rubber adapts itself to the irregular surface and enables such chests to be examined with great facility. The wooden stethoscope has the advantage of simplicity, cheapness, and portability ; it has the disadvantage of having only one end-piece, which is too large for examin- ations of the heart, and too small for those of the lungs, and it cannot be seen while the ear is applied to it. It is also difficult to apply to the sides of the chest and to the under part of the body while the patient is lying in bed -a decided disadvantage in examining weak or coma- tose patients. The binaural stethoscope is more ex- pensive and cumbrous, but it has the advantage of con- ducting the same sound to both ears, and of more per- fectly excluding other sounds. The two end-pieces adapt it to the separate examination of lungs and heart. It can be watched by the physician while he is listening to the chest, and many a mistake, otherwise almost inevi- table, may thus be avoided. The whole chest, front and back, can be examined with comfort to both physician and patient, a matter of great importance in the examina- tion of very weak or delirious patients, and in all cases an examination can be conducted more easily and rapidly than with the other form of stethoscope. Its greater length gives it an obvious advantage on the score of modesty in ladies, and sometimes also on that of cleanli- ness. With the stethoscope, care must be used to avoid errors. The instrument should be pressed lightly and evenly upon the chest, care being taken that no space under one side communicates with the air. See that no article of cloth- ing rubs against the instrument, and that the act of breathing does not cause it to slip on the skin. If a space is left under the mouth of the instrument, the sounds of the chest will be mingled with those outside ; the rubbing of clothing may simulate a pleurisy so closely as to de- ceive the .most experienced. The slipping of the skin under the instrument, which sometimes occurs in persons with hot, dry skins, has led to error even in experienced hands. Too great pressure over a blood-vessel, for in- stance, may give rise to sounds resembling the bruit of an aneurism. The sounds in a healthy chest differ in different parts. The typical normal lung sound is heard under the clavi- cles ; it is soft and breezy, and is called the vesicular murmur. It has been compared to many things, but, in reality, is unlike any other sound in nature. It consists of two parts, inspiration and expiration. Inspiration is louder and continues longer than expiration, the ratio 82 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chest. Chest. being about one to three, but it varies a good deal in dif- ferent individuals. Muscular men have chest-walls of good conducting material, and their respirations are per- formed with vigor; therefore the sounds are loud, and the expiration is comparatively long. Women have weaker muscles and their respirations are less vigorous ; their chest-walls are covered with a thick layer of adipose tissue, and the sounds are, therefore, much fainter, the expiration being often quite inaudible. Over the trachea, a rough blowing sound is heard, in which the inspiration and expiration are of equal length. The sound is con- tinued, though somewhat fainter in character, below the bifurcation of the trachea, and for some distance along the course of the bronchi ; and this fact should be borne in mind or errors in diagnosis may follow. On the back, sounds heard between the scapulae are somewhat rougher than in front. It should not be forgotten that in children the sounds are quite different from those heard in adults. They are much louder and rougher, the inspiration and expiration are almost equal, and the vesicular murmur is scarcely heard. This type of respiration is called puerile, and, if heard in an adult, would be pathological. It grows less marked as age advances, but continues sometimes up to the twelfth or fourteenth year. Respirations in health vary considerably, according to temperament; they may be as low as twelve in a minute, or as high as eighteen or twenty in nervous per- sons. The relation of the respiration to the heart-beat is about one respiration to three or four heart-beats. The pathological sounds that are heard are, first, rales. Rales, or ronchi, are sounds more or less rough, which are produced in the bronchi. They are divided into dry, moist or sibilant, and sonorous rales. The moist rales are bub- bling sounds heard over the large bronchial tubes ; they may be so coarse as to be almost a gurgle, and from this they may gradually become finer and finer until they as- sume the character of subcrepitant rales. Moist rMes are produced by the passage of air through fluid in the tubes, and are the characteristic sound of the moist stage of bronchitis. They are, of course, heard in other condi- tions in which fluid is found in the tubes, as in pulmonary haemorrhage. As might be supposed from the nature of their production, they are exceedingly various both in character and position. They rarely stay in one spot for more than a minute or two, and often change greatly in •character after one or two respirations. Often a patient, who will have the chest full of moist rales at one time of the day, will, at another time, be entirely free from them. Dry rales are singing, or wheezing, or whistling in char- acter, and are quite constant in position. They are some- times produced by swelling of the tubes, sometimes, per- haps, by plugs of inspissated mucus, which partially obstruct the tubes. Dry rales are the characteristic sounds of the dry stage of bronchitis, spasmodic asthma, and emphysema. Crepitant rales are fine sounds, which are described as resembling the crackling of a lock of hair rolled between the fingers, or, more perfectly, that produced by smearing the thumb and finger with some sticky substance, and opening and shutting them rapidly close to the ear. They are heard only once during the respiratory act, in inspira- tion. One theory of the production of crepitant rales is that they are caused by the separation of the walls of the alveoli, which are smeared and partially filled with ex- udation. Another is that they are fine pleuritic friction sounds. They are the characteristic sounds of pneu- monia, and mark the beginning of the exudation. Oc- casionally, in violent attacks, the exudation occurs so rapidly that they are not heard. Sounds resembling crepitant rales are sometimes heard in oedema of the lung. Subcrepitant rales resemble the above very closely, but are a little coarser, and are heard during inspiration and expiration, or twice during the respiratory act. They are probably produced by the passage of air through fine tubes clogged with mucus. Subcrepitant rales are the characteristic sounds of capillary bronchitis. They are also heard in the third stage of pneumonia, constituting the so-called rale redux. Sibilant and sonorous rales are the characteristic sounds of bronchitis, asthma, and emphysema. Flapping sounds are said to have been heard in croup- ous bronchitis. A peculiar crumpling sound is heard in emphysema, somewhat like the crepitant rMe, and is said to indicate the combination of interlobular and vesicular emphysema. The sound is coarser and not so crackling as the subcrepitant rale. Laennec's rtile is somewhat like the subcrepitant rale, and is often heard in emphy- sema. Friction sounds are faint rubbing sounds heard at any place over the lung, .front and back ; they have usually an unsteady to-and-fro sound on inspiration, consisting of two or three irregular jerks ; on expiration the sounds are the same, but often firmer and steadier. Friction sounds, when present, may not be heard for several respirations, and are often extremely faint; sometimes they are heard at the end of inspiration only. Occasionally they resemble crepitant rales very closely, but their superficial character, and the absence of the symptoms of pneumonia, will usually be sufficient to prevent a mistake, if proper care is used. They may resemble mucous rales or gurgles, and may be mistaken for them, if the pleurisy, as is some- times the case, is unaccompanied with pain. Attention to the other signs will guard us against this mistake. Jerky, or cog-wheel, respiration is an unsteady, irreg- ular character of the respiratory sounds ; instead of being- smooth and even and regular, as in health, the inspiration consists of two or three irregular puffs ; the expiration is usually not much altered from health, but occasionally it also partakes of the same character. One explanation of the sound is that one or more fine tubes are closed, partly by the pressure of masses of tubercle, and, per- haps, partly by swelling of the inflamed mucous mem- brane, but not so tightly closed that they cannot be pushed open by the pressure of the air as it accumulates in the tubes. These sounds resemble friction sounds sometimes very closely. They are, however, nearly always produced at the apex of the lung, where friction sound is not common, and, unlike what is observed in pleurisy, variation in the depth of tlic inspiration makes little difference in their character. Jerky respiration usually indicates phthisis. In prolonged expiration the expiratory sound, instead of being inaudible or much shorter than the inspiration, is in- creased in length. Alongwith this increase in length comes a greater loudness of the bronchial sounds (rude respira- tion) and a diminution of the vesicular sounds. Sounds made in the mouth, during the examination, may be heard through the stethoscope, and confounded with sounds made in the lung : care should be exercised to avoid this error. The great cause of prolonged expiration is con- solidation of the lung. It is one of the chief signs in the diagnosis of phthisis. Prolonged expiration also occurs in diseases in which the expulsive power of the lung is lessened, or where some obstacle to the expulsive power of the lung is found. Pro- longed expiration may or may not mean something seri- ous. In prolonged expiration of consolidation, where no obstacle to the exit of the air exists, as in phthisis, the expiration is high pitched, and never longer than the in- spiration. The prolonged expiration of chronic bronchi- tis and emphysema is usually mixed with rales ; it is low pitched and often much longer than the inspiration, some- times two or three times longer, even running into the sound of inspiration. Unlike what is observed in phthi- sis, also, the vesicular murmur is present in bronchitis. Bronchial breathing is a further development of pro- longed expiration. In this form of breathing the expira- tion and inspiration are equal in length, both are harsh and tubular, and often produce an unpleasant, penetrating sound in the ear ; the vesicular murmur is completely ex- tinguished. This sound is one of the characteristic signs of the second stage of pneumonia. It is sometimes heard in extreme phthisis, sometimes in pleurisy, just above the border of the fluid, or when the chest is full of fluid, along the spine over the compressed lung. It is often heard in bronchiectasis. Gurgling sounds resemble very closely large mucous 83 Chest. *Chest. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rales, and are plainly produced by the bubbling of air through fluid in cavities or in dilated bronchi. Metallic tinkling is heard but seldom. It is a metallic, ringing sound, sometimes distinctly like the sound of drops falling into fluid. It is heard in one condition only-pneumo-hydrothorax. In one or two instances, very large cavities, involving nearly the whole of one lung, are said to have presented these sounds. Amphoric or cavernous breathing resembles the sound produced by blowing across the mouth of a bottle, and is caused by air blowing across a cavity in the lung. The sound varies extremely with the size of the cavity, the amount of fluid which it contains, and the peculiar rela- tions of the tubes to the cavity. The amount of fluid contained in the cavities varies greatly. Auscultation of Voice.-If the ear or stethoscope is applied to the infra-clavicular region while the person is speaking, there will be heard a faint murmur with no distinct character. This sound varies somewhat in inten- sity with the thickness of the chest-walls, and the power of the voice ; in no case, however, can anything more than an indistinct rumbling be heard. The sound appears to be at a distance from the ear, and is called the normal vocal resonance. It varies in different localities. Over the trachea the voice can be heard with great distinctness, and appears to be spoken directly into the ear. The sound is somewhat less distinct over the bronchi, and the voice can be heard as though coming from a point di- rectly under the stethoscope, but the words cannot be heard distinctly from this point; the sound fades rapidly into the normal lung resonance. In consolidation of the lung, the voice-sound increases in loudness ; and in complete consolidation, as in pneu- monia, the voice-sound resembles that heard over the bronchial tubes, and is called " bronchial voice." In phthi- sis the voice-sound is loud, but not so distinct as in pneu- monia, except in the case of a cavity. A less degree of voice-sound is called increased vocal resonance. In phthisis all degrees of resonance may be heard, from a sound scarcely less than that heard in pneumonia to one which can only with difficulty be distinguished from the normal standard. Pectoriloquy, or cavernous voice, is the voice-sound heard over the trachea. Its characteristic feature is that the words are heard distinctly, as though spoken into the mouth of the stethoscope. In auscultating the voice, it is usual to cause the patient to count one, two, three, one, two, three, repeating the words slowly and distinctly. Oc- casionally the continued repetition of the words may pro- duce such an impression on the ear of the observer as to in- duce him to suppose that he hears more distinctly than he really does. In doubtful cases, therefore, it is well to cause the patient to repeat some other words, or answer a question. The voice, in pectoriloquy, varies greatly under different circumstances, sometimes having a peculiar ringing qual- ity (amphoric voice). ^Egophony, or bleating voice, is a sound said to resem- ble the bleating of a goat; it is occasionally heard over a cavity, and seems to owe its origin to the circumstance that the bronchial tubes are placed in such a position as to communicate their vibrations to the fluid in the cavity. The sound is of more interest as a medical curiosity than for its practical value. Over pneumo-hydrothorax the voice has a peculiar echo. Diminished vocal resonance is heard in those cases in which the lung is removed to a greater distance than usual from the chest-wall, or in which the tubes are obstructed. Pleurisy with effusion is the most typical example. In pneumonia, plugging of a bronchial tube sometimes causes diminished instead of increased vocal resonance, and pleuritic effusion may also cause the same thing. Coughing will probably remove the plug, but the fluid will remain. In bronchitis, we may sometimes have di- minished voice-sound, and it is also observed in thicken- ing of the pleura. In emphysema, in the young, the voice-sound is usually diminished. In auscultating the lung, the sound of the heart should be noticed. In health the sound of the heart, in the infra- clavicular spaces, is a faint muffled murmur ; but as the lung becomes more consolidated the heart-sounds are heard with more and more distinctness. Occasionally by this means'we can discover a consolidation of the lung, which it would be very difficult to detect in any other way. Succussion is a splashing sound sometimes heard in the chest after shaking a patient. It indicates fluid in the chest, and also the existence of a communication between the external air and the fluid, through a perforation in the lung, and is, therefore, a sign of pneumo-hydrotho- rax, or that rarest of things, a cavity involving nearly the whole lung. The tubercle bacillus has been found so uniformly, and by so many different observers, in cases of tuberculosis, that a failure to find it in any particular instance may be attributed to a want of skill on the part of the ob- server. A knowledge of its presence, or absence, fur- nishes a valuable aid in the detection of the earlier stages of tuberculosis, where the diagnosis is confessedly diffi- cult, and often doubtful. Then the physical characteris- tics of these bodies, and the simple manipulation necessary in order to bring them to view, should be learned by every physician who wishes to become skilful in the diag- nosis of chest diseases. The pneumo-coccus has not yet been proved to be present in all cases of pneumonia, but it is so often present, and is so easily found when it is present, that it is worth while to become acquainted with it also. Examination of the Heart.-On percussion, the heart is found to be triangular in shape, and to extend from the insertion of the third rib to the fifth interspace, and from a point situated a finger's-breadth to the right of the sternum, to within an inch of the inner side of the nipple. It is attached to the great vessels above, and rests free upon the diaphragm below. Its position may be somewhat changed by elevation or depression of that structure. It may also change its position considerably in different positions of the body. In some instances the apex is said to move as much as two inches to the left, when the person lies upon the left side. The contraction of the heart gives it a swinging motion, and the blow upon the chest is the apex beat. The heart is divided into two parts, which are called right and left, but these sides are so twisted that the right side is really in front, while the left side is behind. The right side is smaller than the left, so that the left apex projects beyond the right and forms the apex of the heart. The only place where sounds in the left ventricle can be examined is either at this point or behind, where the heart is covered by the lung. The situation of the valves should be remembered. Ac- cording to Walshe, "a superficial area of half an inch square will include a portion of all the four sets of valves in situ ; an area of about one-quarter of an inch, a por- tion of all except the tricuspid." The pulmonary valves are the most superficial and lie nearly horizontal. They are situated just at the lower edge of the left third costo- sternal articulation, the left edge of the sternum being at about the middle of the valve. The aortic valves are covered by the pulmonary, and are slightly inclined, the right side being lower than the left. They are almost entirely covered by the left half of the sternum, and are a little lower down than the pulmonary valves. The tricuspid valves lie in front of the mitral, and extend obliquely across the sternum from just below the upper border of the fourth costo-sternal articulation to the lower border of the fifth costo-sternal articulation. The mitral valves lie behind the left half of the sternum, and extend from the line of junction of the fourth to that of the fifth rib. From the heart pass off the pulmonary artery and the aorta. The pulmonary artery rises from a point slightly below and surrounding the pulmonary valves. It rises up- ward, first to the left and then to the right, and goes up as high as the lower border of the second rib and dis- appears behind the arch of the aorta, where it bifurcates to send branches to the lung. The aorta originates around the seat of the aortic valves, somewhat behind the pul- 84 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chest. Chest. monary artery, and passes upward and to the right until it reaches the upper border of the second right costal car- tilage and sternum ; sometimes it extends higher up still. At first it is very deeply situated and covered by pulmo- nary artery, then it comes close to the sternum, where it is covered by lung and mediastinum. The pericardium covers the first portion of the vessels up to about the up- per border of the second rib. The transverse portion of the arch begins at the upper edge of the second costo- sternal articulation, crosses at the level of the first inter- space, and at the edge of the sternum turns downward to form the descending portion of the arch and the thoracic aorta. The descending portion passes over the left bron- chus to reach the lower border of the fifth vertebra, where it becomes the thoracic aorta, and descends to the left of the spinal column to its bifurcation. To the right of the ascending portion of the aorta is the ascending vena cava, which attends the vessel like an attending vein. In examining the heart, the patient should be stripped to the waist and placed in a good light, as it is often de- sirable to notice slight points of pulsation. A semi-re- cumbent position is usually the best, but it may be de- sirable to change the position of the patient during the examination. Often the apex beat cannot be felt unless the patient leans forward. Ringer states that pre-systolic murmurs may disappear if a patient sits up. If the fin- ger is placed upon the healthy chest, the apex of the forgotten that transposition of all the viscera is possi- ble, the heart in that event being normally on the right side. The character of the impulse is of great importance. In hypertrophy it is vigorous and small, in dilatation it is weak and covers a large surface; often its distinct lo- cation cannot be detected, but a wavy impulse covers a considerable space. Hypertrophy with dilatation gives a combination of the two, a tolerably vigorous impulse which covers a large space, and is not well defined. Whenever the heart is more exposed than usual, as in retraction of the lung, the apex beat is more vigorous ; also forward displacement of the heart by a tumor may produce the same effect. Whenever the heart is covered more than usual with the lung, as in pulmonary emphy- sema, the impulse appears to be weakened; this is also the case in persons with voluminous lungs, especially if the chest-walls are fat, or the mammae very large. The impulse is diminished in pericardial effusion, in fatty degeneration, and in atrophy. In adherent pericar- dium the impulse may be absent entirely, or only feebly felt. In this latter condition there may be an actual retrac- tion of the chest during systole, and a springing forward during diastole. Occasionally a thrill can be felt when the fingers are applied over the heart, somewhat resembling that felt when the hand is placed on the back of a purr- ing cat. It usually comes from valvular murmurs, es- pecially that due to mitral obstruction, or from the bruit of an aneurism. Rarely, the rubbing of the surfaces of an inflamed pericardium causes a grating feeling ; pleurisy may communicate a similar feeling. The rhythm in the latter case corresponds with the rhythm of the respiration, and will, of course, stop if the patient holds his breath. The rate of the heart is often best studied by palpation. In palpitation, or irregularity, the pulse is often too rapid, or too weak and ill-defined, to give much information. Palpation of the apex is here valuable. Percussion gives the size of the heart. On account of the motion, it is by no means easy to mark the outline, especially of the apex. Increased dulness to the left indi- cates hypertrophy or dilatation of the left ventricle ; dul- ness to the right of the-sternum indicates hypertrophy or dilatation of the right ventricle ; pericardial effusion pre- sents increased dulness, but the shape is triangular, with the apex pointing upward-a condition different from that of hypertrophy. In increased exposure of the heart we may have .an appearance of increased dulness; also tumors of the mediastinum, and consolidation of the lung may be mistaken for cardiac dulness. An apparent diminution of the cardiac dulness is found in cases in which the heart is covered, as in emphysema. In a very few cases gas is found in the pericardium ; it probably always enters from without, from stabs or ulceration of some neighboring organ, as the stomach or pleura; in such cases dulness is diminished. •Inspection.-Any alteration in the shape of the chest due to deformities, tumors, or abscesses should be care- fully noted. Prominence in the praecordial region may be due to pleuritic or pericardial effusion, or enlargement of the heart; occasionally the heart is pushed forward by a tumor behind or by an aneurism of the arch. Flattening of the chest may be due to congenital mal- formation, pleurisy, cirrhosis of the lung, or pericarditis, or it may be the result of pressure, as in the case of me- chanics. Any pulsation in the course of the vessels should be noted. The physiognomy of the case is important. A normal appearance of the face does not exclude serious disease of the heart: it only indicates that at the time of examina- tion the blood is properly aerated. Pallor may indicate imperfect distention of arteries in aortic regurgitation, it may also indicate the various sorts of anaemia, Bright's disease, or mitral regurgitation. In mitral disease the skin is usually yellow or dingy from obstructed liver. In Bright's disease the skin is puffy and pits on pressure. In aortic regurgitation the face has a pinched, anxious expression. Blueness of the face may come from mitral or tricuspid lesion, especially the latter, or it may indicate lung dis- Pulmonary valves, the most super- ficial. Mitral valve, ly- ing between left auricle and left ventricle, cov- ered by tricuspid valves. Aortic ' valves, lower and partly cov- ered by pul- monary valves. . Tricuspid valves, be- tween right auricle and right ven- tricle. Tig. 612.-Diagram Illustrating the Position of the Valves of the Heart. heart will be felt in the sixth interspace, an inch inside the nipple. The character of this pulsation should be noted ; it is not very strong and is confined to a small area, not exceeding greatly the size of the tip of the finger. The size, shape, and location of this area should be carefully noted. One of the first departures from the natural condition is the change in the location of the apex beat. Among the conditions which may affect the position of the apex of the heart, may be mentioned, first, hypertrophy. The base of the heart being fixed, any in- crease in size moves the apex to the left; any increase in weight tends to depress it. In dilatation, also, the apex is moved to the left. The apex may be elevated or depressed. In hyper- trophy of the left ventricle, without much change in the right, the apex is carried downward ; it may be displaced as far as even the eighth interspace. Hypertrophy of the right ventricle may raise the apex slightly. The apex may also be moved mechanically ; it may be pushed to the left by pleuritic effusion, pneumo-hydrothorax, or en- largement of the liver from whatever cause. It is raised by distention of the stomach, and by abdominal dropsy or tumors. An effusion into the pericardium may have for one of its first signs displacement upward of the apex. It is pushed to the right-sometimes even into the right pleural cavity-by effusion into the left side. Occasionally it is pushed downward in emphysema. It should not be 85 Chest. Chest. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ease in which the blood is imperfectly aerated, the pres- ence of a tumor on the veins, or morbus ceruleus. Pulsation of the jugulars indicates tricuspid lesion. A characteristic pulsation of the vessels of the head, neck, and upper extremities is seen in aortic regurgita- tion ; the arteries are seen to swell and elongate, and then suddenly shorten again. This is the so-called Corrigan's or piston pulse. Attitude in advanced cases of heart trouble is char- acteristic. Such patients cannot lie down, they often as- sume a position similar to that in asthma, with the body thrown forward and the weight resting upon the hands. There is usually cough from congestion of the bron- chial tubes, especially in mitral and tricuspid lesions. In aneurisms there is often cough from pressure upon the recurrent laryngeal; this cough is usually short and dry. A short, dry cough, which cannot well be explained, often exists in cardiac disease. There is usually dyspnoea, not always strongly marked at first, and noticeable only after exertion ; but it steadily increases as the disease grows worse, until the patient is unable to lie down or is greatly distressed by the slight- est change in position. Occasionally he has intermittent attacks resembling asthma. Dropsy begins in the feet; the pale face, blue lips, swollen feet and legs, short breath, and increased dyspnoea on slight exertion are unmistakable signs of failing heart- walls. Very rarely a peculiar form of dyspnoea is found, called Cheyne-Stokes respiration. In this condition there is a "auricular systole .112 second, ventricular systole .368 second, ventricular diastole .578 second, entire cycle 1.058 second. The sounds of the aortic and pulmonary valves, and of the tricuspid and mitral valves, are usually heard together, but still they can with some care be dis- tinguished from one another. The best place to hear the mitral is over the projecting part of the left ventricle ; the tricuspid can be heard over a triangular space corre- sponding with the right ventricle. The point of greatest intensity of the aortic sounds is at the second right inter- space. The pulmonary valves are heard separately from the aortic valves over the free border of the pulmonary artery at the second left interspace. Diseases of the valves usually disturb in some way the normal sounds. They may be changed in loudness, and position, abnormal sounds may be heard, or the sounds may be reduplicated. There may be a change in the loud- ness of the sound of each of the valves. In judging of this condition we must notice whether there is an actual increase in the intensity of the sound, or only an apparent increase. Any condition which increases the conducting power of the structures covering the heart increases the loudness of the sounds; such are thinning of the chest- wall, approximation of the heart to the ear of the ob- server, consolidation of the lung or a cavity. The only thing that can cause increase in the valvular sounds is in- creased tension of the valves ; this may be brought about in the aorta by hypertrophy of the left ventricle, or by some obstruction to the passage of the blood, as in cir- rhosis of the kidney, or atheroma and dilatation or aneu- rism of the aorta. In the pulmonary valves the same thing may occur from obstruction at the mitral orifice or in the lung, as in emphysema of the lung or hypertrophy of the right ventricle. Skoda says that accentuation of this sound is an unerring indication of mitral regurgita- tion. Singularly enough, pure hypertrophy of the left ventricle does not increase the intensity of the sound of the mitral valve, the thickness of the muscular walls probably tending to mask the sound ; and when the valve is healthy the sound in hypertrophy is more muffled than in the normal condition of the walls. Hypertrophy with dilatation, combined with an irritable heart, in which the contraction is rapid, tends to produce accentuation of the first sound. The tricuspid also is not apt to be accentu- ated except in irritable heart. Care should be exercised to exclude temporary increase of the sounds, as in local inflammation, recent exercise, or mental excitement. Diminution.-The intensity of the heart-sounds may appear to be diminished by being masked by fat in the chest-wall, by the heart being covered by the lung or by fluid in the pericardium, or by sounds, as rales, in the chest. Diminished intensity of heart-sounds may be tem- porary, as in syncope, or in some acute disease, as typhus. Diminished intensity of the aortic and pulmonary heart- sounds usually depends upon a lack of power in the heart, as in dilatation, or fatty or fibroid degeneration, or upon a failure to properly fill the vessel, as in mitral or tricus- pid lesion. Mitral and tricuspid sounds are weakened by weakness of the heart-walls, though dilatation with irrita- ble heart may cause a sharp accentuation of these sounds. A muffled sound of the mitral valve may depend upon hypertrophy of the left ventricle, or on a stiffening of the segments of the valve. Reduplication of the heart-sounds is a somewhat obscure phenomenon, and many theories have been offered in ex- planation, none of which are entirely free from objections. The reduplication of the second sound is much more com- mon. One explanation of the phenomenon is that the aor- tic and pulmonary valves do not close at exactly the same time. It may be due to a difference in the irritability of the nerve apparatus of the two sides, as in palpitation ; to a difference in the propelling power, as in hypertrophy; or to a difference in the resistance or in the distention of the two sides, as in mitral obstruction. One or more of these causes may operate in any one case. This explanation depends upon the fact that the heart, though apparently a single organ, is in reality composed of two parts, which usually act in concert, but are capable, under unusual conditions, of a certain independence of action. Dr. San- Fig. 643.-Diagram Illustrating the Relations of the Sounds to the Sys- tole and Diastole of the Heart. rapid catching of the breath for a few respirations, after which the difficulty gradually subsides until the breath is entirely stopped, only to begin again with the same cycle. This occurs in advanced cases of fatty heart, especially where the coronary arteries are atheromatous, in uraemia, and in affections of the medulla; it does not occur so often in dilated heart. The cause of these phenomena has not been well explained ; it is a grave indication, and death usually supervenes within a few days after its appearance. In auscultating the healthy heart, sounds which have been compared to the words lupp, dupp, are heard ; the first of these sounds corresponds with the contraction of the ventricles, the other with the beginning of the relax- ation of the ventricles. The first of these is called the first sound of the heart, and the other the second sound ; they are separated by an interval. The period of con- traction is called systole, the period of relaxation diastole. The first sound is made up of several elements, a promi- nent one being the closure of the mitral and tricuspid valves. The second sound is, in the main, made up of the closure of the aortic and pulmonary valves. The length of the systole is four-tenths the length of the cycle, the first pause is one-tenth, the second sound is two-tenths, the second silence three-tenths. The average length of these periods is given more exactly by Dr. Gibson as 86 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chest. Chest. som explains the reduplication as being due to a prema- ture stretching of the mitral curtains by the blood pouring into the dilated ventricle immediately after the first sound. Reduplicated first-sound is rare; it is occasionally heard in cardiac dilatation. Asynchronism in the closure of the valves is the explanation given by some, but the the- ory presents many difficulties. Dr. Sansom's theory is plausible. He says: "During the interval immediately succeeding the relaxation of the ventricle, the blood, sub- ject to the tension in the left auricle and pulmonary veins, has been pouring into the ventricular cavity; the fluid naturally finds its way in the direction of least resistance, that is, its course, when impelled toward the apex, is round the walls of the ventricle, thus coming behind the curtains of the mitral valve, and bellying them out (so to speak), as the sails of a ship are bulged by the force of the wind. At the moment of auricular systole, the ven- tricle, as yet only partially full, is rapidly distended, the force of contraction of the auricle giving an impulse to the apex of the ventricle, and, as may of course be in- ferred, giving a contre-coup to the already partially strained mitral curtains. In normal conditions such con- tre-coup is inaudible, but when the auricle is more than ordinarily powerful, or when the mitral valve is so changed as to give rise to the sound of membranous ten- sion, it becomes perceptible closely preceding the sound produced by the ventricular systole-that is, the sound of complete closure of the valves guarding both auriculo-ven- tricular orifices plus the muscular sounds of the ventricles. " Abnormal Sounds.-Two sounds are found in diseases of the heart which are not heard in health; these are friction-sounds and murmurs. Friction-sounds are produced in the pericardium ; they are to-and-fro rubbing sounds heard over the heart, some- times resembling pleuritic friction-sounds, but may be distinguished from them by difference in rhythm. The pleuritic friction-sounds are synchronous with the respira- tion, and the pericardial sounds are synchronous with the heart-beat. Causing the patient to hold his breath will stop the pleuritic sound and not the other. Sometimes the friction-sound is only heard during systole ; in such cases it is liable to be mistaken for a valvular murmur ; the sound, however, is usually more superficial and its intensity is at a different place; Friction-sound is heard best at the lower end of the sternum and not over the val- vular area. The sound is never propagated into the ves- sels or heard at the back. Friction-sounds are apt to change in rhythm and tone. Sometimes the area in which they are heard changes its location. This never occurs with val- vular murmurs. They are said to be occasionally triple. Endocardial murmurs are produced in the heart itself, and are of two sorts-functional and organic. Functional murmurs are those which are temporary in their charac- ter, and in which no structural change can be discovered in the heart itself. In health no sound is heard when the heart beats, except the valvular sounds. In organic mur- murs, some structural change is found in the valve. Re- gurgitant and obstructive murmurs may occur at each of the valves. The diagnosis of a murmur depends upon two things : first, the location where it is heard, and sec- ond, the time in which it occurs. What is taking place at the time when we hear any particular sound must be kept clearly in mind. If we place our ear over the apex, we feel the impulse of the heart, which corresponds with the contraction of the ventricles. This contraction drives the blood against the mitral valve, closing it with consider- able force; the blood, therefore, can find no exit at this place and must pass out at the aortic opening. If, how- ever, an opening is left by the imperfect closure of the mitral valve, a portion of the blood will be driven through this opening and a sound will be made ; this sound is called a mitral regurgitant murmur, and is heard best at the apex. The passage of the blood from the auricle to the ven- tricle should be noiseless; if, however, a sound is heard at the apex while this is taking place (that is, before the impulse), it is an indication that there is some obstacle to the passage of the blood through the orifice, and we have a mitral obstructive murmur. The passage of the blood through the aortic orifice should also be noiseless. If in- stead of being placed at the mitral area, the ear had been placed over the second right interspace, nothing would have been heard during the contraction of the ventricle, or, at least, nothing more than the far-away sound of the closure of the mitral valves. If a murmur is heard at this time, it indicates some obstacle to the passage of the blood into the aorta. Such a murmur is called aortic obstructive. During the diastole, or the period of relaxation, the second sound should be heard at this place, clear and sharp ; if, instead, a blowing sound is heard, it is an indication that the aortic valves do not close perfectly, and we have aortic regurgitation. The same thing is true of the tricuspid and pulmonary areas. If, while the stetho- scope is placed anywhere within the tricuspid trian- gle, especially at a place just to the left of the sternum, in the fourth in- terspace, a sound is heard during the systole, it indi- cates a tricuspid regurgi- tation ; while a sound heard before the systole indicates tricuspid obstruction. A sound heard during the systole, with the stethoscope placed in the second left interspace, indicates pulmonary obstruction ; while a sound heard at the same place during diastole, indicates pulmonary re- gurgitation. The diagnosis of valvular murmurs is usually not dif- ficult. The typical location for hearing the aortic direct murmur is the second right interspace ; it is propagated in the direction of the blood current into the carotids, and is usually audible over the whole of the upper part of the sternum. It can sometimes be heard in the back over the aorta, beginning at the third and fourth dorsal vertebrae, and continuing downward for some distance until it gradually fades out. Sometimes it is heard at the ensi- form cartilage. In the aor- tic direct murmur, the second sound at the aortic opening is always faint and often inaudible, but the pulmonic sound is al- ways audible at the second left intercostal sptce. The murmur is always harsh, and sometimes it is saw- ing in character. Some- times, in mitral or tricus- pid regurgitation, a mur- mur is heard at the aortic area. The murmur of mi- tral regurgitation is heard loudest at the apex, the aortic murmur at the aor- tic area ; the mitral sound is carried to the left, the aortic into the vessels. In mitral lesion the pulmonic sound is always accentu- ated ; unlike aortic ob- structive, the mitral sound is soft. The pulse of aortic obstruction is small and regular ; in mitral regurgitation it is always irregular. In tricuspid regurgitation the sound is never quite as high as in aortic obstruction ; the pulse also is normal, and jugular pulsation is present. The aortic regurgitant murmur is heard at the same lo- cation as the aortic obstructive, but it is diastolic, and is propagated in the opposite direction ; it is often heard at the ensiform cartilage, and may be propagated to the apex. It is the most widely diffused of all the cardiac murmurs ; it may often be heard at the sides, and is occa- Fig. 644.-Diagram Illustrating the Pulmonary Area; the cross (+) in- dicates the apex; the star (*) the point at which the pulmonary sounds are heard. Fig. 645.-Diagram Illustrating Aortic Obstructive Murmur. The sound is heard with the greatest intensity at the second right interspace, and shades oil within the boundaries of the figure over the sternum. It is propagated into the vessels in the direction of the arrows. 87 Chest. Chest. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sionally propagated into the vessels, and may, in some cases, be heard as far as the radial artery. When the posterior segment of the valve is affected, the sound may be conveyed to the apex ; when the anterior segments are affected, the sound is heard at the ensiform cartilage. It is worth remembering that from the proximity of the coronary arteries, affections of the anterior segments are more liable to lead to se- rious consecpiences than those of the posterior seg- ment. The murmur may be rough, but oftener it is soft and blowing, some- times it is musical. Cor- rigan's pulse is sometimes observed in this lesion. Hypertrophy of the heart is greater than in any other valvular affection. The typical place for hearing mitral regurgita- tion is at the apex ; it is propagated toward the left, and is heard at the angle of the left scapula, and also between the lower border of the fifth, and upper border of the eighth vertebra to the left. A systolic sound heard at the apex, and not at the back, is probably not mitral. Roughening of the ventri- cular wall, or mitral valve near the aortic orifice, or irregular vibration of the chordae tendinae, may give rise to sounds resembling mitral regur- gitation ; this sound is propagated into tlie aorta, and is not heard at the back. Mitral obstructive is heard slightly to the inner side of the apex-beat, and, as it precedes the systole, is often called pre-systolic. It may be difficult to distinguish between mitral obstructive and regurgitant murmurs, especially if the heart-beat is irregular or very rapid, but by care- fully noting the rhythm, with the finger, the distinction can usually be made out. The murmur usually immedi- ately precedes the systole, just as the auricle is contract- ing with the most force to overdistend the ventricle, but this is not always the case ; sometimes the sound is heard at the beginning of the diastole, sometimes in the middle ; occasional- ly two sounds are heard, one at the beginning ami one at the end of the dias- tole. The obstructive and regurgitant murmurs often occur, one following im- mediately upon the other ; in this case it may be diffi- cult to distinguish between them, though the differ- ence in the tone of the two sounds will often be a help. The auricle is apt to be hypertrophied in ob- structions at the mitral orifice, sometimes very much so. In such cases pulsation in the auricle may be detected. Dr. Sansom rec- ommends sticking little cones of cotton wool with vaseline over the auricles and ventricles ; the differences in the time of pulsation will then often show the auricular pul- sation when otherwise it would not be visible. Mitral obstruction may sometimes be detected in this way when it is impossible to distinguish it by the ear. The pulmo- nary sound is accentuated in this affection. Reduplica- tion of the second sound is common. 1 ricuspid regurgitation is heard in the tricuspid area, especially in the fourth interspace near the sternum. The sound, unlike that of mitral regurgitation, is never transmitted to the left, and the pulmonary second sound is enfeebled, the right heart is dilated, and the apex-beat en- larged. Epigastric pulsation, from the dilated right ven- tricle, is common ; pulsation of the jugulars is found in all cases, at first confined to the lower part, but as the valves in the veins give way, it extends higher and may sometimes be seen in the face, neck, and even hands. The liver pulsates markedly ; venous engorgement of the stomach, lungs, and the whole body is decided, and dropsy comes on early. The murmur is often faint and may be overlooked. The relative frequency of the valvular affections should be borne in mind ; the order of frequency is about as fol- lows : " (1) Mitral regurgitation ; (2) aortic obstruction ; (3) aortic regurgitation ; (4) mitral obstruction ; (5) tricus- pid regurgitation ; (6) tricuspid obstruction ; (7) pulmon- ary obstruction ; and (8) pulmonary regurgitation." Mur- murs are often combined ; the frequency of combination, according to Loomis, is : " (1) Aortic obstruction and re- gurgitation ; (2) mitral obstruction and regurgitation ; (3) mitral obstruction and tricuspid regurgitation ; (4) aortic obstruction and mitral re- gurgitation ; (5) double val- vular disease at aortic and mitral orifices (four mur- murs)." Diseases of the left heart are very much more fre- quent than those of the right. Tricuspid regurgi- tation, however, is com- mon, but tricuspid ob- struction is rarely ob- served ; Dr. Fenwick states that forty-six cases have been recorded since 1825 {Lancet, January 22, 1881; quoted by Bramwell). It is probable that when the diagnoses improve in ac- curacy the relative fre- quency of this murmur will be somewhat in- creased. Tricuspid steno- sis is said never to occur without mitral stenosis; in that case two murmurs will be heard, one at the apex, another at the edge of the ster- num, with an interval between. Disease of the pulmonary valves is so very rare that Dr. Sansom says the diagnosis should only be made after every other possible explanation of the symptoms has failed. It is almost always congenital, due either to arrest of development, or to intra-uterine endocarditis. This disease sometimes occurs in the foetus, and it is a singular fact that the side affected, contrary to what occurs after birth, is usually the right ; due, perhaps, to the right side of the heart in the foetus being used more than the left. It is usually accompanied by a failure of the foramen ovale to close, and it often, therefore, pre- sents the signs of morbus ceruleus, in addition to the physical signs of the lesion. Functional murmurs are those in which no structural change is found after death; they are always systolic, and are usually heard at the base of the heart, the most common location being the second left interspace-the pulmonary area. They are also heard in the aortic, mi- tral, and tricuspid areas, often in the carotids, and are accompanied by a venous hum, heard in the jugulars. These murmurs occur in anaemia, especially in chlorosis, pernicious anaemia, and low fevers. The basic murmurs are heard first in the course of the disease, the mitral and tricuspid later. Many attempts have been made to ex- plain the cause of these murmurs, and there has been much discussion on the subject, but it still remains obscure. Perhaps the mitral and tricuspid murmurs are due to an actual regurgitation from deranged muscular action. A Fig. 646.-Diagram Illustrating Aortic Regurgitant Murmur. The sound is often heard with more intensity in the middle of the sternum or even at the ensiform cartilage. When the posterior flap of the valve is affected the sound is propagated to the apex and may be beard under the arm. Fig. 648.-Dingram Illustrating the Area over which Tricuspid Murmurs are heard. The cross indicates the apex, the star the point of greatest intensity of the murmur, which fades out to the boundaries of the triangle. Sometimes the murmur is heard best at the lower left-hand angle of the triangle. Fig. 647.-Diagram Illustrating Mitral Murmurs. Mitral regurgitant is heard at the apex-beat ( x ) and is propagated in the direction of the arrow ; mitral obstruction at the dot (•) a little above and within the cross. The sound of mitral obstruc- tive often appears to lead from the valves down to the dot. 88 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cliest. Cliest. favorite theory with some, as regards the cause of the pul- monary sound, is that it is a mitral murmur transmit ted to the ear through the dilated left auricle ; some think the sound is actually produced in the pulmonary artery. These sounds are distinguished from aortic obstruction by their character, the first being harsh, while the func- tional sounds are always soft. The aortic regurgitant murmur differs from them in being heard at the apex, and being accompanied by great hypertrophy. A genuine pulmonic mur- mur is so rare as to be practically out of the ques- tion. The mitral and tri- cuspid murmurs may pre- sent more difficulties, but the occurrence of such murmurs as have been de- scribed, in persons who are anaemic, or are suffering from low fevers, whose hearts are not hypertro- phied, and who have had no previous history of heart trouble, will usually be sufficient for the diag- nosis that they are func- tional. If the patient lias rheumatism, they are probably due to endocardial inflammation. Hypertrophy of the heart means an overgrowth of the muscular structure ; any one of the cavities, or the whole heart together, may be hypertrophied. In general, hyper- trophy is due to overwork from some increased difficulty in the circulation of the blood. In order for hypertrophy to occur, the muscle must be healthy, and the nutrition of the body good. If overwork is brought upon a heart which is not healthy, or in a debilitated subject, the heart will dilate ; so, too, if there is venous congestion of the heart, overwork will cause dilatation. In diseases of the coronary arteries like atheroma, hypertrophy will not be likely to occur. Hypertrophy usually indicates val- vular lesion, but it may result from overwork of any kind ; excessive exertion, especially in the young, may induce it, so may nervous excitement if continued for a long time ; the hy- pertrophy in exophthal- mic goitre is probably of this nature. General hy- pertrophy of the heart may occur in adherent pericardium, though not as often as would be ex- pected. In pregnancy, there is a normal hyper- trophy which disappears after delivery. Hyper- trophy of the left ventricle indicates obstruction to the arterial system, espe- cially aortic stenosis and regurgitation. In aortic regurgitation, the largest hypertrophy occurs ; cases of this lesion have been reported in which the heart weighed over fifty ounces (cor bovinum). Hypertrophy of the right ventricle also occurs in cirrhosis of the kidneys, and in atheroma or dilatation of the arteries. In mitral regurgitation we also get hypertrophy of the right ventricle, often com- bined with dilatation. The signs of hypertrophy of the left ventricle are those of an enlarged and powerfully acting left heart; the apex is pushed to the left and low- ered, and the whole chest is often shaken with the force of the beat. Hypertrophy of the right ventricle results from obstruc- tion to the passage of blood through the lungs ; it occurs in mitral lesions, especially mitral obstructive, and in disease of the respiratory apparatus, in which difficulty of circulation of the blood occurs, such as spasmodic asthma, emphysema or cirrhosis of the lung, also lesions of valves of the right side-the tricuspid and pulmonary. Hypertrophy of the right heart is never so extensive as of the left, on account of the venous congestion, and it is apt to be combined with dilatation. The signs are those of an enlarged and powerfully acting right heart; the apex is moved to the left, but never so far as in hyper- trophy of the left side ; it may be slightly elevated. The percussion dulness is increased to the right of the sternum. Hypertrophy of the auricles is not so common as that of the ventricles ; if it ever occurs on the right side, it cannot be diagnosed ; on the left side it occurs in con- striction of the auriculo-ventricular opening, and may be suspected whenever the constriction is considerable. When the hypertrophy is great, the percussion dulness may be increased, and the pulsation may be seen, espe- cially by using Sansom's method. Dilatation.-This may be more or less complete. Com- plete dilatation would be a simple stretching and thinning of the heart-walls. Fortunately this is not common ; usu- ally hypertrophy is combined with it. The causes of dil- atation are the same as those which cause hypertrophy, but acting on a heart in which the nutrition is poor. In general, the diagnosis de- pends upon the fact that the .heart is enlarged and weak, and the apex covers a large space. The valvular sounds are feeble, the pulse is weak, and there are signs of venous engorgement. When the left auricle is much dilated, its pulsations can sometimes be felt in the second left inter- space ; when the right auri- cle is dilated, its pulsations can be felt in the third right interspace. Atrophy of the heart can only be suspected when the signs of a weak heart with diminished cardiac dulness are combined with some wasting disease. Cancer of the pylorus and phthisis are prominent causes. Fatty heart is divided into two sorts, fatty infiltration, and fatty degeneration. Fatty infiltration consists of an excessive development of the sub-pericardial fat, which clogs the action of the muscle; its symptoms are those of a weak and somewhat enlarged heart. It usually oc- curs in excessively fat persons. In/aWy degeneration the muscular fibres are transformed into fatty tissue, and the size of the organ is not much changed. The degeneration occurs in the last stages of valvular disease, when the heart is not nourished up to the amount of work required from it; it is one of the results of atheroma of the coron- ary arteries. Often it is a part of general degeneration, whose cause is difficult to determine. Its physical signs are not well marked ; if slight, it may present no signs ; more extensive degeneration will show evidence of weak heart, the valvular sounds lose their sharpness, there is fail- ure of the circulation. In the last stages, Cheyne-Stokes respiration and evidences of cerebral anaemia occur. Palpitation is excessively rapid action of the heart. It may depend upon structural disease and be a sign of great moment, or it may be due to neurotic influences and be of trifling account. If it comes on in persons with car- diac lesion it is an indication of cardiac weakness, and in such cases there will be the history of old cardiac trouble, with enlargement of the heart and valvular murmur. The heart-beats will not be very rapid, but the symptoms will be urgent; there will be dyspnoea with evidences of venous engorgement, which will increase greatly on slight exertion. In nervous palpitation there will be excessive action of the heart, even up to two hundred beats or more in a minute, but the venous system will not be gorged, and Fig. 649.-Diagram Illustrating Hy- pertrophy of Left Ventricle. The whole heart moved to the left, apex pushed to the left and lowered. Fig. 651. - Diagram Illustrating Pericardial Effusion. The line of dulness does not correspond with the pericardial sac, but with the opening leftbythe lung, which has been pushed away by the effusion. Fig. 650.-Diagram Illustrating Hyper- trophy of Right Ventricle. Apex pushed to the left and not lowered. Heart enlarged to right. 89 Chest. Chicago. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. exertion will not greatly increase the trouble. Evidences of hysteria, anaemia, uterine disturbances, excessive use of tobacco, sexual excess, gout, etc., must be looked for. A form of palpitation which occurs in persons who have been exposed to severe exertion, especially in connection with mental worry, is due to strain of the heart; such persons usually present no signs of cardiac trouble, but, on exercise, suffer from palpitation. This may be the be- ginning of dilatation or other serious lesion. Irregularity may be due to neurotic or organic causes. Neurotic irregularity may come from the same causes as palpitation-in most cases of palpitation there is irregu- larity. Occasional dropping of a beat is usually nervous, often the result of excessive use of tobacco, tea, etc. It seems to be due to a blunting of the sensibility of the motor nerves of the heart; some persons regularly miss every sixth, fifth, or fourth beat, without experiencing any inconvenience. Slight irregularities in the rhythm, with occasional dropping of a beat, are not uncommon in the old ; they are perhaps due to blunting of the sensibil- ity of the nerves. Irregularity associated with long-stand- ing cardiac trouble, especially if it is marked, usually indicates failure of the heart-muscle. A peculiar rhythmical irregularity is sometimes ob- served ; the heart will beat regularly for five, six, or more beats, and then will come three or four short imperfect beats, to be followed by the same phenomena in regular succession. This is said always to indicate heart-failure. Dropping a beat may sometimes indicate a very grave trouble connected with the nervous system. The diag- nosis of certain forms of cardiac neurosis, as exophthal- mic goitre and angina pectoris, depends more upon the symptoms than upon the physical signs. The signs of aneurism are a pulsating tumor in the course of the aorta or its branches; aneurisms of the ascending and transverse portions usually show a tumor, while those of the descending may not do so. The eleva- tion may be slight, and it may escape detection unless the eye is brought to the level of the chest with the patient opposite to a strong light. The skin over the tumor may be natural, but usually it is smooth and shining, some- times bluish. When the chest-wall has been eroded, the aneurism often appears to point like an abscess; the di- rection of this pointing varies in different parts-in the ascending part it is apt to be toward the right. Pulsation may often be felt when no tumor can be seen ; sometimes there is a thrill, especially in sacculated aneurisms. Pulsa- tion can also be felt in the suprasternal notch. " In some cases in which the aneurism is deeply seated, and in which there is no superficial pulsation, forcible, deep- seated, and expansile pulsation can sometimes be detected by forcibly compressing the chest, during expiration, be- tween the two palms, one hand being placed on the front, and the other on the back of the chest " (Bramwell). Dul- ness on percussion is usually present when no pulsation can be felt, and resonance is often impaired even in deep- seated aneurisms. A marked and peculiar resistance is often felt in percussing over an aneurism. On ausculta- tion the heart-sounds are sharply accentuated ; one of the most prominent signs of an aneurism is a bruit which can be heard over the sac-an absence of this sound is, how- ever, by no means proof of the non-existence of an aneu- rism, as occasionally no murmur can be heard on the most careful auscultation. The bruit is for the most part syn- chronous with the systole of the heart; it is rarely dias- tolic. Sometimes the murmur may be heard in auscul- tating the trachea, when no trace of it can be detected in any other way. It must be remembered that in some rare instances a tumor pressing upon the vessel has given rise to sounds similar to those heard over an aneurism. A difference in the time of the pulse of the two wrists may often be felt. Secondary signs are often found ; hy- pertrophy of the heart occurs in some cases. Pressure upon various organs may produce remote signs; the heart is sometimes displaced downward by an aneurism of the arch of the aorta, or it may be pushed forward by an aneurism behind. Pressure upon the pulmonary ar- tery may produce a murmur at the second left inter- space ; pressure upon the vena cava may produce venous engorgement and mdema ; pressure upon the oesophagus often causes dysphagia. Alteration in the size of the pu- pils may occur from pressure upon the sympathetic nerve ; there may be disturbances in the capillary circu- lation of the head and face, causing pallor of one side with cool skin, from irritation of the sympathetic nerve ; or congestion, elevation of temperature and perspiration, from paralysis. Pressure upon the recurrent laryngeal may cause paralysis of a vocal cord ; pressure upon the trachea may cause dyspnoea ; pressure upon the bronchi may cause wheezing, loss of vocal resonance, a trouble- some cough, loss of lung resonance, partial collapse of lung, or inflammation. It must not be forgotten that a malposition of the aorta, a sacculated empyema, or a tu- mor, especially a cystic tumor, may simulate an aneu- rism. Tumors, however, do not erode the chest-walls ; the breath-sounds can usually be heard over the tumor, and not over the aneurism ; the sense of resistance is not so distinct on percussion over the tumor, and the sound, on auscultation, is usually less distinct. Aneurisms are often latent; many a patient has died suddenly from the rupture of an aneurism, the presence of which had not been suspected. Lester Curtis. CHESTNUT {Castanea, U. S. Ph.). The American Chestnut, Castanea vesca Linn. ; Order, Cupuliferee, is one of the largest and most valuable of our timber-trees, growing rather rapidly, attaining a large size, and pro- ducing an abundance of straight-grained, rather coarse, but very durable wood. Its flowers are monoecious, the staminate in long, slender catkins, each flower consisting of a campanulate, six-parted perianth, and about twenty stamens ; the pistillate solitary, or two or three together, are inclosed in scaly involucres, which become the ' ' burr '* as the fruit ripens; the flowers consist of an urceolate perianth, which is adherent to the ovary, and six-lobed at the border, a number of sterile stamens, and a six-celled ovary, with two ovules in each cell, all but one or two of which abort as the ovary increases in size. The ripe fruit is well known. The only part used in medicine is the leaves, which we are directed to collect ' ' in September or October, while still green." The officinal description is as follows : "From six to ten inches (15 to 25 centi- metres) long, about two inches (5 centimetres) wide, peti- olate, oblong-lanceolate, acuminate, mucronate, feather- veined, sinuate-serrate, smooth ; having a slight odor, and a somewhat astringent taste." Nothing peculiar has been found among the constituents of chestnut-leaves ; tannic and gallic acids, resin, and a number of mineral com- pounds in the ash, are the principal things observed. Use.-This is entirely empirical. The leaves for a good many years have had a popular reputation for the relief of whooping-cough, and within the last ten or fif- teen years have been considerably used in its treatment by physicians ; their value for this purpose is, to say the least, uncertain. Sometimes there appears to be a marked decrease in the number and severity of the coughing- spells ; at others no.effect is produced. They are not put to any other use. Dose, indefinite, say two or four grams (2 or 4 Gm. = 3 ss. ad 3 j.). There is a Fluid Ex- tract {Extractum Castanea Fluidum, U. S. Ph.). Allied Plants.-The European chestnut resembles the above, only its fruits are much larger and coarser. Its leaves are also used for the same purpose. Allied Drugs.-The properties of chestnut are too indefinite for comparison. W. P. Bolles. CHEWSTICK, the stems of Gouania domingensis ; Order, Rhamnacea. This is a beautiful bushy vine, grow- ing both wild and cultivated in the West Indies, whose stems are used there as tooth-brush and powder com- bined. These stems are very tough and fibrous, and when cut in shortish pieces the ends are chewed until a rude, stiff brush is formed, with which the teeth are rubbed; a pleasant saponaceous froth of an aromatic bitter taste is formed in the operation, and the teeth are said to be whitened and the gums hardened by it. A tincture and powder are proposed as dental remedies. In Jamaica it is said to be used to flavor small beers (Proc. A. P. A., 1879). 90 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chest. Chicago. Allied Plants.-Gouania is a tropical genus of about thirty species, mostly American. For the order, see Buckthorn. Allied Drugs.-See Soap Bark. W. P. Bolles. greatly impaired vitality and impending death. There may be Unconsciousness during the pause and conscious- ness during the active stage. The cause of this form of respiration is wholly conjec- tural. It may be neurotic, or it may be dependent upon the relative amount of CO2 and of O contained in the blood, which affects the respiratory muscles either re- flexly through irritation originating in the lungs, or by local stimulation (automatic) of the respiratory centre in the floor of the fourth ventricle. The phenomenon has been produced in animals after injury to the medulla oblongata, and during opium narcosis. Schiff2 attributed it to compression of the medulla. This might account for certain cases that occur with cerebral congestion or apoplexy, but not for all cases. Rosenbach has a theory that imperfect cerebral nutrition renders the respiratory centre less responsive to stimuli. This causes a tem- porary cessation of the respiratory impulses sent out from this centre. During the pause the centre recovers its irritability and breathing may again be inaugurated. In support of this theory is the fact that Cheyne-Stokes res- piration may occur in frogs which have been immersed for some hours in water and then removed, or in which the circulation of the aorta has been obstructed. Frogs are similarly affected by muscarin and digitalin. The striking features of the phenomenon are the great length of time that the patient abstains from breathing without discomfort, and the remarkable secondary rhythm of the respiratory curve, which suggests the sec- ondary rhythm of certain forms of cardiac disturbance. There are several varieties of respiration which have been described as modifications of the Cheyne-Stokes. Stokes himself says that a commoner kind of breathing than that above described is where the patient simply sighs deeply at intervals. This symptom he found as- sociated with gastric and hepatic disorders, and as a pre- monitory symptom of gout. He attributed it to enfeebled heart-action. Laennec describes a form of puerile respi- ration in the aged with dyspnoea, occurring rhythmically. A modified form of Cheyne-Stokes respiration is some- times found where, after the maximum respiration is reached, the breathing ceases abruptly by a deep sigh, in- stead of falling by lysis, and recommences after an inter- val. William Gilman Thompson. 1 Arch. f. Anat. u. Phys., Phys. Abth., p. 441. 2 Lehrbuch, 1858, p. 324. CHEYNE-STOKES RESPIRATORY PHENOMENON. The phenomenon of Cheyne-Stokes respiration consists of a peculiar disturbance of the normal respiratory rhythm, which is unaccompanied by any discoverable pulmonary lesion. This form of respiration was first mentioned by J. Cheyne ('' Dublin Hospital Reports," 1818, vol. ii., pp. 221- 222), and subsequently by Wm. Stokes (" Diseases of the Heart and Aorta," Dublin, 1854, p. 324). Stokes quotes from Cheyne, and so their names have been jointly as- sociated with the phenomenon by later writers. The phenomenon is thus described : The respirations having ceased for a moment, they become gradually deeper and more frequent, until a condition is reached of hyperpnoea or even of dyspnoea, with the head thrown back and the accessory respiratory muscles all brought into action. The maximum deep inspiration having been attained, the respirations immediately subside by lysis, growing more and more infrequent and shallow, until they cease for one-fourth to three-fourths of a second, during which period the patient may appear as if dead. Then the same process is repeated. The complete cycle includes fifteen to thirty respirations. When the maximum is reached the respiratory murmur, which has gradually become more distinct, becomes 'puerile in some cases. During the pause the pupils are contracted and do not react; when respiration again commences they become normal and the eyeball is rotated (Leube). Stokes says that he never witnessed the phenomenon except in cases of fatty degeneration of the heart, and a few weeks before death. He quotes the only two cases mentioned by Cheyne (one of which occurred with fatty heart), and observes that Cheyne did not refer the symp- tom especially to that form of disease. Subsequent ob- servations, however, prove that the phenomenon is not very rare, and it occurs in a variety of diseases. It is especially common where there is cerebral apoplexy or compression of some sort, uraemic poisoning, or much enfeebled heart action. The writer has further observed it in cases of insolation and of acute metallic poisoning. Mosso1 noticed it in the normal sleep of the hibernating dormouse (Myoxus). The patient may or may not be conscious during the exhibition of this phenomenon, which, as a rule, indicates CHICAGO. The accompanying chart, representing the climate of the city of Chicago, 111., and obtained from Climate of Chicago, III.-Latitude 41° 52', Longitude 87° 38'.-Period of Observations, January 1, 1871, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, 594 Feet. A A A K c D E F 11 6 © © cg§" © , 1 2 1 cS © © 5 .s © ~ .g®sg £ © Q «5 2 2 Eg g |~^g Mean temperature of months :empc . coin Mean temperature im te riod. Absolute maximum Absolute minimum of ( whk slow im te = is 2 E at the hours of - g for jieriod of ob- g£ g - temperature for temperature for ft G C2 § r £ servation. g = period. period. E5 = c g E* gg*E ■erage due © 1 1 © ©5^ ^E£2? £ "55 S St- H ◄ < ".g " 2 O * £.8 © c ft o &8 7 A.M. 3 P.M. 11P.M. Highest. Lowest. Highest. Lowest. Highest. Lowest. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. Degrees. January.... 22.0 28.7 24.8 25.8 40.1 16.3 32.6 17.7 65.0 39.9 19.0 -20.0 24 31 February... 25.2 32.7 29.0 28.9 38.2 14.7 37.5 23.3 63.0 45.0 21.0 -13.0 21 25 March • 31.4 38.0 34.8 34.7 44.3 27.6 44.3 30.7 I 73.0 48.0 25.0 -12.0 25 25 April 42.3 48.9 45.1 45.4 52.2 38.6 54.0 39.7 83 0 67.0 36.0 17.0 20 20 May 54.6 60.4 55.6 56.8 61.2 51.7 64:5 49.7 40.0 27.0 25 26 June 63.3 69.2 64.0 65.5 70.5 57.7 72.1 58.2 98 0 83.8 51.0 40.0 19 22 July 69.8 76.2 71.1 72.3 75.9 68.6 80.1 65.8 99.0 88.0 60.0 50.0 23 19 August 68.5 76.0 71.0 71.8 75.0 68.3 78.8 65.6 98.0 86.0 58.0 51.4 26 20 September. 59.5 68.8 63.2 63.8 69.5 60.7 71.8 57.5 93.9 78.0 49.0 37.0 24 20 October.... 48.5 57.2 51.9 52.5 59.9 47.5 61.9 48.7 84.0 73.0 41.3 25.0 25 20 Nove.aber.. 35.2 42.0 38.3 38.5 43.1 31.4 47.2 33.6 72.0 57.0 31.0 - 2.0 21 22 December.. 26.8 32.5 29.3 29.5 42.8 19.1 37.5 24.7 68.0 44.9 22.0 -23.0 19 28 Spring 45.6 50.7 43.3 Summer 69.8 72.4 66.8 Autumn 51.6 55.1 48.2 Winter 1 28.0 33.7 22.5 Year 48.8 51.4 45.4 91 Chicago. Childhood. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. J K M N ° R s Range of temper- ature for period. Mean relative hu- midity. Average number of fair days. ' Average number of clear days. Average number of fair and clear days. Average rainfall. Prevailing direc- tion of wind. Average velocity of wind, in miles, per hour. Inches. From Miles. January.... 85.0 76.0 12.9 7.8 20.7 2.04 S.W. 9.0 February .. 76.0 72.5 11.3 8.3 19.6 2.28 S.W. 9.1 March 85.0 71.5 13.0 7.1 20.1 2.79 SW..NW. 9.9 April 06 0 66.5 12.2 11 4 8.1 11 1 20.3 22.5 21.9 3 65 N 9 5 May 62.0 58.0 4 61 N.E. S.W. 8.6 7.8 June 70.6 14.5 7.4 4.45 July 49.0 70.6 12.5 12.9 25.4 3.96 S.W. 7.1 August .... 16.6 70.6 13.6 12.5 26.1 2.66 N.E. 6.9 September. 56.9 68.8 12.7 10.9 23.6 2.82 S.W. 7.8 October.... 59.0 69.8 12.6 9.1 21.7 3.86 S.W. 8.5 November. 74.0 70.8 10.1 6.6 16.7 2.96 S.W. 8.6 December . 91.0 73.9 11.8 6.7 18.5 2.07 S.W. 8.6 Spring Summer... 101.0 68.5 36.6 26.3 62.9 10.48 S.W. 9.3 59.0 70.6 40.6 32.8 73.4 11.07 S.W. 7.3 Autumn ... Winter Year 95.9 91.0 122.0 69.8 74.1 35.4 36.0 148.6 26.6 22.8 108.5 62.0 58.8 257.1 9.64 6.39 37.58 S.W. S.W. S.W. 8.3 8.9 8.4 ure, collapse when pricked, and leave behind no swelling or elevation of the skin. Small hypersemic patches, re- sembling roseola spots, immediately precede the appear- ance of the vesicles. The occurrence of two, three, or more successive crops of eruption, each running an independent course, consti- tutes a striking and unique feature of varicella. Between the vesicles first formed new roseola spots appear, and soon ripen into fully developed vesicles. Thus, newly formed vesicles may be seen side by side with others in all stages of development, even to advanced desiccation. The eruption appears first upon the trunk, and spreads irregularly over the entire body. It is most abundant upon the back and breast, and least so upon the face, where it is usually limited to the forehead. The scalp nearly always exhibits a full crop of eruption, which, protected by the hair, maintains its physical integrity longer than in any other location, and thus renders valu- able aid in diagnosis. The mucous membranes are often implicated. The tongue, buccal membrane, and the mucous surfaces of the genital organs, especially in girls, are favorite sites for the formation of vesicles. In these locations the vesicles soon loose their epithelial covering, and leave small, round, superficial excoriations. When the eruption is abundant, the body, as well de- scribed by Dr. Gregory, presents the appearance of hav- ing been exposed to a momentary shower of boiling water, each drop of which has produced a small blister. If unbroken by accident, or by the scratching of the child to relieve the itching so generally present, the ves- icles remain until the third day without change, when their contents become cloudy and desiccation begins. At this stage a few scattered pustules may be observed, but these are purely accidental and not essential features of the disease. The vesicles begin to dry up in the centre, and form thin, brownish-yellow crusts, which soon be- come detached. Faint red spots remain, which pass away in a few days, and carry with them every trace of the eruption, but very exceptionally depressed, slightly pitted cicatrices permanently mark the seat of a few of the ves- icles. Mr. Hutchinson has called attention to the gangrenous ulcers which sometimes, though rarely, complicate chicken-pox in feeble, ill-nourished infants. In these cases a greater or less number of vesicles, instead of pur- suing the ordinary benign course, become gangrenous, in- crease in size, and form black scabs of one-half to one inch in diameter, surrounded by dusky red areolae. The ulcers heal slowly. In fact this condition may result fa- tally in infants whose constitutions are depraved by in- herited taints or bad surroundings. The varieties of chicken-pox described by authors under the names of Varicella Lenticularis, Varicella Conoides, and Varicella Globata, based on the various shapes as- sumed by the eruption, may be wholly ignored, since in every well-marked case vesicles answering all of these descriptions are abundantly found. In fact this varia- bility in size and form of the typical varicellar eruption is a characteristic feature of the disease. Convalescence is uninterrupted by complications or se- quellae, and the prognosis is always favorable. Varicella derives its chief importance from the liability of inexperienced or careless diagnosticians to mistake it for small-pox, or vice versa. In variola, or well-marked varioloid, the physiognomy is so distinctive as to almost preclude the possibility of error. But in exceptional cases of varioloid the consti- tutional symptoms are so mild, and the eruption so rudi- mentary and irregular, that a careless examination will not suffice to distinguish them from the graver forms of varicella. Time will always clear up the diagnosis, but, in the meanwhile, the reputation of the physician and the safety of the community may be seriously compromised. The absence of prodromal manifestations, the short initial fever, the rapidity and irregularity with which the eruption spreads over the body, the globular, non-umbili- cated, transparent, unicellular vesicles, the absence of a the Chief Signal Office in Washington, is here inserted for convenience of reference. A detailed explanation of this and of other similar charts, together with suggestions as to the best method of using them, will be found under the heading Climate. II. R. CHICKEN-POX (Synonyms: Varicella, Crystalli, Swine-pox; Fr., La Varicelle; Ger., Wasserpocken). Chicken-pox is an acute, specific, infectious fever, char- acterized by successive crops of vesicles distributed over the entire surface of the body, which disappear, in from four to seven days, by desiccation. It is the mildest and least important of the eruptive fevers. The belief, formerly so generally entertained by the profession, that varicella is not an independent affection, but a modified variola, is now abandoned, save by a very few clinicians. The proof of the non-identity of the two diseases is overwhelming. Varicella, like the other members of the exanthematic group, is due to a specific virus, or poison, the exact nat- ure of which is unknown. It is pre-eminently a disease of early life. It affects babes at the breast; attains its maximum frequency about the fifth year, and is rarely met with after the tenth year of age. It rarely occurs a second time in the same individual. Adults enjoy special immunity from the disease, although unprotected by an attack in childhood. Sporadic cases of chicken-pox are sometimes observed, but it usually prevails as an epidemic. It is highly con- tagious, and few children who are susceptible to its in- fluence escape when exposed. Most authors affirm that inoculation with the contents of the vesicles yields nega- tive results, but Steiner and others claim to have repeat- edly reproduced the disease in this way. The period of incubation in these experimental cases is about eight days, but when transmitted in the ordinary manner it is longer and more variable, running from ten to seventeen days. Prodromal symptoms are not infrequently wholly ab- sent, the appearance of the eruption giving the first indi- cation that the child is ailing. When present, they rarely last longer than twenty-four hours, and are such as usher in mild febrile attacks, namely, anorexia, lassitude, gen- eral bodily discomfort, chilliness, and slight elevation of temperature. The initial fever is mild, seldom measuring more than 101° F., and the constitutional disturbances are corre- spondingly slight, but in exceptional cases they may be as severe as those which commonly attend mild attacks of the other eruptive diseases. The eruption follows promptly on the first increase in temperature, and in a few hours attains its full development. When fully formed, it consists of perfectly transparent vesicles, more or less abundantly scattered over the body, globular or ovoid in form, and varying in size from a pin-head to a split pea, or even larger. They are unicellular in struct- 92 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chicago. Childhood. papular and pustular stage, and the successive crops of eruption, will very rarely give room to hesitate in the presence of chicken-pox. While any case of varicella may present an occasional vesicle slightly umbilicated or with purulent contents, due to accidental causes, the fact that this appearance is only exhibited by a few scattered vesicles, and is not the predominating character of the eruption, will suffice to establish the diagnosis. It is well to bear in mind that a vesicular eruption oc- curring in a child over ten or twelve years of age, and especially in an adult, is open to grave suspicion. Varicella is a self-limited disease, and needs but little treatment. Light diet, cooling drinks, a gentle aperient, and con- finement within doors, while the fever lasts, is all that will ordinarily be required. IE J. Conklin. effect which sudden changes in the temperature have upon the capillaries of the skin. The long-continued ex- posure to the cold and dampness of autumn days, and the subsequent warming of the feet, gradually cause a paralysis of the capillaries. They lose their tonicity, be- come chronically enlarged, and there is a consequent slight infiltration of the cutaneous and subcutaneous tis- sue with a chronic inflammation surrounding the blood- vessels. Frequent and repeated attacks are sometimes followed by increased oedema and ulcerations, and the disease is called Pernio ulcerans. This does not differ in any way from the second dr ulcerating grade of frost-bite. Treatment is both internal and external. The disease is difficult of cure, and one attack is nearly always fol- lowed by another, for the same causes which excite the first bring on a second much more readily. Internal medicines should be given to relieve chlorosis, anaemia, or trouble with the general circulation. It is hardly necessary to make a long list of drugs suitable in such cases. Where there is a gouty or rheumatic ten- dency this should be borne in mind, and the salicylate of soda, or drugs of its class, may be prescribed with great benefit. For the immediate relief of the pain and itching, plung- ing the feet into very cold water or rubbing them with snow has been recommended. Very hot water is still better. The relief is, however, only temporary and should be followed by the application of some soothing or astringent salve or wash, such as tannic acid, gallic acid, or lead-water. Boracic acid, the various prepara- tions of opium, or salicylic acid, are often useful. The latter should be made up into a live or ten per cent, salve, spread upon thick pieces of flannel, and laid on to the affected parts. The first effect is to increase the burning, the second to deaden sensation decidedly. Painting the chilblain with the tincture of iodine is highly recom- mended. It should be used freely and constantly. Iodine sometimes brings great relief and seems really to prevent in many cases the frequency of the attacks. It should be applied as soon as there are any symptoms of a return. A ten per cent, solution of naphthol in absolute alcohol and olive-oil, equal parts, is another remedy which has been found useful. Gentle pressure of any kind brings often great relief. This may be applied in the form of an india-rubber band- age, a solution of india-rubber, collodion, or of Pick's or Unna's gelatine. These latter preparations are made by dissolving pure gelatine in a small quantity of water over a water-bath, the strength of gelatine being one part to two parts of water. When dissolved it is put on with a brush and allowed to harden. If too stiff when hard, a minimum quantity of glycerine will soften it sufficiently and render it pliable. Any drug may be used to medi- cate the gelatine-it is only necessary to add it while the mixture is warm. Tight, too short, or too thin shoes, should not be worn. It is very necessary to keep the feet dry. Experience has shown, however, that some people cannot wear rubbers for over-shoes, as they seem to aggravate the trouble. Women should not wear tight garters, or do anything to impede the circulation of the extremities. Robert B. Morison. CHICORY {Chicoree Sauvage, Codex Med. ; Succory), CichoriumIntybusLinn., Order, Composita, Cichoriaceais a perennial European herb, with dandelion-like leaves and tall, sparsely branching stems, bearing large, deli- cate, lilac-colored flower-heads. The root is fleshy and branched, very much like that of dandelion when dry, but rather larger, and deficient in regard to the bright yellow woody ring so distinctly seen in the cross-section of dandelion. It is grayish brown externally, whitish within, generally odorless, and but slightly bitter. The leaves, which are somewhat employed abroad as a salad, are irregularly pinnatified, with a large terminal and small lateral segments. They resemble lettuce in taste, but are more bitter. Chicory is not entitled to rank as a medicine, although it is still retained in the French Pharmacopoeia. The root contains inulin, like many others in the order, bitter extractive, and sugar. The flowers contain a pe- culiar glucoside. Dose indefinite. Allied Plants.-Cichorium Endivia Linn. The En- dive supplies a useful root for the table. For a notice of the order, see Chamomile. Allied Drugs.-See Dandelion. IE P. Bolles. CHILBLAIN, from "chill," a cold, and^' blain," a pustule. (Synon.: Pernio, Dermatitis cogelationis erythe- matosa ; Ger., Frostbeule; Yr., Eng elure.} This is a dis- ease of the skin which has its most common situation upon the feet and hands. But it is seen principally upon the former. It may also appear upon the .nose, cheeks, or ears. Its symptoms are the same as those which are present in the first grade of frost-bite-indeed, the two diseases are histologically identical. It is considered by some authorities to be a form of erythema nodosum. Whether a rheumatic diathesis does not render a person more lia- ble to it is a question which has still to be definitely set- tled, although the probability is that it does. The disease is an obstinate one, and the attacks return at certain seasons with unfortunate regularity. October is usually the month to introduce it, and it may not disap- pear until the following spring. It starts as an erythema following the counteracting ef- fect of a warm temperature after long exposure to wet and cold. There is a piercing, burning sensation, accom- panied by intense itching in the parts affected, which is always most intense at night, more especially if the feet are affected, for they, when they become warm in bed or before a fire, cause a general distress greater in propor- tion to the area involved than is experienced in almost any other superficial disease. The erythematous spots vary from the size of a ten- cent piece to that of a silver dollar. The larger spots are usually made by the coalescing of smaller ones, and they, in their turn, often run into each other, so that there is a continuous redness extending over much of the foot. Their bases become cedematous, and they are very pain- ful upon pressure. The finger-nail, when drawn across them, makes a whitish line, which is, however, almost im- mediately effaced. The direct cause of these spots or swellings lies in the CHILDHOOD. Childhood is an arbitrary division of life which cannot be exactly limited in years. It is gen- erally conceded to terminate with puberty, but it is vari- ously stated to commence with birth, with the eruption of the first permanent teeth, or at other times. It seems best, however, to call the first two years of extra-uterine life the period of infancy, and then childhood is the time included between the end of the second year and puberty, which occurs between the thirteenth and sixteenth years. Before the end of the second year nursing at the breast is completed, the anterior fontanelle is closed, the temporary teeth are fairly developed, and the child is learning to talk and walk, and is acquiring a degree of independence which it did not possess in infancy. The age of childhood is characterized by both active 93 Childhood. Childhood. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. growth and development, increase in size of the body and of its several organs, and development of the functions of these organs and of the mind. Among the most prominent features of childhood is the activity and sensitiveness of the nervous system. A young and vigorous child is almost constantly in motion while awake, and takes an amount of daily exercise which, if proportionally followed by an adult, would soon result in exhaustion. The sensitiveness, too, of the nervous sys- tem is so great that the irritation of a single organ may be extended to all the others in the body, inhibiting their functions and giving rise to very grave constitutional dis- turbances. Thus a stomach overloaded with sweets or fruits, or the presence of an intestinal worm, may readily cause general convulsions, as well as alarming fever, vomiting, and diarrhoea. The various actions of the ner- vous system seem less differentiated or specialized than they become later in life. Autopsies upon young children very frequently furnish no clew to the cause of death, be- cause the system has been overwhelmed by functional disturbance before any definite lesion has appeared. Stature.-The average stature of male children is at two years, 79.6 ctm. ; three years, 86.0 ctm. ; four years, 93.2 ctm. ; five years, 99.0 ctm. ; ten years, 128.2 ctm. ; fourteen years, 148.7 ctm. (Quetelet). Female children are from 1.5 ctm. to 2.0 ctm. shorter. The rate of in- crease in stature is greatest in the earlier years ; thus, during the third year it is about 7.0 ctm., while from the fifth year to puberty the yearly rate remains almost uniform at 5.2 ctm. for girls and 5.6 ctm. for boys. Weight.-The average weight of male children is at two years, 12 kilos.; three years, 13.21 kilos.; four years, 15.07 kilos.; five years, 16.70 kilos.; ten years, 26.12 kilos.; fourteen years, 40.50 kilos. (Quetelet, " Anthropometric," Bruxelles, 1875). A boy at thirteen years of age can lift a weight equal to twice the weight of his own body (Street). In young childhood the weight of females is usually a little less than that of males of the same age, but between twelve and fifteen years the weight and bulk of the female body is somewhat greater than the male. Where there exists a marked discrepancy in the weight as compared with the height of a child, it is an almost certain forerunner of disease. The relative measurements of various parts of the body are different in childhood. The long diameter of the chest is shorter as compared with its antero-posterior diameter. The trunk is elongated as compared with the extremities ; this is due to the length of the dorsal part of the spine. The chest circumference at five years is 48.50 ; at seven, 51.0 ; at thirteen, 61.0 to 66.0 ctm. The length of the abdomen at four years is 20.5; at seven, 24.0 ctm. The abdomen appears disproportionately large owing to the flat diaphragm and feeble abdominal walls. The liver, spleen, and thyroid gland are relatively larger in young children than in adults. The thymus gland, which in- creases up to the second year, remains stationary in size for a while, and then diminishes, until at the age of pu- berty it has almost disappeared. The brain increases very rapidly in size up to the seventh year, after which it grows much more slowly. Food.-Rapid growth necessitates active chemical meta- bolism, which is associated with greater activity of the functions of the body than obtains with adults. This chemical activity is estimated as twice as great in young children as it is in adults. Children, therefore, require relatively more food in proportion to their body weight, and their diet must be especially nutritious, care being taken not to overload their stomachs, which are small. Children have a natural antipathy for fats (except, per- haps, butter), which is replaced by a physiological crav- ing for sugars, which are fat-producing agents, and for vegetable acids. Sugars and ripe fruits should form part of their diet, as well as sufficient meat and fat to economize the digestive force which is needlessly ex- pended upon the excess of waste contained in a strictly vegetable diet. Children reared upon an exclusive and little varied vegetable diet may thrive for a time, but they do not develop into as vigorous adults as those who are fed upon a properly mixed diet, and if their daily food is too restricted in variety, they are far more apt to indulge in injurious excesses whenever opportunity offers. The stomach in children is straighter and placed more nearly vertical than in adults, and they vomit readily, and often without much nausea. It is probable that in child- hood the various digestive fluids are as complex as in the adult (Foster1), but the alimentary tract is more easily irritated by food which is improper in quantity or qual- ity. The capacity of the stomach is relatively small, but it varies greatly, and owing to its elasticity it is difficult to obtain reliable measurements. The stomach of a child at two years holds about 350 cc.; at twelve years, 740 cc. (Beneke). The small intestine in childhood, up to from nine to twelve years, is relatively much longer than in adult life. The relation of its length to the length of the body for the second year is as 660 to 100 ; for the third, as 550 or 600 to 100 ; for the seventh, as 510 to 100 ; for the adult, as 450 to 100 (Beneke2). The reason for this great rela- tive length of the intestine is to be found in the fact that since children take a large amount of nourishment to fa- vor their growth, the food requires a large surface for absorption, as well as more time in passing over the absorbing surface. The capacity of the small intestine in children up to twelve years of age is, as compared with their body weight, about double that of adults (Beneke3). Children's bowels move somewhat more fre- quently, and their feces are slightly softer than is the case later in life. The lymphatic system in children is very active, and the lymph-glands are relatively large. They readily be- come enlarged either as the result of a scrofulous dia- thesis or in connection with acute inflammatory processes, especially such as affect the throat. Absorption both from the skin and mucous membranes takes place with remarkable facility. The urine is secreted in relatively larger quantity during childhood, and it contains abundant urea. Uric, oxalic, and hippuric acids are also found, and it is said that there are but few phosphates because they are required in the system to assist in the growth of bone. Young chil- dren micturate more frequently, and have much less control over the bladder than do adults. The pulse is more rapid during childhood. From the second to the third year it is 110 to 100 ; third to the fifth year, 100 to 90 ; fifth to the tenth year, 90 to 80 ; tenth to the fourteenth year, 80 to 70. It is slightly quicker in girls than in boys, and it is very easily disturbed by emotional or other stimulation. The younger the child, the more marked is the difference in the pulse-rate between sleeping and waking, it being frequently twenty to thirty beats slower during sleep. The vascular system is well developed in children. The carotids and subclavians are especially large. To the relatively large blood-supply of the brain in children two to three years of age has been ascribed the frequency of their cerebral and meningeal affections. The great ves- sels gradually decrease in relative size until puberty (Beneke4). The respirations in childhood are a very little more rapid than in adult life, and the difference between sleeping and waking is greater. Between the ages of two and six years a child breathes eighteen times a minute if asleep, but twenty-three times if awake. The respiration in both sexes is mainly diaphragmatic in early childhood, and the abdomen moves freely. Be- fore puberty, females begin to use the thoracic form of respiration more than the abdominal. The frequency of the respirations is very readily increased by emotional disturbances, exercise, etc., and it may be more than doubled without occasioning distress. The percussion note over the chest is louder and more sonorous, almost tympanitic in young children. The vesicular murmur is stronger than in the adult, and is described as puerile (Laennec). It is said that children inhale proportionally more oxygen and exhale less carbon-dioxide than do adults. The oxygen is required to supply energy for the conversion of food into new tissue as well as for the ac- tual formation of the tissue (Foster5); hence the oxygen is stored up and there is less waste CO2. Temperature.-The mean normal temperature in 94 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Childhood. Childhood. childhood does not rise over .3° F. above the adult (Fos- ter). In disease a sudden high temperature in a child is usually much less significant than in an adult. Young children lose heat readily from the surface of the body, and they are particularly susceptible to catarrhal pro- cesses occasioned by "taking cold" while insufficiently clad. It is said that the child's body presents a relatively large surface for the loss of heat (Foster). This seems quite insignificant, but certain it is that the cutaneous capillary circulation is very abundant and active. The surface of the skin is usually moist during exercise, and some children perspire very freely. The clothing of children should be carefully adapted to their special needs, independently of fashion. A gen- eration ago, in the United States, children wore low-neck dresses with short sleeves and bare legs much more gen- erally than they do at present, when the tendency is to dress them too heavily, especially among the poorer classes, who, as soon as a child takes a cold, commence to wrap it in flannel shirts and bandages to the number often of a half dozen. This is injurious, for too much clothing is heavy, it irritates the child, interferes with its respira- tory and other movements, and keeps the skin so hot that sudamina and other eruptions develop. The line should be carefully drawn between over-dressing and the "hard- ening process," as the other extreme of exposure is termed. Young children should be clad in flannel or woollen gar- ments (excepting in the hottest weather), which should be so adapted to the season that the child never feels cold, and yet does not perspire too freely, and which should be of a quality and shape that admit of free exercise without undue exposure. The hair and nails grow more rapidly in childhood, and there is a tendency for the hair of most children to become several shades darker and coarser as they grow older. The skin is softer and smoother, and more trans- parent than in the adult. Being thus delicate, caution is required in the application of blisters. The limbs are proportionally more full and round, and there is a large amount of subcutaneous fat. Co-ordination.-Ordinary grosser movements of co- ordination have already been acquired in infancy to some extent, but in early childhood there remains ifruch to be learned. The power of creeping, walking, running, and such movements as are made by the child in feeding it- self, are only acquired by constant and laborious practice and imitation. The still more delicate movements, such as are accomplished by the fingers in writing and in many other ways, are not usually perfected until toward the end of childhood. The special senses meanwhile are being developed. The young child must learn to distinguish rough, smooth, and sticky surfaces, to appreciate the direction and intensity of sound, to estimate distances by sight and by the sense of touch, to distinguish colors; and the prompt appreciation of external conditions, tlic proper control of reflexes and exercise of new volitional move- ments, are matters for which the child requires years of careful repetition. In many cases after the first few years of childhood, the special senses seem to acquire an acute- ness which is more marked than later in life when the perceptions are associated with more complex mental pro- cesses. The development of the color sense, however, forms an exception to this statement, for in many children it is but slowly established with accuracy. Is is to be regretted that more attention is not paid to teaching chil- dren to be ambidextric. Teeth.-The milk teeth are usually all developed dur- ing infancy, excepting the second set of four molars, which appear at from the twenty-fourth to the thirty- sixth month. After their appearance the child has twenty visible teeth in all; beneath these are'the sacs of the per- manent teeth. About the sixth or seventh year the per- manent teeth, which have lain in their sacs since birth, push outward, and one by one crowd out the deciduous teeth and replace them. In addition to the ten deciduous teeth in each jaw thus replaced, six more teeth appear in the back of each jaw, forming thirty-two all told. The an- terior permanent incisors appear*about the seventh year, the middle incisors about the eighth year, bicuspids ninth to tenth year, canines eleventh to twelfth year, and all excepting the posterior molars (wisdom teeth) are cut by the twelfth to fourteenth year (Kirke). At the sixth year, there are more teeth in the jaw than during any other period of life, for besides the temporary teeth, the crowns of the permanent teeth (except the last molars) are all present, making a total of forty-eight. Sleep.-Children need to sleep oftener and longer than do adults. A healthy child of seven years will often sleep for twelve hours, or even more, without waking. If per- fectly healthy, th^ child lies very quiet in its sleep, and inclines to lie upon one or the other side, with its eyelids imperfectly closed, and the eyes rolled upward. Chil- dren usually sleep more soundly than do adults and dream less. The Expression of the Emotions in young children is different from that of adults. Children express fear, disappointment, anger, pain, and the like by vigorous crying, in which the phonation is accompanied by a copi- ous flow of tears and great facial distortion. The eyes are tightly shut, the mouth is wide open, and the naso- labial fold is intensified, while respiration becomes vio- lent and spasmodic (Darwin)^ 6 and if any resistance be offered, there is violent struggling of the whole body. A child with a severe pulmonary lesion rarely cries hard, because it seeks to avoid any extra movement of the chest. Severe pain is indicated by contracted brows, a pinched mouth, and a look of distress in the eyes. Great stress is laid by some authors on the diagnostic value of different forms of facial expression, as indicating the sit- uation of disease. Thus a sharp nose, dilated nostrils, and sunken eyes indicate pulmonary disease, etc. (Jad- elot), but experience does not endorse such fine-drawn distinctions. Children naturally gesticulate considerably. Disease in Childhood.-The susceptibility of chil- dren to certain diseases, as well as their great recuperative power, is too well known for extensive comment. It is doubtless due to their functional activity. They are es- pecially liable to acute disorders of the alimentary and respiratory system, and to the exanthemata. The num- ber of diseases, such as hydrocephalus, laryngismus strid- ulus, etc., which may be considered as belonging exclu- sively to childhood, is very limited ; but there are a large number of ailments such as "whooping-cough, chicken- pox, mumps, etc., which occur so universally among children in preference to adults, that they are classed as "diseases of children." The invasion of acute diseases in childhood is often marked by a severity which seems out of proportion to the after-course of the disease. The temperature during early childhood may rise to 104° or 106° F., or even higher in such cases, and the respirations and pulse attain a rapidity which would soon prove fatal in an adult. The invasion of acute disease, which in an adult would be marked by a chill, in a young child is more frequently ushered in by severe vomiting or convul- sions. The nervous system of a child suffering from a severe febrile disease is frequently remarkably prostrated, and the extreme apathy which supervenes is in curious contrast to the excitability of the nervous system when in health. It is characteristic of certain diseases in children, no- tably acute general tuberculosis, that they affect a very large number of organs at the same time (Jenner). The effect of many febrile diseases (especially the exanthe- mata), is to stimulate the growth of children to a phe- nomenal degree. The writer has seen a boy of thirteen years, suffering for several months with empyema, grow four inches within a year after his recovery. Very rapid growth is sometimes a cause of pyrexia, 100° to 100.6° F., or of the lassitude and indefinite pains in the joints and extremities, usually referred to as "growing pains." Delicate children grow irregularly. Rachitis and scrofu- lous diseases retard growth very much, and irregular uni- lateral growth is occasioned by hip-joint disease, infantile paralysis, etc. An albuminuria of adolescence has been recently described,7 in which a temporary trace of albu- men appears in the urine, entirely independent of any 95 Childhood. Chloasma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. discoverable kidney lesion. This trace may last several months, and then permanently and entirely disappear. Medicines.-The rules for determining approximately the proper dose of common medicines for a child are, (1) divide the number of the child's next birthday by 24, this gives the fraction of the adult dose ; or, (2) add 12 to the age, and divide by the age, this gives the fraction of the adult dose. It will be seen that the first rule gives a slightly smaller fraction. Certain drugs are especially well borne by children ; such are arsenic, belladonna, strychnine, digitalis, lobelia; while of others, such as opium, they are very intolerant. Mercury does not sali- vate children, but produces rapid anaemia. Mortality.-The percentage of mortality among young children' is enormous, and it steadily decreases as they advance in age. Of 756,893 deaths reported in the United States by the census of 1880,8 302,624 occurred in chil- dren under five years of age ; 43,093 between the fifth and tenth year; and 22,915 between the tenth and fifteenth year. By far the greater part of this mortality is among the children of the poor of cities who live in crowded tene- ments under bad hygienic conditions and with poor or in- sufficient food. The death-rate among children of this class is double that of the rural districts. Very hot weather always raises the death-rate among children. The commonest cause of sudden death among young pre- viously healthy children is laryngeal spasm ; other fre- quent causes are syncope, pulmonary atelectasis, and convulsions. At two years of age the most frequent causes of death stand in the following order : Diphtheria, scarlatina, cholera infantum, dysentery ; at three and four years of age: diphtheria, scarlatina, croup, pneumonia, malarial fever; from five to ten years : diphtheria, scar- latina, malarial fever, pneumonia, croup. If, however, all the various diseases of the alimentary tract be grouped together, they rank first as a cause of death in every age up to ten years. In the United States the mortality8 for two years is 23.4 per 1,000 (in cities, 36.7); for three years, 15.4 ; for four years, 11.3 (in cities, 17.9) ; from rive to ten years, 6.7 ; from ten to fifteen years, 4.0. Race and climate influence the mortality of childhood. In France, Belgium, and Switzerland the rate is lower than in the United States. In Italy, Spain, and Russia it is higher, while in England it is about the same. Among civilized nations the mortality in the United States ranks as the tenth highest between one and five years, while be- tween five and ten years it is the third highest. The mor- tality among negro children is several per cent, higher than that of white children. The disease most fatal to Indian children is consumption, next are diarrhoea, diph- theria, and measles. Mind.-With the growth of the body the mind de- velops, and the relations of cause and effect depen- dent upon increasing memory are established. Thus the sudden sight or sound which in infancy only made the child start for an instant, in early childhood will cause it to turn its head and seek the cause with evident signs of recognition. The infant mind seems to act in an auto- matic manner, and ideas succeed one another before the will can concentrate attention upon them (Carpenter10). Many children spend years before they can fully separate subjective and objective conceptions (Galton11). The child has next to learn to form the general from the par- ticular, and finally to comprehend the universal from the general, and alike to reason from the actual to the possible (Carpenter 12). Thus it first appreciates its mother's eyes, then it learns that every one about has eyes, and eventu- ally it recognizes that eyes are a universal feature of man. The rapidity of mental development will be seen to be greatest in early childhood, for then it is that the child learns to talk, and learns the properties, qualities, and names of a vast number of natural objects. The mental status of children has of recent years received special at- tention (Stanley Hall13). Children are taught as they are also fed, very differently to-day as compared with the early part of this century, although our systems of mental as well as physical training are still far from perfect. Methods of teaching by object lessons, kindergarten sys- terns, practical work, and illustration are constantly gain- ing in favor (Spencer 14). The acquirement of much use- ful knowledge, that was formerly mere drudgery to children, is now-invested with the pleasure of a pastime. The dangers, too, of overstimulating the minds of children are receiving a great deal of careful attention, and the necessity for vigorous physical training as an adjunct to early mental training cannot be too carefully studied. In most of the United States there are laws requiring attend- ance at school during fixed periods between the ages of eight and fourteen years, and children cannot be employed in active labor under fourteen years of age.15 Heredity early shows its influence in childhood, as shown in the features, gestures, predisposition to diseases, etc. William Gilman Thompson. 1 A Text-book of Physiology, p. 708. 2 Deutsch. Med. Woch., 1680, vi., 433 to 448. 8 Loc. cit. 4 Loc. cit. 5 Loo. cit., p. 709. 6 Expression of the Emotions in Man and Animals, p. 150. 7 Kinnicutt: Transient Albuminuria, Medical Record, 1882, vol. xxi., p. 17. 6 Page 44 ; Table VII. 11 Census of 1880. 10 Mental Physiology, p. 264. 11 Researches into Human Faculty, p. 100. 12 Mental Physiology, p. 228. 13 Contents of Children's Mind, Princeton Review, May, 1883. 14 Education, p. 132. 16 Report, Commis. of Education, 1882-1883, p. xxxi. CHINOLINE. Chinoline, or quinoline, as it is also called, is a non-oxygenated basic body represented by the formula CJLN, and obtained by the distillation of certain natural alkaloids-notably quinine and cinchonine-with potassic hydroxide, and also, synthetically, by a patented process (Skraup's), from a mixture of aniline, nitro-benzol, gly- cerin, and sulphuric acid. An isomeric body-leucoline- obtained from coal-tar responds to chemical tests differ- ently from chinoline, and is to be regarded as a distinct compound. Chinoline is a colorless limpid fluid, of alkaline reac- tion, forming, with acids, crystallizable salts. Of such salts, those of the so-called mineral acids are mostly too deliquescent for convenient medicinal use, but chinoline tartrate is free from this objection and is available as a medicine. Chinoline tartrate is in minute, white, silky crystals, which, in a specimen made by Merck, of Darm- stadt, the writer finds to be of a faint combined bitter- almond and coal-gas odor, of a peculiar, sharp, yet cool- ing taste, having a flavor as of kerosene with a soupym of peppermint, and to be slowly soluble in about twenty- five parts of cold water. The effects of chinoline tartrate are analogous to those- of salts of quinine. In solutions ranging from 0.2 to 0.4 per cent, it is said to inhibit fermentative and putrefactive- processes (Donath), and in doses such as would be given of quinine, to prove antipyretic and antiperiodic after the manner of that alkaloid (Donath, Loewy, and others). As against quinine, chinoline tartrate has the advantage of comparatively low price; but the disadvantage of a de- cided tendency to sicken, vomiting being quite a common consequence of a medicinal dose. The drug is best given in a sweetened aromatic water, and a teaspoonful of lemon- juice or a lump of ice after the dose is said to lessen the- tendency to nauseate. Neither chinoline nor any of its salts are officinal in the U. S. Pharmacopoeia. Edward Curtis. CH I RAT A, U. S. Ph., Br. Ph. ; Chiretta, Sicertia Chirata Wall. (Ophelia Chirata Griesebach, Gentiana Chirayita Roxb.); Order, Gentianacece, the source of the above new officinal, is an upright annual herb with a simple tapering root something less than a decimetre in length (three to four inches), and a slender branching stem which is cylin- drical below, and about three-fourths of a centimetre in diameter, and, together with its branches, bluntly four- angled above : the pith is large, often obliterated, leaving the wood hollow in the lower part. Height from three- fourths to more than one metre (two to five feet). Leaves opposite, ovate-lanceolate, sessile, smooth, in loose axil- lary clusters. Corolla four-parted, each petal having a pair of glands on its upper surface. Stamens, four in- serted upon the corolla. Ovary, one-celled with two pla- 96 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Childhood. Chloasma. centte. Stigmas, two. Fruit, a one-celled many-seeded capsule. Chiretta is a native of Northern India, especially in mountainous districts in Nepal, where it is found at an elevation of from five to nine thousand feet (Bentley and Trimen). Its use was introduced from India, where it has been long employed, into European medicine about fifty years ago. The plant is gathered when fully grown ; the flowering stems being pulled up entire, dried, and tied into long bundles. Its description as a drug is included in the above botanical section, excepting to add that it has no odor, but a very bitter taste. The active principles, as found by M. Hohn, are ophelic acid, a viscid, yellow, very bitter substance, and chiratin, a light-yellow, crystalline, bitter glucoside. Use.-Chirata is a pure bitter, with the general medici- nal properties of other Gentianacea ; in small and medium doses it is tonic, in larger ones it nauseates or produces vomiting ; it probably has no advantages over gentian, and is very little called for in the United States. Dose, one or two grams. A tincture (Tinctura Chirata}, U. S. Ph., strength -^1 and a fluid extract (Extractum Chirata, Fluidwn, U. S. Ph., strength •}) are officinal. Allied Plants.-The genus Swertia contains forty species of mountainous plants, several of which are used in India for the same purposes and under the same name as the officinal Chirata ; for the Order, see Gentian. Allied Drugs.-See also Gentian. IF. P. Bolles. may not be sharply defined. They are usually coin-sized, but may be smaller or larger; not infrequently several coalesce, and the result is one large patch. Chloasma may be idiopathic or symptomatic. Grouped under the head of idiopathic chloasma are all those forms of pig- mentation caused by external agents. Continued scratch- ing, as in eczema, pediculosis, and other itchy diseases, produces more or less discoloration as a consequence of prolonged hypersemia. The pigment deposit which some- times follows the use of sinapisms and blisters may here be referred to. Exposure to the rays of the sun is another well-known cause. In fact, any external irritant, espe- cially if long continued, may be followed by varying de- grees of pigmentation, which may, in many cases,*be per- manent, Under the head of symptomatic chloasma are included all forms of pigment deposit which occur as a consequence of various organic and systemic diseases. In tuberculosis, cancer, and malaria there is frequently more or less general pigmentation. The discoloration of Addi- son's disease is another example of this group. In these instances the pigmentation is, as a rule, diffuse, being more noticeable on parts which are naturally darker, as the face, backs of the hands, axillae, and genital region. The most important form, however, in this class is chloasma uterinum. It is seen most frequently on the face, especially about the forehead. Occasionally patches appear on the breast and abdomen. The color is usually of a yellowish-brown tint. It commonly occurs as well- defined patches, but in some cases the division line be- tween the normal and pigmented skin is difficult to recog- nize. The pigmentation is more intense in brunettes. The skin is smooth ; occasionally a mild degree of sebor- rhoea coexists1, in which case the surface may be either oily or slightly scaly, usually the former, depending, however, upon the variety of seborrhoea. This form of chloasma is seen in those between the ages of twenty-five and fifty. It seldom appears after the climacteric period. It is most commonly observed during pregnancy, but may occur in connection with any functional or organic dis- ease of the utero-ovarian apparatus. The process is apparently under the control of the nervous system. The sole change, anatomically, consists in an increased deposit of pigment. The pigmentation may disappear and the parts assume their natural color. The only disease to which it bears a resemblance is tinea, versicolor, from which it may, however, be very easily distinguished. The first essential to a permanently successful result in the treatment of chloasma is a removal of the exciting cause. Unless this can be done, the relief furnished by local applications is usually but temporary. External remedies act mainly by removing the rete cells and with them the pigmentation. Corrosive sublimate in solution is probably the application which proves of greatest value. It is to be employed in the strength of from 65 milligr. (gr. j.) to 32 ctgr. (gr. v.) to the 31 grm. (| j.) of alcohol or water, depending upon the susceptibility of the skin. A lotion made up of 52 ctgr. (gr. viij.) of cor- rosive sublimate, 2 grm. ( 3 ss.) each of sulphate of zinc and acetate of lead, and 125 grm. (§ iv.) of water, will be found useful. The following is also valuable : Corrosive sublimate, 4 dcgr. (gr. vj.); dilute acetic acid, 8 grm. (3 ij.) ; borax, 26 dcgr. Oij.); rose-water, 125 grm. (^iv.). The action of a lotion is best obtained by dab- bing it on several times daily, a few minutes at a time. An ointment made up as follows is sometimes efficacious : Subnitrate of bismuth, 4 grm. (3 j.); white precipitate, 4 grm. ( 3 j.); benzoated lard, 31 grm. ( § j.). A rapid removal of patches may be accomplished by a. method suggested by Hebra. This consists in the appli- cation of a solution of 32 ctgr. (gr. v.) of corrosive sub- limate to the 31 grm. (3 j-) of water, by means of com- presses ; these are to be kept moist and constantly applied for four hours. A blister is produced, the epidermis of which is removed and the surface dressed with an indif- ferent powder. The newly formed epidermis will be free from pigmentation. Under the head of chloasma it is usual to refer to argyria, the discoloration which follows the prolonged CHITTENANGO SPRINGS. Location and Post-office, Chittenango, Madison County, N. Y. Access.-By New York Central & Hudson River Rail- road to Chittenango, thence by carriage to springs, three miles. Analysis.-One pint contains : • White Sulphur, 49° F. Prof. C. F. Chandler. Cave Spring, 49° F. Prof. Gy F. Chandler. Magnesia, 49° F. | Prof. C. F. Chandler. Grains. Grains. Grains. Carbonate of magnesia 1 631 1 776 1 439 Carbonate of iron 0 007 0.014 0.029 0.029 0.041 Chloride of potassium 0.019 Chloride of sodium 0.129 0 196 0 229 Chloride of lithium trace Sulphate of soda 0 027 Sulphate of magnesia 0.244 0 948 1 589 Sulphate of lime 10 177 13.265 14.385 Sulphate of strontia Hydrosulphate of sodium 0.014 0.043 0 094 Hydrosulphate of calcium 0 140 0 116 Hydrosulphate of soda 0.032 0 027 0.002 Alumina o.oio Silica. 0.035 0.064 0.072 12.293 16.534 17.996 Gases (Prof. Collier). Cub. in. Cub. in. Cub. in. Carbonic acid 4.5 3.2 2.3 Sulphuretted hydrogen 0.1 0.4 1.6 Therapeutic Properties.-The peculiar constituents of these waters are sulphate of lime and sulphuretted hy- drogen. They are, therefore, calcic-sulphur waters, and applicable to chronic skin and mucous membrane dis- eases. They are not cathartic. G. B. F. CHLOASMA. Chloasma consists of an abnormal de- posit of pigment, which occurs as variously sized and shaped yellowish, brownish, or blackish patches. The affection is one of pigmentation only, the skin in other respects being normal. It may appear in patches, which is commonly the case, or as a diffuse discoloration. Its appearance may be either rapid or gradual, usually the latter. The color varies from a light-yellow to blackish ; in the greater number of cases, it is of a yellowish-brown tint. The patches are rounded or irregular, and may or 97 Chloasma. Chlorides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. administration of nitrate of silver. The skin is of a bluish-gray or slate color. In a few instances reported, doses of iodide of potassium have been followed by good results. (Yandell.) Henry IK. Stelwagon. produced by a direct action of the poison upon the nerve- centres presiding over the functions deranged. Of the effects, those of greatest clinical importance are the hyp- notism and the paresis of the respiratory centre and the motor tract of the spinal cord generally. When chloral hydrate is taken habitually, certain pecu- liar effects may follow. Perhaps the most common is some form of skin eruption, which is generally erythema- tous, though sometimes papular. In other subjects, urtica- ria or purpura may result. In other cases, conjunctival or faucial irritation ; in others, dyspnoea ; and in unique cases, pains in all the limbs, and partial paraplegia, have been clearly traced to chloral poisoning (Anstie). Quite a common effect, seen even in cases of single dosage, is that where chloral and alcohol have been taken together ; deep flushing of the face and throbbing of the vessels may occur, exactly as produced by amyl nitrite. Prolonged habitual use of the drug probably tends to debase the mind and morals of the subject in the same manner as indulgence in alcohol, ether, or chloroform ; and sudden discontinuance, after a fixed habit of excess, may natu- rally lead to the same consequences as the sudden break- ing of a pronounced alcohol habit. In the matter of toxicology, cases of fatal or of even dangerous poisoning have, as yet, generally resulted from inadvertent medicinal overdosage. The smallest authenti- cated fatal dose is twenty grains (1.30 Gm.), and the fact that such dose-one less than the usual medicinal dose- has killed, only emphasizes the fact, now pretty generally recognized by the profession, that individuals show very different degrees of susceptibility to the action of chloral hydrate. The condition of dangerous poisoning is one of narcosis, distinguishable from the narcosis of opium, with which it is most likely to be confounded, by the condi- tion of the pupils. The pupils, in chloral poisoning, are either dilated, or if contracted are but moderately so, and dilate upon the subject's awakening. Very often, also, in chloral narcosis, the face is deeply flushed and somewhat bloated, the lips and eyelids swollen, and the eyes blood- shot. The treatment of poisoning by chloral hydrate is to evacuate the stomach, best by the stomach-pump, and to sustain the flagging lungs and heart by artificial respi- ration. Medicinal respiratory and cardiac stimulants, though theoretically indicated, are practically of little use, because of the already hopelessly paralyzed condition of the tissues upon which they are to act. Therapeutically, chloral hydrate is available to pro- cure sleep, to oppose spasm, and to blunt pain. As a hypnotic it takes front rank among medicines, because of the combined certainty and yet pleasantness of its action. Yet the indiscriminate use of the drug in all conditions of wakefulness may easily work great harm. Thus remem- bering the strong specific action of chloral hydrate to de- press respiratory activity, it is plain that in the restlessness and wakefulness that result from dyspnoea, in such con- ditions as congestion of the lungs, emphysema, or bron- chitis with obstructed circulation, the drug is the most improper thing that could be prescribed. Similarly, from its asso.ciated cardiac depression, all conditions caused or attended by feeble or embarrassed circulation contraindi- cate chloral. As an antispasmodic, chloral hydrate is peculiarly appropriate where the cause of the spasms is morbidly excited reflex irritability of the nerve-centres. In tetanus it has thus worked many cures. As an anodyne this remedy is inferior to many others, as might be in- ferred from the fact already mentioned, that anaesthesia is not a very pronounced element of its physiological operation. A special use of chloral hydrate, not medicinal, yet availed of by the physician, is as a preservative. Like the related substances, the volatile alcohols and ethers, chloral hydrate is markedly antiseptic, and possesses the peculiar feature that, while preserving putretiable tissues from decay, it yet does not obviously change the physical appearance of even the most delicate structures. The agent is, therefore, peculiarly useful as a preservative for urines set aside for microscopical examination. As much of the drug in crystals as will lie on the thumbnail added to about one hundred cubic centimetres (about three fluid- CHLORAL. By the title Chloral, Chloral, the U. S. Pharmacopoeia recognizes not what is, chemically speak- ing, chloral proper, but an entirely distinct body, chloral hydrate. Chloral proper, C2HCI3O, is, chemically, acetic aldehyde (common aldehyde) with three atoms of hydro- gen in the molecule replaced by chlorine. It is a thin, oily, colorless, heavy fluid. On mixing chloral with wa- ter, the two bodies unite, forming a crystalline hydrate of chloral, CiHCLOjHsO, which is the substance used in medicine under the misnomer chloral. Chloral hydrate, or " chloral," appears in " separate, rhomboidal, colorless, and transparent crystals, slowly evaporating when ex- posed to the air, having an aromatic, penetrating, and slightly acrid odor, a bitterish, caustic taste, and a neutral reaction. Freely soluble in water, alcohol, or ether ; also soluble in four parts of chloroform, in glycerin, benzol, benzin, disulphide of carbon, fixed or volatile oils. It liquefies when mixed with carbolic acid or with camphor. Its aqueous solution soon acquires an acid reaction, but its alcoholic solution remains neutral. At about 58° C. (136° F.) it melts to a clear liquid of sp. gr. 1.575, which solidifies to a crystalline mass at a temperature be- tween 35° and 50° C. (95° and 122° F.). At about 78° C. (172° F.) it begins to yield vapors of water and of anhy- drous chloral, and it boils at 95° C. (203° F.). When dis- solved in water and treated, while hot, with solution of potassa or of soda, or with water of ammonia, a vaporous, milky mixture of chloroform is obtained, with a formate in solution " (U. S. Ph.). Chloral hydrate should be kept in glass-stoppered bottles in a cool and dark place. Chloral hydrate was proposed as a medicine by Lieb- reich, in 1869, on the theoretical assumption that when absorbed into the circulation it would, by virtue of the warmth and alkalinity of the blood, undergo decompo- sition and conversion into chloroform. But, though chlo- ral hydrate has proved itself a valuable medicine, it is now certainly known not to undergo the assumed decom- position in the circulation, so that its effects are those of itself as such, and not of secondarily derived chloroform. The effects of chloral hydrate upon the animal economy, while much resembling those of chloroform, yet differ therefrom in many marked respects. Chloral hydrate, like chloroform, is locally a sharp irritant, and constitu- tionally a powerful neurotic, capable of producing arrest of the more important of the nervous functions, and, so, death. The most important difference between the action of chloral and chloroform is that the former drug has, relatively, a greater tendency to determine sleep, depres- sion of respiration, and fall of temperature, and a dis- tinctly less pronounced power to dull sensation than chloroform. In ordinary medicinal dosage (a single dose of from 2.00 to 3.00 Gm., equivalent to from thirty to forty-five grains) the only marked effect of chloral hy- drate is a gentle, calm, agreeable, dreamless sleep, which, if induced at bedtime, will, unless there be special rea- sons to the contrary, probably last till morning, and from which the waking will be natural, unattended by the dis- agreeable by-effects of an opiate. During the chloral sleep, forced awakening is as easy as during a natural heavy sleep, and the subject, when roused, is perfectly rational. Pulse and respiration are a little slowed, but otherwise the functions are not obviously affected. In in- creased dosage natural sleep deepens into coma; respi- ration, blood-pressure, and pulse-rate are markedly de- pressed, or the heart's action may be rapid while weak ; temperature distinctly falls ; sensation, after an initial temporary hyperaesthesia, becomes moderately blunted ; motor paralysis, voluntary and reflex, comes on, and, if the dose has been sufficiently large, death ensues by failure of respiration ; or, if the action has been sudden and overwhelming, death is by syncope, as in shock. The principal post-mortem revelation in fatal chloral poi- soning is congestion of the lungs and of the cerebro- spinal axis. These various phenomena are undoubtedly 98 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chloasma. Chlorides. ounces) of urine will preserve the same perfectly for days, or even weeks, and that, too, without affecting the ready recognizability of casts, blood or pus corpuscles, epithe- lial scales, or spermatozoa. The addition does not affect the heat and nitric acid test for albumin, but it vitiates the test for sugar by Fehling's solution, since a solution of chloral hydrate of sufficient concentration will itself reduce the copper of that test fluid. The antiseptic action of chloral hydrate is possible to utilize in surgery, and lotions of from one to three per cent, strength have been proposed for wounds. Such weak percentages are neces- sary, else the application will both smart locally and, perchance, develop constitutional poisoning by absorption. Chloral hydrate has, lastly, been suggested as an anaes- thetic for surgical use, by the procedure of injecting an aqueous solution directly into a vein. The quantity of one hundred grains has been so injected, with the effect of producing in eight minutes a complete anaesthesia that lasted an hour, and was follo'wed by a deep sleep, with blunted sensibility, for fourteen hours. In other cases death has been reported as a consequence, as might natu- rally have been anticipated, and the procedure is little likely to find favor with conscientious surgeons. For medicinal giving for its legitimate purposes, the dose of chloral hydrate for an adult should not at first ex- ceed 1.30 Gm. (twenty grains). Often twice and three times that quantity is perfectly well borne, but, until the individual susceptibility of a given subject is tested, it is best to prescribe the smaller doses. The remedy is given in solution, with the sharp twang of the taste dis- guised by some syrupy and aromatic addition. Edward Curtis. odorless, having a purely saline taste, and a neutral reac- tion. Soluble in 2.8 parts of water at 15° C. (59° F.), and in 2.5 parts of boiling water ; almost insoluble in alcohol. When heated, the salt decrepitates ; at a red heat it melts, and at a still higher temperature it is slowly volatilized with partial decomposition. A fragment of the salt im- parts to a non-luminous flame an intense yellow color, not appearing more than transiently red when observed through a blue glass" (U. S. Ph.). While, as described, perfectly pure sodic chloride is permanent in the air, com- mercial table-salt, containing, as it does, variable propor- tions of magnesic chloride, is more or less hygroscopic, becoming damp on exposure to moist air. Salt is the principal saline ingredient of sea-water, and occurs native, also, as a mineral in enormous quantities. It is obtained for commerce from salt-mines, and also, to a certain ex- tent, by evaporating the water of the sea and of saline springs. Sodic chloride being an important normal constituent of the body fluids, is naturally a perfectly innocent sub- stance to swallow in any ordinary quantity. The only effects following the special administration of it are, in moderate dosage, an improvement of appetite and diges- tion, and probably also a quickening of assimilation and nutrition. In large single doses salt is decidedly emetic, especially if taken in a lukewarm draught. Therapeuti- cally, it is in the first place important to remember the absolute necessity of salt in the dietary, and so to see to it that the dishes for the sick-room are not made too in- sipid by lack of salt. Next, salt is a fairly serviceable emetic, but not sufficiently powerful for urgent require- ments. It is therefore used more as an adjuvant to more active emetics, than as itself a vomiting agent. An- other application of salt is its administration, dry, in quantity of a teaspoonful or so, in haemorrhage of the lungs, over which affection salt is supposed to have some control, but such use, although unobjectionable, should not be to the exclusion of more potent remedies. In the matter of external application, it is notorious that salt water is more stimulating to the skin than fresh, and that, for the purpose of the constitutional reaction to be ob- tained, salt baths are more serviceable than fresh, and are borne by weaklings with less danger of giving "cold." The dose of salt as an appetizer is about 0.65 Gm. (ten grains), but the dosage is obviously very indeterminable, and much may be left to individual peculiarities of taste. As an auxiliary emetic, from 15.00 to 30.00 Gm. (one-half to one ounce) should be given in a tumblerful of luke- warm water. For saline baths sea-water is best, but, when not available, a good substitute is afforded by a three per cent, aqueous solution of common table-salt (a pound to four gallons). For the bathing of sensitive mucous mem- branes, such as the conjunctiva, or the Schneiderian mu- cous membrane in its upper portion, a weak solution of common salt affords a fluid far less painful than simple water, because approaching more nearly the normal spe- cific gravity of the fluids of the part. Such solution should range between one-half and one per cent, in strength, but it is near enough for practical purposes to make the solution by adding to a couple of fluidounces of water as much salt as will lie on the thumbnail. For in- jection into the nasal cavity, the solution should be blood- warm. Ammonia Chloride: NII4C1.-This salt, commercially known as sal-ammoniac, and still often by the old-fash- ioned chemical name muriate of ammonia, is officinal in the U. S. Pharmacopoeia only in a purified condition, under the title Ammonii Chloridum, Chloride of Ammo- nium. Commercial sal-ammoniac is now most commonly obtained from an ammoniacal liquor that occurs as a by- product in the making of illuminating gas, and is in the form of fibrous crystalline cakes of a peculiarly tough texture, making the substance very difficult to pulverize. In this condition the salt is contaminated with chloride of iron, and has to undergo a purification therefrom to fit it for medicinal use. Such purification is effected by dissolving the salt in weak water of ammonia, filtering hot, and evaporating to dryness with constant stirring. The purified sal-ammoniac is thus obtained granulated, CHLORAL ALCOHOLATE. This body, C2IIC13O, C2H6O, forms during the process of manufacture of chloral from alcohol. It is in white crystals, distin- guished from those of chloral hydrate by their insolu- bility in cold water, although they melt on admixture with hot water. This body is not used as a medicine, and needs mention only because it may possibly be mis- taken in the market for chloral hydrate. Edward Curtis. CHLORAL CAMPHOR. This name has been applied to the clear fluid that results from trituration of equal parts of chloral hydrate and camphor. The fluid is soluble in alcohol, ether, glycerin, and fixed oils, but on mixture with water suffers precipitation of the camphor. It possesses the medicinal properties of its ingredients, and in a teaspoonful dose in one case produced severe, irritant, and narcotic poisoning. The compound is not officinal, but has been used medicinally as a nervous sedative in doses of from ten to twenty drops. Edward Curtis. CHLORIDES. The chlorides used.in medicine are, of the heavy metals, the chlorides, severally, of iron, mer- cury, gold and sodium, and zinc ; of the alkali bases, the chlorides, severally, of sodium, ammonium, and calcium ; and of the alkaline earths, the chloride of barium. The chlorides of the heavy metals are, with the single excep- tion of mercurous chloride (calomel), distinguished among their sister salts for comparative freedom of solubility and great intensity of action. The ferric, auric, and zincic chlorides are, furthermore, deliquescent to a high degree. For detailed discussion of the metallic chlorides, see the articles under title of the several metals, and for baric chloride, see under Barium. In the case of the chlorides of the alkali bases, the influence over nutrition which they derive from their chlorine element exceeds in me- dicinal importance what properties they are possessed of out of their basic radicle. They are, therefore, properly considered under the present heading as constituting a clinically distinct group of medicines. Sodic Chloride: NaCl.-Sodic chloride, well known as common salt, table-salt, sea-salt, or simply salt, is officinal in the U. S. Pharmacopoeia as Sodii Chloridum, Chloride of Sodium. It occurs as " white, shining, hard, cubical crystals, or a crystalline powder, permanent in the air, 99 Chlorides. Chlorine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and presents itself as a " snow-white, crystalline powder, permanent in the air, odorless, having a cooling saline taste, and a slightly acid reaction. Soluble in 3 parts of water at 15° C. (59° F.), and in 1.37 part of boiling water; very sparingly soluble in alcohol. On ignition the salt volatilizes, without charring, and without leaving a residue" (U. S. Ph.). Physiologically, ammonic chloride seems to combine to a certain extent the peculiar virtues of ammonia (see Am- monia) with those of the chlorides. In continuous full dosage it deranges the stomach and bowels, exciting vomiting and purging. Its medicinal applications have been very varied, but those which have best stood the test of w'ell-observed experience are the use of the salt to relieve myalgia and some neuralgias, and to promote free expectoration in bronchial catarrhs in the second stage, especially in cases where the secretion is thick, tenacious, and difficult of dislodgement. By German practitioners the salt is also much employed in inflammatory affections, generally where there is some product of the inflamma- tion wfliose reabsorption is desirable. Thevaverage dose of ammonic chloride is from 0.30 to 0.65 Gm. (five to ten grains) every two or three hours. It is generally given in solution, as an ingredient of composite prescriptions, and, as its taste is very disagreeable, it is well to have a a little liquorice added to the mixture to disguise the flavor. Troches of chloride of ammonium are officinal, each containing 0.13 Gm. (two grains) of the salt. Externally applied, sal-ammoniac in solution is a gentle irritant, and an aqueous solution, from one to three per cent, in strength, may be used as a lotion to sluggish ulcers, etc., requiring a mildly irritant impression. A local application in respiratory catarrhs has also been devised, whereby the patient inhales the salt, formed in a fine cloud in air, by an arrangement that brings together the vapors of hydrochloric acid and water of ammonia. Lastly, am- monic chloride furnishes a possible means of applying cold, since by solution in water it reduces the temperature thereof quite decidedly. Thirty-five parts each of am- monic chloride and potassic nitrate to one hundred of water will lower the temperature from ten to fifteen de- grees of the Fahrenheit scale. In the absence of ice such a mixture may be put into a rubber bag and applied for purposes of refrigeration during the time that the salts are in process of dissolving. Calcic Chloride: Ca CL.-Calcic chloride, "deprived of its water by fusion, at a low, red heat," is officinal as Calcii Chloridum, Chloride of Calcium. Such fused salt occurs in "colorless, slightly translucent, hard, and fri- able masses, very deliquescent, odorless, having a hot, sharp, saline taste, and a neutral or faintly alkaline reac- tion. Soluble in 1.5 part of water and in 8 parts of alco- hol at 15° C. (59° F.); very soluble in boiling water, and soluble in 1.5 part of boiling alcohol. At a low, red heat the salt fuses to an oily liquid, which, on cooling, solidifies to a mass of the original appearance, entirely soluble in water" (U. S. Ph.). Calcic chloride, because of its extreme proneness to deliquesce, must be kept in w'ell-stopped bottles. This salt presents a combination of an acid and basyl- ous radicle, both of which are peculiarly effective in the determining of sound nutrition, and it is found clinically that in many chronic states of mal-nutrition, such as, notably, the existence of indurated and enlarged glands, or of a manifest scrofulous cachexia, or of tabes mesen- terica, marked benefit may follow a course of calcic chlo- ride. In large dose the salt is a dangerous irritant. The therapeutic dose is from 0.65 to 1.30 Gm. (ten to tw'enty grains) taken preferably dissolved in a wineglassful of milk (Coghill: The Practitioner, vol. xix., p. 251) and after eating. Edward Curtis. rhages, and possibly followed by death. Habit, how- ever, establishes considerable tolerance, so that workmen in bleacheries get to breathe without distress a chlori- nated atmosphere impossible of respiration to one unac- customed. Feebly chlorinated air excites only a glow of warmth in the air-passages, and an increase of bronchial mucus. Taken internally, in the form of strong chlori- nated solutions, chlorine is powerfully irritant, and even corrosive. In poisoning by inhalation of chlorine, the sufferer should be made to breathe, cautiously, the fumes, of ammonia, or a weak mixture of sulphuretted hydro- gen in air. In poisoning by swallowing, albumen should be freely given, and the lesions treated upon general med- ical principles. Chlorine is valuable to the physician because of a conse- quence of the strong affinity of the element for hydrogen, with which body it unites to form hydrochloric acid. By virtue of this affinity chlorine can decompose water, especially in the light, appropriating the hydrogen and setting free the oxygen. Such nascent oxygen is then active for oxidizing, and will so attack and decompose by oxidation any organic matter that may happen to be within reach. Vegetable coloring matters and noisome products of putrefactive or fermentative processes fall particularly easy prey to active oxygen, and as a result of their oxidation the color of the one group and the smell of the other undergo complete abrogation. In a. roundabout way, therefore, chlorine, in the presence of moisture, is a powerful bleacher of organic dyes, and de- odorizer of organic foulness. Reasoning from the easily obtained deodorant action of chlorine, it is naturally hoped that the element may also, under the conditions that cur- rently present, oxidize, and so disinfect the organic matter of particulate carriers or generators of contagium-disease- germs, commonly so called. But while there is no doubt of the power of chlorine so to do, if in sufficient concen- tration and in the presence of moisture, yet clinical expe- rience and exact experiments combine to prove that to. disinfect a room occupied by one ill of a contagious dis- ease, the chlorination of the air must be carried beyond the limit of respirability, and to a degree which will also determine the bleaching, more or less, of colored fabrics. Sternberg, experimenting with vaccine points, found that to destroy their potency by exposure to chlorine-charged air, a charge per volume of one-half of one per cent., perfectly maintained, was necessary, and an exposure to such atmosphere of six hours' duration.1 Considering, however, the conditions presented by a sick chamber, where the apartment is difficidt to close from leakage of air, and where the germs easily fall into places compara- tively inaccessible, a percentage at least double the above -one per cent., that is-should be regarded as the mini- mum of probable efficiency. The therapeutic application of gaseous chlorine is to deodorize, disinfect, or both. For purposes of deodoriz- ing, simply, chlorinated lime or chlorinated soda are fairly efficient, but for aerial disinfection chlorine gas. must be generated in greater volume than can be con- veniently gotten from those preparations. At best, how- ever, chlorine is inferior for this purpose to sulphur di- oxide, since the latter is probably more efficient as a disinfectant, while less obnoxious to carpets and clothing. To be even probably thorough, chlorine gas should be evolved in great excess of estimated minimum percent- ages, with the room as perfectly closed as possible, and with all articles to be disinfected as freely exposed on all sides to the atmosphere as may be. Much more com- monly, however, chlorine has been used on the small scale in sick chambers while still inhabited by the patient -a procedure which, from the point of view of genuine disinfectioil, is not merely futile, but leads to the positive danger of the omission of other and really potent disin- fectant measures. Gaseous chlorine is most conveniently generated in considerable volume by Wiggers' method, as follows : " Mix 18 parts of finely ground common salt with 15 parts of finely pulverized good binoxide of man- ganese ; put the mixture into a flask, and pour a com- pletely cooled mixture of 45 parts of concentrated sul- phuric acid and 21 parts of water upon it, and shake the CHLORINE. Chlorine is a greenish-yellow' gas, solu- ble in water, possessed of a peculiar and disagreeable odor, and an intensely irritant action upon animal tissues. Even in the comparatively weak dilution of one per cent, in air, chlorine excites violent spasm of the larynx, and if actually inhaled, leads to irritation and inflamma- tion of the air-passages, accompanied, perhaps, by haemor- 100 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chlorides. Chlorine. flask ; a uniform and continuous evolution of chlorine gas will soon begin, which, when slackening, may be easily in- creased again by gentle heat " (Fresenius). According to Squibb,2 " about two hundred grains of the common salt mixture, and half a fluidounce of the sulphuric acid mixt- ure, liberates in the course of twelve or twenty-four hours about fifty cubic inches of chlorine, giving it off pretty rapidly for the first two or three hours, and very slowly afterward." Estimating from these data, a cubic foot of chlorine requires for its yield about a pound and a quarter of the salt mixture, and a little over a pint of the acid ; and, therefore, for a one per cent, chlorination, by volume, of the air of the average bedroom of about two thousand cubic feet capacity, twenty-five pounds of the salt mixture, and about eleven quarts of the dilute acid, would have to be used ! And remembering that the one per cent, impregnation thus obtained is probably the minimum of efficiency, comment is unnecessary on the common practice of setting a saucer or two, holding each a half-ounce of the salt mixture, under the sick-bed with a serious view to disinfection. All that such procedure can possibly accomplish is a slight deodorizing. Locally, chlorine, applied in the form of chlorinated sub- stances and solutions, operates as a disinfectant, detergent, and deodorant, and, by virtue of its irritant properties, also as a stimulant to healthy action in wounds and sores. The U. S. pharmacopceial preparations of chlorine, avail- able for the purposes, thus suggested, are the following : Aqua Chlori, Chlorine Water.-"An aqueous solution of Chlorine, containing at least 0.4 per cent, of the gas " (U. S. Ph.). Chlorine gas, generated by the action of diluted hydrochloric acid upon black oxide of manganese, is conducted into a bottle of distilled water until the lat- ter, after agitation, is saturated with the gas in solution. The product, from its extreme proneness to spontaneous change, must be put up in "dark, amber-colored, glass- stoppered bottles," and these completely filled and kept in a dark and cool place. Chlorine water, when freshly made, is a "greenish-yellow, clear liquid, having the suffocating odor and disagreeable taste of chlorine, and leaving no residue on evaporation. It instantly decolor- izes dilute solutions of litmus and indigo" (U. S. Ph.). Chlorine water, especially on exposure to light, tends to lose strength by reason of the chlorine decomposing the water, and uniting with the hydrogen thereof to form hydrochloric acid. Chlorine water is used mainly in medicine as a local ap- plication, either as a lotion for foul or indolent ulcerated surfaces upon the skin, or as a gargle in analogous con- ditions of the mucous membrane of the throat. If freshly made it is intolerably pungent of chlorine, and should be di- luted several fold with water for use. Internally the remedy is occasionally given, generally in the so-called zymotic dis- eases, in the hope, probably, of a constitutional antiseptic action-a hope little likely to be fulfilled. From half a tea- spoonful to a teaspoonful may be given at a dose, diluted with five or six volumes of water, and with avoidance of all admixture of organic substances. The potion is very disagreeable to take. Calx Chlorate, Chlorinated Lime.-This is the prepa- ration, commonly miscalled chloride of lime, which results from exposing calcic hydroxide (slaked lime) to chlorine gas. The lime absorbs the chlorine with the formation of a peculiar product, which by the standard of the U. S. Pharmacopoeia, should contain "at least twenty-five per cent, of available chlorine." Chlorinated lime is in the form of "a white, or grayish-white, dry, or but slightly damp powder, or friable lumps, becoming moist and grad- ually decomposing on exposure to air, having a feeble, chlorine-like odor, and a disagreeable, saline taste. It is partially soluble in water and in alcohol. On dissolving chlorinated lime in diluted hydrochloric acid, chlorine gas is given off, and there should not remain more than a trifling amount of insoluble matter . . . The aqueous solution quickly destroys the color of a dilute solution of litmus or of indigo " (V. S. Ph.). Chlorinated lime, un- dergoing spontaneous change on exposure to air, must be kept in well-closed vessels in a cool and dry place. If put up in glass-stoppered bottles, the stoppers must be guarded by-a thin smear of paraffin, else they will be- come irremovably fixed to their seats. The composition of chlorinated lime has proved a diffi- cult matter to definitely determine. It has been supposed to be represented by a mixture of calcic chloride and cal- cic hypochlorite (CaCl2 -+- CaCl2O2), but certain chemical considerations make it likely that the true composition is according to Odling's formula, viz., CaCl.OCl. The im- portant chemical reaction upon which the medical vir- tues of the compound rest, is the ready decomposition of chlorinated lime by any acid, however weak-even car- bonic acid-wifh the evolution of free chlorine. Hence, by mere exposure of the preparation to the atmosphere, it continuously disengages chlorine through attack by the carbon dioxide ever present in the air, and if treated with an acid of any power, such as hydrochloric, nitric, acetic, etc., the yield of chlorine is prompt and decided. Medicin- ally, partly through its evolving free chlorine, and partly by virtue of its properties while under its own form, chlorinated lime is alkaline, desiccant, irritant, deodorant, and disinfectant. It is also cheap, and so combines many qualities that make it of genuine value. Its most com- mon employment is as a disinfectant; in which capacity for aerial disinfection its yield of chlorine is insufficient, but for direct application to solid or fluid infectious ma- terial, or for the cleansing of contaminated articles, it is excellent. Its only drawbacks are its chlorinous odor and its powerful bleaching action. As a deodorant it is very potent, operating in this service even aerially upon the foul gases, but being, of course, more efficacious if directly applied to the noisome thing itself. For use as a disinfectant or deodorant, chlorinated lime may be thrown, in bulk, and liberally, down privies, drains, or sinks, or into chamber-vessels before use ; or strewn, before scrub- bing, upon foul floors ; or in solution, from one to three or four per cent., in water, used as a detergent lotion upon corpses, sloughing wounds, or strong-smelling feet or armpits, etc. In these various applications the prepa- ration must not be applied strong to colored or delicate fabrics, lest the color be discharged and the texture in- jured. Apart from its mere deodorant property, chlorin- ated lime is serviceable in promoting healthy action in sluggish and foul sores, skin eruptions, etc. For this purpose a one per cent, lotion is a convenient form of ap- plication. Internally, chlorinated lime has been given as a source of chlorine, aimed to combat the morbific prin- ciple in zymotic disease. It may be so given in sweet- ened solution, freshly mixed, and in doses of from 0.06 to 0.40 Gm. (one to six grains). A last and special appli- cation is the inhalation of the fumes of chlorinated lime, in cases of poisoning by breathing sulphuretted hydrogen, as may occur to workmen entering sewers. The gas is always immediately decomposed by the chlorine of the lime compound. Liquor Soda Chloratw, Solution of Chlorinated Soda; Labarraque's Solution.-This preparation is made by pouring a boiling-hot aqueous solution of sodic carbonate into an aqueous solution of chlorinated lime. The so- dium and calcium change places, calcic carbonate being precipitated, and a chlorinated compound of sodium, analogous in composition to the pre-existing calcic com- pound, remaining in solution. But the sodic carbonate being ordered in excess, some of this salt, unchanged, re- mains in the preparation. The mixture, after cooling, is brought to standard strength by the addition of water, is strained, allowed to settle, and the clear solution then drawn off by siphonage. The product must be kept in well-stopped bottles, and if these be glass-stoppered, the stoppers should be overlaid with a thin smear of melted paraffin, else they will become irremovably fixed in their seats. Solution of chlorinated soda is a "clear, pale, greenish liquid, of a faint odor of chlorine, a disagree- able and alkaline taste, and an alkaline reaction. Specific gravity, 1.044. Addition of hydrochloric acid causes an effervescence of chlorine and carbonic acid gas. It ra- pidly decolorizes indigo, and produces a copious, light- brown precipitate, with solution of ferrous sulphate " (U. S. Ph.). By appropriate tests the solution should represent at least " two per cent, of available chlorine." 101 Chlorine. Chloroform. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chlorinated soda has, intrinsically, similar properties to chlorinated lime, and, like the latter compound, is readily decomposed by. acids with the evolution of free chlorine. Its therapeutic uses are therefore the same as those of the lime compound. The solution may be used as a deodorant disinfectant, poured down drains, sinks, or into chamber-vessels, or, diluted from five to tenfold, em- ployed as a detergent and gently irritant lotion to foul ulcers, skin eruptions, etc. Like chlorinated lime, this solution has been given internally in zymotic diseases, the dose being from one-half to one teaspoonful, diluted manifold with water, and repeated every two or three hours. Edward Curtis. 1 Sternberg : National [IT. S.] Board of Health Bulletin, vol. iii., p. 21. 2 Squibb : Disinfectants, The Medical liecord, May 1 and 15,1866. acid, in a glass-stoppered bottle, and allowing them to remain in contact for twenty-four hours, no color should be imparted to either liquid. If a few C.c. be permitted to evaporate from blotting paper, no foreign odor should be perceptible after the odor of Chloroform ceases to be recognized " (U. S. Ph.). It would be well for the prac- tising surgeon, before permitting himself to use any un- known sample of chloroform as an anaesthetic, to apply at least the above simple test with litmus paper and the evaporation-test with blotting-paper. Chloroform should be kept in glass-stoppered bottles, in a cool and dark place. In its action upon the animal economy, chloroform com- bines the properties of an irritant and a specific neurotic. It is a substance of high diffusion power, and hence one capable of rapid and intense action. Applied, pure, to the skin in such manner as to be saved from dissipation by evaporation, chloroform excites redness and burning pain, readily followed, if the application be prolonged, by blistering. Absorbed into the blood it produces pro- found perversions of current physiological status, of which the most important are derangement of the cerebral faculties, beginning with emotional excitement and end- ing in entire unconsciousness ; derangement of sensation -most prominently exaltation of the hearing and dulling of the tactile sense; and derangement of motility-first tremblings, or even spasms, and exaltation of reflex ac- tivity, and, later, paresis, paralysis, absolute muscular relaxation and abolition of the reflexes, passing, in suf- ficient dosage, to arrest of action of heart and lungs. As clinically seen in the inhalation of diluted chloroform- vapor for the production of anaesthesia, the essential phenomena present themselves thus : Very shortly after beginning the inhalation, the subject shows emotional derangement generally analogous to that seen in alcoholic intoxication, but, as a rule, one of quiet tone. In the case of naturally calm and self-contained individuals, all expression of emotional perversion may be absent, the subject passing to perfect unconsciousness without a word or a movement. As a rule, furthermore, the period of active emotional display is short, and unconsciousness supervenes not much later than four minutes after be- ginning the inhalation. Meantime, in the matter of af- fection of the senses, the hearing has been excited so that noises seem enormously magnified in intensity, but the tactile sense, on the contrary, has been progressively dulled. This latter effect-anaesthesia-the most im- portant, therapeutically, of all the effects wrought by chloroform-begins earlier and is relatively more pro- nounced than in intoxication by either alcohol or ether. So great is the sensory dulling indeed, that surgical pro- cedures, except upon the most acutely sensitive parts of the body, may be practised without pain in many cases long before muscular relaxation is complete, and even while considerable conscious intelligence remains. Motor disturbances commonly begin with a moderate degree of rigidity, which after a flitting general tremor just*as con- sciousness fails, quickly gives way to a condition of re- laxation. During the evolution of these various phe- nomena the respirations have at first quickened and then slackened, until at last they have become shallow, slow, and irregular; the heart has also at first quickened its pulse-rate, then reassumed the normal, and, later, taken on a more rapid but feebler action ; and the pupil has at the beginning dilated, and then contracted, and only re- dilates, with progressive advance of the intoxication, when the coma has become profound. By the march of these various phenomena the subject is brought to a con- dition where consciousness is lost, the muscular system relaxed, respirations quiet and shallow, rate and quality of pulse not far removed from the normal, the pupil still rather contracted, and reflex winking upon touch of the conjunctiva still slightly manifested. Such condition is as far as the intoxication need be carried for surgical purposes under ordinary circumstances, and under ordi- nary circumstances, therefore, should be recognized as the limit of effect sought to be attained. If the chloro- form be further pushed, the respiration becomes stertor- ous, the heart's action more rapid and weak, the pupils CHLORODYNE, Chlorodine. This title has been ar- bitrarily applied to mixtures differing considerably in composition, and none of them officinal in the U. S. Phar- macopoeia. Remington ("National Dispensatory") pro- poses the following formula : Dissolve 16 grains of hydro- chlorate of morphia in 1 drachm of water and 1 fluid ounce of alcohol; add to this chloroform, 3 fluidrachms ; tincture of Cannabis Indica, 2 fluidrachms ; tincture of capsicum, 18 minims; oil of peppermint, 4 minims; dilute hydrocyanic acid, 24 minims; and perchloric (or hydrochloric) acid, | fluidrachm. Each fluidrachm con- tains 1 grain of morphia. Oldberg gives the following as an imitation of the original chlorodyne : Chloroform, 140 C.c. ; Ether, 35 C.c.; Alcohol, 35 C.c. ; Molasses, 35 C.c. ; Purified Extract of Liquorice, 85 Gm. ; Hydro- chlorate of Morphine, 0.60 Gm. ; Oil of Peppermint, 1.20 Gm. ; Diluted Hydrocyanic Acid, 70.00 C.c. ; Simple Syrup, enough to make a total of 1 litre. Dissolve the morphine and the oil of peppermint in the alcohol, and add the chloroform and the ether. Triturate the ex- tract of liquorice with the syrup until dissolved, and add the molasses. Mix the syrup with the above solution, and finally add the hydrocyanic acid. Edward Curtis. CHLOROFORM. Chloroform, chemically trichloro- methane, or methenyl chloride, CHC13 (formerly called terchloride of formyl, and, popularly, chloric ether'), is an ethereal body commonly obtained by cautiously distilling a mixture of chlorinated lime, alcohol, and water. Com- mercial chloroform is very frequently impure, and though unobjectionable for external medical use, or, pharmaceu- tically, for solvent purposes, is entirely unfit for admin- istration by inhalation as an anaesthetic. The U. S. Pharmacopoeia, therefore, while recognizing under title Chloroformum Venale, Commercial Chloroform, any commercial sample " containing at least 98 per cent, of Chloroform," also ordains a careful process for thorough purification, the product of which is officinally entitled Chloroformum Purificatum, Purified Chloroform. Such purified chloroform only should be used for internal medical administration, whether by inhalation or inges- tion, and since in the case of this article impurities are positively dangerous, the pharmacopceial tests for stand- ard purity are quoted below, following the pharmacopceial description. " A heavy, clear, colorless, diffusive liquid of a characteristic, pleasant, ethereal odor, a burning, sweet taste, and a neutral reaction. Soluble in about 200 parts of water, and, in all proportions, in alcohol or ether : also in benzol, benzin, fixed or volatile oils. Sp. gr. 1.485-1.490 at 15° C. (59° F.). It boils at 60° to 61° C. (140° to 142° F.), corresponding to the pres- ence of three-fourths (f) to one (1) per cent, of alcohol. If 5 C.c. of Purified Chloroform be thoroughly agitated with 10 C.c. of distilled water, the latter, when separated, should not affect blue litmus paper (absence of acids), nor test-solution of nitrate of silver * (chloride), nor test-solu- tion of iodide of potassium f (free chlorine). If a portion be digested, warm, with solution of potassa, the latter should not become dark colored (absence of aldehyde). On shaking 10 C.c. of the Chloroform with 5 C.c. of sulphuric * Solution of argentic nitrate in distilled water, one to twenty. + Solution of potassic iodide in distilled water, one to twenty. 102 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chlorine. Chloroform. dilate, and all reflexes cease ; and, next and last, if the inhalation still continue, pulse and breathing fail and the subject dies. Upon discontinuance of a chloroform in- halation, the return to consciousness is comparatively rapid, and is followed by little tendency to nausea, head- ache, or other malaise. Such are, in brief, the essential phenomena ordinarily seen in the induction of chloroform-narcosis, but unfortu- nately the picture is not always as thus presented. The clinically important abnormal occurrences are unnatural intensity and prolongation of the period of emotional ex- citement ; unduly strong and persistent spasmodic symp- toms, and, most important of all, sudden syncope or failure of respiration. Prolonged and high excitement and strong muscular rigidity, or spasms, very commonly occur together, and are most frequent in the case of hard drinkers, who take chloroform, as they take all anaes- thetics, very badly. Syncope, also, is prone to occur in just such cases, but syncope can also happen by itself and without warning in an inhalation progressing in perfectly normal fashion, and when so occurring attacks most fre- quently subjects in the height of health and vigor. Strong and active males in the prime of life, who take chloroform on the occasion of some trivial surgical procedure, thus constitute the class that furnishes the majority of instances of the occurrence of chloroform-syncope. With children the accident is rare, and with parturient women rarest of all. Other things being equal, the presence of pain seems opposed to the supervention of syncope, and very probably the immunity of parturients from chloroform-faints is due to the influence of the labor-pains. Syncope may happen at any stage of the narcosis, or even after the sub- ject is well-nigh wholly recovered therefrom, but yet is far most common in the earlier stages, generally before consciousness is lost. It may come on quite suddenly and without warning, or it may follow great and prolonged excitement, violent struggling, or strong and continued muscular rigidity or convulsions, or vomiting. The at- tacks are commonly readily recovered from, under the in- fluence of removal of the anaesthetic and appropriate treatment, but yet every now and then it is not so, and another ' ' death from chloroform " is entered on the dis- credit account of surgical annals. Primary failure of respiration, apart from syncope, is very rare, and as it is an accident whose onset gives warning, and which is also easy of treatment, its occurrence does not require dis- cussion. The rationale of the action of chloroform is not clear. Added directly to blood, the drug affects the red cor- puscles, determining a shrinkage of their texture, and, if air be allowed free access, even their complete disap- pearance, presumably by oxidation of their substance. In narcosis from chloroform inhalation, however, there is no proof of any marked derangement of structure or of func- tion of the blood-discs, and the probabilities arc that the phenomena of narcosis result from direct action of the poison upon nerve and muscle tissue. And in such action clinical observations upon man and experiments upon animals combine to show that the nerve-centres in the brain and spinal cord are the parts most particularly affected. One special structure, however, seems pecu- liarly obnoxious to the action of chloroform, and that is the heart. For when brought into direct contact with chloroform, as by injection of the drug into the jugular vein of the living animal, or by the blowing of chloro- form vapor upon the exposed heart of a frog, the organ instantly stops beating, and its musculature relaxes and refuses to respond to any kind or degree of stimulation. The therapeutic applications of chloroform are locally as an addition to liniments for rubefaction, or, in dilute mixt- ure, as an anodyne for the relief of itching or of surface pains ; by the stomach, principally as an antispasmodic, notably in intestinal colics, where the power of chloroform is unrivalled ; and by inhalation, as an antispasmodic, an anodyne, or, carried to full narcosis, as an anaesthetic in surgical procedures. For the local uses of chloroform the U. S. Pharmaco- poeia offers Linimentum Ghloroformi, Liniment of Chloro- form, a preparation compounded of commercial chloro- form, forty parts, and soap liniment, sixty parts. In continuous application as an anodyne, this liniment should be applied under some air-proof texture, to pre- vent the dissipation of the chloroform by evaporation. Chloroform is also much used as a local anodyne in the form of an extemporaneous ointment, made by incorpo- rating one part of chloroform with eight or nine parts of some simple fatty basis. For giving by the stomach, chloroform itself may be pre- scribed in extemporaneous mixture with glycerin, muci- lage, or syrup. The dose ranges, for an adult, from a few drops to a teaspoonful. The latter dose, however, is a large one : will bs apt to be followed by decided nar- cotic symptoms, and often, also, provokes vomiting. If ordered by drops, it must be remembered that the drop of chloroform is unusually small, the number required to till the measure of four cubic centimetres (one fluidrachm) ranging from one hundred and eighty to two hundred and seventy, according to the circumstances of the drop- ping. Most commonly chloroform is given internally in the form of one or other of the following officinal prep- arations of the U. S. Pharmacopoeia : Spiritus Chloro- formi, Spirit of Chloroform. This is a ten-per-cent, solution of purified chloroform in alcohol-a strength only about one-half that ordered in the 1870 revision of the U. S. Pharmacopoeia. Dose, anywhere up to a tea- spoonful, diluted in some form of mixture. Mistura Chloroformi, Chloroform Mixture, is compounded of eight parts of purified chloroform, two of camphor, ten of fresh yolk of egg, and eighty of water. This mixture keeps well, dilutes smoothly with water, and so forms a convenient preparation for the giving of chloroform. Containing no alcohol, the dose can safely be proportion- ately greater than that of the spirit just described, and may be set at from one to two tablespoonfuls. For administration by inhalation, purified chloroform of known good quality is alone to be used, and is most commonly employed without admixture of other sub- stances, the vapor being breathed, diluted with air. Whether the inhalation be a. few whiffs only for the relief of pain or spasm, or whether it be for the establishment of full narcosis for anaesthesia, the fundamental principle must be observed to administer the vapor sufficiently diluted. Air overcharged with chloroform-vapor is cer- tain and swift death to all animal life, and the proportion of admixture for human inhalation should not exceed, for continued use, three and a half per cent, of chloro- form to air. When, therefore, chloroform is adminis- tered by the homely apparatus of a handkerchief or towel, the points should be observed not to put more than half a teaspoonful or so of the agent upon the towel at any one time, and to hold the cloth free from imme- diate contact with the face, so that the inhaled vapor may be mixed with abundant air. It is in this way that brief inhalations are practised for anodyne and antispasmodic purposes, and partly, perhaps, because of their brevity, and partly because of the existence of pain on the occa- sion of the inhaling, accidents under these circumstances are rare, except by inadvertence in the case of self-ad- ministration. For in such case, the inhalation being with the subject lying on his back, the towel or sponge holding the chloroform may fall upon the face during semi-unconsciousness, and so determine a fatal over- dosage. For obvious reasons self-administration should, as a rule, be professionally condemned, and allowed only in the case of adult patients of exceptional care and in- telligence, and then only under stringent orders to prac- tise the inhalation in the semi-recumbent posture, so that, should unconsciousness unwittingly come on, the hand holding the chloroform-charged towel will, in its paraly- sis, drop down and away from the face, and so further absorption of the poison be automatically prevented. In administering chloroform for the induction of full narcosis, the surgeon should first satisfy his conscience that he is morally justified, under the circumstances, in subjecting his patient to a procedure which, in spite of the utmost skill and caution, may kill. And if the sub- ject be an old toper, or a sufferer from any condition pre- disposing to heart-failure, such as shock, suspected fatty 103 Chloroform. Chlorosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. heart, congestion of the lungs, or uraemic or septicaemic poisoning, it must be remembered that the danger which always obtains will, in such case, be multiplied manifold. Justification being conscientiously felt, the operator must assure himself of the quality of his chloroform (see tests for purity, above), and settle upon his method of admin- istration. Two different methods are followed by differ- ent practitioners. The one is to maintain from the begin- ning, as equably as possible, a three-and-a-half-per-cent. charge of chloroform vapor in the air given for inhalation, and the other is to first administer a much higher concen- tration of vapor, and afterward, when anaesthesia is estab- lished, to reduce the percentage for further maintenance of narcosis to the ordinary standard. The theory on which this latter method is based is, that safety lies in a speedy and complete abolishment of the reflexes, which, of course, is most readily effected by early strong dosage with the chloroform. If this method be followed, how- ever, it is indispensable to promptly reduce the strength of the chloroform-charged air as soon as narcosis is de- clared, else death will almost certainly result. As to the comparative safety of the two methods, the writer of this article cannot venture an opinion, since he docs not know of any sufficiently extensive published experience of the method of rapid forcing for the basing of a sound judg- ment. The method being selected, the form of inhaler is the next matter to engage attention. The commonest used inhaler is simply a folded handkerchief or napkin, upon the centre of which the charge of chloroform-in the common way of giving, from one-half to one tea- spoonful at a time-is poured. The napkin is then held about an inch or so away from the mouth of the subject, the charge being renewed from time to time as the chlo- roform evaporates. This inhaler, however, while simple and handy, is intrinsically faulty, and its use, the writer believes, from a considerable personal observation, is dis- proportionately apt to lead to syncope. The trouble lies in the fact that, by the very nature of the plan followed for charging this inhaler with chloroform, the charge must vary in amount in wave-like fluctuations, and there- fore, correspondingly, must vary the chloroform-strength of the air inhaled. Very often, with this inhaler, syn- cope follow's the renewal of the chloroform-charge upon the handkerchief. Another equally simple inhaler is Simpson's, consisting of an opened handkerchief, laid lightly over the face of the subject in a single layer. Upon the portion of the handkerchief covering the mouth chloroform is allowed to fall drop by drop, the dropping to be so timed as just to make good by renewals the loss by evaporation. The nose and lips of the subject must be greased to prevent excoriation by direct contact with the chloroform-wet cloth. In this procedure, in skilled hands, quite an equable charge of chloroform can be maintained upon the inhaler, but the plan has the objec- tionable feature that it interferes too much with the free access of air. The air of expiration, itself of course charged with chloroform vapor, is, with this arrangement, liable to be re-inhaled, and thereby the percentage of chloroform in the air of inspiration to become unduly high. A modification of this device that retains its ad- vantages, while at the same time it is nearly free from the disadvantage described, is to stretch a porous material, such as thin flannel or merino, over a bowl-shaped wire frame, fitting the face, and upon the centre of this to drop the chloroform at a uniform rate. All these simple devices, however, failing as they do to secure an accu- rately determined percentage strength of chloroformized air, various apparatuses have been gotten up, looking to the correction of the failing. Of these, such as accom- plish the aim, as is the case with Clover's device of air- bags of fixed size charged with properly proportioned fixed quantities of chloroform, are to be recommended. Yet even such are not free from objectionable features; they are likely to be cumbrous, costly, and, if accident- ally out of order, unsuspectedly dangerous; and in field expeditions and out-of-the-way places-occasions when alone many surgeons feel justified in using chloroform at all-they are not to be obtained. Next in order for consideration in the giving of chloro- form for anaesthesia is the condition of the patient, and the following points should be looked to : the stomach should be fairly food-free, by the timing of the inhalation, when such can be done, at a period several hours after a meal, and by having such meal a light one, and composed of non-solid food; the clothing must be loose about neck, chest, and waist, so as to permit of full breathing : false teeth must be removed, and shortly before proceeding to the inhalation some cardiac stimulant medicine may or may not be administered. Some give a tablespoonful or two of spirits-brandy or whiskey, some a hypodermatic injection of a salt of morphine, about 0.01 Gm. (one-sixth of a grain) in quantity, and some avail themselves of the peculiar cardiac action of amyl nitrite, by combining about two per cent, of this ether with the chloroform to be used in the inhalation (Sanford). Others, and probably the great majority of administrators, give no stimulant. The subject, being ready, should be laid flat upon the table or bed, since the sitting posture per se favors syn- cope, and, if a woman, a female witness from among her friends or family should be required to be present. This requirement is in order to refute a possible charge of improper behavior on the part of the administrator that might otherwise be made in good faith by the subject by reason of a vivid erotic hallucination occurring during recovery from the anaesthetic. Proceeding to the inhala- tion, quiet throughout the room should be enjoined, and the administrator, with due regard to the responsibilities of his position, must mind nothing but his own business, and must mind that sharply, keeping constant watch on the pulse and respiration of the subject under his hands. Having obtained the condition of unconsciousness and muscular relaxation that follows a slight general tremor, the further giving of the chloroform is to be only such as may be necessary to maintain that condition during the period of the surgical procedure, without, if possible, forcing the further grade of narcosis characterized by stertorous breathing, dilated pupil, and entire abolish- ment of reflex winking upon touching the conjunctiva. As soon as the surgeon shall have done his work, the in- halation is to be discontinued, but the subject is to be kept flat and the administrator is to remain in attendance until recovery is practically complete. Neglect of these rules has often led to the supervention of an unnecessary syn- copal attack, which, when occurring, has also been recog- nized too late. Untoward events during chloroform-inhalation are to be treated as follows: Occlusion of the throat by falling back of the tongue is easiest obviated by slipping the lower jaw forward as far as its articulation will allow ; or the tongue may be seized and drawn and held free from the fauces. Stoppage of breathing by general muscular spasm, involving the muscles of the chest and diaphragm, should be treated by temporarily withdrawing the anaesthetic and making pressure upward upon the epigastrium, or even instituting a few passes at artificial respiration. Heart- failure, the one formidable accident of chloroform narco- sis, may be rendered manifest by flickering or disappear- ance of pulse, by characteristic pallor, or, in cases where the surgical operation is in progress, by sudden arrest of haemorrhage from cut vascular parts. Instantly upon recognition, decisive measures at resuscitation must be instituted. The chloroform administration is, of course, to be at once stopped, and artificial respiration, coolly, systematically, and efficiently done, should be practised, care being taken to begin with a full expiratory act, in order to drive out what chloroform-charged air is present in the trachea and bronchial tubes, and to see to it that the tongue does not block the throat. Assistants mean- time should apply heat to the chest and extremities. The procedure commonly so effective in an ordinary fainting fit, of dashing cold water upon the face and bared chest, should most punctiliously not be practised. For it will, in the first place, utterly fail of effect, because of the chloroform-abolishment of the reflex by which its effect is brought about, and, so failing, will, in the second place, work positive harm by the depression of heart and lung activity wrought by the cooling. Another procedure much in vogue of late is to carry the heels upward until the 104 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chloroform. Chlorosis. subject rests head, neck, and shoulders only upon the table. The principle of this inversion is to re-excite heart-action by mechanically pouring from the lower ex- tremities a full tide of venous blood into the right heart. But, as Eben Watson, of Glasgow, points out (Lancet, March 10, 1883), in chloroform-syncope, as has been abundantly shown post mortem, the very condition of undue engorgement of the right heart and contiguous great veins, and of congestion of the lungs, is markedly present, and is a probable factor in the maintenance of cardiac embarrassment. The Nelaton inversion of the body is therefore certainly, as Watson maintains, a questionable procedure in syncope from the present cause. Artificial respiration is then, after all, probably the most reliable means for effecting resuscitation, and in chloroform-syncope, as in suspended animation from drowning, the rule should invariably obtain to persevere for at least an hour before abandoning the unfortunate subject as hopelessly dead, and this despite a prolonged and complete absence of all sign of life. Resuscitation having been effected, only a hardihood difficult of under- standing would prompt a renewal of the administration to a subject thus proven dangerously prone to syncope. A last mode of medically using chloroform is by deep injection by means of the hypodermatic syringe for the relief of neuralgia. About two cubic centimetres (half a fluidrachm) is injected at a dose, but the procedure is a harsh one, severe local reaction having several times fol- lowed the practice. In the matter of the toxicology of chloroform, the first point to note is that chloroform taken by swallowing, even undiluted, is much less dangerous than would be supposed. The smallest fatal dose of which the writer has read was a drachm taken by a child four years old (Taylor). Boehm (" Ziemssen's Cyclopaedia") mentions half a fluidrachm as a fatal dose, but does not give the age of the subject. On the other hand, doses of from half an ounce to four ounces (presumably fluidounces) have been reported as recovered from. The symptoms in poisoning by swallowing, are the production of a nar- cosis generally similar to that induced by inhalation of chloroform, with, also, in many cases, gastric troubles due to the direct irritation of the potion. The treatment must be conducted upon general principles, as there is no chemical antidote to the drug. The topic of poisoning by inhalation has been already presented, and it only re- mains to note a point of possible importance from a medico-legal point of view. That is, whether it is possible to narcotize a sleeping person by chloroform inhalation without the subject's first awakening from the natural slumber so as to become cognizant of the attempt. The question happens to be one lately raised within the pro- fession, and quite a number of reports of experiments have recently been made, some recording only repeated failures, but others, on the contrary, giving such clear accounts of successes that in the opinion of the writer the possibility of the procedure must be conceded. Edward Curtis. rosis, there being no enlargement of the spleen nor of the glands, not even of the thyroid, except in a few instances, nor multiplication of leucocytes in the blood as in those affections in which the spleen and the lymphatic system participate in spansemic or leukluemic processes. From the paleness of certain extreme anaemic states in renal disease, chlorosis is easily distinguished by the absence of any true signs of disease in the urine, which, though usually of a pale color and of a low specific gravity, with deficient urea, yet has neither albumen, nor casts, nor any other indications of kidney disorder. From cancer- ous anaemia it is distinguished by the absence of the char- acteristic cachexia and by the youth of the patients, as well as by the absence of either tumor or pain. From the anaemia of heart disease, with which it may be con- founded owing to the frequent presence of cardiac mur- murs and palpitation in chlorosis, it may be distinguished by the want of any signs of hepatic or renal engorgement and by the absence of dropsy. Lastly, it should always be practicable to distinguish it from the many forms of febrile anaemia, of which phthisis is an example, by the absence of fever, and likewise of emaciation. It is the special characteristic of chlorosis, indeed, that there is no emaciation, however extreme in degree its anaemia be- comes ; rather, there is often a tendency to increase of fat and of albumen in the blood. If the blood may be prop- erly termed a tissue, then blood emaciation may be said to accompany all the above-enumerated anaemias, for besides the deficiency of red corpuscles in them there is also a great waste of all the non-mineral ingredients. This is especially true of febrile anaemias, for the fever process consumes not only the fat, the muscle, and the bone of the body, but it particularly diminishes the albuminous constituents of the blood. In chlorosis, however, the loss seems to be limited to the red corpuscles alone. The leu- cocytes are not decreased in number, while the albumen of the serum, as a rule, is actually increased. Becquerel and Rodier found the percentage of albumin- ates in the blood, in six cases of chlorosis, as high as 72.1 per millimetre, instead of 57.0 per millimetre, the average in health. On the other hand, certain cases of gastric or intestinal dyspepsia severe enough to cause malnutrition by starvation, may be confounded with chlorosis, es- pecially as gastralgia, with or without gastric ulcer, is not uncommon in chlorotic patients. The development of the case, however, is generally sufficient to determine the question, for instead of the anaemia preceding the dys- pepsia, as it does in chlorosis, it appears as a late result of gastric or of intestinal catarrh, after a more or less pro- longed history of pain, vomiting, or diarrhoea, with at last a marked loss of flesh as well as of color. More difficult, in some respects, is it to distinguish chlorosis from certain cases of that little-known disorder to which the term, pro- gressive pernicious anaemia, has been applied. Some of these so-named cases, especially those with a tendency to haemorrhages and extravasations und^r the skin, which have been described in medical journals, may have been suffering from chronic ulcerative endocarditis ; others from unrecognized haematozoa ; but there still remain a number of instances of a fatal anaemia in which the au- topsy shows nothing explanatory of an extraordinary im- poverishment of the blood, which continued to progress without check from the first sign of its existence. The difference of this malignant form of anaemia from chloro- sis is, then, usually deducible from the steady march of the disease to a fatal issue, wholly unaffected by the rem- edies which are so efficacious in chlorosis; from the re- current attacks of fever ; and lastly, from the greater age of the patients, many of w hom show the first symptoms of the complaint either during or after pregnancy. Symptomatology. - Owing to the great variety of causes of anaemia, it is well, in any suspected case of chlo- rosis, to make some such review as the preceding of the dif- ferent forms of blood impoverishment, and, if the case does not come within the requirements of either, but presents a more or less marked correspondence with the symptoms and conditions about to be detailed, to consider it then as a specific morbid state of the blood, which is in some way related to the development of puberty, at least in CHLOROSIS.-Chlorosis is a term applied to a specific form of anaemia often characterized by a greenish-yellow tint of the complexion (whence the derivation of the name, xkupos, yellowish-green), which occurs in young persons about puberty, and rarely for the first time after twenty years of age. For the purpose of distinguishing it among the many diverse forms of anaemia, and in order to show cause for regarding it as a separate and special morbid con- dition of the blood, we may state: 1, that it differs from the sallow anaemia of chronic hepatic disorder by the entire absence of a jaundiced tint in the conjunctiva, the bluish transparency of the sclerotic being distinctive of chlorosis; there is also no enlargement of the liver, nor do we find the rough parchment-like condition of the skin, with movable folds from want of subcutaneous fat, which distinguishes hepatic marasmus, for the skin of chlorotics is of silky smoothness, and particularly well rounded or plump. The same contrasts, except in color, also distin- guish chlorOsis from anaemia due to splenic disorder, for paleness alone without other cachexia is the feature of chlo- 105 Chlorosis. Chlorosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. women. It has been asserted, especially by older writ- ers, that chlorosis occurs in both sexes. According to all, however, the preponderance in females is so very great, the etiological factors in the genesis of the disorder con- nected with their sex are so distinct, and other forms of anaemia, superficially resembling chlorosis, which may occur in boys are so numerous (e.g., from scrofula, cret- inism, onanism, malarial infection, etc.), that for one I do not believe in male chlorosis any more than I would see analogies to the morning sickness of pregnancy in the vomiting before breakfast of some male dyspeptics. Chlorosis usually begins in a young girl not long after the establishment of the menses, and in the majority of instances it dates from some derangement occurring dur- ing or near the time of her courses. As is well known, many healthy women begin to grow pale even before the menses commence to flowT, this apparent anaemia often continuing through the period, out of all proportion to the loss of blood which takes place ; for a similar loss from haemorrhoids, for example, would not cause such changes in the complexion. As the disorder itself is wholly painless, and sometimes rather rapid in its devel- opment, the paleness may be the first symptom of chlo- rosis which attracts notice. There is also much that is quite distinctive in the hue of the patient. It is evidently due to a fading of the coloring matter of the blood itself, for the mucous membranes participate equally with the skin in the change. The lips, which, especially in youth, have such a fresh living tint that but few processes of dis- ease ever affect it, are more blanched by chlorosis than by the extremest emotion of fear. The difference in this particular from the countenances of the phthisical is striking, for in them the lips often seem redder than nat- ural, from the contrast between the whitened skin and the still well-colored mucous membranes-a contrast which indicates a fundamental difference between these two forms -of blood impoverishment. Another distin- guishing mark of chlorosis is the yellowish-green tint, usually most pronounced about the folds of the well-filled and rounded cheeks. This is a positive discoloration, and not, as some writers guess, a bleaching out of a dark or brunette complexion ; for it is equally observable in many blondes, while on the other hand it is rare to find anything like it in other forms of anaemia, even though they be non-febrile, as in the anaemia of Bright's disease, in which the most pronounced brunettes do not turn either yellow or green. As above stated, this discoloration in chlorosis is not properly a form of jaundice, for the con- junctiva is perfectly colorless, and no traces of bile-pig- ment can be found either in the urine or in the other secretions. But that it has some connection with a de- rangement of the normal destructive metamorphoses of the red corpuscles which take place in the liver, is ren- dered probable by the markedly pale color of the faeces in chlorotics-a fact which would be more often noticed but for the prompt administration of iron to these pa- tients, which quickly masks this indication of deficiency in the coloring matter of the evacuations. As already in- timated, chlorotics usually are not emaciated, but often so much the reverse as to lead to the natural mistake that they must be dropsical. True anasarca, however, is so uncommon that we may exclude a case of the kind as not chlorotic, ^ut anaemic from some other form of dis- ease. Next to the anaemia the most significant symptoms are connected with the functions of the alimentary canal. Here the earliest departure from health is generally an obstinate constipation, whose relation to the genesis of the disease itself is often not sufficiently appreciated. After a time the intestinal paralysis extends higher up, and is accompanied by the formation of great quantities of flatus, which give rise to the loudest and most annoy- ing borborygmi. Ere long another train of very sugges- tive symptoms develop, connected with the innervation of all the organs of alimentation. The appetite first fails and then becomes perverted, or insane, as it has been aptly termed. The patients do not know what they want to eat or drink, and yet they are likely to have every kind of suggestion occur, sometimes for the most repulsive articles. As a rule the ability to digest fats fails first, and on that ac- count the patients crave sour or tart things like vinegar, pickles, etc. A distaste for meat soon follows, and this is succeeded by fits of inability to take food in any form, soon to give place to an unnatural desire for something, which may lead them to try to eat the first thing at hand, like slate-pencils, clay, etc. The similarity, in kind, of these symptoms with those of early pregnancy, and with nothing else, are enough to indicate that the origin of chlorosis, in most cases at least, is to be traced to some form of pelvic irritation. As wre shall soon see, there is no condition in which the secretions of the whole diges- tive tract may become so extraordinarily changed as in chlorosis, and this element in the causation of the anaemia, therefore, should not be lost sight of. Directly dependent upon the diminution of the red corpuscles, and the consequent deficient absorption of oxygen, is the next great characteristic of chlorosis-mus- cular debility. Throughout the animal kingdom muscu- lar power is always proportioned to the activity of the res- piration, for oxygen is the most necessary to the muscular function of all others in the body. The heart, even if hypertrophied, is weak and very irregular in its action, and the patients are easily fatigued by the slightest exer- tion. The breathing is quick and shallow, and the pa- tients are soon rendered breathless by going up-stairs. On the same account the visceral muscles are equally sluggish, muscular atony being the true reason for a great variety of the patient's troubles, such as the above-men- tioned constipation, and often an ineffectual cough, which may suggest the presence of phthisis, but which soon dis- appears with the improvement in the blood by treatment. The pulse is that of anaemia generally-small, easily com- pressible, and easily quickened. Occasionally, when the debility of the circulation is very great, there may be some puffiness from slight oedema about the ankles, but it rarely increases beyond that amount. As in other forms of anaemia, we often find a systolic murmur, es- pecially at the apex of the heart, which is merely func- tional, as it disappears with the cure of the disease. The bruit de diable, or venous hum over the jugulars, is also very frequently observable and sometimes extraordinarily loud. The origin of these haemic murmurs has been a favorite theme of speculation, and the commonest ex- planation of them as due to thinness of the blood is shown by chlorosis to be false, because the blood in this disease, though it be wanting in red corpufecles, is thicker than natural from hyperalbuminosis of the serum. The men- tal condition of chlorotics is not distinctive among the anaemias. Often the patients seem to be lethargic, or slow both in thought and comprehension ; more generally they are depressed in spirits, and not infrequently hysteri- cal, with much capriciousness of temper and disposition. With reference to the state of the menses, it should be noted that chlorosis and amenorrhoea are not convertible terms, for in some the menses continue regularly, and oc- casionally to such an extent that Virchow speaks of a menorrhagic form of the disease. The few cases of the kind, however, do not justify such a position being assigned to them, because in every form of anaemia it hap- pens that the poor state of the blood, conjoined with a cer- tain thinness or malnutrition of the vessels, with hyper- trophy of the left ventricle, causes, in some anaemic pa- tients, a haemorrhagic tendency, which may thus affect also the menstrual flow. Course.-Chlorosis is not a self-limited disease, but is of very uncertain duration, with no tendency to spontaneous cure. On the other hand, in the majority of cases it is remarkably amenable to treatment, yielding in the course of a few weeks to the proper medication and regimen, after nature has in vain allowed months to pass by without a favorable turn. Usually, also, a single cure is enough, the morbid condition never returning throughout life. In others there is a more or less persistent tendency to relapse, though in them, also, proper treatment is likely to relieve the symptoms as often as they occur. In others, however, the anaemia persists, with gradually in- creasing severity, until the whole nutrition of the body suffers, and textural derangements develop in various 106 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chlorosis. Chlorosis. organs, but notably in the stomach and intestines. Gas- tric catarrh, gastrodynia, and vomiting become leading symptoms, along with pain, flatulence, and diarrhoea, until the patients sink from exhaustion. The indication most decisive of an unfavorable course in chlorosis is emaciation, best seen on the dorsum of the hands. It is much more common to have chlorosis cause death, not as a direct result of its operation, but from its lowering the resisting power of the system to injurious influences of all kinds. Such patients are particularly liable to con- tract inflammations, or to become subject to infection, and then a pneumonia or a fever befalling them is apt to assume a severe type. The same may be said of the liability of chlorotics to phthisis, and to a less degree to Bright's disease. Pathology.-It is not easy to decide whether the changes of the blood in chlorosis, which, as we have seen, point to a pure deficiency of haemoglobin, consist in an actual diminution of the number or proportion of the red corpuscles, or whether they are due to a deficiency of the coloring matter of the corpuscles only. That this latter condition is the case seems probable from the rapid re- turn of the blood to a healthy tint when iron is adminis- tered ; whereas, in other forms of anaemia in which it is evident that the corpuscular element is consumed equally with the albuminates of the serum, it is very difficult, comparatively, to cure the anaemia. Observa- tions on this point, however, are wanting, except that of Duncan, who, in two'cases, concludes that the color of the blood was only one-third as deep as normal, while the corpuscles in number were about the same as in health. He found also that the corpuscles took a longer time to sink through the stratum of serum in a test-tube than is the case in healthy blood, from which he con- cluded that they were of lighter specific gravity than usual, owing to the small quantity of haemoglobin which they contained. Becquerel and Rodier's observations on the proportion of red corpuscles remain but little affected, as regards the general correctness of their conclusions, by subsequent researches. In six cases examined the pro- portion varied between 109.17 and 45.37 per cubic milli- metre, while eight healthy women, from twenty-two to fifty-eight years of age, gave from 113.0 to 137.5 As the proportion per cubic millimetre in their blood. The interesting question of the origin of this disease is not readily answered. Rokitansky and Virchow, from post-mortem investigations, pronounced chlorosis to be de- pendent upon arterial malformation, because in the bodies of patients who had died while suffering from chlorosis, a remarkable diminution in the calibre of the aorta and of the large arteries was found, so that Rokitansky com- pares the aorta of chlorotics in size to the iliacs of healthy persons. That such malformation has any essential con- nection with chlorosis is wholly negatived by the fact that the disease itself is a very curable one, the great majority getting well after proper treatment; which would not be the case if they were the victims of a congenital malfor- mation. It can hardly be supposed that iron pills can cure the disease by readily dilating a very small aorta, and hence this anatomical explanation of chlorosis can have place only as a probable complication, which makes a given case severe, so that relapses are constantly oc- curring. Too small arteries, then, must be regarded as aggravating a chlorosis when it occurs, by heightening the tendency to malnutrition and anaemia. How such a condition of the vessels causes only diminution of red cor- puscles, but not of the leucocytes nor of the albumen ; and, lastly, why small arteries should be thus operative only in females, are questions which this theory does not begin to explain. Another observation made on the con- dition of the vascular system, has, as we shall see, a more appreciable relation to the genesis of the disease. The arteries themselves are abnormally thin throughout, ow- ing to atrophy of their middle or muscular coat. The vessels are not more brittle than usual, but the intima is often waxy, alternately thickened and attenuated, giving an appearance of striae of dull yellowish color. We incline altogether to the view that chlorosis origi- nates in a nervous irritation produced by external cold alone, and rarely by anything else, which is felt or spent upon the nerves of the female organs of generation in the first instance, and then radiated to the nervous ap- paratus which regulates the functions of the digestive or- gans. This irritation of cold occurring under circumstan- ces favorable for this effect, i.e., when applied to the feet while the ovaries are excited by the process of ovulation, produces a permanent effect upon the circulation of the pelvic viscera first, and of the other abdominal organs afterward ; an effect wholly similar to that sometimes caused by a puncture or mechanical irritation of a nerve of the arm or leg, like the musculo-spiral or anterior tibial. An irritation of this kind, seemingly most trivial in its inception, sometimes will be followed by far-radiat- ing pains, contraction of all the arteries of the limb, with consequent tonic and progressive contraction of the muscles and coldness and wasting of the whole limb, un- less arrested by treatment. Often it has been found neces- sary to cut the trunk of the irritated nerve across before the circulation will return to the affected part. If the arteries of the contracted arm or leg could be examined after the condition had lasted for a length of time, it is very probable that the same atrophy of their middle and inner coats would be found as in the case of chlorotics, for the simple reason that nothing tends so rapidly to atrophy of muscular structures as the condition of tonic contraction, which interferes with the supply of blood to the affected muscles,-in this instance kept contracted by the permanent vaso-motor irritation. A remarkable case, published by me in " Transactions of the State Medical Society of New York " for 1867, illustrates very fully these considerations on the origin of chlorotic states of the blood. The case was that of a girl who got a wetting in a cold thunder shower while she had her courses. They were immediately arrested, but she took no notice of any effect therefrom until she became so constipated that she passed a week without an evacuation. She was obliged then to admit that this was the case to her teacher at school, because of the excessively loud borborygmi which were heard by all in the class-room. Two physicians wTere called in consultation, who, finding they were un- able to cause a movement, and stercoraceous vomiting having set in, summoned Dr. White, of Buffalo, late Professor of Obstetrics in the Bellevue Medical College of New York. He diagnosed intestinal obstruction, and advised a course of treatment which produced a number of free movements, which were remarkable for the almost total absence of any color, the faecal lumps resembling coarse plaster. On my seeing the case and recommending a free use of nitro-muriatic acid, some copious " bilious" discharges followed, and hopes of re- covery were entertained, when the same constipation and stercoraceous vomiting returned, along with a singular and very different train of symptoms. Her urine was sud- denly suppressed one morning, but in twenty-four hours the saliva and tears welled out to the extent of from one to three pints a day. This continued for about a week, with total suppression of urine meantime, when it as sud- denly ceased and the urine recommenced as before ; and this strange alternation of secretion recurred again and again, about every week, for two months, with alternate arrest of the bowel movements to be followed by faecal vomiting, until the death of the patient occurred from sheer exhaustion. This instructive case at least proves that a shock of cold proceeding from the feet may not only arrest the menses by reflex irritation, but also proceed to paralyze the rectum and large intestine, and then con- tinue to spread from one sympathetic ganglion to another, until the entire association of secretory nerves becomes de- ranged in turn, and the whole process of alimentation becomes perverted. That the disturbances of early preg- nancy present us with derangements the same in kind, is familiar to every one, and there seems to be no intrinsic improbability in the supposition that a more serious dis- order may be propagated from the same region, and im- poverish the blood by suspending both gastric and in- testinal functions, by an irritation whose efficacy is shown in the beginning by its sudden arrest of the menstrual flow. It has been a constant observation of mine, that 107 Chlorosis. Cholagogues. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. long antecedent to the development of the special symp- toms, chlorotic girls have suffered from coldness of the feet, often with repeated muscular pains in the lower ex- tremities, indicative of a pelvic vaso-motor irritation. When it is considered also how often girls expose them- selves to chill of the feet, especially on retiring to bed, by long delays in undressing, it need not be wondered at that chlorosis is such a widely distributed affection. Treatment.-There are few complaints in which the good effects of treatment are more palpable than in chlorosis. It is one of the evidences, in fact, that a case of anaemia is not chlorotic, if it does not show any result from medication, for even in the most relapsing forms of the disease, iron will show its powers as often as it is administered. The effect of iron, indeed, is specific in this malady, for it succeeds better when given in free doses than when given in small ones. This well-estab- lished fact shows us that the action of iron in anaemia is not as simple as many routine practitioners imagine. It is not because iron assists in making corpuscles, or be- cause the corpuscles contain iron, for the best results are obtained when we give more iron by a hundredfold than the corpuscles can possibly take up, and not when we ad- minister the remedy in small doses,-presumably physi- ological, because more like the very small quantities of this metal which reach the healthy blood from the food. If swallowing material suitable for the nourishment of corpuscles makes them, then cod-liver oil should make more corpuscles than iron, as there is twice as much fat, by weight, in the corpuscles as there is iron. But whereas this oil enriches the blood with red corpuscles much oftener than iron does in anaemia, it does not accomplish this in chlorosis, and is generally contra-indicated from the inability of the patient to endure fats of any kind. Iron, therefore, is the remedy to be employed here, but it still remains one of the most difficult of foods to assimilate, because of the free supply of digestive secretions (as after well-relished meals) which is needed to take it up, and in chlorotics these secretions are nearly as deficient as in fever. One of the most effective adjuvants, therefore, in a course of iron, is repeated heating of the feet, so as to neu- tralize the pelvic irritation which is so potent a factor in suspending both the gastric function of appetite and the intestinal peristalsis. An occasional cathartic is also de- cidedly beneficial, and may be profitably employed in alternate doses of one or two glasses of hot Carlsbad water in the morning, and compound rhubarb pills taken at night, at intervals of three or four days. Having done this, the iron is to be continued without intermission un- til the anaemia is removed ; the form of administering the metal not being of much consequence. Experienced practitioners generally become wedded to some one form of iron, because their first case of chlorosis happened to be treated by it, and their success impressed them with the fancy that the particular preparation had a great deal to do with the result; but it is doubtful if there be much choice between the multitudinous salts and liquid prep- arations of iron, except, perhaps, in avoiding the consti- pating or astringent forms of the drug. My own prefer- ence in administering iron for chlorosis is according to the following formula: 1J. Ferri sulph., 3 j. ; kal. carb., 3 j. ; pulv. nucis vomicae, 3 ss. ; bismuth carb., 3 j. ; ext. gentianae, q. s. ; f. pilul. xxx. S. One or two after meals. If there be much torpor of the gastric functions, espec- ially nausea or perversion of desire, the most effective remedy is to follow each dose of iron with a teaspoonful of spts. ammoniae aromat. in a wineglass of water. William H. Thomson. the faeces was held to be a certain criterion of the quan- tity of bile secreted : dark-colored stools indicating re- dundancy, light-colored ones deficiency of bile. Medi- cines which produce highly-colored motions, it was supposed, greatly augment "the secretion of bile. But the researches of physiological chemists have given little support to this theory. While it was found in experi- ments on animals in which biliary fistulae had been made, and in observations on men with accidental biliary fistu- lae, that a considerable quantity of bile is secreted in twenty-four hours, only minute quantities could be de- tected in the faeces. From this it became evident that by far the greater part of the bile is re-absorbed into the blood. Besides, it was ascertained that the solid constitu- ents of bile, especially the pigments, suffer great changes in the intestines, and that these may vary much in health as well as in disease, depending upon the length of time the bile sojourns in the alimentary canal, the kind of food eaten, and other unknown conditions. Hence it followed that the color of the faeces affords no clue to the quantity of bile secreted. It became extremely doubtful, there- fore, whether the medicines which produce high-colored stools have any influence on the biliary function. But still greater doubt was created as to the existence of cholagogues by the results of the earliest experimental investigations on the physiological action of medicines on the secretion of bile. These seemed to prove that the most esteemed cholagogues, especially the mercurials, exert no influence whatever on the secretion, except to diminish it when they are administered in large, purgative doses. The most recent researches, however, have fully vin- dicated the ancient theory. They have conclusively es- tablished not only that some of the medicines formerly supposed to possess cholagogue powers do notably in- crease the biliary secretion, but that some others which do not alter the color of the faeces in health also possess this property in a high degree. They have also led to the very important discovery, that certain medicines cause an increased secretion of bile without in the least affect- ing the action of the intestines. Cholagogues, therefore, may be considered in two groups : First, those which act upon the liver but do not influence the intestines, and, secondly, those which in- crease the activity both of the liver and the intestines. Cholagogues which have no Purgative Action.- To this group belong salicylate of sodium, benzoate of sodium, benzoate of ammonium, bicarbonate of sodium, nitro-liydrochloric acid, ipecacuanha, and phosphate of ammonium. Salicylate of Sodium.-This medicine has been much employed as an antipyretic in various febrile affections, and as a specific in acute rheumatism, since first recom- mended by C. E. Buss,1 in 1875. Although large doses were administered, no effects were observed which could be attributed to an increased secretion of bile. The credit of the discovery of its cholagogue action belongs to Pro- fessor Rutherford.2 Having found experimentally that the benzoates increase the bile-flow, he supposed, from the chemical similarity of salicylic and benzoic acids, and from the fact that both combine in the body with glycocol, that salicylate of sodium would exert some effect on the secretion of bile. A series of experiments on dogs with permanent biliary fistulae gave a positive re- sult. Within half an hour after the salt was injected into the duodenum, a marked increase of the bile-flow en- sued. The dose administered was small, in one experi- ment twenty-five grains, in all the other experiments twenty grains. Rutherford gave a man thirty grains at night, and next morning a dose of sulphate of magnesium, and felt convinced that there was an increased discharge of bile. The more recent researches of Lewaschew3 have con- firmed the results obtained by Rutherford. This ex- perimenter also employed dogs with biliary fistulae, but in all instances he gave the medicine internally. He found that the quantity of bile secreted became greatly increased within an hour after the administration of one- half gramme. Such small doses sometimes failed to CHOLAGOGUES-This term is applied to medicines which increase the secretion of bile. It has been in use for more than two thousand years. The ancients ob- served, after the administration of certain purgative medi- cines, that the faeces became markedly yellow or dark. They supposed this change of color to be due to an in- creased secretion of bile, and hence distinguished the pur- gatives producing it from others by the term cholagogues. Until recently clinical experience afforded the only evidence of the existence of cholagogues. The color of 108 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chlorosis. Cholagogues. augment the bile-flow, which never occurred when the dose exceeded one gramme. Larger doses than two grammes did not produce a corresponding increase, the maximum effect resulting from doses of one to two grammes. The increase of the bile-secretion lasted longer than after any other soda salt, being evident for twenty- four hours, and sometimes for several days. Lewaschew Carefully examined the bile. He found the solids in- creased, but the water much more, so that the bile was very fluid. From the experiments on dogs, and the observation of the action of thirty grains on a man, wre may infer that doses of fifteen to thirty grains will cause an increased flow of watery bile in patients with catarrhal jaundice, or other conditions of the bile-passages fairly attributable to inspissation of bile or accumulation of mucus. In several cases of catarrhal jaundice recently observed by the writer, the administration of fifteen grains of salicylate of so- dium three times in the day, and a laxative pill at night, was rapidly followed by colored stools. Benzoate of Sodium and Benzoate of Ammonium.-Ben- zoic acid was recommended in diseases of the liver, especially in catarrhal jaundice, by Falck and Justi in 1857. This recommendation was based on theoretical considerations. As is well known, benzoic acid in the organism combines with glycocol to form hippuric acid, which is eliminated with the urine. Experiments made by Kiihne and Hallwachs seemed to prove that this chemical change takes place in the liver. Theory also pointed to the liver as the organ in which benzoic acid unites with glycocol. Glycocholic acid, one of the con- jugate bile-acids, consisting of glycocol and cholalic acid, is formed in the liver. Since this compound originates in the liver, it seemed not improbable that other com- pounds of glycocol might be formed. But it was shown by later experiments that hippuric acid is formed chiefly, if not entirely, in the kidneys. The recommendations of benzoic acid fell with the theory on which they were based. Certain practical physicians, however, who had employed the acid in catarrh of the bile-ducts and in hepatic congestion were convinced of its utility. For several years benzoate of sodium has been much employed as an antipyretic and antiseptic. Notwith- standing the administration of large doses, no action on the biliary function was observed. That, however, it markedly affects the bile-secretion was conclusively proved in the careful experiments of Rutherford and Dodds (op. cit., p. 111). These investigators found, after the ad- ministration of twenty-grain doses, that the flow of bile became rapidly and decidedly increased. The composi- tion of the bile secreted under the influence of benzoate of sodium was not determined, but from the results ob- tained by practitioners in catarrh of the bile-ducts, and from the now well established fact that some other so- dium salts render the bile very fluid, it is very probable that the water is more increased than the salts of the bile, Benzoate of ammonium in the dose of twenty grains also rapidly increased the flow of bile, and Rutherford considered it equally as powerful as the sodium salt. It would seem, however, to be a less eligible cholagogue, as it caused more irritation of the mucous membrane of the small intestine. The dose of benzoate of sodium as a cholagogue need probably not exceed thirty grains. As a rule, it should be given in the evening and followed, if necessary, by a purgative on the next morning. Doubtless fifteen grains, taken three times daily, would exert a very decided in- fluence. Bicarbonate of Sodium.-It has long been observed that mineral waters containing a notable quantity of this salt are of decided utility in catarrhal jaundice, hyperaemia of the liver from dietetic excesses or malaria, and to dis- solve gall-stones and prevent their reformation. Frerichs 4 entertained the opinion that alkaline mineral wTaters, es- pecially Carlsbad, Vichy, Marienbad, Ems, and Eger, produce a copious secretion of alkaline bile, and that such bile exerts a solvent effect upon cholesterin, mucus, and lime salts. Hence, very watery alkaline bile may loosen gall-stones, dissolve their connecting material, and thus lead to their mechartical destruction or comminution. Ewald5 also attributes to the alkaline mineral waters the property of increasing the secretion of bile, and rendering it more watery and alkaline. Murchison 6 held that the undoubted utility of alkaline mineral waters and alkalies in cases of gall-stones is due to improvement of the gen- eral health, reduction of hepatic congestion, and such alterations of the bile as prevent the formation of fresh concretions. The eminent writers on diseases of the liver and bile- passages referred to based their opinions on clinical ob- servations. These had, indeed, conclusively proved the utility of alkalies in affections of the bile-passages, but not that they act by rendering the bile more watery and alkaline. Nor did the experimental researches on the physiological action of alkalies on the secretion of bile, until very recently, sustain this view. Hence, nearly all writers on Materia Medica maintain that the utility of alkalies is due to direct action on the mucous membrane of the bile-passages. Experiments with bicarbonate of sodium on dogs with artificial biliary fistulas have been made byNasse, Rohrig, Rutherford and Vignal, and Lewaschew. Nasse and Rohrig found a decrease of the secretion of bile, but Rutherford and Vignal a slight increase. The methods adopted by Nasse and Rohrig were faulty, and the ex- periments performed by Rutherford and Vignal too few to be decisive. Lewaschew (op. cit., p. 104), made a large number of experiments with doses varying from one-half gramme to thirty grammes. One gramme or less did not alter the bile either in quantity or consistency, but larger doses decidedly increased it, and rendered it more watery, the maximum effect resulting from four grammes. The change in the composition of the bile occurred when the dry salt was administered, but was more pronounced when it was given dissolved in a large quantity of water. These experiments prove the correctness of former clin- ical observations, and establish beyond doubt that bicar- bonate of sodium is a powerful cholagogue. From the fact that small doses failed to increase the flow of bile in Lewaschew's experiments, it may be in- ferred that the dose for man should not be less that twenty or thirty grains, and that the medicine should be admin- istered in a large quantity of water. Nitro-hydrochloric Acid.-This acid has been employed in jaundice and hepatic diseases attended with a lessened flow of bile. The opinions of good observers as to its utility differ widely. Its good effects have been explained by some writers as due to improvement of the digestive process; others have held that, by acting upon the mu- cous membrane of the duodenum, it causes a reflex ex- pulsion of bile from the gall-bladder and bile-ducts. Its physiological action on the secretion of bile has been investigated by Rutherford and Vignal (op. cit., p. 86). They performed two experiments on dogs with biliary flstulae. In the first the result was negative, but in the second a very decided increase of the bile-flow ensued. From this they concluded that the acid is a hepatic stimulant of considerable power. Although one experi- ment hardly warrants such a conclusion, yet the positive result obtained sustains the observations of many clini- cians, and justifies the employment of the acid in appro- priate cases. The dose of the dilute acid is from ten to twenty drops. It should be diluted with a large amount of water and im- bibed through a glass tube after meals. Ipecacuanha.-This medicine has been highly extolled in the treatment of dysentery. It has often been ob- served that large doses, when retained, soon cause the stools of dysenteric patients to become feculent, and yel- low or dark. In catarrhal jaundice, also, the dejections have rapidly become colored after other remedies had been used in vain. Hence it has been inferred that ipe- cacuanha increases the flow of bile. Physiological in- vestigations have proved that it is a powerful cholagogue. Experiments on dogs with biliary flstulae, to determine its influence on the bile-flow, were made by Rutherford and Vignal (op. cit., p. 54). In all their experiments, four in number, the amount of bile secreted became rapidly 109 Cholagogues, Cliolagogues. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and decidedly increased. Small doses, three grains, acted nearly as powerfully as very large doses, sixty grains. The bile secreted was carefully examined, and found not to differ in composition from the bile collected before the administration of the medicine. As the investigators had clamped the cystic duct of the dogs, and the augmented bile-flow was too prolonged to be attributable to contrac- tion of the bile-ducts, they concluded that ipecacuanha has the power of stimulating the secreting apparatus of the liver. Future clinical observations will have to determine in what affections of the liver or other organs the cholagogue power of ipecacuanha may be utilized. Since it does not alter the composition of the bile, it would seem to be less eligible in catarrhal jaundice than the cholagogues which render the bile more watery and alkaline, especially the salicylate, benzoate, bicarbonate, sulphate, and phosphate of sodium. Phosphate of Ammonium.-Rutherford and Vignal (op. cit., p. 119) investigated the action of this salt on the bile- secretion of the dog, and found that twenty grains pro- duce a very decided and prolonged increase. In man no action on the liver has been observed, probably because it does not purge. Whether it alters the consistency of the bile was not determined. 2. Cholagogues which have a Purgative Action. -This group comprises a large number of medicines. Most of them will probably not be found available in cases requiring cholagogues. These we shall merely mention. The others we shall consider briefly, as space permits us to give only a short account of the researches establishing their cholagogue action. Sulphate of Sodium.-This salt is the principal constit- uent of certain alkaline mineral waters, as Carlsbad and Marienbad, long celebrated in diseases of the liver and bile-ducts. It is the well-known saline purgative called Glauber's salt, which, on account of its nauseous taste, is now less used than formerly, sulphate of magnesium being generally preferred. It should be recollected that the latter salt has no cholagogue action. The influence of sulphate of sodium on the bile-secre- tion has been investigated by Rutherford and Vignal (op. cit., p. 67), and by Lewaschew (op. cit., p. 112). The former experimenters, in two trials with large doses, found a slight increase of the flow of bile, from which they con- cluded that sulphate of sodium is a hepatic stimulant, but not of great power. They did not determine the composi- tion of the bile. Lewaschew performed an extended series of experi- ments. He found the cholagogue action of this salt very pronounced. After administering four grammes to dogs with biliary fistulae, the secretion of bile became greatly augmented and very watery. Smaller doses produced less effect, and one gramme and less usually caused no change in the quantity or consistency of the bile. Lewaschew observed no marked difference in action between sulphate of sodium and bicarbonate of sodium on the bile-secretion. From these experiments, which conclusively prove the cholagogue action of sulphate of sodium, it follows that this salt always deserves preference to sulphate of mag- nesium in cases of icterus attended with constipation, and in persons who indulge excessively in rich food and alco- holic beverages. Lewaschew investigated the action of the following mineral waters on the bile-secretion : Carlsbad, Vichy, and Essentuck. All rapidly increased the flow of bile, aug- menting both solids and water, but the latter more. The effects of the different mineral waters were nearly the same, and hence Lewaschew concluded that they act on the liver with equal energy. Comparing the mineral waters with the sodium salts, he found that the action of the former was slightly more energetic, although the dif- ferences were not very marked. But the action of sali- cylate of sodium, even in small doses, was more energetic and prolonged than the action of the mineral waters. Phosphate of Sodium.-Professor Stephenson, of Aber- deen, recommended this salt in the diseases of children, when clayey stools indicate a deficiency of bile. Other observers have reported success in similar cases. Its action on the bile-secretion has been investigated by Rutherford and Vignal (op. cit., p. 74), and Lewaschew (op. cit., p. 116). The former experimenters found a very decided increase of the flow of bile, with diminution of its consistency. Lewaschew, in an extended series of experiments, fully confirmed this result. Four grammes, both in the dry form and dissolved in water, produced a very marked augmentation of the bile-secretion, and ren- dered it more watery. Doses of one gramme and less had no effect, while larger doses than four grammes did not cause a corresponding increase. lie concluded that phosphate of sodium acts as powerfully on the bile-secre- tion as bicarbonate and sulphate of sodium, and that all of these salts produce the maximum effect on the bile- flow of dogs in doses of four grammes. The results of these experimental investigations strongly corroborate the observations of Stephenson. As the phos- phate of sodium not only increases the secretion of bile, but makes it more fluid, it will doubtless be found useful in catarrhal jaundice. In adults doses of twenty to sixty grains, several times daily, will probably prove effective. Potassii et Sodii Tartrat.-The action of large doses of this salt on the bile-flow was investigated by Rutherford and Vignal (op. cit., p. 76). The results of the experi- ments were not uniform. In one experiment a rapid and decided increase took place ; but in another only a slight augmentation ensued. Hence the investigators concluded that " this substance is a cholagogue, but not a powerful one." In man it will probably be found that doses which do not produce active purgation will exert a pow- erful effect on the bile-secretion. Podophyllin.-A cholagogue action has been attributed to this purgative, because frequently the stools which it produces have a dark color. It has also been observed that, when the motions are white or clayey, moderate doses often speedily restore the normal color to the evacu- ations. Murchison (op. cit., p. 622) held podophyllin to be a good substitute for mercury when from any cause this is contraindicated. F. E. Anstie1 investigated the physiological action of podophyllin on dogs and cats. He found that occasion- ally bile was poured out in large quantities. This he at- tributed not to a direct action on the liver, but to irrita- tion of the mucous membrane of the small intestine. Experiments on dogs with biliary fistulae were made by the Edinburgh Committee,8 and by Rutherford and Vig- nal (op. cit., p. 13). The committee found that podo- phyllin diminished the secretion of bile. Large doses were administered and free purgation resulted^ which, doubtless, as shown by later investigations, prevented the action on the liver. In the experiments performed by Rutherford and Vignal, doses which did not purge se- verely always caused a very decided increase in the bile- flow. The composition of the bile did not become changed. They inferred that the augmented flow was due to increased secretion, and not merely to expulsion. That podophyllin increases the bile-secretion in conse- quence of a direct action on the secreting apparatus of the liver, is strongly sustained by an extended series of experiments on cats and dogs made by Podwyssotzki.9 He investigated the physiological action of podophyllin, and of podophyllotoxin and pikropodophyllin, two active principles which he had isolated from podophyllin and the rhizome of podophyllum peltatum. Frequently the dejections had a bilious color. In the autopsies he found the liver small, soft, very dark and hyperaemic, and the gall-bladder distended with bile. The fact that podophyllin does not alter the chemical composition of the bile, shows that it is not a suitable cholagogue in catarrhal jaundice, or in any form of jaun- dice due to occlusion of the bile-passages. The physiological action of numerous other medicines on the biliary secretion was investigated by Professor Rutherford and his assistants, Drs. Vignal and Dodds. Striking differences in their action were found ; some of them producing a decided increase of the bile-flow, others little or none. The following medicines acted powerfully: aloes, coL chicum, colocynth, corrosive sublimate, euonymin, iridin, 110 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholagogues. Cholagogues. sanguinarin, baptisin, and phytolaccin. The bile secreted under the influence of aloes, colchicum, colocynth, and sanguinarin was more watery. The following medicines moderately augmented the bile-flow: rhubarb, jalap, sulphate of potassium, leptan- drin, hydrastin, and juglandin. The following medicines acted feebly : senna, scam- mony, croton-oil, taraxacum, chloride of sodium, jabor- andi, and Calabar bean. The following medicines did not increase the bile-secre- tion : calomel, sulphate of magnesium, iodide of potassium, chloride of ammonium, gamboge, and castor-oil. The following medicines neither increased nor dimin- ished the bile-flow : morphia, atropia, hyoscyamus, pure alcohol, and tannic acid. The following medicine, in large doses, diminished the secretion of bile : acetate of lead. Calomel.-This medicine was formerly supposed to be a very powerful cholagogue, because it frequently pro- duces green stools, and was found useful in congestion of the liver, and in some other derangements attended with deficient secretion of bile. At the present time, however, it is held that the numerous experiments made on dogs have conclusively proved that calomel, in purgative doses, lessens the biliary secretion. Experiments to elucidate the action of calomel on the bile-secretion of dogs in which a biliary fistula had been es- tablished have been made by Nasse, Kolliker and Mueller, Mosier, Scott, the Edinburgh Committee, Rohrig, and Rutherford and Dodds. In all the experiments in which the methods were not faulty the result was the same, namely, a diminution of the bile-flow when the medicine produced purgation. A very careful observation of the action of a large dose of calomel on a man with a biliary fistula, made by West- phalen,10 gave the same result-a very decided decrease of the flow of bile from the fistula. Taken together with the experiments on animals, this case establishes beyond doubt that calomel, in purgative doses, is destitute of cholagogue power. But how explain the green stools, and the undoubted benefit resulting from the use of calomel in certain he- pptic affections ? Do the stools contain large quantities of bile ? Of this there can be no doubt, since Michea, Simon, Buchheim, and Radziejewski found large quan- tities of bile in calomel stools. That the green color may in part be due to a compound of mercury formed in the intestines seems probable, although Buchheim11 found the quantity of subsulphide of mercury too minute to im- part a marked color to large motions. Wickham Legg12 supposes that the green color is possibly due to some compound of mercury, but that the cause is "not well made out; " other purgatives also cause a green color in the stools, for example, Carlsbad and Marienbad waters. The manner of action of these mineral waters is, however, no longer doubtful, as Lewaschew's experiments conclu- sively prove that they cause a very decided increase of the bile-flow. Radziejewski found also in calomel stools notable quan- tities of the products of pancreatic digestion, peptone, ty- rosin, and leucin. The presence of these substances in the dejections has been variously explained. It was sup- posed that calomel, acting strongly upon the upper part of the small intestine, causes them to be carried forward so rapidly that their absorption is prevented. To the same irritant action on the duodenum was ascribed also the presence of large quantities of bile in the stools, a reflex contraction of the gall-bladder and bile-ducts resulting, which expels the bile previously secreted. Against this view may be urged the fact found by Rutherford and Vignal (op. cit., p. 38), that gamboge, which produces intense irritation of the duodenum, does not cause bile to appear in the stools. It was surmised by Buchheim, that possibly the large quantities of green bile in the evacuations might be due to arrest of decomposition in the intestines. Wassilieff's13 researches seem to show that this is probably the true explanation. Under normal circumstances the bile-pig- ments, bilirubin and biliverdin, are destroyed by the putrefactive processes taking place in the intestines, so that unaltered coloring matter cannot be found in normal faeces. Calomel prevents these decompositions, hence the biliary pigment retains its green color, and, in conse- quence of the accelerated peristalsis, is discharged before re-absorption can take place. If it be true that calomel arrests those chemical changes of the bile and the products of pancreatic digestion which normally take place in the intestines, and in this way, and in part by accelerating peristalsis, prevents their absorp- tion, it is readily understood why calomel should have been found of special utility in certain diseases of the liver. By diminishing the amount of material absorbed into the portal circulation, it effectually depletes the liver, reduces its functional activity, and lessens the secretion of bile. While it may be regarded as well established that calo- mel, in purgative doses, possesses no cholagogue prop- erties, it is quite probable that small doses, which are gradually absorbed, do increase the secretion of bile. All that is known of the absorption of calomel seems to show that it becomes converted into the bichloride of mercury. But this salt was found by Rutherford and Dodds (op. cit., p. 147) to produce a very marked increase of the bile- secretion. Mode of Action of Cholagogues.-Although the experimental researches have not fully elucidated the manner in which cholagogues increase the secretion of bile, they have shown that it is probably by a direct ac- tion upon the hepatic cells or their nerves. That all cholagogues, however, do not affect these parts exactly in the same manner is evident from the fact that, while all more or less increase the secretion of bile, only a lim- ited number alter its composition. It might be supposed that cholagogues act like siala- gogues, which, by irritating the buccal mucous mem- brane, cause the salivary glands to secrete abundantly. But if this were so, those medicines which intensely ex- cite the duodenal mucous membrane should cause a vast increase of the bile-secretion. But it has been found ex- perimentally that some medicines which severely irritate the duodenum, as gamboge and sulphate of magnesium, do not in the least augment the secretion of bile, and that some others, which cause no notable excitement of the intestine, as bicarbonate, salicylate, and benzoate of so- dium, powerfully increase the bile-flow. It has also been supposed that cholagogues act like the acid chyme, which, coming in contact with the mucous membrane of the duodenum, causes a reflex contraction of the gall-bladder and bile-ducts. That this explanation will not hold for those cholagogues which induce a flow of very watery bile is evident ; and whether it is applica- ble to the other cholagogues is very doubtful, since their power to excite the bile-flow is not proportionate to the irritation of the mucous membrane which they produce. Thus, gamboge, although causing great vascular excite- ment of the intestinal mucous membrane and free purga- tion, does not produce bilious stools. Whether they directly increase the circulation of the liver is not known. But doubtless, as a consequence of their stimulant action on the hepatic parenchyma, an in- creased flow of blood to the liver takes place. That this gives rise to augmented secretion is unquestionable ; for it is well established that the amount of bile secreted is largely dependent on the quantity and pressure of the blood streaming through the hepatic capillaries. Indications for the Use of Cholagogues.-Chola- gogues are indicated when the secretion of bile is defec- tive in quantity or quality, and active hypersemia, in- flammation, and organic diseases of the liver are absent. There are, however, only few diseases of which it can be positively affirmed that they result from defective per- formance of the biliary function. The symptoms per- taining to the alimentary canal, which are often produced by diminished or arrested flow of bile, such as flatulency, constipation, and impaired digestion of fatty food, may be caused also by other pathological conditions. And jaun- dice merely shows that the bile-pigments have become deposited in the visible tissues, but not that the biliary 111 Cholagogues. Cholecystectomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. function is impaired. Authors who have devoted much attention to the diseases of the liver, and have thoroughly investigated the normal and abnormal states of the biliary function, differ remarkably in their views as to the origin of the bile-pigments. While most hold that they are elaborated by the hepatic cells, some 14 assert that they exist pre-formed in the blood, and are only excreted from this liquid. The former ascribe jaundice to absorption of bile after its secretion, the latter maintain that it is often due to diminution or suppression of the biliary function. It is evident that the applicability of chola- gogues in some varieties of jaundice cannot be determined until this point is decided. It has long been observed, however, that certain dis- eases, usually attributed to derangement of the bile-secre- tion, are benefited by medicines which have been shown by experimental research to possess the power of increas- ing the secretion. The most frequent of these diseases is biliousness ; often called, when of protracted duration, torpidity of the liver. It is characterized by symptoms denoting disorder of the alimentary canal, liver, and nervous system. The most salient phenomena are a dis- agreeable or bitter taste, a coated tongue, defective appe- tite, sometimes nausea and vomiting ; a sallow complex- ion, light-colored stools, and dark or lateritious urine; headache, giddiness, dimness of vision, and mental de- pression. Most authors attribute these symptoms to a catarrhal state of the stomach and duodenum. Harley (op. cit., p. 191) maintains that they are caused by hepatic capillary congestion, which, though at first increasing the secretion of bile, soon interferes with it, the engorged capillaries and distended bile-ducts exerting a sufficient amount of backward pressure on the secreting hepatic cells to prevent them performing their work properly. In the lighter forms of biliousness, which usually last only a few days, cholagogues are not required, while medicines which reduce hepatic congestion are decidedly beneficial. The treatment which experience has shown to be most useful, namely, a purgative dose of calomel at night, followed next morning by a saline laxative, has been proved by the experimental researches on the action of calomel to be the most appropriate. But when the affection becomes chronic, the prolonged use of those cholagogues which cause a free secretion of watery bile, especially bicarbonate, salicylate, sulphate, and phosphate of sodium will be indicated. In case the bowels do not act effectually, a purgative cholagogue should be given at bedtime, especially small doses of podophyllin with ipecacuanha. A defective secretion of bile, at least in quality, is held to be the cause of the concretions of inspissated bile some- times formed in the bile-ducts and gall-bladder. To ob- viate the re-formation of such concretions in patients who have presented the symptoms denoting their presence, those cholagogues are indicated which increase the al- kalinity and fluidity of the bile, especially the bicarbonate of sodium. Under their influence the glycocholate and taurocholate of sodium, the normal biliary solvents, be- come increased. In cases of gall-stones, also, the salts of sodium are in- dicated. Much evidence might be adduced showing that mineral waters containing notable quantities of bicarbon- ate and sulphate of sodium not only prevent the forma- tion, but even reduce the size of already formed gall- stones. The salts of sodium prove useful by augmenting the alkalinity of the bile, thus enabling it to hold the cholesterin in solution. But while the alkaline chola- gogues are useful in the treatment of gall-stones, chola- gogues which do not alter the composition of the bile arc baneful. Attacks of biliary colic, due to gall-stones, have followed the prolonged use of podophyllin. Whether cholagogues are indicated in jaundice depends upon its cause. In all cases due to irremediable obstruc- tion of the bile-ducts, cholagogues would be harmful. Nor would they be useful in cases resulting from active hepatic congestion or inflammation, unless these affec- tions were caused by disease-germs, when salicylate or benzoate of sodium should be employed. As to the utility of cholagogues in catarrhal jaundice, the opinions of authorities differ. While most authors hold that salts of sodium and mineral waters containing sulphate and bicarbonate of sodium are beneficial, some assert that an increase of the bile-secretion, and hence further distention of the bile-ducts, already overloaded, could only result in harm. Schiippel15 supposes that alkaline waters are use- ful, because they do increase the pressure in the bile- ducts and at the same time render the bile alkaline. Perhaps it will be found that the salicylate of sodium will prove the most useful cholagogue in catarrhal jaun- dice. It not only exerts a more decided effect on the bile-secretion than other sodium salts, but it also possesses marked antiseptic power. The benzoates have been found by Harley (op. cit., p. 145) rapidly to remove the bile-pigment from the skin, after the disease giving origin to the jaundice had been cured. All cholagogues are contraindicated in structural dis- eases of the liver, such as chronic atrophy, cancer, fatty and amyloid degeneration. Samuel Nickles. Refebences. 1 C. E. Burs : Ueber die Anwendung der Salicylsaure als Antipyreti- cum. Deutsch. Arch. f. klin. Med., 1875, Bd. xv., p. 457. 2 William Rutherford : An Experimental Research on the Physio- logical Actions of Drugs on the Secretion of Bile. Edinburgh, 1880. 3 S. W. Lewaschew : Zur Frage uber die quantitative^ Veriinderungen der Gallensecretion unter Einfluss alkalischer Mittel, Deutsch. Arch. f. klin. Med., 1884, Bd. xxxv., p. 93. 4 F. T. Frerichs: A Clinical Treatise on Diseases of the Liver, vol. ill.. p. 215. New York, 1879. 5 Eulenburg's Real-Encyclopadie, Bd. v., p. 405. 6 Charles Murchison : Clinical Lectures on Diseases of the Liver, p. 363. New York, 1877. 7 F. E. Anstie: Med. Times and Gazette, 1863. 8 Edinburgh Committee : British Association Reports, 1868. 9 V. Podwyssotzki: Pharmakologische Studien liber Podophyllum Peltatum, Arch. f. Exp. Path. u. Pharm., 1881, Bd. xiii., p. 29. 10 H. Westphalen: Ein Fall von Gallenfistel, Arch. f. klin. Med., 1873, Bd. xi., p. 588. 11 R. Buchheim: Arzneimittellehre, p. 270. Leipzig. 1878. 12 J. Wickham Legg: On the Bile, jaundice, and Bilious Diseases, p. 178. 13 Wassilieff: Wirkung des Calomel auf Gahrungsprocesse, Zeitschrift f. Physiol. Chemie, 1882, Bd. vi., p. 112. 14 George Harley : The Diseases of the Liver, p. 69. 1883. 15 O. Schlippel: Ziemssen's Handbuch der Speciellen Path, und The- rapie, Bd. viii., Abtheil. 2, p. 32. Leipzig, 1880. CHOLECYSTECTOMY. This term indicates the ex- cision of the walls of the gall-bladder, or the extirpation of this sac with ligation of the cystic duct. As a neces- sary consequence of the relations of this reservoir of the bile to the normal functions of the liver, any material modification of its structure interferes with health. A partial or complete arrest of the entrance and dis- charge of bile, through the cystic duct, does not imply an obstruction of the hepatic ducts, nor of the common bile-duct. The peculiar arrangement of the several ducts by which this fluid is conveyed from the secretory appa- ratus of the liver into the gall-bladder, and thence dis- charged, as occasion may require, through the ductus communis choledochus into the duodenum, may be sup- plemented by its direct passage. Under ordinary cir- cumstances a large proportion of the bile reaches the duo- denum directly, and this quantity is increased by degrees as the communication with the reservoir becomes gradu- ally obstructed. In the event, therefore, of complete oc- clusion of the cystic duct, while there is no restriction of the direct passage from the liver into the duodenum, a compensation for the normal process is available, without this diversion into the gall-bladder. The cases of congenital absence of the gall-bladder, and those in which it has become shrivelled up after having performed its function as a diverticulum, while the hepatic ducts and common duct maintain the com- munication of the liver with the duodenal canal, do not show any signs of serious trouble from the lack of this relay station. In the few instances of congenital absence of this sac, the hepatic and common ducts are said to ex- ceed the normal size, and this seems to be the ride in such cases. The liver is stated to be less than the natural size in cases of congenital deficiency, whereas it is enlarged when accidental or acquired ; and, doubtless, this same chronic enlargement of the liver will be found to follow the extirpation of the gall-bladder. Instead of the diver- 112 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cliol ago" ties. Cholecystectomy. sion afforded by this reservoir, admitting of periodic dis- charges of bile, it must flow continuously from the he- patic ducts into the ductus communis choledochus, and thence into the duodenum. But the valvular arrangement of the entrance must cause more or less delay in the dis- charge of bile, and this partial arrest at the outlet leads to a modified regurgitation, which tends to produce engorge- ment of the glandular structure of the liver, and conse- quently hypertrophy of this organ.1 It is uniformly observed that in cases of occlusion of the duodenal orifice of the common duct there is dilata- tion of the calibre of this duct as well as that of the hepatic ducts; and when the natural diverticulum is wanting, from accidental causes, the free discharge of the bile does not occur through the outlet, so that there is a backward pressure until the hydrostatic element forces the bile into the duodenum. On the other hand, when the common duct becomes partially or entirely obstructed at its outlet, while the hepatic ducts and the cystic duct are patulous, there is an accumulation of bile in the gall-bladder. This may lead to a greater or less dilatation of its walls, with inspissation of the fluid, or deposition of concre- tions. But there is generally a marked diminution of the secretion of bile following the arrest of its flow into the duodenum, and eventually the liver ceases to yield bile, so that a stasis exists in the bile-froducing process. In this respect the livpr follows that law' which is ob- served in all secretory organs, as to the increase or dim- inution of action in direct proportion to the consumption of the products. In the normal condition, the yield of bile varies considerably with different articles of food, and with the changes which ensue in the alimentary canal ;2 but in this abnormal state of accumulation in the sac, without an outlet by the common duct, the de- mand for its production ceases, and consequently this function of the liver is arrested for the time. But it has been found that the evacuation of such an accumulation, and provision for a free discharge subsequently from the sac, lead to a restoration of the secretion of bile, even when it flows away by a fistulous outlet through the ab- dominal wall. The derangement of the intimate struct- ure of the parts may proceed, howrever, to such a point as to change completely the bile-making apparatus. Should disintegration of the tissues occur, and shrivelling or obliteration of the sac and ducts exist, there is no in- dication for interference, as under such given deteriora- tion of structure no surgical relief is practicable. A post-mortem examination of a case reported in the Weekly Medical Review,3 under the observation of Dr. R. G. Bogue, of Chicago, revealed six gall-stones, each about the size of a filbert, in the common duct. The gall-bladder was found atrophied, and the cystic duct obliterated. As reference is made to the " distended common duct," it may be inferred that a manipulation of its surface in an exploration during life might well have misled the operator. But in this instance no such exam- ination was instituted, owing to the fact that the patient was so nearly in the arms of death, when the case came into the hands of Dr. Bogue, that the operation did not seem to be justifiable. It was a woman, fifty-seven years of age, who had suf- fered for five or six years from some intermittent pain in the region of the liver, and had become greatly emaciated. She was jaundiced, suffering greatly from vomiting, and exhibited tenderness over the region of the liver, radiat- ing, apparently, from the gall-bladder as a centre, but no gall bladder could be felt. This atrophied condition of the gall-bladder, Dr. Bogue informs us, he has seen on several occasions before, associated with a previous his- tory of hepatic trouble ; and it is calculated to increase the difficulties of diagnosis in these cases. It is a well-ascertained consequence of an occlusion of the cystic duct, for any considerable period, that dilata- tion of the walls of the gall-bladder, primarily by bile, is eventually followed by various abnormal collections in its cavity, such as glairy mucus, or sero-purulent fluid. The presence of gall-stones in the ducts, or intermixed W'ith the accumulation in the sac, is a frequent complica- tion of such cases; and the evacuation of the fluid con- tents of the gall-bladder does not ordinarily afford relief from trouble. The prime question for consideration is the practica bility of adopting any measure of treatment which shall restore the function of the liver and preserve the office of the gall-bladder ; and in case the derangement should prove to be irremediable by other means, excision is indi- cated. Under such conditions, the attention of the sur- geon may be appropriately directed to the radical opera- tion of cholecystectomy, as first practised by Von Lang- enbuch, and since,by Courvoisier and Thiriar. Important modifications of this operation are suggested by the proceedings of Dr. J. Marion Sims and of Dr. S. W. Gross, in which portions of the sac were excised, so as to lessen the material to be restored in cases of extensive dilatation of the gall-bladder. While Sims considered this a mistake on account of the haemorrhage that oc- curred, it might have proved advantageous if such a por- tion of this immensely dilated sac had been excised as to reduce it to the ordinary dimensions of the gall-bladder when distended with bile. It is not inferred that the exci- sion of a portion of the sac by Gross was a serious com- plication in the fatal result of his nephrectomy ; and hence should not be put down to the discredit of partial ablation of the gall-bladder. The history of extirpation of the gall-bladder, so far as known, is confined to the cases of Langenbuch, Cour- voisier, and Thiriar ;4 and it must be considered as a new claimant to surgical notice which demands careful investigation. This proceeding should not be classed with ' ' operative audacities," because of its novelty and boldness, without due consideration of its merits. While recuperative meas- ures should have precedence so long as they are available, it is in the light of an ultimate recourse that cholecystec- tomy appeals to us as averting evils which cannot be forestalled by other means. Should it appear that Langenbuch has not sufficiently restricted the indications for removal of the gall-bladder and ligation of the cystic duct, this affords no proper ob- jection in extreme cases which may demand this opera- tion to preclude the formation of gall-stones, and to obviate other accumulations in this sac. It is not out of place, under the prospect of developing all the capabilities of cholecystectomy, to consider the propriety of some modi- fications which may, perhaps, be regarded as improve- ments upon the operation as performed by Langenbuch. The dissection of the adherent layers of the gall-blad- der from the under surface of the liver does not seem requisite for success in excision of the sac. Should this portion be left attached to the liver, it is not likely that any complication could arise in the further progress of the cases. In one of my canine experiments the outer wall of the gall-bladder underwent a disintegrating proc- ess, while the adherent tissue was still firmly united to the under surface of the liver, and presented the appear- ance of being identified with its structure. If this coat- ing, then, can be retained after trimming away all the loose wall of the sac, it would simplify materially the surgical procedure, since the dissection of this layer from the proper structure of the liver is attended with more risk than any other step in the operation of cholecystec- tomy. Again, an excision of the greater portion of a dilated sac, leaving the more healthy part of the wall adjoining the hepatic attachment to be closed by a linear suture, or to be secured to the opening in the parietes, might be proper when extirpation of the gall-bladder is not called for by impermeability of its duct. A reprint from the Berl. Klin.Wochenschrift, No. 51, 1884, tending to elucidate operations on the gall-system, has been kindly forwarded to me by the eminent author. Dr. Carl Langenbuch, of Berlin. As he occupies so conspicuous a position in connection with cholecystectomy, the medical public will recognize his views as authoritative, and I avail myself of a trans- lation of this paper, made at my request and generously furnished by Dr. Henry Bak, of Atlanta, to present some 113 Cholecystectomy. Cholecystectomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the important matters embraced in it without going into all its details. Dr. Langenbuch states that chronic cholelithiasis in- duced him in five cases to extirpate the entire gall-blad- der. The first patient, operated on July 15, 1882, and also the second and fifth, are living, and permanently re- lieved. The third case, operated in 1883, was nearly cured, when about three weeks later the patient suddenly died from a cerebral tubercle, of the size of a hazel-nut, in the plexus choroides. In the fourth case, operated early in 1884, ulcerative perforation at the junction of the cystic with the hepatic duct led to a flow of bile into the peritoneum, which caused the death of the patient within a few days after the operation. Hence he remarks : " None of my pa- tients died of the operation or its consequences; and Lawson Tait certainly did not peruse my own publica- tions when he asserted that in six cases operated upon by my method three terminated fatally. ' ' On the contrary, my. experience gained in the first four cases has lately been improved upon by a fifth op- eration, attended with complete success. It was on the person of a gentleman over fifty years of age, who, for more than thirty years, had suffered with the most pro- nounced symptoms of gall-stone colic. " The paroxysms returned year after year with in- creased severity, and baffled all treatment. The patient at such times became desperate, and repeatedly tried to commit suicide. He heard of the possibility of a per- manent cure by a radical operation, and asked me to ex- amine his case. There was no doubt in regard to the diagnosis, as the frequent and painful passage of gall- stones through the intestines, and their presence in the stools, with the sensitiveness to pressure in the region of the enlarged gall-bladder, clearly verified it. The patient was very anxious to be freed from his trouble, and urged me to perform the operation at once; but owing to the frequent paroxysms of colic, and a slight indication of jaundice, I thought it advisable to desist for the time from operating. After a few weeks had passed without any passage of gall-stones, and also the jaundice had disappeared, I concluded not to resist further the im- portunities of the patient, and to make an exploratory incision, with a view to be guided afterward by circum- stances. "On September 5th of this year (1884) the operation took place. The attending physician, Dr. Thiriar, and Professors Sacre and Heyer, all of Brussels, had the kind- ness to assist me, while Dr. Lohlein, of the Lazarus Hospital, attended to the after-treatment of the case. "The first incision, of twelve to fifteen centimetres in length, was made along the outer border of the right rectus abdominus muscle, tending downward from the arch of the ribs ; the second, about ten centimetres long, ran parallel with the arch of the ribs toward the ensiform cartilage. The gall-bladder was filled with stones, and had an attachment the size of a dollar to the interior surface of the abdomen, while on the other side it was attached throughout to the colon. Under such circumstances it was very tempting to simply slit the sac and thoroughly examine it, with the evacuation of its contents. But after mature consideration, I determined to bring about a defi- nite and permanent cure. " I thought it important to inform myself as to the con- dition of the gall-ducts, and more particularly to learn whether there were stones in the cystic or common ducts. The latter might exist without necessarily causing jaun- dice, since it is a known fact that impacted stones will permit the flow of bile for a more or less limited time. Had there been a large concretion near the outlet of the ductus choledochus, indicating the stagnation of the bile, we certainly would have erred by providing for a gall- fistula, as in so doing we would have removed the vis-a- tergo toward the common duct, the bile flowing unre- stricted through the fistula. It is probable that the ductus choledochus, through disuse, would then have contracted, and finally have embraced the stone so tightly that serious inflammation would have been the result. The outcome would then have been a definite occlusion of the duct and a permanent fistula, two circumstances not promoting the comfort of the patient. I therefore proceeded with the somewhat difficult and tedious task of detaching the gall-bladder, in which I was finally suc- cessful. The ducts were brought within reach of my fingers, almost up to the diverticulum Vateri, by separat- ing the peritoneal connections of the colon, and dividing the retroperitoneal relations of the duodenum. " I could now easily ascertain that there were no stones in the common or in the hepatic duct, but found some con- cretions in the cystic duct. The gall-bladder was much enlarged, and crowded with stones of various sizes. Al- though it seemed easy to push back the stones from the cystic duct into the sac, it was undoubtedly preferable to remove the diseased product with the source of its forma- tion. To accomplish this, I detached the bladder from the liver, where, in consequence of its chronic inflamma- tory condition, it had closely adhered, and, after being satisfied that no concretions had been left within any of the ducts, I ligated the cystic duct with a strong silk thread. After removing the gall-bladder, I secured the parts with several additional catgut sutures, tending to firmly unite the surroundings of the duct. This being done, the abdominal incision was closed, and convales- cence progressed without noteworthy interruption, so that the sutures were removed on the tenth day. A few days later the patient had an attack of pneumonia from which he soon recovered, and later reports confirm his complete cure." Dr. Langenbuch says the fact that certain dis- eases of the gall-system not only justify, but absolutely require surgical interference, has long been recognized. In 1743, J. L. Petit operated on the gall-bladder by in- cision, and formulated certain rules for the operation. Since then Morand and Blocks reported other cases. The celebrated Richter later proposed, as a safer proceed- ing, to create by caustics an adhesive inflammation be- tween the gall-bladder and the abdominal wall. Thudi- chum went still further, and, in 1859, proposed to lay bare the gall-bladder, to sew it to the abdominal wound, and to open it subsequently. This idea was first carried into effect by Sims, in 1878, but with doubtful success. (The incision of the sac being immediate, it was not the same idea.) Subsequent attempts by Kochen, Keen, Lawson Tait, and others, were more or less successful, according to Langenbuch. The method adopted by these authors in exposing the bladder, then opening and emptying the same either be- fore or after sewing it to the abdominal wound, results in retaining the bladder and establishing a fistula for an uncertain period, combined with a temporary cessa- tion of the secretive pressure of the bile in the ductus choledochus, and with a final possibility or probability of the formation of new stones after the lapse of months or years in the retained bladder. On the other hand, with the excision of the entire dis- eased bladder we exclude a possibility of the recurrence of the trouble with less dangerous interference, avoiding the risk invariably connected with attaching the bladder to the abdominal wound, accomplishing at the same time, without the formation of a fistula, a definite union of the external wound, leaving the secretive pressure of the gall intact, and effectually and permanently accomplishing a cure. Langenbuch then goes on to say that common to both methods is the danger connected with the opening of the abdominal cavity, since in either case the incision has to be sufficiently large to enable the finger to ascertain whether there are stones in any of the larger gall-ducts. In most of the published cases nothing but a small opening has been cut into the abdomen, a sort of loop-hole just big enough to sew the bladder into the wound either before or after its incision. This apparently convenient pro- cedure, independent of the fact that we could not ascer- tain the state of the ducts, is also inexpedient, because it prevents a thorough examination as to the condition of the walls of the bladder and their relations to the matters they contain. This examination is indispensable, from the fact that an operation is only performed after all other methods of treatment have failed to relieve the case, and 114 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystectomy. Cholecystectomy. the mucous membrane of the sac is most probably in- volved in a chronic ulcerative process, with peritoneal ad- hesions of the gall-bladder to neighboring organs, so that under such conditions the bladder has acquired a danger- ous fragility. This fragility of the bladder may, after its artificial attachment to the abdominal wall, lead to very serious consequences. It is known that the liver accom- panies the up and down movement of the diaphragm, and transfers this motion to the gall-bladder, now fixed to the abdominal wall. This undoubtedly would overtax the sutures of a frail bladder, especially if sneezing, cough- ing, or vomiting should occur, and the consequence would be, the tearing of the stitches, and the influx of bile into Ihe abdominal cavity. Granted that such an accident may occur only exceptionally, the bare possibility should induce a thorough examination of the tissues of the gall- bladder previous to sewing it into the abdominal wound. Langenbuch further claims that it will be inconvenient to search for bodies in a bladder which has been slit open after it has been fixed in the abdominal wound. Though easy to clear the bladder of small stones which are loose in its cavity, it may prove much more difficult to remove larger impacted stones from the neck of the bladder or from the cystic duct. It would not seem justifiable to attempt the forcible extraction of stones which are ad- herent to or encysted in the mucous membrane of the bladder ; for in such efforts the wall of the bladder is lia- ble to be ruptured. The serious consequences in such cases are known facts' in the pathology of the gall-blad- der, and demand great caution in proceeding with the exploration of its surroundings. We have thus given a resume of the practical bearings of Langenbuch's proceeding, and there can no longer exist •a doubt as to the propriety of this radical operation under favorable circumstances. The prerequisite for differen- tiating the conditions warranting the extirpation of the gall-bladder from those derangements in which other modes of correction are available, is a thorough compre- hension of the normal functions of the gall-bladder, with a minute examination of all the consequences of the ob- struction of the gall-ducts, and the feasibility of the vari- ous measures of relief that have been proposed or put into operation. But for the present we are alone con- cerned in the proper execution of cholecystectomy. It consists in a careful dissection of the attachments of the gall-bladder and cystic duct, with ligation of the latter near its entrance into the common duct, so as to prevent any escape of bile, should it prove to be permeable. Should there be any sanguineous exudation from the denuded surface, or any bleeding from the twig of an ar- tery, prompt measures for arresting the flow of blood must be adopted. These may vary in different cases, tor- sion or ligation being resorted to for the arterial branches, while styptics or galvano-cautery may be used for oozing from the surface. The elastic ligature serves well for closing the duct, and offers no impediment to the imme- diate union of the external wound. A continuous catgut suture may be employed in the peritoneal incision, and the interrupted silk suture in that of the skin and sub- cutaneous tissue. The results of this procedure, in the hands of Dr. von Langenbuch, have been entirely satis- factory with four cases, while one died from an oversight at the time of operating. An accidental and undiscovered ulcerative perforation of the cystic duct, close to its junc- tion with the hepatic duct, allowed of the escape of bile into the peritoneum. A recovery after the operation of cholecystectomy by Courvoisier, of Basle, and two recent favorable results of Thiriar, of Brussels,5 show a mortality thus far of only 12.50 per cent, in cholecystectomy. Whereas an analysis of the cases of cholecystotomy, properly so called, in which the operation has been completed by incision of the gall-bladder, show's nine deaths out of thirty-three operations, being a fatality of 27.27 per cent. In this estimate the five incomplete operations recorded are ex- cluded, in which two deaths occurred, giving the still larger fatality of forty per cent.6 Thus it is clear that of all the operative procedures undertaken on account of ob- .struction of the gall-duct, the results of cholecystectomy are the most encouraging, and that there is less gravity attending it than the performance of either complete or incomplete cholecystotomy in the proportion that 12.50 stands to 27.27 and forty per cent of mortality. In the paper of M. Ie Dr. J. Thiriar, presented to the French Congress recently, on surgical interference in cer- tain cases of biliary lithiasis, it is stated,1 that the extir- pation of the gall-bladder, as proposed by Herlin and Champaignac, had not been performed on a human sub- ject, when Langenbuch, of Berlin, operated on a patient with biliary calculus. Since then seven cases have been recorded, making in all eight operations, five being done by von Langenbuch, one by Courvoisier, and two by Thiriar. These achievements of modern surgery have encoun- tered, up to the present time, numerous critics who have opposed the application of surgery to the gall-bladder on various grounds, both physiological and pathological, which Thiriar epitomizes as follows : 1. The necessity of the gall-bladder to the digestive process in the human subject. 2. Calculi can form elsewhere than in the gall-blad- der. 3. Cholecystectomy is too severe and dangerous an op- eration. 4. The formation of a biliary fistula (cholecystotomy) ought to be preferred to cholecystectomy. In answer to these objections it may be said :-1. It is clearly shown that the gall-bladder is not indispensable to the regular performance of digestion in man. This organ is absent in many mammalians, and is not infrequently found in the human subject completely occluded and atrophied. 2. Even if it must be granted that the formation of calculi is not wholly confined to the gall-bladder, it is an exceed- ingly rare occurrence, certain pathological conditions ex- cepted, which can induce the formation of concretions in the biliary canals and ducts. Also, the existence of these pathological conditions (carcinomatous obstruction of the biliary passages) forms an express contra-indication for cholecystectomy. 3. Cholecystectomy is evidently a deli- cate and difficult operation to perform, but considering the slight importance of peritoneal injuries inflicted, in accordance with antiseptic rules, M. Thiriar regards the extirpation of the gall-bladder, of all forms of laparotomy, as the least severe and least dangerous. He states further, 4. that while cholecystotomy is easier to perform, it has the disadvantage of resulting in a biliary fistula with all its dangers, and it does not remove the organ in which the calculi are produced or prevent their re-formation. There is, doubtless, a tendency on the part of the advo- cates for one or the other operation to undervalue the final cause in the respective cases. Excision of the gall- bladder is not to supply the place of other processes for correcting its disorders, but is a dernier ressort in the failure of such proceedings to meet all the requirements of the case, or in view of the inadequacy of any means for restoring the functions of this organ and for re-habilita- tion of the surrounding structures. When the gall-bladder and cystic duct become ob- noxious to the adjacent tissues, so as to cause local dis- order and general derangement of the health, it is the legitimate province of surgery to get rid of them by ex- tirpation forthwith. They no longer subserve the ends for which they are provided by nature, and constitute an abnormality in the animal.economy. Their obliteration is, therefore, rational and philosophic, in like manner as the separation of any other offending member from the adjacent structures. The obliteration of the cavity that results from a dilata- tion of the gall-bladder by the extensive accumulations of mucus or sero-purulent fluids, can only be effected slowly, by the use of injections which serve to contract the walls of the sac. But prompt relief is afforded by amputation of the entire mass, and instead of the exuda- tion that ensues upon the evacuation of a large collection of fluid, no drain is requisite after resorting to cholecys- tectomy. This principle is adopted generally for the re- moval of cysts, and when degeneration of structure with decomposition of the contents of the sac is found in 115 Cholecystectomy. Cholecystotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. occlusion of the gall-bladder, it belongs properly to the category of cysts, as it has no longer any of the proper- ties and functions of a receptacle for the bile. After a permanent obstruction of the cystic duct has been verified, it matters not what may be the character of the contents of the sac ; their removal is indicated in like manner with any foreign matter confined within the abdomen, as their presence only serves to keep up disturb- ance in adjacent parts. After they have been evacuated, it then devolves upon the surgeon to decide as to the pro- priety of detaching the useless tissues of this appendage, that has ceased to perform its functions, and is a source of disorder to neighboring organs. Instead of retaining an offending member to propagate trouble to other parts, it is the dictate of common-sense and sound judgment to sever its connection with the body. This operation is not warranted in cases of temporary obstruction of the cystic duct, which admits of relief by mechanical or other means, excepting when there is dis- organization of the gall-bladder. In the permanent obliteration of the cystic duct, however, the communica- tion of the gall-bladder with the hepatic ducts and the common duct ceases; and though the structure of the sac may not have undergone degeneration up to the time of an exploratory operation, it is reasonable to infer that such a deterioration will ensue, so that it becomes a legitimate proceeding to remove it. After evacuating the contents, whether of a fluid, semi- fluid, or solid nature, first by aspiration, and subsequently by an incision of the sac, as near the margin of the liver as practicable, a thorough exploration of the cystic duct is to be made, and failing to effect any outlet, there re- mains no doubt in regard to excision of the redundant structure. Under certain circumstances, then, the opera- tion of cholecystectomy becomes one of the most rational and effective proceedings in surgery. The criticism of this operation from any other stand- point than that herein presented is short-sighted and un- warrantable, since the facts must be accepted in their true significance as the basis of forming a correct judgment. No surgeon of large opportunities for observation, and with comprehensive views of the scope of cholecystec- tomy, should condemn it without a thorough investigation of the grounds upon which it is undertaken. The attitude of some operators, under a preconceived bias against this process for relieving the troubles originating from the gall-bladder, excludes their opinions from consideration in this branch of surgery, as in other proceedings with which they are not personally familiar. We must, therefore, be guided in our decision of its merits by the judgment of those whose practical acquaintance with the details of the operation entitles them to recognition as authorities in the matter. In presenting a summary of the recognized facts and principles relating to cholecystectomy, all dubious specu- lation and theory have been excluded. I have sought to incorporate only such matter as has a practical character. The legitimate fruits of an impartial consideration of the facts which are now brought to light in regard to extirpa- tion of the gall-bladder, must soon be apparent with the advances of surgery in this country. We have observed a very marked change in the attitude of one of our most influential medical weeklies, touching this operation, within the past six months, and while excision was com- bated previously, this measure is now defended by it. In commenting upon the antagonism of a distinguished surgeon to this operation the editor remarks that, as he has fully tested incision hnd drainage, " wetrust, in view of these correct statistics, and of the unequalled oppor- tunities that he has in this class of cases, that he may be induced to give excision of the gall-bladder an equally fair test. When this has been done, his views, based upon actual experience, and not "upon theoretic objections, will be entitled to serious consideration." Although twenty-five of the thirty-three completed op- erations of cholecystotomy have been done by English and American surgeons, it is a notable fact that cholecys- tectomy has not thus far been undertaken in a single case in Great Britain or the United States; but it only re- quires to be properly understood to be duly appreciated by surgeons. J. McF. Gaston. 1 Ziegler's Pathological Anatomy, p. 325. 2 Legg on the bile, p. 114. 3 January 17, 1885, p. 44. 4 Bull, de l'Acad. Roy. de M6d. de Belgique, t. xix., 1885, p. 51 and p. 83. 5 Proceedings of French Congress of Surgeons, April 12, 1885. 6 Table at the close of the article in this volume on Cholecystotomy. 7 See in the Boston Medical and Surgical Journal, April 30, 1885, p. 427. CHOLECYSTOTOMY. Under this designation are in- cluded such operative measures for the relief of the dis- orders of the gall-bladder as may be undertaken beyond puncturing the sac through the walls of the abdomen, and without complete excision of its tissues. Spontaneous perforations, or incisions of the parietes of the abdomen, for the discharge of collections from the gall-bladder, do not pertain to this surgical procedure. Hepatic abscess, originating in the organ, or connected with dysenteric disease of the bowels, does not fall within the scope of this paper, yet calls for consideration when it results from irritation of the bile-ducts. When the biliary channels become diseased, and the retained bile forms con- cretions in them, a noxious influence is propagated to the liver, so that characteristic abscesses result in the liver. In the elaborate work of Professor Ziegler on ' ' Pathological Anatomy," those modifications from the various irritants capable of exciting inflammation in the gall-bladder and ducts are so well presented that a resume of these changes affords a fitting preliminary for this investigation. He states that the irritant will first affect the walls of the ducts and their surroundings, and set up inflammation there. Biliary concretions and gall-stones are by far the commonest abnormalities in the contents of the gall- bladder and biliary ducts (hepatic, cystic, and common). The gall-stones, or biliary calculi, which may be as small as a millet-seed, or as large as a hen's egg, are rounded or ovoid, or angular or faceted. The latter is the case when several gall-stones have lain together in contact within the gall-bladder, the former when they have lain singly in the bladder or in one of the ducts.1 The exact way in which gall-stones are formed is not fully under- stood. In many cases foreign bodies are found within them, and we know that such bodies introduced into the biliary passages become crusted over. For example, a round worm, which has crept into the common duct and there died, becomes covered with a coating of granular matters precipitated from the bile. Stagnation and de- composition of the bile seem to favor the formation of gall-stones. Certain conditions of the general nutrition are probably not without influence, seeing that stones are much more common in patients of mature age than in younger patients. . . . Gall-stones give rise to very painful attacks (gall-stone or biliary colic) when they become impacted in the com- mon or the cystic duct. Stones formed in the gall-bladder and in the ducts themselves are frequently discharged into the intestine through the common duct. But if one of them lodges or lingers in the duct, retention of the bile ensues : and this may give rise to dilatation of the ducts and to infiltration of the liver with bile. The liver-tissue may thereupon become degenerate or inflamed, while the parts around the impacted stone become also inflamed or even ulcerated. If the stone is near the mouth of the common duct the inflammation and ulceration may ex- tend to the papilla at its mouth, and in this way set the stone free. Stones may escape from the gall-bladder into the intestine (duodenum or colon) directly ; this of course can happen only when inflammatory adhesions have al- ready been set up between the intestine and gall-bladder. In unfavorable cases the stones break through into the peritoneal cavity, or into the retro-peritoneal tis- sue, or peritonitis is induced.2 . . . The bile-ducts sometimes become dilated behind an obstructing con- cretion. The seat and extent of the dilatation depend, of course, upon the seat of obstruction. Closure of the common duct leads to accumulation and stagnation of the bile in the gall-bladder, as well as in the hepatic duct and its branches. Closure of one of these branches nat- urally affects the bile and the smaller ducts of the corre- sponding region, and no other. A duct may be closed 116 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystectomy. Cholecystotoniy. either by concretions forming within it, or by inflamma- tory growths or tumors in or near its walls. Parasites, such as the round worm or the distoma, sometimes creep into the ducts from the intestine and occlude them. The secretion which accumulates behind an obstruction is not always simply bile. When the cystic duct is oc- cluded, it is plain that no bile can collect in the gall-bladder. When, therefore, this becomes distended, it is owing to the secretion of a mucous liquid from the mucous glands in its lining membrane. This condition is described as dropsy of the gall-bladder. Something similar takes place in the ducts when a portion of a duct containing mucous glands becomes obstructed,-a mucous secretion may be poured out and distend it. Cysts of various sizes and having smooth, slimy walls, are thus formed within the liver. According to Von Recklinghausen (Virch. Arch;, vol. Ixxxiv.), this is the usual mode of the origin of the small cysts, which are found lying just beneath the serous membrane of the liver. In these cases there has been at no time any retention of bile ; the rasa aberrantia of the biliary ducts (Ferrein) have simply become distended by the mucous secretion of their own glands. Some cysts of the liver are due to the distention of the lymphatics with ac- cumulated lymph. When no secretion is poured into a gall-bladder whose duct is obstructed, the normal con- tents become sometimes inspissated or even calcified. The bladder itself usually shrinks ; and, if inflammation is set up within its walls, it may become notably thickened, or in some parts ulcerated.3 . . . Inflammation of the gall-bladder is not an uncommon affection, and may be set up by the extension of an intes- tinal inflammation to the common duct and its branches, by stagnation or by decomposition of the bile, or by irri- tant matters brought to the mucous membrane by the blood. Even the slighter forms may lead to obstruction of the ducts, retention of the bile, and jaundice ; the ob- struction being due to excessive mucous secretion or to swelling of the mucous membrane. In more intense or more chronic inflammations the exudation from the ducts and gall-bladder may be puru- lent. The connective tissues are thickly infiltrated ; and not infrequently the capsule of Glisson round the hepatik duct, or the peritoneum round the gall-bladder, is like- wise intensely inflamed. This last is especially the case when the primary inflammation is of a neurotic charac- ter, accompanied by diphtheritic excoriation and ulcera- tion. Within the liver purulent inflammations of this kind give rise to small abscesses, containing liquid bile and biliary concretions. When such abscesses are formed in the gall-bladder, or in the larger ducts outside of the liver, or when they lie close beneath the capsule on its surface, they are apt to cause peritonitis. Chronic inflammation of the gall-bladder leads in gen- eral to thickening of its walls and to adhesions with the surrounding fibrous structures. The bladder frequently shrinks in consequence. The fibrous capsule around the ducts becomes in like circumstances notably hyperplastic. Now and then the bladder and larger ducts appear beset with papillary outgrowths from the same causes. When such an inflammation of the ducts persists for a long time, or leads to persistent retention of the bile, the inflamma- tory changes extend to other parts of the liver. Brown or yellow granular biliary concretions appear in the in- terlobular tissue and within the lobules. The liver-cells perish at various points, and inflammatory infiltrations appear within the lobules and terminate in abscess or in fibroid induration. Many cancers of the liver start in the smaller bile-ducts. Cancers of the gall-bladder begin as soft growths arising from the inner surface, which, as they develop, may ex- tend to and invade the liver. Destructive adenoma of the duodenum sometimes develops at or near the opening of the common duct, and may obstruct or altogether occlude the passage.4 Independent of this record by Ziegler, in regard to the pathological changes of the structures connected with the biliary function, it has been ascertained by other trust- worthy observers that the closure of the natural outlet of the bile brings many troubles in its train. The develop- ment of inflammation, and consequent ulceration in the tissues of the gall-bladder, occurs at times without pre- senting phenomena of much gravity, and even an external pointing of pus takes place without being preceded by any marked constitutional symptoms. But most fre- quently the progress of dilatation of the gall-bladder with the consequent suppuration and disorganization in the surrounding structures indicates the serious nature of these cases. An interesting report upon affections of the gall-bladder, tending to result in cutaneous biliary fistula, by G. W. H. Kemper, M.D., is-reprinted from the "Transactions of the Indiana State Medical Society for 1879." A copy has been kindly sent to me by the author ; and eleven cases of the external discharge of accumulations in the gall- bladder are recorded from different sources, with many interesting details. One of these cases, under the per- sonal care of Dr. Kemper, has such important features illustrating the diagnosis of such tumors in their different stages of development that a brief synopsis of its main points cannot fail to prove instructive. Mrs. II , aged fifty-three, had several bilious at- tacks during April and May, 1878. A considerable en- largement on the right side, descending on a line with the umbilicus, appeared about June 1st. The tumor had gradually extended down to the level of the spinous pro- cess of the ilium by August 1st, having rather a hard and a doughy feel, with little tenderness upon pressure. It was about half the size of a foetal head, with well-defined borders. The skin was unchanged ; the liver tender on pressure, and extending about two and a half centimetres below the ribs. The patient was "sallow," and had pain in the tumor upon motion of the body. It was regarded as an ovarian tumor. On October 14th it had descended into the right inguinal region. There the skin had a red- dish-brown appearance and was studded with little nod- ules. The tumor indicated approaching suppuration, and poultices were applied. On October 16th a thin, yellow- ish fluid was oozing from two or three points, but no signs of pus. The skin was purple, and malignant dis- ease was then suspected. Zinc dressings were applied. On November 1st two gall-stones were expelled, and twelve more were extracted having facets. The opening was in the right inguinal region, and simply a brownish- yellow fluid escaped. On November 20th two more cal- culi passed, making sixteen in all. The fistula healed in March, 1879, and her health was restored subsequently. Case No. 10 was a man, aged sixty-four, in the Liver- pool Workhouse Hospital, presented August 7, 1875, and affords important information as to the pathological de- velopments from gall-stones. It was reported by Drs. Alex- ander and Irvin in the Medical Times and Gazette. When admitted, the patient was much emaciated and debilitated, but without jaundice, and had good appetite. There was a ragged opening at the ensiform cartilage, with a ridge to the left and right. The discharge was variable in quality and quantity, being sometimes thick, at other times thin and watery, with considerable pyrosis. On August 21st an oval-shaped gall-stone was found in the opening, and after its removal for two days small portions of food escaped. Subsequently all of the food escaped until his death on October 6th. The autopsy showed the stomach much dilated, but the cardiac region was healthy, while the pyloric region pre- sented several excavated ulcers. The first part of the duodenum was considerably dilated, with its right ex- tremity adherent to the liver, completely concealing the site of the gall-bladder; its mucous membrane ulcerated and thickened, and its cavity filled with pus and food. At the place where the duodenum was attached to the liver, an opening existed and extended to the upper sur- face of the liver, with a fistula between the liver and the abdominal wall, extending to the external opening. No trace of the gall-bladder was found. The hepatic ducts and the common bile ducts were normal, and a small por- tion of the cystic duct, still pervious, extended to the point of adherence of the liver to the duodenum. The eleventh case in this series, reported by J. Cockle, M.D., in theMedical Times and Gazette, required an opera- 117 Cholecystotomy, Cholecystotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion. There were seventeen stones dislodged from the gall-bladder, leaving an opening the size of a crow's quill in an oblique line below the umbilicus, into which a probe passed readily upward for nearly six centimetres, when it came in contact with a solid body. It was requisite to slit up the sinus for the removal of the stone, and sub- sequently a second calculus was removed in the same manner. In a similar case under the care of M. Robert, at the Hotel-Dieu, it is stated that the attempt at extraction brought about disturbance of the adhesions, and fatal peritonitis ensued. Great caution is, therefore, necessary in endeavoring to extract calculi under such circum- stances. Of the eleven cases eight were females and three males, thus showing a much greater proclivity to affec- tions of the gall-bladder on the part of women than of men. The age of the youngest patient was forty-one years, and of the oldest sixty-nine, being thus confined to the middle or advanced periods of life. Pain in the right side, and a hard ill-defined tumor in the right hypochondriac or iliac regions, with abscesses within the abdominal wall near the umbilicus, or in the right groin, were the most frequent accompaniments or consequences of the disorder of the gall-bladder. A mistaken diagnosis occurred in several cases ; for example, ovarian tumor, suppurative ovaritis, and malig- nant disease were supposed to exist. In six of the cases a spontaneous ulceration and dis- charge of the contents of the gall-bladder took place ; in one case a blister was used to hasten suppuration ; in one, Vienna paste; and in another Vienna paste and the knife, combined, were used. The duration of the discharge in two cases was only two months ; in three it was three months ; in one, a dis- charge occurred at intervals for four years ; in one it con- tinued for six years, when the expulsion of a second stone gave relief; and in one case a fluid discharge was kept up for fourteen years. The number of calculi discharged varied from one to fifty-two. All but one patient recovered, or reached a comparative degree of comfort, and in the fatal case ulceration connected with the adhesions of tlte pyloric orifice of the stomach and duodenum presented a com- plication involving organs not directly the seat of dis- order. Dr. Kemper remarks that obstruction of the cystic duct, when long continued, leads to its obliteration and resulting disease of the gall-bladder, affecting its nu- trition and predisposing to inflammation and ulceration, with expulsion of its contents through adjacent structures. Again it remains hypertrophied and a source of distress, without the development of suppuration. In the June number of the New Orleans Med. and Surg. Jour, for 1881, a case is reported by Mr. Frank E. Ar- taud, entitled "Acute Hepatitis, resulting from the Presence of Biliary Calculi found in the Parenchymatous Structure of the Right Lobe of the Liver." But the facts do not warrant the conclusion that the proper structure of the organ was involved, and it was most probably a puru- lent collection mixed with biliary calculi in the distended gall-bladder, which being evacuated, relief followed. Dr. Walter Mendelson reported in the July number of the American Journal of the Medical Sciences for 1881, a ' ' Case of Abscess of the Liver complicated with Empy- ema," but without any evidence of the existence of gall- stones in the sac. There is good reason for considering the gall-bladder as the seat of this purulent collection, since ' ' nothing that could be distinctly identified as liver- cells were found " in the examination of the pus by the. pathologist of the hospital. The icteric hue was wanting in both these cases ; and while Artaud notes the lack of bile in the discharges prior to the operation and its appearance afterward, Mendelson makes no statement on this point. These two operations were performed at remote localities on December 22, 1880, and progressed so favorably that both were dismissed at the close of a week. Notwithstanding the grave features of some cases, the tendency in this class of affections, in most instances, is to spontaneous recovery. When no threatening compli- cation or imminent danger is presented in course of the suppuration, Dr. Kemper considers that the safest plan is to trust the case to nature. But the aim of surgical interference is to arrest the march of the disorder by a timely operation, and to ac- complish in a shorter time, by a direct method, that adhe- sion of the gall-bladder with the abdominal wall which results from the tedious process of local inflammation in the tissues surrounding the distended sac. Delay in un- dertaking the appropriate measure of relief brings disin- tegration, which undermines the recuperative powers of the system, and hence the great importance of an early recognition of the nature of the disorder, so that this dis- organization may be arrested by a judicious surgical pro- cedure. In this point of view the reports of clinical ex- perience have their significance, especially in the limited number of observations thus far presented to the profes- sion touching these disorders. As an illustration of the practical insight gained by operative proceedings in this class of cases, I would note the earliest result on record of the fulfilment of a radical measure for relief of occlusion of the gall-bladder. The account given by Kemper of the successful operation of Professor J. S. Bobbs, from the " Transactions of the In- diana State Medical Society for 1868," may be appropri- ately recorded here, as the initial step in cholecystotomy. His patient was a lady, thirty years of age. The growth of the gall-bladder had been gradual for about four years. The true nature of the enlargement was in doubt prior to the operation, but the patient insisted upon operative measures. Accordingly, on June 15, 1867, as- sisted by a number of medical gentlemen, Dr. Bobbs made the operation. An exploratory incision was made through the abdominal wall, extending from the umbili- cus to the pubis. This revealed extensive adhesions of the omentum to the adjacent tissues. The incision was then extended two and a half centimetres above the um- bilicus, and laterally over the most prominent point of the tumor. Tearing through the adhesions with his fingers, he reached a sac about thirteen centimetres long, and five centimetres in diameter, evidently containing a pellucid fluid. As no pedicle could be discovered, the lower point of the sac was incised, " when a perfectly limpid fluid escaped, propelling, with considerable force, several solid bodies, about the size of ordinary rifle-bul- lets." • The gall-bladder was thus emptied, the incision in its walls stitched, and the ends cut closely and returned into the abdominal cavity. The external wound was properly closed. Her recovery was rapid, without an untoward symptom. In four weeks she was able to ride out. Kemper says : " When the operation of cholecysto- tomy shall have been placed on a firm and scientific basis, and recognized and acknowledged by our profession-as it assuredly will-and its literature fully considered, the lustre of no name on its roll shall exceed that of Dr. Bobbs." Though not a premeditated cholecystotomy, it serves to guide us in similar proceedings, authorizing, in suitable cases, the suturing of the opening in the gall- bladder separately from that of the abdominal wall, and dropping it back into the abdominal cavity. With the practical outlook as it is at present, we can glance back to the allusions of Sharp, Goode, Block, Morgagni, Andre, Petit, and Morand, as paving the way to the more precise suggestions of Thudichum, Daly, and Maunder, which preceded the performance of the first cholecystotomy, in due form, by Bobbs. The most extended and satisfactory notices of the vari- ous steps resorted to by different operators have been presented by Dr. W. W. Keen, in the January number of the American Journal of the Medical Sciences for 1879, and by Drs. J. H. Musser and W. W. Keen, in that of October of the same journal for 1884. From these re- ports of cases, it appears that the idea of removing foreign bodies from the gall-bladder by incision of the abdominal wall, and subsequent opening of the sac, occurred to the minds of Petit, Thudichum, Maunder, and Hughlings 118 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy, Cliolecystotomy. Jackson at an early period, but none of them undertook the operation of cholecystotomy, as afterward performed. Handfield Jones proposed to push the gall-stones into the duodenum without opening the gall-bladder. Bartholow aspirated the gall-bladder with a fatal result, and suggested the use of a probe for exploring the bile duct, with a view to the removal of obstructions in this canal. Brown detected gall-stones, but after making an exter- nal incision of two and a half inches, closed the wound, without reaching the gall-bladder. Bile, however, came away during the following night, and the patient recov- ered without a fistula. Bryant removed a large biliary calculus, which had caused suppuration of the gall-blad- der, and after discharging for some months the opening closed, restoring the biliary tract. Morgagni describes three cases with tumors in the epi- gastric region, from which biliary calculi were dis- charged through openings by ulceration or incision. It is stated that the first healed, the second recovered with a fistula, and the third with an ulcer ; but 'these eases need authentication. The radical proceedings instituted by Sims and by Keen, in their cases of dropsy of the gall-bladder, are types of the operation styled cholecystotomy, and their untoward results only hastened the early termination of sufferings which were tending to a fatal issue at no distant day. The extensive collection in the distended •gall-bladder in the case of Keen was not connected with biliary concre- tions, but it is to be regretted that the condition of the ductus choledochus does not appear in the report of the post-mortem examination. In the case reported by Sims we are led to infer from the autopsy made by M. Ganal that obstruction of the common duct had not taken place. ' ' He cut the gall- bladder loose from the parietes of the abdomen, and then introduced his hand into it and removed sixteen gall- stones, from the size of a pea to that of a pigeon's egg. They were all sacculated, and this was the reason that they were not removed at the time of the operation. He then removed the gall-bladder entire ; it was very large, and its walls were much thickened. After doing thi^he was able to pass a probe from the gall-bladder through the ductus choledochus into the duodenum." In the table of thirty-five cases presented by Drs. Mus- ser and Keen there are four in which the abdominal cav- ity was opened without incision of the gall-bladder, and consequently not coming properly under the classifica- tion of cholecystotomy. Under the heading of " Cholecystotomy, properly so called," there are two cases in which the gall-bladder was sutured and dropped into the abdominal cavity, five in which the gall-bladder was extirpated, and one in which a connection between the gall-bladder and the intestinal canal was effected. It is inferred that in the remaining twenty - seven cases the edges of the incised sac were attached to the borders of the opening in the parietes. In fifteen cases no date is given of the operation, and in six the operators are not known. In twelve of the operations the simple statement ' ' Cholecystotomy " appears, without giving any of the details. The record of sex, including a note at the close of the article, shows that twenty-one females and nine males were the subjects of operative procedure, leav- ing the sex of five unknown. As observed in the cases of fistula reported by Kemper, there is a large preponder- ance of women over men in the patients. The complications resulting from adhesions of the gall- bladder and ducts with the surrounding tissues and organs are strikingly illustrated by Case No. 1 of Dr. J. H. Mus- ser, operated upon May 3, 1882. The colon was adher- ent to the liver, and a hard mass, as large as the fist, was attached to the liver, the colon, and the small intestine. The gall-bladder was supposed to be included in this in- flammatory agglutination, so that no gall-stones could be detected. The diagnosis being so obscure, it was decided to close the wound, including the peritoneum, with the skin in the ten wire sutures. After sundry haemorrhages and suppuration at some points, the incision healed, leav- ing several pockets for the granulating process, one of which remained on July 1st. At this date the jaundice had diminished, but the indurated area extended four inches vertically from the xyphoid cartilage, and twenty days later undue exercise was followed by pain, swelling, and tenderness in the epigastrium. In August traces of jaundice continued, but the itching of the skin ceased. Upon visiting Saratoga the patient drank of the Hathorn Spring water with benefit, excepting that the mass in the epigastrium was unchanged. The ultimate recovery of this patient was due, perhaps, to ulceration of the gall- stone into the small intestine, though unnoticed in the re- port. In Case No. 2, reported by Dr. Musser, the lower border of the liver was defined by a uniform curved line, extending from a point an inch and a half above the iliac spine to the ensiform cartilage. At the middle of its border there was a tumor projecting toward the navel, having a diameter of two and a half inches each way. It was tapped with a short hypodermic needle, and one ounce of limpid viscid serum drawn off. On June 19, 1883, cholecystotomy was performed by Dr. Keen. In- cision five inches long, one-half way between umbilicus and ribs, parallel with the latter ; inner end just reaching the right rectus muscle; slight bleeding. The special scoop devised by Keen was invaluable in keeping the bowels out of the way, and in carrying off the contents of the cyst. The pear-shaped gall-bladder was tapped, and discharged twenty ounces of the same fluid as had been withdrawn previously. Upon the opening being enlarged to admit two fingers, the discharge of a few ounces of pus mixed with bile followed. Walls of gall- bladder, one-fourth inch thick ; bleeding slightly. Ex- ploration before and after the incision found no stone, and the probe with forceps entered a distance of seven inches without detecting anything or discovering an outlet by way of the cystic duct. The gall-bladder, on being opened, was kept under control by a wire ligature passed through the edges of the incision. The wound was closed by twelve sutures, six being used to attach the opening in the gall-bladder to that in the abdominal wall, with a rubber fenestrated drainage-tube inserted, thus creating a biliary fistula. June 24th.-Removed tubing and probed five inches into the gall-bladder. It was much contracted as com- pared with its former size. No stone found. His color is lighter, but the abdomen tympanitic. June 25th.-Dressing stained with blood, and also with bile ; no evidence of suppuration ; still has tympanites. Died at 12.30 p.m., on June 26th, and the post-mortem, six hours afterward, showed the tissues all bile-stained ; the intestines distended with gas and dark colored ; a small amount of ascitic fluid in peritoneal cavity ; perfect adhe- sion of gall-bladder to abdominal wall, and slight traces of lymph on transverse colon ; about two ounces of clotted blood in folds of gastro-colic omentum ; adherence of upper surface of liver to the diaphragm; gall-bladder about as large as the fist, with thickened walls, and mucous coat inflamed and containing bile. The cystic duct was about the thickness of an ordinary lead-pencil, and at its junc- tion with the gall-bladder there seemed to be a honey- combed projection of the mucous membrane, thereby occluding the duct; common duct enlarged and walls thickened ; calibre increased enough to admit forefinger at cystic duct, and thumb at duodenum ; mucous mem- brane inflamed ; orifice impervious to blowpipe and to liquid ; a small probe was forced through with some diffi- culty from the duodenum; there was no evidence of ulceration or cicatrix. The hepatic ducts were dilated and inflamed in their ramifications through the liver, some terminating in blind pouches. In the periphery of the left lobe of the liver there were several retention cysts, the size of a filbert, filled with pus and bile ; the tissue of the liver was very soft, olive-green in color, and had the appearance of disintegration ; glands in fissure not enlarged ; pancreas was normal, ducts di- lated, and containing pancreatic fluid. The main duct was larger than the forefinger, while the subdivisions far into the gland were also enlarged. The stomach was di- 119 diolecyst otoiny. diolecystotomy. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. lated, and contained blood, and liquids which had been given. The mucous membrane of the duodenum was thickened, and Dr. Musser claims that the inflamed ap- pearance of the duodenum explained perfectly the reason of the obstruction at the mouth of the duct. As there is no report of the presence of blood in the ejections from the stomach, it is inferred that the blood found in the stomach after death resulted from the general haemor- rhagic tendency characteristic of these affections. The origin of the train of troubles connected with oc- clusion of the biliary and pancreatic ducts calls for thor- ough investigation ; and this exemplification of the prog- ress of disease, with the traumatic modification of the structures, deserves a careful consideration by all opera- tors. While it is stated that pus and bile were found in the peripheral cysts of the left lobe of the liver, there is an omission in respect to the contents of the hepatic and common ducts. But in a private note from Dr. Musser, I am informed that " they contained some pus and bile." This is a typical case of the indications for cholecysto- tomy, and of the recognized mode of proceeding with the operation, while the details of the autopsic examination are quite instructive. The operation was undertaken with all due precautions, and must be considered a philosophic substitute for the progressive disintegration of tissues that usually attends the spontaneous development of an abscess and its termi- nation in an external fistula. But the lesson to be learned from such cases as this, is, that of anticipating the evil, and nipping it in the bud by an early operation. The autopsies of the few cases specified exhibited such degeneration in the liver as was likely to prove fatal, and hence they should serve as a caution against leaving these cases to progress without an early operation. The interest attaching to the remarks made by Drs. Musser and Keen touching the indications for surgical interference in obstructions of the gall-ducts, is my excuse for introducing here a somewhat full synopsis of them. According to Dr. Musser, there are four pronounced conditions, which are dangerous as sequences of biliary ob- struction, and which may be looked upon as indications for operative interference. They are jaundice; a tumor in the right hypochondrium, presumably an enlarged gall- bladder ; frequently recurring paroxysmal pain; and symptoms of suppuration. He considers jaundice as one of the most distinctive evidences of obstruction ; and that it is important to determine whether the case is jaundice by suppression, so called, or jaundice by obstruction. In the cases of Sims and Keen great stress was laid upon itching as a symptom of the obstruction variety of jaun- dice. Important data respecting jaundice are gathered from a study of the table of cases, in which it is reported seven times. The average age of these patients was a fraction over forty-six years ; five were males, two fe- males ; the duration of the jaundice, when given, was over four and a half months ; enlarged gall-bladder was present six times ; a distinct history of gall-stones in four cases ; of cancer of the pancreas, of occlusion by lymph, and of catarrhal jaundice in one each, while cholaemia appeared only once. The facts noted do not warrant the inference that jaun- dice by suppression could have resulted from acute yellow atrophy of the liver. If the liver be atrophied, 'jaundice by suppression is probable ; if enlarged, by ob- struction. ' If anatomical changes in the stomach, duo- denum, pancreas, lymphatic glands, blood-vessels, etc., be present, Dr. Musser states that the jaundice is in all probability obstructive. The diagnosis of obstructive jaundice having been de- termined, and the irremediable diseases of the liver being eliminated, it is next important to define the nature of the obstruction, for only some varieties would admit of interference. In seventeen tabulated cases of obstruction it was caused by gall-stones thirteen times; cancer of the pan- creas, peri-hepatitis, and gastro-duodenal catarrh, each caused it once, and in one case the cause was doubtful. The causes in general of stenosis in the bile-ducts are considered by Dr. Musser as three: 1, Foreign bodies within the ducts (gall-stones, parasites, etc.); 2, diseases of the walls of the ducts (a, congenital; b, adhesive in- flammation or cicatrization of ulcers ; c, peri-hepatitis), 3, tumors, etc., external to the ducts. Worms or hydatid cysts may be the source of hepatic colic, and lead subsequently to local inflammation in the ducts. The presence of biliary calculi gives trouble more frequently ; and, in twenty-one cases, they were present in sixteen, causing obstruction, or otherwise endangering life. The only definite sign of their existence is to see or feel the gall-stone. If one has been passed from the bowels, it probably was the cause of obstruction ; if it presents facets, a fellow may be the cause. If not found in the passages from the bowels, exploration of the gall- bladder with the hand or proper instruments may still detect calculi. The diagnosis is very probable when the patient has had attacks of hepatic colic, followed by jaundice and the symptoms of duodenal catarrh, or if constipation and putty-colored stools accompany the jaundice. It is further corroborated if the nutrition of the patient remains good after impaction has occurred, while the liver enlarges only slightly, and the gall-bladder increases in size. The suggestion of Campbell, in the " Brooklyn Annals," that the relief of tension by aspira- tion allows the stone to recede and the bile to escape, does not recognize the contractility of the ducts as a factor in retaining biliary calculi, which fact must invalidate the diagnostic value of bilious stools after this operation as indicating the cause of the obstruction. The second indication given by Musser for the perform- ance of cholecystotomy is the presence of a tumor due to the arrest of bile, to the retention of gall-stones, to in- flammation of the walls of the gall-bladder, or to malig- nant disease of its structure. It was observed in eleven of the tabulated cases, and the position and size varied greatly. It is essential to note the point of departure and the direction in which the tumor grew. The gall-bladder is not so large when gall-stones or carcinomas are present, as when purulent or biliary fluid is confined in its cavity. The enlargement of the gall-bladder is generally pyri- form in shape, or it forms a semi-globular or globular tumor, and is usually movable, tender, elastic, and fluc- tuating, but may have different qualities, and the intestine is never in front of the growth. An investigation into the nature of the contents of the tumor yields the most definite facts for diagnosis. The contents of the gall-bladder upon making an au- topsy may differ materially from the fluid evacuated by an aspirator during life. A glairy, pellucid fluid was found in three cases ; pus in two ; and bile with blood, a light-green fluid, a thick brown fluid, and muco-pus in one each. When bile or bile-stained fluids are present it is almost certain that the source is the gall-bladder. Even if the fluid contain no bile elements, it may still come from a distended gall-bladder whose duct is occluded so that no bile enters it, for after a certain time the bile disappears and is replaced by the mucoid secretion of the lining mem- brane of the gall-bladder. Absence of the chemical and microscopic characters of a hydatid, renal, or ovarian cyst would exclude either of these. It may, however, be a tumor of the liver itself, of the stomach, duodenum, pancreas, or the lymphatic glands. If an abscess is suspected, the in- duration and then the softening and fluctuation should be present. The painless, slow course of hydatid disease, the broad base of the cyst, the fremitus, and the results of tapping serve to render the recognition of this disease possible, if taken with the negative symptoms of enlarge- ment of the gall-bladder. In addition to the above, floating kidney and renal and ovarian tumors must be considered and eliminated in making the diagnosis of an enlarged gall-bladder. But having once determined its existence, we should decide whether it is due to distention by bile, pus, serum, or mucus ; to the presence of calculi; or to a carcinoma of its walls ; and the last is of most practical moment. The third indication for the performance of cholecys- 120 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy. Cholecystotomy. totomy, according to Musser, is the occurrence of severe pain in the region of the gall-bladder, due presumably to a gall-stone. Hepatic colic without jaundice occurs when the stone is confined in the cystic duct; and this pain must be dis- tinguished from that of pleurodynia, intercostal neuralgia, gastralgia, renal and intestinal colic, or local inflamma- tion. Cholecystotomy is also indicated when the symptoms are due to internal suppuration. Hectic, endangering life, may be from simple or multiple abscess of the liver, abscess of the gall-bladder, suppurative inflammation of the ducts and of the portal vein. The latter condition especially must be differentiated. While it has the symp- toms of jaundice, pain, enlargement of the liver, hectic, and emaciation, in common with the other inflammatory affections, pylephlebitis lacks the tumor of gall-bladder affections, and of abscess of the liver. Excluding it, and also simple and multiple abscess of the liver, we have left the similar affection of the gall-bladder, and laparotomy at least should be performed in stippurations threatening life. It is true there are cases of suppurative inflammation of the hepatic duct that get well; rare are the cases of recovery in multiple abscess. Now if the gall- bladder be opened, and the collection of pus is discharged, it certainly gives the patient a very good chance of re- covery. After this study qf hepatic affections, Dr. Musser insists that the duty of the medical man is to observe with extreme minuteness the course of the affection, so as to be able to make a clear diagnosis, and, above all, not to postpone any attempts at surgical relief until pathological changes have ensued which are beyond re- pair. Upon examining the " surgical remarks by Dr. Keen," it is found that he sanctions the resort to aspiration and acupuncture for the diagnosis of affections of the gall- bladder, in advance of opening the abdomen. But his advocacy of exploratory punctures through the abdom- inal parietes is not sustained by facts. Being satisfied that such preliminary steps are not requisite as a means of diagnosis, and that unforeseen risks attend such modes of exploration, while safer means of investigation may be relied upon for a correct judgment as to this class of dis- orders, we cannot acquiesce in this proceeding. Yet it is proper to state that others concur in the propriety of these processes, and in a clinical lecture reported in the April number of the Medical Bulletin, Professor Roberts Bar- tholow states that ' ' this diagnosis can be reduced to an absolute certainty. It is perfectly easy, and, let me add, perfectly proper, to pass an exploring needle into the gall-bladder." I have, therefore, to record the statement of Dr. Keen, that the diagnosis by surgical means is made by-1, as- piration w'ith or without exploration by a probe ; and, 2, by acupuncture. While recognizing these processes, he says exploratory opening of the abdominal cavity under antiseptic precautions, strange as the doctrine may sound to those of us old enough to have been accus- tomed to hear the peritoneum named with dread, is one of the safest operations in surgery. But little if any reaction follows it, and if the facts learned are such as to prohibit any further action, the abdomen is simply closed and the patient almost invariably recovers, the wound healing by first intention within a week. Of the cases that have perished from gall-stones many lives have been sacrificed to timidity and neglect of action. To wait, as was formerly done, for adhesions to form and the " abscess" to point, is, in most cases, simply to wait for death. Exploratory operations are, therefore, advocated by Keen, and, if the ascertained facts warrant it, followed by cholecystotomy. There are various methods of reaching the gall-bladder. The patient is worried and time is lost by provoking the formation of adhesions by means of caustics, and, while waiting for this to take place, we fail to get the light afforded by abdominal section as an exploratory measure. In an exploratory laparotomy, with a view to subse- quent opening of the gall-bladder, adhesions result from inflammation while the wound is let alone, or kept open by dressing, and the sac remains untouched. The objection to this course is, that other organs than the gall-bladder may adhere to the wound, and, moreover, it .has the serious feature of leaving the abdominal cavity exposed. Again, the unopened gall-bladder may be stitched to the abdominal wound, and by their adhesion escape of the contents of the sac into the peritoneal cavity is pre- vented. The attachment of the edges of incisions made in the walls of the abdomen and the gall-bladder obviates all the inconveniences and dangers of the other processes. The first one, says Keen, to propose this operation, was undoubtedly Thudichum, in a paper on the ' ' Pathology and Treatment of Gall-stones" (British Medical Journal, 1859, ii., 935). Mr. Maunder proposed (British Medical Journal, 1876, ii., 694) to attach the bladder to the abdom- inal walls and to open it afterward. Still later, Handfield Jones (Medical Times and Gazette, 1878, i., 246) proposed cholecystotomy. But the actual surgical step was taken by two American surgeons. June 15, 1867, Dr. Bobbs (" Trans. Indiana State Medical Society, 1868," p. 68), in an obscure case of abdominal tumor, opened the abdomen, and then the tumor, which proved to be the gall-bladder, and removed a number of calculi. But to Sims must be given the credit of first distinctly formulat- ing such an operation, and of practically perfecting it, both in design and technique (British Medical Journal, 1878, i., 811). Slight modificationshave been proposed and carried out since, but practically the real work was done when his paper was published. According to Keen, the incision should be made, as a rule, over the centre of the tumor, and parallel to the free border of the ribs. The far greater facility of ac- cess to the tumor overbalances, in his estimation, any less haemorrhage from an incision in the linea alba. It should be sufficient for exploration, being made about three inches in length, and enlarged, if need be, afterward. All bleeding should be arrested by haemostatic forceps, or catgut ligatures, before opening the peritoneum. This being opened, two fingers should be used, or, if neces- sary, the whole hand, to explore the condition of the various abdominal organs, and learn the exact nature, attachment, etc., of the tumor, and, so far as possible, the character of its contents. The cystic duct and common duct are to be examined to determine the presence and situation of gall-stones, with their size, shape, and mobility. If any be found in the ducts, the suggestion of Handfield Jones, to endeavor to push them into the duodenum, should be tried. This failing, we should endeavor to push them back into the gall-bladder, as this part of the duct has already been dilated by their onward passage. Whether we can find any stones or not, if the bladder be distended with fluid, it should be aspirated, and its wall subsequently cut to the extent of an inch or more, if necessary, the scoop, devised by Keen, being used to carry off any liquid contents that might otherwise flow into the abdomen, and, at the same time, to keep back the intestines that tend to escape from the cavity. By the probe and forceps, of various forms, any gall- stones that are present may now be discovered and re- moved. It is not always practicable to find all the stones at the outset, and stones, not encountered at the opera- tion, have escaped subsequently, or have been extracted by the operators. This shows the propriety of establishing a biliary fist- ula, and a large fenestrated drainage-tube should be in- serted while the whole is covered with antiseptic dress- ings. The collapsing gall-bladder does not appear to drag on the abdominal wall from adhesion to it, as might have been expected. A compress and bandage should be used to obviate any tendency to ventral hernia after the opera- tion. Haemorrhage from oozing, due to the condition of the blood connected with jaundice, is often troublesome. The liver, in such cases, is softened, and its integrity al- 121 Cholecystotomy. Cholecystotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. most destroyed. These conditions show the wisdom of early operations. The closure of the opening in the gall- bladder by sutures, and dropping it into the abdomen, is worthy of consideration. If the stone be in the cystic duct, the sac would be refilled with its own secretion, and if in the common duct, by bile ; but should all the stones be removed, and the ducts be pervious, the fistula will soon close. Keen therefore considers the creation of a biliary fistula as the better practice, yet he holds that in case a probe could be passed into the duodenum, with a reasonable assurance that all stones have been removed, closure of the gall-bladder, by Gely's suture or otherwise, might be done with propriety. Though the extirpation of the gall-bladder, with liga- tion of the cystic duct, has been executed with success in some cases, he thinks it a needless additional risk for the patient. But the results given in our article upon Chole- cystectomy show that less danger attends it than the operation of cholecystotomy, properly so called. Keen remarks that if we are sure no calculi remain in the gall-bladder, it might be possible, instead of establish- ing an external biliary fistula, to open the small intestine at as high a point as practicable below the duodenum, and by sutures unite this opening to that made in the gall-bladder, thus re-establishing the flow of bile into the intestine. Von Winiwarter (Prog Mediz. Woch., No. 21, 1882) attempted this procedure with partial success. Clearly nature meant that the bile should enter the small intestine high up, and play its role in the digestive process. If by art we can re-establish this disordered process, without too much danger in doing it, it should be our aim. In corroboration of this position taken by Keen, I would say that when the outlet of the common bile duct into the duodenum is permanently closed, and the bile finds its way through the cystic duct into the gall-bladder, the most philosophic proceeding is to effect a direct pas- sage of the bile from the gall-bladder into the duodenum. But as I shall have occasion, under the heading of Duo- deno-cholecystostomy, to treat of this process, by which the bile is returned to its proper destination for the per- formance of its office in the animal economy, a considera- tion of this operation is deferred for the present. I have to remark, however, in this connection, that the plan adopted in giving exit to the bile by a fistulous opening externally may yet be replaced by that of causing it to discharge internally. An interesting and instructive resume of the great prog- ress made in operative procedures for obstructions of the gall-ducts appeared in the numbers of the Medical News for December 20,1884, and February 14, 1885. Notice is given of four operations in cases that had not previously been published in our American journals. Courvoisier, of Basle, has recorded in the Correspondenzblatt fur Schweizer Aerzte, No. 15, a successful cholecystotomy and a re- covery after cholecystectomy. Cholecystotomies from the practice of Trendelenbergare reported by Witzel; of Konig, recorded in the Verhandlungen dev Peutschen Ge- sellschaft fur Chirurgie for 1882 ; of Boeckel, referred to in the Gazette Medicale de Strasbourg, No. 8, 1884. After enumerating the various operations in which the gall-bladder and abdomen were opened, it is stated that in twenty the edges of the opening in the sac were at once stitched to that in the abdominal wall, thereby form- ing a temporary fistula. In the case of Sims a portion of the viscus was extirpated, previous to sewing it to the superficial wound. In the case of Konig the belly was opened, the bladder attached to the abdominal wall by sutures and not incised until the tenth day. In Kocher's case adhesions were excited by placing a bit of Lister's gauze in the w'ound, and the gall-bladder was incised on the seventh day. In three of the remaining exceptional ex- amples, the incision was closed by sutures, and the organ returned into the abdomen. The case of Dr. Bobbs, in which one stitch was used, recovered, as did that of Courvoisier after using the continuous suture, while death occurred in the third case referred to, in which the con- tinuous suture was employed for the incision of the sac. It is my privilege to supply the name of Mr. W. A. Meredith, of London, as the operator in this last case, and to correct an erroneous impression from the report of Tait as to the escape of bile into the peritoneal cavity after the use of the continuous suture, which will appear in the notes of the cases. In the seventh exceptional case, referred to in the Med- ical News, it is stated that Von Winiwarter established a fistula between the gall-bladder and the small intestine. This was effected by uniting them with stitches, suturing the intestine to the abdominal wound, opening the gut on the fifth day, puncturing the opposed surfaces through the incised intestine, and finally closing the latter with sutures. Alluding to cholecystotomy and cholecystectomy, it is said that neither operation is justifiable unless the com- mon duct is patulous and icterus is absent. This statement, in the editorial department of the News for February 14, 1885, p. 183, implies that the escape of bile by an external fistulous opening is not considered proper, since there could be no embarrassment to its out- let, provided the cystic duct is patulous. The occlusion of the common duct would, of course, prevent the en- trance of the bile into the alimentary canal, which the operation performed by Von Winiwarter is intended to remedy, by effecting an artificial communication with the intestine. Whatever may be the properties of the bile, it would seem to have been designed for a useful purpose by ad- mixture with the chyme soon after leaving the stomach, and, in combination with the pancreatic secretion, it is claimed by physiologists to promote those changes which enable the lacteals to take up the nutritive elements of the food, and, besides, to serve as an antiseptic in preventing decomposition of the refuse materials, while it stimulates the peristaltic action of the intestines.5 In comparing the different measures adopted by sur- geons for the relief of the distended gall-bladder, we shall find that their relative advantages depend upon the greater or less probability of restoring the bile to the in- testine. In the fifth volume of the " International Encyclopaedia of Surgery," allusion is made by Mr. Morris to the case of Mr. W. A. Meredith, of London, in which the incision of the gall-bladder was closed with continued suture, and dropped into the abdominal cavity. But the full report of this cholecystotomy not being given, and Mr. Meredith not having had leisure to publish the details of his case previously, the succinct account of it forwarded to me, February 11, 1885, must prove instructive.* ' ' The patient was a woman, aged fifty-nine, who had suffered for six months previous to operation from a swell- ing in right hypochondrium, giving rise to recurring paroxysmal attacks of severe pain, without jaundice. "The dilated gall-bladder was readily exposed by an incision practised over it, along the outer border of the right rectus muscle. Introducing my finger, I explored its connections, and at once detected a mass of calculi, evidently impacted in the cystic duct. After tapping, and evacuating the gall, I enlarged the puncture in its wall, and then readily extracted three calculi from the duct, which weighed collectively thirty grammes. " After making sure that no farther obstruction existed, I decided, partly on the suggestion of Sir Spencer Wells, who was present at the operation, to suture the opening in the gall-bladder, and drop it in. This was accordingly done by means of a fine silk thread, introduced as a con- tinuous suture, and inverting the edges of the peritoneal coat. The abdominal incision was closed in the usual way ; no drainage being employed. "This patient died in forty-eight hours with suppression of urine. At the autopsy the incision in the gall bladder was found securely closed, and quite impervious to fluid. The gall-bladder itself contained a quantity of bile, as did also the duodenum. The ducts were quite unob- structed throughout. Several ounces of bile were found * A full report of this case was made by Mr. Meredith, in the British. Medical Journal for February 28, 1885, to which the reader is referred for the details. 122 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy. Cholecystotomy. lying free in the peritoneal cavity among the folds of the mesentery, having evidently escaped during the opera- tion from the sponges which I had inserted around the gall-bladder while emptying it. There were no signs of peritonitis, and no evidence of localized irritation from the presence of the effused bile. All the viscera were fairly healthy, with the exception of the kidneys, both of which were small and contracted, with adherent capsules, and showed evidence of recent congestion. There can, I think, be no doubt that the woman's death resulted from this kidney condition, which was probably aggravated by the attempt to eliminate the bile from the peritoneal cavity. " As regards the method adopted-of dispensing with drainage-I do not feel inclined to recommend it, al- though there appears to me no reason why it should not succeed in a favorable case, provided always that it was possible to ascertain that no obstruction remained in the ducts. This, of course, constitutes the chief difficulty, and may be impossible, so that, on the whole, I believe that the more usual plan of draining the gall-bladder should be preferred, at all events in the majority of in- stances." This operation was performed on January 30, 1883, at the Samaritan Free Hospital. It will be observed that Meredith states distinctly that the bile found in the cavity of the abdomen at the au- topsy escaped during the operation, and hence the im- pression that the discharge occurred from the yielding of the stitches in the walls of the gall-bladder is without foundation, so that the reader can judge of the propriety of this procedure in other cases of cholecystotomy suited to it. Although Meredith manifests some concern in regard to closing the sac separately from the external opening, the immediate union of the incised wall of the gall-blad- der, so perfectly as to render it impervious to the fluid bile which was found in its cavity should encourage a resort to this process whenever the cystic duct and the ductus communis choledochus are found to be patulous.* It is evident that the grave complication of renal dis- ease had much influence in bringing about the fatal result, which was attended with suppression of urine. The presence of the bile among the folds of the mesentery had, perhaps, little unfavorable effect, as there were no indica- tions of local inflammation. The observations of others warrant the conclusion that the normal biliary secretion is not an irritant to the peritoneum. It was noted in my sixth canine experiment that the bile escaped by the ex- ternal incision, leading to the inference that some por- tion of it must have passed into the peritoneal cavity, and yet without causing peritonitis or any other serious in- convenience in the subject. While vitiated bile or other decomposed accumulations in the gall-bladder should be discharged externally in operating, there is no just cause of apprehension from the leakage of freshly secreted bile through the sutured sac when the gall-bladder is dropped into the cavity of the abdomen. Of course, all due precaution against such a result should be observed; and it might prove an addi- tional security, in using the continuous suture, to make a reversed line of stitches throughout the length of the incision after the margins have been approximated by the first suture. In the case under consideration, how- ever, the simple continuous suture proved entirely ef- fectual in securing the union of the edges so as to prevent any exudation of the bile into the cavity. An interesting and profitable report of a case was kindly furnished me by Dr. N. Senn, of Milwaukee, Wis., on February 11, 1885, which by a strange coinci- dence is precisely the same date of the communication from Mr. Meredith, of London. Though the operation was not completed, the details well illustrate the history of biliary obstruction upon which operative procedure is to be decided, and, as Dr. Senn remarks, sometimes it is more important to report unfavorable than favorable cases. After laparotomy a discovery was made showing the great importance of accurate observation. " Mrs. K , fifty years of age, had suffered a few years ago from icterus, preceded and accompanied by every symptom of gall-stone. She recovered fully from this attack until six weeks before she came under my care, when she was taken with pain in the region of the gall-bladder, paroxysmal at times, but never remitting completely. The pains were soon followed by intense jaundice. The attending physician diagnosticated im- paction of gall stone and dilatation of gall-bladder. When I was called in consultation she was confined to bed, but presented no well-marked emaciation. The whole surface and the conjunctiva presented a deeply jaundiced appearance. Urine heavily loaded with color- ing material of bile, stools clay-colored. In the region of the gall-bladder a pyriform tumor could be distinctly felt, the lower margin of which extended to a line on a level with the umbilicus. The tumor on palpation im- parted a distinct sense of fluctuation, and moved upward and downward synchronously with the respiratory move- ments. " There could be no doubt that the tumor was a dis- tended gall-bladder. For the purpose of ascertaining, if possible, the nature of the obstructing cause, and to de- termine the contents of the cyst, a small and well disin- fected needle of an aspirator was introduced over the most prominent point of the tumor, and in an oblique direction, with a view to. prevent subsequent escape of fluid. With the needle search was made for gall-stones with negative results ; a small amount of fluid was with- drawn, which showed all the appearances of bile. I now believed that I was justified in assuming that we had to deal with an impacted calculus in the ductus communis choledochus and over-distention of the gall-bladder. The history of the case, the signs and symptoms presented, as well as the exploratory examination, seemed to combine to corroborate this view. ' ' As the usual treatment produced no effect, it was de- cided to give the patient the benefit of operative treat- ment. Under strict antiseptic precautions abdominal section was made. An incision about four inches in length was made over the most prominent part of the tumor, and parallel to the right costal arch, down to the peritoneum. After carefully arresting all haemorrhage, the peritoneum was opened to the same extent. No ad- hesions were found between the tumor' and the parietal peritoneum. Through the incision the distended gall- bladder could be distinctly seen and felt. With a view to ascertain the exact location of the impacted calculus, the region of the duct was explored by introducing the index and middle fingers, when, to my astonishment, I discovered well-marked evidences of malignant disease in the shape of nodular and irregular masses over the com- mon bile duct. As the disease was quite extensive, no further efforts were made to establish a biliary fistula. The wound was closed, and an antiseptic dressing ap- plied. The patient recovered well from the effects of the operation ; the wound closed in the usual time by primary union ; but the patient succumbed to the inroads of the malignant disease four weeks after the operation (which was done September 15, 1883). "Thecaseis interesting in illustrating the difficulties which are sometimes encountered in making a correct diagnosis in spite of improved methods of examination. " Inasmuch as primary cancer of the bile-duct is an ex- ceedingly rare occurrence, I am still inclined to the belief that an impacted gall-stone may have been present, and that the development of the cancerous affection was owing to the irritation which it produced. Unfortunately a post- mortem examination was not allowed." Upon suggesting to Dr. Senn the possibility that en- cysted gall-stones in the course of the gall-ducts might have been mistaken for malignant nodular masses, he re- plied to my communication in the following words : "I and every one present were convinced that the masses felt * In the case of Dr. Courvoisier, in which the incision in the wall of the sac was sutured and dropped into the cavity, a perfect union occurred and remained intact at the autopsy of the patient, who died from pneu- monia two and a half months subsequent to the operation (Correspon- denz-Blatt, August 1,1884), 123 Cholecystotomy. Cholecystotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and seen on the under surface of the liver were of a ma- lignant nature, as the disease had infiltrated the adjacent hepatic tissues in the shape of hard nodules. The only information a post-mortem examination could have re- vealed, would have been the question whether an impacted calculus constituted the primary obstruction, and whether the development of the cancer was not due to the irrita- tion incident to the obstruction caused by the calculus." The attention of all operators is directed to my descrip- tion of the altered condition of the coats of the common duct at page 366 of the October number of Gaillard's Journal for 1884. Thore -were no signs of any malig- nant degeneration discovered in this fatal case ; and "it was found, upon the autopsic investigation, that the sac forming the tumor was the relaxed and distended gall- bladder, which was filled with a semi-fluid dark-brown collection of inspissated bile, in which there existed sev- eral concretions of different sizes,* and offering but little resistance to compression. The entire tract of the ductus choledochus was obliterated with thickening and hard- ening of the tissues. At what had been the orifice of the cystic canal there was a very considerable dilatation, con- taining a biliary concretion, which was closed in on all sides by a membranous formation, into which an incision was made for its removal." That scirrhous degeneration of the pancreas, pylorus, and duodenum, may involve the common bile-duct in such manner as to cause thickening and induration of its tissues, has been verified by me in other cases than those specified in the cadaveric examinations detailed on page 379 in the above-named journal. But this is a conse- quence or a secondary result of the malignant disease in organs that are prone to undergo this kind of degenera- tion ; whereas, Dr. Senn has properly stated that "pri- mary cancer of the bile-duct is an exceedingly rare occur- rence." If the reader will refer to plate 228, in the "Atlas d'Anatomie Descriptive," by Cloquet, it will be observed that the presence of encysted gall-stones in the hepatic ducts would be discerned in the shape of hard nodules on the under surface of the liver, which are attributed by Senn to malignant disease. Again, the existence of gall- stones within the ductus choledochus would be felt in the shape of nodular and irregular masses, as described by him ; but unfortunately a post-mortem examination was not allowed. In a communication from Dr. C. T. Parkes, of Chicago, Ill., of January 27, 1885, I have been favored with the following graphic account of his important case of chole- cystotomy : ' ' In my case the incision was made parallel with the margin of the ribs, about three inches below-obliquely over the situation of the gall-bladder; The division of the abdominal walls displayed the surface of the liver enlarged, so as to reach fully a hand's breadth below the edge of the costal cartilages. By raising its edge upward, the distended gall-bladder was exposed to view, and drawn into the wound. It was.fully distended with an apparently clear fluid-its walls were very thin. Its con- tents were aspirated of about three ounces of perfectly clear, slightly viscid mucus. No trace whatever of bile. The walls of the bladder were then incised, and the open- ing held apart by snap forceps. An exploration of its cavity, with finger and with forceps and probe, failed to find any stones in the bladder. The walls of the gall- bladder were then sewed to the abdominal wall by silk sutures, and the wound closed ; a large drainage-tube was passed to the bottom of the gall-bladder and left in-an- tiseptic dressings applied. The patient had no vomiting, and rested comfortably the first twenty-four hours. On the second day the dressings were charged with appear- ance of a profuse flow of greenish-colored fluid from fist- ula. On the fourth day again dressed ; while probing the bladder, this day, I detected and removed two stones. On the seventh day I again found and removed five stones, one as large as the end of the finger. Since then none have been found. She was entirely free from pain for three weeks, all the bile apparently coming through the fistula. At the end of three weeks the old pain returned, and continued for some time. Still no bile in faeces. Under the supposition that another stone was impacted in the common duct, I did a second operation on the pa- tient, making a vertical incision from the centre of the first one ; I found no more stones, but passed a No. 10 Van Buren sound through the fistula and common duct into the duodenum. Since then bile has been discharged freely and naturally through the normal way, and the patient is apparently entirely well. My finger in abdom- inal cavity guided the sound. It must have displaced some thickened mucus in its passage, for I am quite sure no stone was in the duct. Neither was any found in the passages from the bowels." Upon my writing to Dr. Parkes for information as to some points not specified in this record, he replied on April 7, 1885, as follows : ' ' The patient's age is twenty-nine years. The first operation was made December 19, 1884. The second operation was made January 18, 1885. The patient was discharged February 1, 1885. The fistula healed entirely in two weeks. The patient remained well and free from suffering for two months, when the recurrence of some pain led me to re-open the fistula and to introduce a drain, giving relief. I am convinced that there is a contraction of the common duct in this case, rendering it too small in calibre to carry off the biliary secretions, and for the present, at least, the fistula will have to be kept open."* Never has diligence in following up an operation by other expedients been so well rewarded as in this pro- ceeding of Parkes. After realizing the communication of the gall-bladder with the duodenum by the second opera- tion, it still was found necessary to re-open the external outlet for the bile, and thus vindicate the propriety of attaching the gall-bladder to the parietes of the abdomen in this case. It woul^l seem that a suggestion of mine on page 380, in the October number of Gaillard's Journal, might have been put into execution on the occasion of Parkes's second operation, had it appeared then, as it has since, that the calibre of the common duct was not sufficient to carry off the bile, viz. : " Should any communication with the duodenum exist, however small it may be, dila- tation of the ductus choledochus should be attempted." But in view of all the surroundings of this case, it is a matter for congratulation that such a satisfactory result has been secured by the various proceedings instituted, and they are calculated to guide others under similar em- barrassments. Among the details presented in the differ- ent operations reported, the steps taken in this combina- tion of measures for the relief of the patient are the most encouraging for perseverance in using the means cal- culated to effect the end in view. It is only by com- parison of the process adopted with the result attained in individual cases that any very decided progress can be made in cholecystotomy. The lessons learned from the failures and successes of various operators have already led to marked improvements upon the original modes of operating, and other advances will doubtless grow out of the experience that daily observation yields. As in ova- riotomy for the past? success must crown its future. Without endorsing in detail the conclusions of Pro- fessor Jules Boeckel, in a paper read before the French Surgical Congress held at Paris recently, it may be stated that in his view cholecystotomy is influenced very much in its gravity by the presence or absence of biliary fistuke. His statement that the existence of a fistula due to calculi calls for an operation should be qualified, as most assur- edly this condition would not warrant the proceedings instituted ordinarily for the relief of cases without adhe- sions. When early intervention in cases of fistula hastens tlie cure by preventing the accidents due to incessant draining of the bile, as alleged in his paper, it can only be from removal of gall-stones which impede the flow of bile by the natural outlet, and this operation of detaching * In the Canada Medical and Surgical Journal for April, 1885, p. 540, is a report of thirty-two stones in the gall-bladder of a subject in the dis- secting-room of McGill College, three of which measured an inch square. * A report of this case may be found in Transactions of the Amer- ican Surgical Association, at Washington, D. C., April 21, 1685. 124 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy. Cholecystotomy. iinpacted calculi is not so very simple as represented, with adhesions between the gall-bladder and the parietes of the abdomen, as these preclude the requisite manipula- tion. In the absence of fistula and adhesions, when the his- tory, progress of the disease, examination of the patient, and, above all, the presence of a biliary tumor and explora- tory puncture reveal* the presence of biliary calculi, chole- cystotomy is recommended by Boeckel. But he holds that, in all other cases, the operation is in itself too grave and its results too uncertain to justify its performance. When the ordinary channel for a discharge of bile be- comes closed from any cause, it may happen that an arti- ficial passage will be effected by an ulcerative process between the gall-bladder and duodenum, or the adjacent portion of the small intestine, thus remedying the diffi- culty temporarily, if not permanently. An outlet is thus afforded to the biliary concretions, or to the collections of semi-fluid bile, and even sero-purulent discharges may take place through such an ulcerated opening. In the record of a case in which I thought' this highly probable, it is stated that the jaundice had disappeared ; but my patient was annoyed very much with indigestion and irregularity of the bowels, being at times inactive, and on other occasions passing off what seemed to be bilious matter. It was perceived that there was a constant acceler- ation of the pulse, exceeding a hundred to the minute, with nervous irritability. This patient gave no signs of organic heart-disease, and with the continued gastric and intestinal trouble, associated with more or less tenderness over the epigastrium, along with nervous excitability and acceler- ation of the pulse, dating from the period of the attack of hepatic colic, it is, perhaps, a legitimate inference that the structural changes, initiated then, had progressed with ulceration in such form as to account for the whole train of disorders, and that I was correct in diagnosing obstruction of the gall-duct with abnormal cysto-intestinal communication. As it was known that he did not suffer from sea-sick- ness, the rest and quiet of a sea-voyage was advised by me as most conducive to a subsidence of any inflamma- tory process which had existed, and the result confirmed my anticipations. It is not impossible that a stoppage of the cystic or common duct may occur temporarily from inflammation and turgescence of its walls without adhesion of the lin- ing membrane ; and with the subsidence of swelling, the tissues of the canal may return to their normal condition and the contents of the sac be discharged through the natural channel. Any obstruction to the gall-ducts, whether from the presence of calculi in their tract or from inflammatory infiltration and thickening of their walls, may cause en- tire stoppage of the passage of bile. When the impedi- ment is simply mechanical at the outset, this, by con- tinuance, becomes a source of irritation, and subsequently of inflammation in the tissues of the canal. Hence, there is never, perhaps, any protracted obstruction to the outlet of the bile without inducing thickening of the walls of the duct and ultimately agglutination of the adjacent surfaces. When the obstruction has gone to the point of irritation which leads to the effusion of coagulable lymph, it will be found impracticable to combat the adhesive inflammation in the tissues, and the canal must remain impermeable without an operation. As a constant accompaniment of occlusion of the ductus communis choledochus there is jaundice, and it has been noted as one of the frequent indications of biliary obstruction that itching over the surface attends the jaundice and is relieved when it ceases. These concomi- tants, which have been regarded as pathognomonic of the closure of the common duct, are not observed in the simple occlusion of the cystic duct with a free flow of bile from the hepatic ducts through the common duct into the duodenum. It should, therefore, be remembered that occlusion of the gall-bladder from an impermeable state of the cystic duct is not indicated by the icterose hue of the surface, nor by the absence of bile in the fecal evacuations. When the bile is retained for any considerable time by closure of the common duct, it is absorbed into the cir- culation and diffused throughout the system, causing all the train of symptoms associated with jaundice. It has been ascertained by observation of cases that the closure of the natural outlet for the bile is followed by an inspissation or thickening of this fluid, without assuming a solid form, but that eventually masses of biliary matter are developed in the sac, giving the impression to the touch of a well-defined body. In one of my cases, noted on page 367 in the October number of Gaillard's Journal for 1884, "a hard mass about the size of a kidney was discovered in the anterior right lumbar region, and it might have been mistaken for a floating kidney if further examination had not revealed that it was within a sac of an oblong shape, that extended up under the ribs. There was a well-defined unoccupied space between the upper border of this indurated mass and the lower margin of the ribs, and by thrusting the fingers below and drawing upward, this body could be carried up to the line of the ribs, moving readily within the sac. That portion of the tumor not occupied by this body gave the sensation of a semi-fluid collection, and though the evidence of fluctua- tion was not very distinct I was convinced that it was inspissated bile, while the kidney-shaped mass was a con- cretion from the same. My diagnosis was, therefore, obstruction of the bile-duct with dilatation of the gall- bladder, containing a considerable quantity of semi-fluid bile and this large biliary concretion."* Again, there may exist in the cavity of the gall-bladder an effusion of clear, glairy mucus, or a purulent collec- tion ; and in the event of disorganization of the con- tents, a vitiated and decomposed fluid may be found, constituting what is styled dropsy of the gall-bladder. Such accunmlations lead to the distention of its walls, and ultimately to great dilatation, so that the tumor ex- tends downward into the right hypochondriac, the iliac, and even into the inguinal region, according to the stage of development. It presents under these circumstances an oblong fluctuating tumor, with a breadth of four or five or more inches, and is liable to be confounded with hepatic abscess, suppurative inflammation of the portal vein, or other purulent collections, such as psoas abscess, etc. The enlarged gall-bladder may likewise be mistaken for an ovarian tumor on the right side in the female, and but for the history of the case similates urinary infiltration from rupture of the ureter. The surgical proceeding that is indicated for dropsy of the gall-bladder, as distinguished from suppuration set up by the presence of gall-stones, or developed indepen- dently of them, in the neighboring tissues, is so different as to render the diagnosis of much importance. The re- sults of spontaneous or artificial openings in ordinary ab- scesses of this region are much more favorable than the consequences of that degeneration of the fluids which characterizes dropsical or sero-purulent collections in the gall-bladder. The burrowing tendency of these vitiated matters, when extravasated by local ulceration, should prove as a warning against delay in resorting to operative procedures for collections in the dilated gall-bladder. In a fatal case of disease of the gall-bladder under my care, the autopsy revealed ulcerations connecting the sac with that portion of the small intestine adjacent to the duode- num, and an opening through the diaphragm into the lungs,-these parts having become firmly adherent to each other. The ductus choledochus was completely occluded, and its walls thickened and indurated. The collection of disorganized bile and serous exudations, which was origin- ally confined in the dilated walls of the gall-bladder, had made its way into a cavity formed between the upper surface of the liver and the lower surface of the dia- phragm, shut in by adhesions, and, perforating the latter, had entered the bronchial tubes, being expectorated freely, and eventually causing the death of the patient. The operation of cholecystotomy, technically consid- * Notice was received of the subsequent death of this patient, but no opportunity was afforded for an autopsy. 125 Cholecystotomy. Cliolecystotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ered, includes the various steps taken for incision of the parietes of the abdomen ; examination of the condition of the several ducts concerned in the discharge of bile; in- spection of the sac, which is a temporary receptacle for it; incision of the wall of the gall-bladder, with explora- tion of its cavity and removal of its contents ; and closure of this incision by suture, or securing it to the corre- sponding external opening. In the latter case antiseptic in jections should be employed afterward for washing out the cavity of the sac, and a drainage-tube should be intro- duced into the sac in the event of there being suppura- tion from its mucous lining. The dangers of laparotomy have been so much dimin- ished by the improved processes of surgery that an ex- ploratory incision is warrantable at an early period of all suspected cases of occlusion of the gall-bladder, and if the obstruction of the gall-ducts be verified, there can be no doubt in regard to the propriety of proceeding at once to the adoption of proper measures of relief. Two distinct means have been instituted ; in one con- dition the edges of the wound in the sac are secured by stitches to the external opening, and in the other the in- dications warrant its closure by suture and returning the gall-bladder into the abdominal cavity. A decision as to the merits of these different modes of proceeding depends upon the feasibility of establishing a communication with the duodenum, as complete occlu- sion of that outlet of the gall-bladder is held to be a good and sufficient reason for establishing a fistulous opening externally. There may exist a temporary obstruction in the cystic or common duct, which being removed, leaves the track free for the flow of bile ; and exploration has, in some instances, demonstrated the permeability of the ducts after evacuating the gall-bladder, so that an exter- nal outlet is not requisite. Under such favorable condi- tions, the practicability of effecting a closure of the incis- ion in the gall-bladder separate from the external incision is to be considered. Should the dilatation of the sac have been considerable, the cavity is not likely to refill with bile or mucous secretion before adhesive inflammation occurs throughout the line of suture ; and hence no dis- tention should ensue prior to the complete union of the incision. Eventually there is contraction of the fibres in the tissues of the sac, with gradual restoration of the lin- ing membrane to its normal state, so that the mucous discharge disappears, and the supply of bile, which has been interrupted, flows out at its natural opening into the duodenum. The practice of employing an exploring-needle for the purpose of detecting the presence of gall-stones, without making an external incision of the parietes, is now justly held by many surgeons to be a measure of doubtful pro- priety, and very little calculated to aid in the proper in- vestigation of these disorders of the gall-bladder. But a resort to the exploring-needle after the sac is ex- posed, with a view to ascertain the nature of the fluid contents, and for the purpose of using the canula as a probe in detecting any solid concretions within the sac, commends itself to our attention. If upon aspiration the contents of the sac are found to be such as may be properly emptied into the alimentary canal, an effort should be made by manipulation or me- chanical means to rid the ducts of any obstruction with- out incising the sac. By pressure with the fingers or with forceps, semi-solid masses may be crushed and urged either forward or backward so as to relieve the obstruc- tion, and graduated compression of the gall-bladder may succeed in forcing its fluid contents through the cystic and common ducts. An attentive examination with the hand, and especially the fingers, may then enable the operator to discover whether any solid body remains in the gall-bladder, and, though encysted gall-stones may not be detected either by external or internal digital examination within the cavity of the sac, negative results from such exploration would not warrant opening the gall-bladder. Should, however, the presence of gall-stones be thus verified, it would then be incumbent upon the surgeon to incise the sac and proceed to their removal with scoops, forceps, or small drag-nets upon stylets so curved as to reach the depressions where they are lodged. Gall-stones which obstruct the cystic or common ducts, that could not be dislodged previously, may sometimes be reached successfully from within the sac and removed entire or piece by piece. The various forms of obstruction, whether mechanical or organic, require corresponding* modifications in the processes for their correction ; from the simple passage of a sound to displace tenacious mucus or inspissated bile, to the introduction of a curved trocar for the purpose of perforating either the closed orifice of the cystic duct or that of the common duct at their respective outlets. The various conditions of 1 lie gall-bladder which justify the operation of cholecystotomy originate generally from some obstruction in the cystic duct, the common duct, or the hepatic ducts; and the operation may also be called for on account of stenosis from inflammation in the walls of one or another of these ducts, propagated from some neighboring part, or caused by the irritation in the passage of gall-stones. Abdominal section and incision of the sac are resorted to not only for the removal of fluid or solid accumula- tions from the cavity of the gall-bladder, but also to facili- tate the use of means for the relief of any kind of obstruc- tion in the ducts. In the event that no outlet can be secured from the ductus communis choledochus into the duodenal canal, and the cystic duct is patulous, so as to admit of the entrance of the bile from the hepatic ducts, the case is a proper one for opening an external fistulous discharge for the bile. But should both these ducts be freed from impediments to the flow of bile, the incision in the wall of the gall-bladder may be sutured and dropped into the abdominal cavity, with immediate clos- ure of the external wound, reliance being placed upon the re-establishment of the natural outlet. A preliminary stitching of the wall of the gall-bladder to the edges of the abdominal opening, with a view to effect adhesions of the peritoneal surfaces prior to incis- ing the sac, offers no advantages over that of securing the margins together at the time of the operation. On the contrary, it is, perhaps, more liable to be-followed by extensive peritonitis, as was observed in stitching serous surfaces together in my experiments on inferior animals. It is, therefore, held to be the safest and best plan to omit this stitching in advance, as likewise to abstain from the preliminary exploration with the aspirating needle, while on the occasion of the operation it is well to take all the precautions requisite for a proper diagnosis. While the linea alba has been preferred by some for the abdominal incision, an oblique line, at such a distance below the costal arch as the extent of the tumor may in- dicate, offers superior facilities for the different steps of exploration and subsequent operative measures. The same general precautions which are requisite in other cases of laparotomy should be observed in this operation, as to arresting all bleeding from the superficial incision prior to opening the peritoneal coat; and, besides, great care is necessary to prevent the escape of the con- tents of the gall-bladder into the peritoneal cavity upon incising the sac. The securing temporarily the wall of the gall-bladder with two loops of ligature introduced at a distance from each other corresponding to the anticipated length of the incision, and brought out at the respective angles of the abdominal opening, will enable the operator to control per- fectly the aperture when made ; and with two other loops fastened at points midway on the margins, or with a te- naculum introduced on either side, the incision in the sac may be kept protruded from that in the parietes so as to block it up completely. Thus no discharge of the fluid contents of the sac can escape into the peritoneal cavity, and no portion of the omentum or intestines can find its way out of the opening during the progress of the opera- tion. Should it so happen, however, from the attenuation of the tissues of the gall-bladder, that it is found impracti- cable to make such tension upon the margins of the in- cision in the sac as to bring the circumference of this 126 • REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy. C'liolecystotoniy. aperture into the external opening, then the scoop devised by Keen may be available for the end in view. In the event that any of the contents of the sac or blood find their way into the cavity, they must be removed before closing the external wound. I would repeat here a sug- gestion, made in connection with my report of a case of suture of the intestinal canal in the January number of the Southern Medical Record, for washing out the peri- toneal cavity by a syringe with warm water, so as to flood out any matters which may be amongst the coils of the in- testine and folds of omentum, or in the pelvic basin.* The use of sponges or cloths for removing any such mat- ter necessarily irritates the delicate serous membranes, and this warm bath applied to the viscera after the manip- ulations of the various parts attending an operation, should have a decidedly soothing effect upon the tissues. Every nook and corner of the cavity must be reached by the water, which may, if it is thought advisable, be ren- dered antiseptic by medication. Should there be any trouble in removing all the fluid from the cavity, a per- forated bulbous nozzle attached to the syringe would by suction bring it away from even the most dependent parts. A flexible drainage-tube with openings in its wall may also be passed among the coils of intestine so as to reach the depressions, and by turning the patient from side to side the fluid will escape through it. When a drainage-tube is used in this manner, and also when it is employed in the cavity of the dilated gall-bladder, it should be secured by'a strong silk or flax thread, which is passed around the body. It might seem to be a work of supererogation to caution operators against leaving sponges in the cavity of the abdomen when completing an operation. But it has occurred in several instances, in the hurry of closing the external wound after laparotomy, that sponges have been allowed to remain, and have caused serious trouble afterward ; so that it is well to have a cord attached to each sponge employed, and to let its free end be held outside by an assistant. The closure of the peritoneal lining, when the gall- bladder is sutured and dropped into the cavity, may be effected most satisfactorily with the continuous catgut suture. x For the external wound, loops of silver wire carried through the skin and subcutaneous tissues, in the form of interrupted suture, are best calculated to retain the parts in accurate apposition. When provision is made for a fistulous opening, the edges of the incisions in the sac and parietes are stitched together with silk, and the wound is covered by antisep- tic dressing. Considering the fatal consequences of delaying opera- tions until local disorganization and general prostration have undermined the vital powers, and the favorable re- sults of timely operative measures, all diligence should be used in reaching an early diagnosis and in adopting prompt measures for the relief of affections of the gall- bladder. The tabular statement at the close of this paper gives the complete record of authenticated cases in which oper- ations have been undertaken. For convenience in refer- ring to the cases, distinct headings are used for the incomplete operations, the cholecystotomies and the chol- ecystectomies in their separate divisions. As no pro- ceeding short of incising the sac should be classified as cholecystotomy, so the entire removal of the gall-bladder should not be included in such a general designation, but falls properly in a special class of operations. It will be noted that the mortality of unfinished operations reaches forty per cent., there being two deaths out of five cases, while the fatality in completed operations of cholecyst- otomy is 27.27 percent., nine having died out of thirty- three cases ; and cholecystectomy gives but 12.50 per cent, of mortality, one death in eight cases of extirpation of the gall-bladder. Thus it appears that there is less gravity in the latter than in the former operation, and while the greater proportion of deaths in partial operations may be due to the serious complications, the statistics indicate that exploratory operations are not free from danger. Some imperfections appear in the data, notwithstand- ing diligence on my part, and valuable assistance from Dr. S. W. Gross, to whom I am indebted for supplying important items for this table. Eliminating from the tables of Drs. Musser and Keen two cases reported by Tait, without sufficient data for their verification, and adding nine cases from abroad, with two new cases from this country, I find that there are five incomplete oper- ations and thirty-three complete cholecystotomies, with eight cholecystectomies reported, being in all forty-six cases, as follows': Incomplete, with only Abdominal Section. No. Date of Operation. Age. Sex. Result. Operator. 1 June 29, 1870. 47 F. Recovered. Hughes. 2 .January 22, 1878. 45 F. Recovered. Brown. 3 ! February 4. 1878. M. Died. Blodgett. 4 May 3, 1883. 34 M. Recovered. Musser and Keen. 5 September 15, 1883. 50 F. Died.* Senn. * Recovered from operation. No. Date of Operation. Age. Sex. Result. Operator. 1 June 15, 1867. 30 F. Recovered. Bobbs. o April 18,1878. 45 F. Died. Sims. 3 June, 1878. 30 F. Recovered. Kocher. 4 November 4, 1878. 60 F. Died. Keen. 5 August 23, 1879. 40 F. Recovered. Tait. 6 October 9. 1881. 55 F. Recovered. Tait. 7 January 15. 1882. 24 F. Recovered. Tait. 8 1882. 34 M. Recovered. Winiwarter. 0 1882. 47 F. Kiinig. 10 October 13, 1882. 39 F. Recovered. Tait. 11 October 31. 1882. 53 F. Recovered. Eddowees. 12 November 24, 1882. 47 F. Death. Trendelenberg. 13 January 5. 1883. 28 F. Recovered. Tait. 14 January 30, 1883. 59 F. Died.* Meredith. 15 April 20. 1883. 59 F. Died. Gross. 16 May 3, 1883. 76 M. Died. Rausohoff. 17 May 6, 1883. 35 F. Recovered. Tait. 18 May 10, 1883. 42 F. Recovered. Tait. 19 May 28, 1883. 66 M. Died.* Tait. 20 June 19, 1883. 31 M. Died. Musser and Keen. 21 October 31, 1883. 38 F. Recovered. Gardner. 22 October 6. 1883. Old M. Recovered. Savage. 23 November 14, 1883. 44 F. Recovered. Tait. 24 December 20, 1883. 44 F. Recovered. Tait. 25 May 8, 1884. 62 F. Recovered. Tait. 26 June 26, 1884. 45 F. Recovered. Tait. 27 August 6, 1884. 73 M. Recovered. Tait. 28 March 4, 1884. 64 F. Recovered. Courvoisier. 29 1884. Died. Boeckel. 30 Mav 17, 1884. 39 F. Recovered. Savage. 31 September 5, 1884. 43 F. Recovered. Taylor. 32 December 19. 1884. 29 F. Recovered. Parkes. 33 January 13, 1885. 50 F. Recovered. Tait. Complete, with Incision of Parietes and Sac. * Recovered from operation. Extirpation of Gall-bladder. No. Date of Operation. Age. Sex. Result. Operator. 1 July 15, 1882. 45 M. Recovered. Langenbuch. 2 1882. 53 M. Recovered. Langenbuch. 3 1883. 35 F. Recovered.* Langenbuch. 4 January, 1884. 48 F. Died. Langenbuch. 5 June 6, 1884. F. Recovered. Courvoisier. 6 September 9. 1884. 53 M. Recovered. Langenbuch. 7 January 17, 1885. 44 F. Recovered. Thiriar. 8 February 1, 1885. 25 F. Recovered. Thiriar. * Died subsequently from cerebral tubercle. Since making up the above table, I have received from Dr. W. F. Thornton, the following brief report of a case of cholecystotomy, by Dr. Bernays, of St. Louis, in which the gall-bladder was sutured and dropped into the cavity with a successful result. It was done in the person of Mrs. Charlotte O , aged forty-six. An incision was made in the linea alba extending from the ensiform cartilage to an inch below the umbilicus; the tumor, which proved to be the enlarged gall-bladder, then appeared in view ; a trocar was introduced, and a considerable quantity of clear mucus was removed, fol- lowed by a green sediment. An incision was then made in the cupola of the gall-bladder one inch and a half in * A consideration of the propriety of using distilled water for the pur- pose of flooding the abdomen is found in the April number of the Ameri- can Practitioner, p. 243, year 1885. 127 Cholecystotomy. Cholera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. length, extending from the point where the trocar en- tered, and twenty gall-stones were removed. Digital ex- amination showed that one stone as large as a filbert was firmly impacted in the first convolution of Reister's valve of the cystic duct, and by making several small cuts in the valve this was removed. The gall-bladder was then closed with sutures, dropped into the cavity, and the ex- ternal wound closed. The patient has entirely recovered, August 24, 1885. James McF. Gaston. 1 Text-book of Pathological Anatomy, part ii., p. 341. 2 Ibid., p. 342. 3 Ibid., p. 343. 4 Ibid., p. 344. 5 Legg on the Bile, pp. 135-156. pulse. After the development of the disease, the symp- toms follow each other in such a way as to allow of a division into two distinct periods. First Period.-This is marked by an increase in the number of dejections and acts of vomiting;-a flux is established which is at first serous or slightly bilious, and afterward becomes "choleraic." This term is used to designate those characteristic discharges of cholera which are liquid, whitish, grumous, sometimes resembling un- clarified whey, sometimes a decoction of rice or oatmeal, and sometimes thickened meal, and nearly clear, which emit an insipid spermatic odor, and sometimes present traces of blood or bile. These evacuations arc rarely ab- sent, often continuing to the termination of the disease. Burning thirst, pain in the epigastrium, and prolonged hic- cough are usual accompaniments. Intense cramps of the limbs occur, particularly in the calves of the legs ; the mus- cles are often in a state of tonic contraction. Spasmodic movements, as involuntary flexion and extension of the fingers and toes, may often be seen. The pulse is very feeble-often imperceptible. The features are altered, trembling and great agitation come on, the pulse becomes suppressed ; bluish spots appear, first upon the extremities ; the skin becomes blue or black almost everywhere; the nails are livid and almost black, the fingers wrinkled, and the genital organs retracted. The volume of the body diminishes rapidly and perceptibly ; the eye is sunken and dull and surrounded by a bluish circle, the conjunctiva fades, respiration is slow and feeble, the breath cold, and the pulse is reduced to a mere oscillation. The secre- tions are arrested, especially the urine, the voice is re- duced to a whisper, the nose is cold and-rarely-gangren- ous, the cornea flattened and puckered; spots of blood appear on the sclerotic, viscid sweat on the face and limbs, the intellect becomes obscure, respiration is em- barrassed, hiccough commences, and death follows in the midst of an apparent calm. This is called the cold, livid, or asphyxia period. When patients escape death in this stage they enter upon the Second Period.-In this the coldness ceases to increase, warmth returns, the pulse improves and gradually be- comes febrile, the face regains color, the eye becomes animated, and a general reaction occurs. If recovery is to be easy and rapid, vomiting is less frequent, the diar- rhoea remains, but the discharges no longer present the appearances peculiar to the disease, the secretion of urine returns, nausea, thirst, and pains in the stomach cease to be felt, the pulse becomes regular, and convalescence be- gins. If reaction is incomplete, the cold stage returns with re- newed severity ; or, on the other hand, if reaction be too severe, such accidents may occur as apoplexies, spasms, convulsions, local congestions and inflammations, and oc- casionally latent pneumonia. Stupor is sometimes pres- ent, with some of the signs of the last stage of typhoid fever. Swelling of the parotid glands and various skin affections, as roseola, urticaria, erythema, erysipelas, etc., may appear toward the close of the disease. The average duration is from one to three days, but sometimes death occurs in less than six hours, and is oc- casionally delayed a long time, in one case for fifty days. Symptoms in Detail.-Besides this general account of the disease, the symptoms should be briefly discussed in the order of their occurrence. Precursory Phenomena.-An attack is often preceded by initiatory uneasiness, which should attract attention ; such are languor, pallor, anxious expression, sunken feat- ures, weight in the stomach, and movements of the in- testines. Then vertigo follows, with abdominal pain, dimness of vision, and difficulty of hearing; the eyes be- come more brilliant than ordinary, like those of a drunken man. In other cases, the progress of the preliminary symptoms differs-there is diminution of appetite for several days, general disagreeable sensations, and fre- quent alvine dejections, without pain, which are yellow- ish, more and more fluid, and, finally, become almost like water. A diarrhoea like this may occur without any other symptoms, and turns into cholera. Lastly, the dis- ease comes on suddenly, and without warning over- CHOLERA, ASIATIC. Synonyms.-Epidemic Chol- era, Cholera Asphyxia, Algid Cholera. Malignant Cholera, Cholera Spasmodica, Pestilential Cholera, Pes- tilential Asphyxia, Oriental Cholera, Choleric Pestilence, Indian Cholera, Ganglionitis peripherica et medullaris, Trisplanchnia, Hyperanthraxis, Morbus oryzeus (because supposed by Tytler to be due to damaged rice), Trousse- galant, Cholera Gravior, Vishucki or Vishuchiki (by Hindoo physicians), Haouwa (tornado) in Bagdad. (For wider discussion of terminology, see Macpherson, "An- nals of Cholera," chapter ii., ed. 1884.) The derivation of the word cholera is usually from XoAfj (flow of bile), or %oAas p^ (intestinal flux), but the correct one is probably that given by Jobard, of Brussels (Gaz. Med. de Paris, 1832, p. 389), who considers the term to be made up from two Hebrew words, choli-ra (or morbus malus). This derivation is the one adopted by most writers of the present day. Mention of the disease is made in Sanscrit and Chinese writings. It is spoken of by Hippocrates (Epidemics), and successively by Aretaeus, Celsus, Galen, Caelius Aurelianus, Aetius, Paulus yEginatus, and Alexander de Tralles. All of these writers, with many others, refer to affections resembling the cholera, but it is not until the seventeenth and eighteenth centuries that we find descrip- tions of the epidemic disease. Genuine epidemics, analog- ous to cholera, are described by Riviere, who made his observations at Nimes in 1564, and by Zacutus Lusitanus, who saw several in different parts of Europe in 1600. The most remarkable accounts by authors of this epoch are those of Willis ("Opera Gen.," 1680, t. xi., p. 74), describing epidemics in London, in 1670, of what he called "dysenterica aquosa epidemica," of Thomas Sydenham, in 1669-1676 (" Oper. Med.," Geneva, 1723, pp. 106 and 184), and of Torti (" Therap. Spec.," liv. iii., cap. ii., and liv. iv., cap. j.). Bontius (" De Medic. Indorum.," Lugd. Batav., 1642, p. 136), Dellon(" Voyage auxlndes Orient.," Amsterdam, 1684), and Thevenot ("Voyage aux Indes Orientates," Paris, 1689, tom. iii.) observed and described epidemic cholera in India. In 1761, Donald Monro (" An Account of the Diseases in the British Military Hospital in Germany," London, 1764, p. 97) saw an epidemic of cholera in Westphalia ; as did Agton Douglass and Bisset, in 1768, in the north of England and in Scotland. Harlem (" Die Indische Cholera," 1831, t. i., s. 144) quotes many dissertations upon the disease, but it is not until the pres- ent century that we have a clear account of the trans- portation of the disease from place to place. From 1817 it seemed to take on a new power of travelling, and owing to its spread the opportunities for study have vastly in- creased. The new methods of intercourse and commerce were probably responsible for the appearance of the dis- ease in Europe-not any new property which it developed. Description.-Asiatic Cholera has marked character- istics distinguishing it completely from any other disease, and in the following description no attention is paid to the ' ' divisions " of many authors which include cholera morbus and other gastro-intestinal affections that may simulate it. In general the disease may suddenly develop-its on- set being marked by great uneasiness, repeated discharges from the bowels, followed by syncope. This attack may overtake the victim while walking on the street in ap- parent good health. It is often preceded by a state of vague suffering, rapid prostration, deep colicky pains, anorexia, sometimes a diarrhoea, profuse sweats, disturb- ance of the senses, and more or less retardation of the 128 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholecystotomy. Cholera. vasion ; cephalalgia, often very severe, appears during reaction ; it is generally heavy, and more marked in the frontal regions ; at the same time occur ringing and buzz- ing in the ears. The sight is generally affected during the whole course of the disease ; it is blurred, double, or perverted, so that the patient sees objects colored blue, or alternately black and red ; it is occasionally completely extinct. The touch and general sensibility are much blunted. Intellectual Faculties.-These are generally unaltered, although the power of expression may be impaired. It is only in certain modes of reaction in the second stage, and in certain complications, that stupor and, more rarely, delirium occur. Strength.-There is in all cases almost entire loss of strength, the least displacement of the limbs being un- bearable. Most patients, either stretched on the back or with the limbs closely drawn up, remain in a state of complete immobility through fear of fatigue. Transient faintness appears in some cases. Voice.-It is characteristic; changing very rapidly from a state of feebleness at the commencement of the disease to a rough and whistling tone. It occasionally becomes entirely extinct, but in some cases retains strength enough for loud cries. It gradually returns to its normal condition as the disease lessens in intensity, and recovery progresses. Respiration is ordinarily very difficult, the frequency varying from ten to fifty-two per minute. This does not depend upon any altered condition of the lungs as re- vealed by physical examination, but seems to be in some way connected with the presence of less than the normal amount of carbonic acid in the expired air. Circulation.-1The circulation is very gravely affected. The pulse becomes more and more feeble, and disappears entirely in the height of the cold period ; it is always more frequent than in health. The blood moves slowly and will not flow from a vein or an artery of small size. This sort of stagnation aids in producing the bluish hue peculiar to the cold stage. This bluish hue makes its ap- pearance first in the extremities, in the genital organs, and in the face. It is especially observable in patients who are plethoric and of florid complexion. It dimin- ishes and often disappears during reaction, and sometimes does not occur at all. It may go so far as to produce gan- grene, as has been observed in the nose, tongue, and sex- ual organs. Temperature.-The temperature is seemingly reduced ; the expired air being only 25° to 27° C. (77° to 80.6° F.). This reduction in temperature is confined to the surface, however, the internal temperature being higher than in the highest fever (Guterbock, Virch. Arch., xxxviii., p. 30). Appearance.-The aspect is characteristic ; the face is contracted, the brow wrinkled, the cheeks hollow, the lips thin and pressed in upon the teeth, the complexion becomes livid and bluish, the eyes more and more sunken, and surrounded by a dark circle. Expression is lost by degrees, and death seems to have occurred while life is still present. The eye is dim, its surface wrinkled, sunken, and sometimes dry, the globe is left exposed by the lids, and the conjunctiva becomes injected and covered with spots of blood. Even if recovery takes place, the normal aspect of the face returns very slowly. Complications, Secondary Affections.-Complica- tions are rare, and apparently accidental; among them peritonitis, jaundice, gangrene, oedema of the lung's, ery- sipelas of the face, abscesses, ulceration of the eyelids, and aphthae may be mentioned as of occasional occur- rence. Secondary affections are, however, very common. They may consist of gastro-intestinal inflammations, immediate, or after some days of convalescence, or of affections of the respiratory organs. In other cases persons who have apparently escaped the accidents of cholera have a sec- ondary fever, described as of a typhoidal type, dry skin, tension and tenderness in the epigastrium, jactitation, dry tongue, bilious stools, and chills. Various skin eruptions occur, and temporary albuminuria has been ob- served following an attack of cholera. The most grave whelms the victim with its full force-this often occur- ring at night. Diarrhaa.-This is most frequently the mark of the onset of the disease, and when it is so, becomes at once more and more frequent. Fifteen, twenty, or more de- jections in twenty-four hours are usual, and in some cases (these are fatal) the evacuations occur in an almost con- tinuous and involuntary jet. They are often accompanied by colic, borborygmi, and gurgling, either spontaneous or excited by pressure upon the abdomen. They are at first made up of bilious, faecal, or sero-mucous matter, but soon assume the characteristic appearances, that is, of a whitish flocculent fluid as before described. A large floc- culent sediment is deposited from this fluid, a part of it looking remarkably like cooked rice. The fluid is blood- serum, and the sediment is made up of the epithelial lin- ing of the intestines and of mucus. Sometimes the evacu- ations are tinged with blood-coloring matter, giving them the appearance of the lees of wine, or they may be of a deep brownish color from the same cause. The frequency of the dejections is not always increased with the progress of the disease, they are occasionally completely arrested during the cold period, and death may occur without their beginning again ; on the other hand, they may return with increased violence. After recovery obstinate consti- pation may occur. Vomiting.-Nausea and vomiting, sometimes almost constant, occur from t)ie very beginning of the disease. The vomitus is poured out by an almost constant effort; it does not differ in character from the dejecta, except that it is sometimes more limpid, and is sometimes slightly tinged with bile. It is very rare that vomiting persists to the second period of the disease, but the inges- tion of the smallest quantity of fluid may excite it with great violence. It often alternates or coincides with a very troublesome hiccough. Abdominal Pain.-This often precedes the vomiting and choleraic diarrhoea. It is griping, and of the most intense character, situated in the region of the epigas- trium, or over the entire abdomen. There is a doughy sensation to the hand upon pressure, and percussion gives, usually, an almost universal dull or flat note. Anorexia; Thirst; Tongue.-Loss of appetite is com- plete, and corresponds in point of time with a burning and inextinguishable thirst. The throat and mouth are parched, the tongue is frequently clean, commonly large, pale, moist, cold, very rarely dry, and occasionally cov- ered with a yellowish coat. This condition is peculiar to the first period ; it varies later on with the degree of reac- tion, or the nature of the complications and secondary af- fections. Urine.-Upon the first appearance of the gastro-intes- tinal evacuations the urine becomes scanty, and may be completely suppressed ; exceptional cases are reported in which it remains normal throughout. Emission is invol- untary. Sometimes, after suppression, it reappears about the middle of the cold stage ; being again suppressed for the remainder of the disease. The desire to urinate re- mains, although the power may be lost; the secretion and flow are generally re-established duripg the period of re- action. There are no observations pointing to the occur- rence of renal disease. Cramps.-Violent and prolonged cramps, beginning with the first diarrhoea, in the muscles of the legs and ex- tending to the abdomen, arms, and even to the face, are one of the most characteristic, and at the same time one of the most terrible, symptoms of cholera. They some- times persist throughout an attack, and even after a cure, and muscular contractions have even been observed after life was extinct. During an epidemic cramps have been observed without any other symptoms. It has been sug- gested (Weir Mitchell: "Injuries of Nerves," p. 52, ed. 1872) that they are caused by the loss of water from the body, and the consequent "drying" and irritability of the nervous system, an analogous phenomenon to the violent contractions of a frog's leg when the sciatic nerve is exposed and allowed to dry in the air. Headache ; Derangement of the Senses.-Weight in the head, with giddiness and vertigo, occurs during the in- 129 Cholera. Cholera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the secondary affections, however, are those which af- fect the nervous system. The cerebral congestions dur- ing reaction are, in some cases, followed by a typical men- ingitis with trismus. Bayer's " etat cerebral cholerique" includes a group of phenomena distinct from those of men- ingitis, which supervenes upon the cold stage; the skin is cold, the pulse feeble, the head heavy, the countenance stupid, and sometimes the cholera tint remains. Another affection is a sort of non-febrile delirium, lasting for two or three days, and the spasmodic contractions of the fore- arm which occur during convalescence. True intermit- tent febrile attacks, with initial chills, occurring every day during reaction, have also been observed. All these af- fections are, for the most part, more rapid than when occurring in the individual previously healthy. Course, Duration, Termination.-If death does not occur during the cold stage, the disease undergoes a peculiar transformation and reaction sets in. This reac- tion varies in different cases, being slow and tedious in some, abrupt and rapid in others ; the course is not espe- cially modified by any antecedent disease, even those oc- curring as complications. In all cases cholera runs its course with great rapidity, the majority of attacks lasting from eighteen to twenty-four hours, the shortest from one to six hours, and the longest from fifteen to twenty days. Its duration is the shortest in the height of an epidemic. The termination of epidemic cholera may be favorable, the progress of recovery varying widely in different cases ; it may be complete in a few days, or even hours, and the patient may return to his ordinary occupations ; on the other hand, recovery may be deferred until after the long and perilous struggle sometimes necessary against complications and secondary affections. There may remain a general debility such as is not often seen after any other disease ; the emaciated features, languish- ing expression, capricious appetite, obstinate gastralgia, colic, wakefulness, tendency to coldness, partial or gen- eral, intellectual and moral dejection persist for a long time. An attack has been known to change the whole constitution and temperament of a patient. One attack furnishes no immunity against another, and relapses are always to be feared. Forms.-The forms spoken of by various authors are merely variations of the disease. They may be classified under the heads of: 1, The common form, or grave cholera, such as has been described; 2, cholerine; 3, foudroyant cholera ; 4, paralytic cholera. Cholerine appears especially at the beginning of an epidemic. In it cramps are rarely seen, and the livid discoloration of the skin with the phenomena of asphyxia are never present. The other symptoms are present, but in milder form. The attack may last several days, rarely more than a week, and generally ends in recovery, which, however, may be slow. Foudroyant cholera appears in almost every epidemic. In it the vomiting, cramps, and diarrhoea occur at once, with no precursory symptoms, and death may occur in one or two hours, sometimes coming on before the diar- rhoea, by reason of the violence of the epigastric pains and cramps. Paralytic cholera, described by the Russians and Ger- mans, is a form in which the access is very slow. For a week there may be excessive depression, the muscles are completely relaxed, the intellect loses all activity, and death occurs in the midst of this weakness. The vomit- ing awl diarrhoea are often wanting. Such cases arc very obscure, although they seem to be allied to cholera by their conditions of development and precursory phe- nomena. Pathological Anatomy.-The alterations of the in- ternal organs in a case of death from cholera bear little relation to the violence of the disease. Cases examined present about the following appearances : External Surface. - Emaciation is general, there is marked lividity of the lips and nostrils. Rigidity is not rare before the warmth of the body has wholly dis- appeared. Internal Examination. - The peritoneal surface is sticky and covered with a viscid exudation ; the vessels of the mesentery engorged with blood. The calibre of the intestinal canal is more often increased than dimin- ished, and it always contains some fluid choleraic matter. The fluid is blood-serum, and the thicker material found in it is made up of intestinal epithelial cells and mucus. The intestinal mucous membrane is usually normal in thickness, but is denuded of epithelium. The villi are swollen, giving the surface a velvety appearance, and Peyer's patches and the solitary glands are much en- larged. The glands of the stomach and of the duodenum are enlarged, and the surface is largely denuded of epi- thelium. There are no special lesions of the other ab- dominal organs. The liver is rarely enlarged, but is usually congested with dark, thick blood. The gall-blad- der is also usually distended with bile which is thicker than normal. The biliary duct is not obstructed. The pancreas presents no marked alteration. The spleen, in rapid cases, is small, hard, and wrinkled upon its sur- face, of a deep red color on section, and sometimes dotted with ecchymoses. In slow cases it may be slightly en- larged and less deep in color. The blood is thicker than normal, coagulates slowly, and the separation into clot and serum is very incomplete. The corpuscles are not altered in shape, but there is a remarkable diminution in the proportion of water and neutral salts, and a decrease in the amount of fibrin and albumin. The heart is usually soft and flabby, with ecchymoses in the pericardium. The left side is usually empty and contracted, while the right side is distended with dark, thick blood. The arteries are, generally, nearly empty, the veins always engorged with blood. The pleurae are very frequently coated with a glutinous stringy substance, and ecchymoses often appear in the sub-pleural cellular tissue. The lungs are usually healthy but contracted, often presenting engorgements at the posterior portions. The bronchi are much congested, and may contain a white, viscid, and stringy mucus, analogous to that found lining the surface of the intestine. The condition of the brain and spinal cord and their appendages is merely that of congestion without special lesion, although it has been declared that a sensible in- crease in consistency takes place in the nerve substance. The ganglionic system presents no symptom worthy of notice. The muscles are often engorged with blood, and a very marked reddish-brown discoloration of the bones and teeth has been noticed in those dying in asphyxia. In regard to the genito-urinary system, renal congestion is the marked symptom, and the straight tubules are, in many cases, denuded of epithelium. In those dying in the cold stage, the bladder is empty and firmly contracted. Theories.-The theories in regard to cholera are nu- merous, and may be summed up very briefly as : a. The physiological theory, which considers the disease to be a stoppage of the reabsorption of the watery secre- tions of the intestines, thus creating a tremendous dis- turbance of the economy of the system. b. The gland theory of Isaac Hays and others, who thought the disturbances in Peyer's patches and the soli- tary glands to be the basis of the disease. c. The elimination theory, asserting the discharges to be Nature's effort to get rid of some poisonous material in the body, and that therefore these discharges are to be assisted. d. The paralysis theory, by which all the vessels and nerves presiding over absorption are supposed to be par- alyzed, and this paralysis extending to the sympathetic system, allows the blood to be drained of its serum and salts. e. The first spasm theory, assuming the poison to be in- haled, supposes it to pass into the blood, and, being irri- tating, to contract the minuter blood-vessels, and thus to arrest the passage of the blood through the lungs. f. The second spasm theory, of Bell and Braithwaite, considers the poison to act specifically upon the pneumo- gastric nerve, through the blood, and subsequently upon the great sympathetic, thus producing the phenomena of cholera. These two theories are supported by very little evidence. g. The congestive theory believes passive congestion to 130 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholera. Cholera. be active in producing the disease, and that this phenom- enon is too prominent to allow of its severance from a relationship to the serous discharges. h. The germ theory of cholera has gained a large num- ber of supporters of late years, more upon the strength of the evidence obtained in regard to other epidemic dis- eases, than by the value of work done in this special direction. By this theory the disease is ascribed to the entrance into the alimentary canal, and growth there, of a form of bacterium which has a specific irritant action, or produces a substance which has such an action. Epidemics.-Cholera is endemic in India, the explo- sions occur upon the arrival of masses of strangers, or upon the transportation of the disease to other countries, where an immunity among the populace at large has not been established. (In regard to the question of immu- nity, ride A. Fauvel, " Memoire lu a 1'Academie des Sci- ences," Paris, 1883.) No account of cholera could be complete without a mention of the various epidemics which have occurred since the disease began to travel out of India. A brief mention is here appended. From 1770 to 1790 cholera was epidemic in Southern Hindostan, on the coast of Coromandel, and even as far south as Ceylon. It is, however, from the date of its beginning to spread out of India that the disease has attracted great attention from Europeans. In 1817 an epidemic appeared in Bengal, near the mouth of the Ganges ; in May, spreading westward, it reached the Eng- lish army on the banks of the Sind, in the district of Malva, in November. From here it spread over.all Hin- dostan, reaching Calcutta, Madras, and Bombay. Pass- ing eastward it appeared in Malacca and Manilla in 1818, and in the isles of France and Bourbon in 1819 and 1820 ; in 1823 it reached Nankin and Pekin. Travelling westward from Hindostan it reached Mus- kat, on the extremity of Arabia, in 1821. From here it extended almost immediately along the Persian Gulf, and, entering Persia, it continued through Syria, Turkey in Asia, and finally reached the shores of the Caspian and Mediterranean seas. In its march the disease closely fol- lowed the great routes of travel. It was in 1823 that cholera first made its appearance in Europe, by the double channel of the Caspian Sea and the frontiers of Georgia. This appearance was not repeated until 1829, the route being again through Georgia and along the shores of the Caspian. In this year, and up to 1831, the ravages of the disease extended over the whole of Russia, from Mohilev to Odessa. Arrested by cold, in January, 1831, it began its journey anew, and in April entered Warsaw. It reached Prussia in July, attacking Berlin in August, and Vienna in September. From these two centres it spread through Hungary and along the Baltic, and finally crossed the North Sea and entered England at Sunderland in November, 1831. It reached London in February, 1832, and Sweden and Norway in October of this year. It entered France from England, at Calais, in March, reached Paris the last of the month, and from this point spread over the country and passed into Belgium. The disease first crossed the Atlantic in June, reaching Canada the first of the month, and New York early in July. From New York it spread southward, attacking Philadelphia and Baltimore in July, and Charleston in November. In February, 1833, it reached Havana, and passed to Mex- ico in the same year. From Montreal the epidemic passed westward along the great lakes, and from Albany in the same direction, reaching Buffalo and Detroit, and then travelling down the Mississippi Valley arriving at St. Louis about the first of October. The disease lingered in the country for two years, its course being the same as in Europe, along the principal high- and water-ways. Its ravages extended from Canada to Yucatan, visiting nearly every place of importance between these points. South America was not invaded. The epidemic con- tinued to spread in Europe, visiting Spain and Africa in 1833 and 1834, in the latter year reappearing in the south of France. In 1836 and 1837 it extended into Italy and along the northern coast of Africa. Greece was spared, as was Switzerland also. The next great epidemic started from the borders of the Ganges, appeared in Tartary in September, 1845, and fol- lowing about the same course as the preceding one, spread over Europe in this and the following years, and reached New York and New Orleans in the fall of 1848. Arrested at quarantine at New York, the disease escaped the officials at New Orleans, passed up the Mississippi Valley, and finally reached San Francisco. A third epidemic reached this country from Europe in 1854, or possibly was a renewal of the previous one, and a fourth arrived here in 1865 and 1866. This last came out of India via the Red Sea and Suez Canal, which is the first instance of an epidemic coming from India to Eu- rope by sea. The last outbreak of cholera in America occurred at New Orleans in 1873 and was preceded by a prevalence of the disease in Europe for at least three years. New York, thanks to the efforts of its health officers, escaped the epi- demic but it spread from New Orleans throughout the Mississippi Valley and the adjoining States ("Gov. Rep. on Cholera Epidemic of 1873," 43d Cong., 2d Session; Ex. Doc., No. 95). This is the last epidemic by which this country has been visited, although it is possible that before these lines are printed the announcement of the renewed appearance of the disease will have been made. It was in the South of France the whole of the sum- mer of 1884, it having reached that country by way of Egypt in 1882 and 1883, and the Suez Canal from India (in 1881); and again in 1885 its ravages have been experi- enced even more severely in Italy and Spain. General Characteristics of Epidemics.-The places vis- ited vary so much that, with the exception of the polar region, almost every portion of the globe has been at- tacked by the disease. The line of progress is along the routes of travel- the course of rivers, and the sea-shore, and the great land routes. Its rate of progress from place to place seems to depend upon the frequency and rapidity of the means of intercommunication. No relation seems to ex- ist between the course of cholera and the prevailing winds, it travels against as easily as with them. The progress of an epidemic is invariably arrested by cold- the winter season having always stopped those of which we have any record. The arrest is not always a perma- nent one, however, the return of warm weather frequently bringing a renewal of the disease. Many epidemics have been preceded by a greater fre- quency of intestinal affections. A coincidence in the appearance of cholera and of epidemics among animals has been noticed in India, Russia, and Poland, and was very marked among poultry in France in 1832. The presence of cholera does not exclude other epidemics-as is shown by the activity of the plague at Constantinople in 1832, at the same time with the cholera. Intensity and Mortality.-An epidemic presents a movement of increase, a stationary condition, and one of decline. All stations of life and all races are liable to the disease-the poorer classes, or those surrounded by bad hygienic conditions, more so than the more favored. The rate of mortality varies but little in proportion to the number of cases, it rarely falls below one-third and is gen- erally more than one-half of those attacked. The severity of the epidemic seems to have little connection with its duration, although it has been asserted that the more se- vere the onset the shorter will be its probable length. Causes.-The conditions favoring the production of cholera are many, but all investigations tend to show that the disease is dependent upon a specific cause, the pres- ence of which is a prerequisite to any outbreak. Telluric conditions have been held to be very active in determining an outbreak of cholera, the theory being that soil of a certain geological formation may produce the disease. This, however, is not proven by any rational investigations. Theoretical assertions in regard to atmospheric influ- ences upon cholera, are much more common than accu- rate observation. An increase in density has been noted, but no other changes have been satisfactorily demonstrated. It has been repeatedly shown, however, that cold retards and heat favors the progress of an epidemic. 131 Cholera. Cholera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity, extreme humidity (especially with an ele- vated temperature), and the action of the winds, have all found their supporters as the cause of cholera, but none of their advocates bring forward sufficient scientific evi- dence, Pettenkofer has for years advocated the causal relation- ship between subsoil moisture (Grundwasser) and cholera, and declares that the disease cannot occur in places where there is perfect drainage with a dry soil. Hygienic Influences.-The influences exerted by the various occupations and surroundings of a population have an undeniable effect upon all epidemic diseases, and upon cholera among them. These influences should be considered as follows: Salubrity.-In spite of exceptions which are more ap- parent than real, it is acknowledged universally that it is in obscure, dirty, and moist dwellings, in streets hardly accessible to sun and wind, and where a crowded popula- tion lives in dirty lodgings, that the cholera produces the most fatal results. Statistics do not show that the least influence is exerted upon the progress of the disease by the special profession followed ; such differences as are to be found being ac- counted for by corresponding differences in the conditions of physical and moral well-being. Regimen.-The manner of living, and especially im- proper food, should be named as among the most impor- tant predisposing causes of cholera. Privation, or excess, equally seems to have a strong influence in favoring the disease. Constitutional Influences.-Children under seven seem to be partially or wholly exempt from the disease ; above this age, neither sex nor condition seems to be exempt. Moral Conditions.-Mental affections or depressing in- fluences have been said to be causes predisposing to the disease, and undoubtedly are so by placing the system in a receptive condition. Contagion.-The question of the contagiousness of cholera is one of the most vital importance, and has been very fiercely discussed. Its non-contagiousness is gener- ally believed in at the present day, upon the strength of the best observations hitherto made. The great differ- ence between an infectious and a contagious disease is this-that the former may appear among the passengers, after they have landed in perfect health from a ship in which the disease has been, while the latter will only appear when there is a person sick of the disease, and will spread from him to those in contact with him. The former has occurred in innumerable cases of cholera out- breaks. Another argument against the contagiousness of cholera is the comparative freedom from the disease of those in closest contact with it-as the physicians and nurses in hospitals, most of these being affected only when run down and exhausted by long hours and hard work. That cholera is transmissible is, however, unquestion- able, and the various means by which it makes its progress are included under the following headings. Its distribu- tion is possible by ships, by drinking-water (this is one of the commonest and most powerful factors, especially in India), by wind (possible, but not probable-at any rate, not common), by clothing soiled by cholera evacuations (very common), by masses of filth (but not without the specific cause), by soil (if Pettenkofer's theories of the in- fluence of " Grundwasser" be correct), by the different vehicles of transportation, and by individuals. The "fungus" theory of a cause for Asiatic cholera is an old one ; the best resume of the condition of the ques- tion at the time is given by Dr. Cowdell (British and Foreign Medico-Chirurgical Review, July, 1848). To-day, those interested are following with eagerness the line of Koch's investigations upon the bacterial origin of the dis- ease. These were begun in the fall of 1883, during the decline of the epidemic in Egypt. Three scientific com- missions were sent out, by the French, English, and Ger- mans. The French discovered what they claimed to be the specific cause, in a micrococcus, but failed to support their assertions by scientific proof. There were no competent mycologists on the English commission, and the result of its work was the conclusion that cholera was not "specific," but that it should be classed among the tilth-diseases. The experience of Koch, as the master-mind in inves- tigations of this kind, led to the hope of better results from the commission of which he was the head. The scene of his labors was transferred from Egypt to India, and he worked there during the winter and spring of 1884. His work has been since continued in Berlin, and, although not yet completed, the results thus far obtained are as follows : A peculiar-shaped bacillus (the so-called comma-bacillus, because it is curved) is found in the intes- tinal fluids, Peyer's patches, and glands of cholera pa- tients, and in no other cases. These bacilli are one-half to two-thirds as long as the bacillus of tuberculosis, but much blunter, thicker, and with a slight curve. Some- times two are joined together end to end, giving an S form, and sometimes there are long strings of six or eight, very much like the spirochaete recurrentis of relaps- ing fever. They can be cultivated in meat-broth, milk, blood-serum, cooked potato, and best in gelatine specially prepared for the purpose (Nahrgelatine). When grown upon the surface of the latter they present a characteristic form of colony, differing from any known to the observer. They form a little glistening drop on the gelatine, and as their growth progresses they liquefy the culture-medium, and gradually sink into its body, forming a cone-shaped cavity, with the colony in the centre. They can be cul- tivated also upon an " Agar-Agar" culture-medium, and this they will not liquefy. They grow best in a tem- perature between 30° and 40° C. (86° to 104° F.) ; they will increase down to 17° C. (62.6° F.), but below this with great difficulty and very slowly, if at all. Their growth is very rapid, being complete in from two to three days. They will not resist drying more than twenty-four hours, and only as long as this when there are masses of the bacilli present. This organism seems to have no spores, and does not belong with the bacilli but with the spirilla. The organism was found only in the intestines of the cholera patients, and not in the blood or other fluids of the body. Repeated search failed to show its presence in any other form of gastro-intestinal disease. The link in the chain of evidence connecting it with cholera as a specific cause-successful inoculation experiments-was at first wanting, but the announcement of success in this direction also has been made. The inoculation was made by introducing one one-hundredth of a drop of a pure culture of the organism into the duodenum of rabbits and guinea-pigs, with the result of death in from one to three days with all the symptoms of cholera, and the dis- covery of masses of the bacilli in the intestinal fluids. These observations of Koch's are confirmed by Van Ermengem, of Belgium (" Recherches sur le Microbe du Cholera Asiatique," Paris, 1885), in every particular, and he supports the assertion that the discovery of the organ- ism either in the dejecta^or in cultures from the dejecta in doubtful cases, is diagnostic of cholera. The critics who claim to have found the comma-bacillus in the mouths of healthy persons are answered by proof of the difference in size, form, and behavior under cultivation of their organism. Finkler and Prior, who last autumn announced the dis- covery of a bacillus which they at that time considered to be identical with Koch's comma-bacillus of Asiatic chol- era, have recently (" Erganzungshefte zum Centralblatt fur allgemeine Gesundheitspfiege, Bd. I., Heft. 5 and 6) published the results of their more recent work upon this subject. They find that their curved bacilli are as con- stant accompaniments of cholera nostras as are Koch's bacilli of cholera Asiatica. They acknowledge that there are such differences between the two organisms, that, not- withstanding their very great similarity under the micro- scope, they cannot be considered to be identical. They claim that the differences are more relative than absolute, however, and that it is only possible to distinguish be- tween the two by a careful study of their behavior under all the conditions of mycological observation. These bacilli (of cholera Asiatica) are present in small 132 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholera. Cholera. numbers at the beginning of the disease and in algid cases, in large masses at the height of an attack and in foudroyant cholera, and gradually diminish in number as the violence of the disease diminishes. A full ac- count of the work done in this direction is awaited with interest, and will probably be furnished within a few months. (Vide Deutsche Med. Woch., August 7 and 10, 1884.) Diagnosis.-The symptoms are so characteristic that the diagnosis is generally easy. Those diseases which, during some period of their course, may be confounded with cholera are, sporadic cholera, acute poisoning, gas- tro-enteritis, severe indigestion, asphyxia from the fumes of coal, and the plague. Confusion can only arise at all during an epidemic. Sporadic Cholera.-The affections which may be grouped under this head can only be confounded with Asiatic cholera at the beginning of an epidemic. In true cholera, cyanosis, asphyxia, suppression of urine, etc., do not leave a doubt as to the nature of the attack; the absence of rice-water discharges, the less rapid progress and almost constant recovery, are still further means of differentiation. Poisoning occurring in the midst of an epidemic may be very difficult to detect, and, of all forms that from ar- senic is the most so. Vertigo, derangement of the senses, depression, epigastric distress, and suppression of urine, are common to both. Arsenical poisoning, however, has some special characteristics of its own, viz., in manifest- ing its symptoms almost at once after the ingestion of some food or drink, and in the persistent constriction of the throat and oesophagus. All doubts are at once re- moved when the character of the evacuations is estab- lished. At all times foudroyant cholera is difficult to dis- tinguish from this condition. G astro-enteritis.-The ordinary forms of this disease do not in the least simulate cholera. It is possible, how- ever, to attribute to it the precursory phenomena of chol- era, this possibility lasting for a very short time. Indigestion may rarely reach such violence as momen- tarily to simulate cholera,; the violence of the evacuations is the only confusing point. Their character, and the absence of all the other signs of cholera, clear up any doubt which might exist. Asphyxia from the fumes of coal is liable to be con- founded with cholera only in the cyanotic period, but in all cases the discharges and other symptoms preceding this stage leave no doubt as to the disease. The plague may be, but rarely is, met with at the same time and place as cholera. The prodromes may be simi- lar, but all doubt disappears when the two diseases have reached their acme. It will thus be seen that there are but few diseases, and these under rare conditions, which can be confounded with epidemic cholera. Prognosis.-The prognosis is very grave ; there is no pestilence which has weighed so heavily upon mankind. Where the disease attacks suddenly and violently, the prognosis is much more doubtful than where precursory phenomena are present, and it should be very guarded during a slow convalescence, for this more frequently points to a relapse, or to some severe alteration in the general constitution. Hygienic surroundings influence the prognosis also ; the better they are the greater the chance for a given individual. Adolescence and youth are the most favorable, old age and infancy the least fa- vorable, times of life. Although less frequent at the lat- ter period, the disease is more fatal when it does occur. The character of the epidemic has but very slight influ- ence upon the prognosis. Treatment.-There is no specific for cholera. In a consideration of what may be done, treatment may be divided into prophylaxis, and the means to be employed against the prodromes, the cold period, the period of re- action, complications and secondary affections, and the accidents of convalescence. Prophylaxis.-That which is meant here is that of the individual, and not of the state. Precautions should be -taken against dampness, insufficient or excessive eating, and in every way the endeavor should be to keep to a healthful and moderate regimen, and to retain calmness and firmness of mind. On the approach of an epidemic a flannel band, constantly worn upon the abdomen next to the skin, is a very good safeguard against a chill. Those already leading a regular and healthy life should make no change, but others should avoid the use of any food calculated to produce diarrhoea, as unripe or over- ripe fruit, pastry, etc. All excesses at the table-as also those of venery-even though occasional, should be com- pletely done away with. Unless the water-supply is cer- tainly of the best quality, a certain quantity for daily use should be boiled ; that for drinking purposes immediately before using. In regard to the poorer classes, the law of self-preservation, if nothing else, should secure to them substantial food, and clothing sufficient to protect them from cold or dampness. Treatment of the Prodromes.-These are not always confined to the disorders of the intestinal canal, but may be manifested in depression of spirits, headache, vertigo, and various other nervous phenomena. If digestion be disordered, attention should be paid to it at once by en- forcing a rigid regimen, and possibly by the employment of a purgative. If diarrhoea be present, rest in bed, opium, and subnitrate of bismuth have been found very useful. If gastralgia be the prominent symptom, tonics, broth, meat, wine in small quantities, combined with bit- ters, such as gentian, are effective in removing this symp- tom. If the precursory phenomena are those of vertigo, general lassitude, etc., all occupation should be at once given up, and friction with warm flannels, rest in bed, and diaphoretic drinks, as tea, infusion of peppermint, etc., should be used. By this strict attention to the first symptoms of disease during the time of an epidemic of cholera, it seems to be possible to arrest an attack at once, in certain cases. Where no prodromes are present, of course, nothing can be done. Treatment of the First Period.-The most important thing to do is to thoroughly disinfect all the evacuations, no matter how small, by receiving them in a vessel con- taining a watery solution of corrosive sublimate (1 to 1,000). All the linen should be soaked in the same imme- diately upon being soiled. All privies and water-closets that have, by any chance, been the receptacle for choler- aic matters, should be thoroughly washed out with the same fluid. Everything about the patient should be kept scrupulously neat and clean, and by these means can the disease be kept from spreading. It is upon the first stage that all efforts to arrest the disease should be concentrated. The indications are two- fold-to arrest the evacuations and to restore the heat. The means that have been employed to these ends are numberless in their variety and methods of application. Of the internal means, those that have been thought to be most useful are; Blood-letting, which has but few advocates and little to recommend it to-day. Opium and its salts, which stand at the head of the medicaments, and form the basis of most of the treatment used in India. The quantities taken in that country are enormous, the dose frequently being half an ounce of laudanum to an ounce of brandy Hypodermic injec- tions of morphia often remove the cramps, check vomit- ing and diarrhoea, and produce general comfort. Ipecacuanha in doses of ten grains to begin with, fol- lowed every half-hour with from one to five grains, has many believers in its efficacy. Subnitrate of bismuth used to be highly extolled, but more recent experience does not justify the praise for- merly bestowed upon it. These remedies have been very usefully combined with diffusible stimulants, tonics, and anti-spasmodics, in the most varying proportions. Those most commonly used are : infusions of tea,"peppermint, and sweet balm ; warm wine with canella and lemon, grog, black coffee, and various hot drinks, to which may be added ammonia, camphor, ether, or oil of cajeput. Camphor is considered by many to be almost a specific 133 Cholera. Cholera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in this stage of the disease, and may be combined with ether and opium. Ether may be given with freedom, either alone or with any other preparation, and seems to have been very useful. Oil of cajeput, gtt. xx.-xl., with a little tea, has been employed with apparent success in the Indies, its effect being that of a very energetic diaphoretic stimulant. Another method of obtaining diaphoresis is by the use of water, in doses of a tumblerful every ten to fifteen minutes, as hot as can be borne without scalding. Other methods of treatment, based upon theoretical ideas of the disease, have been the use of cinchona or quinine, on the idea of a connection between cholera and intermittent fever; charcoal, directed against a mias- matic cause ; alkalies, to remedy the thickening of the blood ; mercurial frictions, the inhalation of gases, as oxygen or protoxide of iron, and the attempts at transfu- sion of blood, or the intravenous injection of a saline solu- tion to make up for the loss of blood-serum in the dejecta. This latter method is certainly based upon reason, and is said to have given good results in the south of France in the summer of 1883, but no detailed account of its use has come to the writer's notice. Guaco, hascheesh, and chloroform, by inhalation, have been tried, with no especial benefit. Oil of naphtha has been used very widely in Russia, and is an ingredient in the famous Elixir of Voronej, which is : and opium. Constipation, which is sometimes obstinate, may be met with powdered rhubarb or magnesia. Cramps and insomnia may be treated with warm baths and with some preparation of opium. Especial attention must be paid to hygiene, and particular care must be taken against exposure to heat and cold. The diet must be watched and regulated carefully according to the conditions of the digestion, and none of these precautions must be omitted until recovery is complete. Review of the Treatment.-First, whatever medication is adopted must be persisted in and not varied nor intermit- ted. After prophylaxis has been thoroughly observed, attention should be directed to the prodromes, and these should be treated carefully and rigidly. At the begin- ning, in whatever form the attack shows itself, the en- deavor should be to restore heat, excite perspiration, and to modify and arrest the evacuations. The external and internal means are to be employed conjointly and with- out cessation, until a modification of the symptoms is ob- tained. As soon as heat begins to return and the pulse reappears, the means directed to these ends should be omitted in order to avoid excessive reaction. The dif- fetent degrees of reaction call for different therapeutic measures, and the great care which convalescence de- mands and the precautions to be taken against a relapse should be constantly borne in mind. Sanitary Measures.-Besides the measures that the individual must take to guard against an attack of cholera, there are others which devolve upon the State. These are, 1, the provision of means of isolation and sequestration ; 2, of rendering localities healthful and of keeping them so ; 3, of public assistance ; 4, of public instruction. 1. The idea of the necessity for sanitary cordons and absolute quarantines is gradually passing away, and justly so, in view of the ill-success attending these meas- ures in the past. A strict watch should be kept upon all vessels coming from an infected port, however, and all should be thoroughly inspected before being given clean bills of health. 2. Localities are to be made healthy and kept so by keeping in repair the public ways ; by the complete and rapid removal of all filth ; by the rigid inspection and regulation of unhealthy establishments, and, especially, by the scattering of the crowds of poor people oftentimes collected in a single tenement. These measures rigidly enforced, together with a pure water-supply and good drainage, are better than all the disinfectants that can be used for the stamping out of an epidemic. 3. There should be secured to the poor a more healthy and abundant nourishment, proper shelter, and sufficient clothing. 4. Public instruction, of the nature of " Emergency Lectures," should be given by every government at the beginning of an epidemic. It should include directions for the general rules of conduct and hygiene, some advice as to the administration of remedies until the doctor can be reached, and other items necessary for an understand- ing of what to do. Such instructions should also include and lay especial stress upon the necessity for immediate disinfection and destruction of all evacuations and soiled clothing, and upon the importance of a pure water- supply. The theories upon Asiatic cholera, which are held to- day by the majority of the most experienced and scien- tific physicians, may be summed up as follows : 1. Asiatic cholera is an infectious disease, resulting from the entrance into the alimentary canal of a poison, which poison is probably a specific bacterium, whose life-history has not yet been fully determined. 2. The disease is endemic only in India, and the spe- cific organism which is its cause is distributed primarily by the evacuations of a person affected with the disease, and secondarily by contaminated clothing, utensils, food, and water. 3. That dried evacuations upon bedding, clothing, etc., retain their virulence for an indefinite period of time, and that an outbreak of the disease may be produced by such means at a great distance from the original source of con- tamination. (In the light of the most recent scientific re- 1. The Stronger. Sal. ammon 3 x. 01. naphthae 3 vj. 01. caryophylli 3 x. Acid, nitric 3 vj. Potass, nitrat., Turkey pepper aa 5jss. Menth. vir ' viij. Acet O j. Spts. vin. gall Oiv. 2. The Weaker. Camphor, 01. naphtha?. Ess. terebinth., Acid, nitric aa 3 ij. Turkey pepper 2 pods. Acet 3 vjss. Spts. vin. gall 3iv. Wood naphtha, TR, xv.-3 j., is said to have succeeded in relieving vomiting in every case in Boston in 1849 (" Rep. on Cholera in Boston in 1849," Boston, 1850). External Measures.-These should be especially directed toward restoring the warmth and circulation, and the first means by which to attempt this is artificial heat. This may be obtained by the application of warm sheets, or warm felt about the limbs and upon the abdomen, warm baths, the hot-air bath, and bags of hot bran or oats. Care must be taken against too great a degree of heat, and efforts should be made to establish Natural Reaction, the means for inducing which are limited and of the number, stove-baths, dry or moist, and affusions and applications of cold water, are the best. The latter is probably the most powerful appliance we have, and may be employed by the use of cold applica- tions to the head, chest, and abdomen, and the ingestion of large quantities of cold water. Revulsives of the most energetic kind have been employed-blistering, general mustard baths, and frictions, with irritating liniments- as have also dry frictions with the hand or brush. One of the most violent remedies we have heard of is to stretch a cloth over the abdomen, saturate it with alcohol, and then to set fire to it. This procedure has been said to produce recovery ! Collapse.-No drug is of the slightest value in this stage, and the only hope is in persistence in the adminis- tration of diluents (as water, etc.) and of nourishment (as of cordials, etc.). It is in this condition that the most startling results have been obtained by the injection into the veins of an artificial blood-serum or of hot water. Reaction must be treated very carefully, and the first symptom of its occurrence must be left to itself, for ac- tive interference may easily destroy it. If reaction comes on too violently, however, active measures must be taken, and quinine and cold, internally and externally, may be employed. Convalescence, when rapid, needs little care, but the most minute precautions must be taken in cases in which anything occurs to disturb or retard it. Gastralgia, atony of the stomach, and flatulent dyspepsia, are to be met with bitters and tonics. Diarrhoea demands astringents 134 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholera. Cholera. searches this seems doubtful, for the cholera-bacillus does not resist drying for more than a day or two.) 4. That no amount of filth or moisture will produce the disease, without the presence of the specific poison, but that both filth and moisture furnish a suitable culture- medium for the organism. 5. That the cholera poison, unless destroyed, may in- fect an entire water-supply, and cause the disease to spread indefinitely. 6. That the virulence of an epidemic depends upon the hygienic surroundings of the people among whom it appears. 7. That an intelligent quarantine and vigorous sanitary measures, will serve to prevent the appearance of the scourge, while thorough disinfection and sequestration will prevent its spread after it has made its appearance. 8. That the disease is not contagious, in the sense of being communicable by contact, and that this fact should be made plain to all. 9. That strict attention to personal hygiene will im- measurably diminish the chances of its attacking any single individual. subside into more or less protracted intestinal catarrh, and others in which the course of the latter disease is dis- turbed, perhaps abruptly ended by an attack of infantile- cholera. But, although this is true, typical cholera infantum con- trasts so strongly in symptomatology and fatality with all other forms of summer diarrhoea, as to entitle it to a separate chapter and a distinctive name. Little or no difficulty would be experienced if the term were rigidly restricted to the form of gastro-intestinal inflammation outlined in the above definition. Etiology.-Infancy, excessive atmospheric heat, im- proper feeding, and bad sanitary conditions are the chief factors in the etiology of cholera infantum. They go hand in hand in producing the disease, and, except in occasional instances, are singly inoperative. Cholera infantum, as the name implies, is a disease of early childhood, and in the presence of favorable con- ditions, the liability to its development is in direct pro- portion to the age of the infant. It occurs more often during the first six months than at any other period of infancy, and is rarely met with after the completion of the first dentition. There is, how- ever, no ground for the belief that dentition is a factor in the causation, save that the great developmental and functional activity of the intestinal follicles during this period is a powerful predisposing cause to all kinds of intestinal derangement. Cholera infantum is a disease of the summer months, and attains its greatest prevalence when the thermometer ranges the highest. In this latitude cases begin to appear in the latter part of May, and occur with varying frequency until October. The disease, however, rarely assumes an epidemic form except in the months of July and August, when it reaches its maximum prevalence and fatality. High atmospheric heat exerts its deleterious influence, both by enervating the child's physical powers and by impregnating the air with the poisonous exhalations of decaying animal and vegetable matters. Improper food is the cause of multiplied digestive dis- orders in the infant, but, except in the presence of sum- mer heat, rarely, if ever, lights up a choleraic attack. However, not infrequently a single improper meal will transform a mild diarrhoea into the graver form of dis- ease, and will sometimes develop an attack when the previous health is undisturbed. Premature weaning, the use of commercial baby foods, and the American habit of admitting infants to the family table invite the disease. Hand-fed babies, however in- telligently cared for, are prone to choleraic seizures, es- pecially when exposed to the anti-hygienic surroundings, personal or domiciliary, of tenement-life in the larger cities. For obvious reasons the disease attains its greatest frequency and mortality among the children of the city poor and in foundling hospitals. Morbid Anatomy.-The pathological lesions vary with the period at which death occurs, and are rarely as pronounced as the alarming character of the symptoms would indicate. In many cases which proceed rapidly to a fatal issue, the post-mortem revelations are negative, or, at most, only disclose a few patches of arborescent injec- tion scattered over the intestinal mucous membrane. In the more protracted cases, the lesions are better marked, and are very similar to those found in ordinary entero- colitis. The mucous membrane is reddened, thickened, and softened, uniformly or in patches. The intestinal glands exhibit the most constant change. Both the patches of Peyer and the solitary glands are enlarged, and form translucent projections above the surface. Many of these enlarged glands soften, break down, and leave the mu- cous membrane more or less thickly studded with follicu- lar ulcers. The mesenteric glands are congested. The brain is anaemic and wasted, and serum is freely effused into the ventricles and on its surface. More or less hy- postatic congestion of the posterior lobes of the lungs is nearly always observed. Symptoms.-Cholera infantum usually begins abruptly Bibliography. Christie, James : Cholera Epidemics in East Africa. New York, 1884. Conference, Internat. Sanitary, at Constantinople : Report of Committee on Cholera, 1866, by E. Duvivier and A. Fauvel. Paris. Fabre, A.: Traitement dn Cholera. Marseilles, 1884. Fauvel, A.: Memoire sur le Cholera, etc. Imp. Nat. Paris. 1883. Finkler and Prior : Forschungen iiber Cholerabacterien. Ergiinzungs- hefter zum Centralblatt fur Allgemeine Gesundheitspflege, Bd. i., Heft 5 and 6. Bonn, 1885. Griesinger, W., Pettenkofer, M., and Wunderlich, C. A.: Cholera Regu- lativ. Zeitsch. f. Biologie. Munchen, 1866, vol. ii., p. 434. Hallier, Ernst: Das Cholera Contagium. Leipzig, 1867 (a botanical re- search). Koch, R. : Fortschritte der Medicin, Beilage, November 1 and December 15, 1883; February 1, March 1, April 1, May 1, 1884. Die Conferenz zur Eriirterung der Cholerafrage, Deutsche Med. Wochensch., Nos. 32 and 32a, August 7 and 11, 1884; Deutsche Med. Wochensch., Novem- ber 15,1884, and September 21, 1885. Macnamara, C.: A History of Asiatic Cholera. New York, 1884. Macpherson, J. : Annals of Cholera from the Earliest Periods to the Year 1817. Second edition. London, 1884. Mass. Med. Society : Report on Spasmodic Cholera, Boston, 1832. Peters, John C.: Notes on Asiatic Cholera. Second edition. New York, 1867. Pettenkofer, M. : Boden- und Grundwasser in ihren Beziehungen zu Cholera und Typhus, Zeitsch. f. Biologie, Band v., Heft 2. 1869. Phoebus, P. : Ueber den Leichenbefund bei der Orientalischen Cholera. Berlin, 1833. Practitioner, The, 1883 : Summary of Reps, of Eng., French, and Ger- man Cholera Commissions. Ibid. : Cholera in Damietta, 1883. Proust, A. : Le Cholera, Etiologie et Prophylaxie. Paris, 1883. Rayer, P.: Gazette M6d. de Paris. 1832. Scoutetten, H. : Histoire Chron. du Cholera. Paris, 1870. Samuel, S.: Die Subcutan Infusion als Behandlungsmethode der Cholera. Stuttgardt, 1883. Tardieu, A. : Du Cholera Epidemique. Paris, 1849. Ibid.: Treatise on Epidemic Cholera. Boston, 1849. Tytler, R.: Remarks upon Morbus Oryzeus. Calcutta, 1820. Ibid. : Production of Cholera by Rice. Lancet, 1834, vol. ii., pp. 895, 896, Van Ermengem, E.: Recherches sur le Microbe du Cholera Asiatique. Pans et Bruxelles, 1885. Harold C. Ernst. CHOLERA INFANTUM (Syn.: Gastro-EnteritisCholer- iformis, Choleraic Diarrhoea, Summer Cholera, Summer Complaint). Cholera infantum is an acute gastro-intes- tinal catarrh affecting young children, and characterized by large watery stools, profuse vomiting, high tempera- ture, great prostration, and rapid wasting. It is the most sudden and dangerous form of gastro-in- testinal inflammation to which children are liable, and is largely instrumental in causing the excessive infant mor- tality of the summer months. Cholera infantum is es- pecially a disease of the crowded cities, but is far from uncommon in the sparsely settled country districts. The custom, so general with physicians everywhere, of grouping all severe infantile diarrhoeas under the generic name of cholera infantum, leads to much con- fusion, and seriously vitiates the deductions drawn from compiled mortuary tables. The line of demarcation between cholera infantum and the ordinary summer diarrhoea, entero-colitis, cannot always be sharply drawn. Every epidemic exhibits cases which, beginning with distinct choleraic symptoms, soon 135 Cholera. Cholesteatoma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with violent vomiting and purging, but it may be pre- ceded by a short and ill-defined prodromal stage. In this latter event, anorexia, fever, fugitive abdominal pains, and a few liquid stools precede, for a few hours, or a day or two at most, the peculiar serous evacuations which give character to the attack. It is a matter of common observation that the disease very frequently occurs in the course of a diarrhoea, more or less protracted, attended with emaciation and asso- ciated with intestinal inflammation, but, even in these cases, the distinctive choleraic symptoms almost invari- ably begin suddenly and are sharply outlined. The antecedent diarrhoea unquestionably exerts a pow- erful influence in precipitating the attack, but it is not an essential feature of, nor can it be properly considered a preliminary stage of, cholera infantum. The stools first voided contain the contents of the intes- tines, milk curds, and particles of undigested food, mingled with intestinal mucus and liquid fseces. As long as faecal matters are present, the discharges have a peculiarly fetid and penetrating odor, which clings to the clothing and person after repeated washings. These dis- charges are soon replaced by large odorless stools, devoid of faecal matter, and so thin as to soak through the diapers like water, leaving only a greenish stain. The number of the stools varies. Ten, twenty, or more may be passed in the twenty-four hours ; occasionally, they recur at long intervals-four or six hours apart-but are so copious as to deluge the clothing and bedding. The discharges are quite irritating, and give rise to an erythema about the anus, which adds greatly to the child's discomfort. Abdominal pains and tenderness on pressure are usu- ally not marked. Vomiting soon succeeds, or occurs simultaneously with, the intestinal discharges. It is nearly always persistent, and causes the immediate rejec- tion of everything-food or drink-taken into the stom- ach. The stomach is speedily emptied of its contents, and afterward the ejected matters consist of the food taken, a greater or less quantity of serous fluid, the con- tents of the duodenum, and bile from the gall-bladder. The reaction of the vomited matter is at first acid, but subsequently becomes neutral or alkaline when the intes- tinal fluids and bile enter largely into its composition. The evacuations, both gastric and intestinal, take place suddenly, with little or no warning, and are ejected with considerable force. The two symptoms just enumerated-free watery purg- ing and vomiting-recurring again and again, either simultaneously or in close succession, constitute the prom- inent and distinctive features of cholera infantum. The quantity of fluid discharged in a few hours through these channels is sometimes enormous. This excessive depletion necessarily causes rapid wasting and speedy ex- haustion. The child soon loses its plumpness, the mus- cles become soft and flabby, and the skin hangs in folds about the joints. The features become more and more pinched and drawn, and so changed in appearance as to seem unnatural. It is extremely restless and moans con- tinuously, not so much from pain as from thirst and the general ill-feeling which comes from rapid exhaustion. Fever of a remittent type is present from the first. The surface may seem to the touch but little ■warmer or even cooler than natural, but measured by the thermome- ter in the rectum, the temperature, in a case of ordinary severity, will range from 102° F. to 105° F. " There is no disease of infancy in which the temperature of the blood is higher" (Smith). The mouth soon becomes dry and glazed, and the lips deeply fissured. The tongue is dry and shining, or coated with a brown fur. The loss of fluids causes intense thirst, and the little patient eagerly accepts the proffered breast or cup. Water and ice, if allowed, are taken almost incessantly, though re- jected by the stomach as soon as they are swallowed. The secretion of urine is always greatly diminished, and in some of the graver cases totally suppressed. Cerebral complications develop in a large proportion of the severe cases. These are sometimes due, especially when the urinary secretion is scanty or suppressed, to uraemic poisoning; but are more often attributable to that form of cerebral anaemia first described by Mar- shall Hall under the name of spurious hydrocephalus. When this condition is imminent the evacuations sud- denly cease or recur at lengthened intervals. The fever disappears and the temperature sometimes drops below normal. The fontanelle, if unclosed, is deeply depressed, and, owing to the wasting of the brain tissue, the bones of the skull frequently overlap and render the surface of the cranium quite uneven. If the case does badly, the child becomes dull and heavy, the occiput is bored into the pillow, the eyelids remain half-open, the cornea is bleared, and the pupils irresponsive to light. Drowsiness, which has been marked from the first, gradually deepens into fatal coma. Convulsions occur in many of the fatal cases. The duration of cholera infantum is short. Death may occur in eight or ten hours from the first disturbance of the intestinal canal. Cases rarely last longer than a week, by which time death ensues or convalescence is assured. It must be remembered that an entero-colitis may indefinitely prolong convalescence or even cause a fatal termination long after the disappearance of the choleraic symptoms. In those cases which pursue a favorable course, the first indication of improvement is the cessation of the vomiting. The child takes food and retains it; next, the diarrhoea becomes less violent, and the fever soon abates. On the other hand, if the profuse flux from the gastro- intestinal tract is not arrested, fatal exhaustion necessarily results. In this event, the face grows more and more haggard and old-looking; the eyes shrunken, bleared, and surrounded by dark rings ; the surface cold and cya- nosed ; the respiration sighing, and the pulse uncount- able. Prognosis.-The prognosis is grave. The frequency with which collapse and brain complications arise in cases apparently pursuing a favorable course, always justifies a guarded prognosis. Marked remissions in the symptoms occasionally occur, even in the later stages, which lead to the building of false hopes by parents and friends. The duration of the disease is largely influenced by the sever- ity of the attack and the vigor of the child. It usually proceeds promptly to death or recovery. A constitution impaired by bad inheritance or previous illness, exposure to unhealthy surroundings, early age, and recent wean- ing, affect the prognosis unfavorably. The mortality is greatest in children under a year old, deprived of the breast. The choleraic attacks which occur in the course of ordinary summer diarrhoeas are less amenable to treat- ment than those developed in rugged health. The occurrence of collapse, or the hydrencephaloid condition, unless promptly relieved, renders the outlook hopeless. Death occurs from exhaustion or cerebral effusion. (Edema of the lungs, due to failure of the heart, often hastens the fatal termination. Diagnosis.-The diagnosis is easily made. In fact, there is no disease, excepting Asiatic cholera, for which it can be mistaken. The severe serous vomiting and purging, the high fever, the rapid wasting and exhaustion, stamp it with an individuality which almost precludes the possibility of error. Treatment.-The importance of suitable food, good nursing, and proper hygienic surroundings in the pre- vention and treatment of cholera infantum can scarcely be overstated. The coolest and best ventilated room in the house should be chosen for the patient. If the weather is fine, the house may be profitably exchanged for the garden during a large portion of the day. The most scrupulous cleanliness of the person, clothing, nursing- bottle, and everything about the patient, must be ob- served. If the child is under one year of age, hand-reared, or lately weaned, a wet-nurse, if possible, should be at once secured. Beef-tea, broths, starchy foods, and the whole list of proprietary infant foods, should be proscribed. 136 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholera. Cholesteatoma. The latter are, perhaps, not all injurious, but many of them are, and as none are essential to the successful man- agement of the attack, it is better, for obvious reasons, to ignore the whole list. Unquestionably the best available substitute for the breast is cow's milk. However, even pure cow's milk will sometimes disagree, in the irritable condition of the digestive organs. The difficulty is usually with the casein of cow's milk, which coagulates into indigestible and irritating lumps. This tendency may be largely overcome by the addition •of farinaceous substances; and nothing subserves this purpose better than thin barley-water to which has been added a little extract of malt to convert the starch into grape-sugar. Lime-water also forms an excellent diluent and tends to correct the acid fermentation, always pres- ent in infantile digestive disturbances. Cow's milk, peptonized according to the formula of Professor Pfeiffer, of Wiesbaden, or Professor Leeds, of Stevens Institute, is highly recommended by Professor Lewis Smith and others. The bitterness caused by the peptonizing process, un- less it be skilfully conducted, is a serious objection. Great care should be exercised that the child is not overfed. The intense thirst leads to the eager taking of everything proffered, and the excess is sure to act as an irritant to the inflamed gastro-intestinal membrane. It is frequently advisable, especially when the attack is devel- oped suddenly and the vomiting is excessive, to withhold all food for several hours. If this is not deemed judicious, small quantities of a light barley-water, to which a few drops of brandy are added, may be allowed. The white of an egg, stirred into a cup of barley-water, and seasoned with a little salt, will sometimes be retained when everything else is vomited. Water should be given freely, but in small quantities at a time, or the child may be permitted to suck small pieces of ice wrapped in a napkin. One of the most important of the modern contributions to the management of certain choleraic attacks is the cold bath. The best results attend its use in those cases which have an abrupt beginning, the previous health having been good, and are characterized by a high range of tem- perature. The hyperpyrexia, which is in itself ,an element of danger, with the attendant nervous phenomena, is more promptly relieved by it than by any other means. The bath also noticeably relieves the thirst from which chol- eraic patients suffer so intensely. The child is gently immersed in water at 100° F., when the temperature is gradually reduced by the addition of cold water or ice to 80° F. or 70° F. Colder water, or an ice-bag, may be ap- plied to the head. The immersion is continued eight or ten minutes, and repeated two or three times in the twenty-four hours, if the temperature reaches the danger line. If symptoms of exhaustion or collapse are present, the cold bath is, of course, inadmissible. The traditional purge in the beginning of the treat- ment, still recommended by some authors, is unnecessary and hurtful. The copious spontaneous evacuations speed- ily remove all irritative matters from the alimentary canal. There is no remedy, in our experience, so generally use- ful as opium, although its use is condemned by excellent practitioners. It should always be administered with caution and dis- continued at once, should cerebral symptoms appear. It is an excellent rule to give the opiate by itself ; in this way the dose and frequency can be readily changed without interfering with other remedies. The hypodermic use of morphia is advised by some authors, but, with infants, the practice is questionable. Morphia (one-hundredth of a grain), deodorized tinct- ure of opium (one drop), or paregoric (fifteen to thirty drops), are the more eligible preparations.* A most efficient prescription is the combination of the compound chalk and opium powder (three grains), and subnitrate of bismuth (ten to twelve grains). In those cases attended with excessive vomiting, carbolic acid (one-fourth to one-half drop) in lime-water or chalk mixt- ure, combined with full doses of bismuth, often prove effective. We have also seen excellent results from the following prescription : R. Acidi sulphurici aromat gtt 3. Tinct. opii deodorat gtt 1. Aq. amygdalae amarae Hl. 40. M. Repeat in from two to four hours. Sometimes, when the vomiting is persistent, minute doses of calomel (one-tenth to one-twelfth grain), finely triturated with sugar and dropped dry upon the tongue, every half-hour, will exert a marked sedative effect on the stomach. If good results are not soon obtained it should be discontinued. The routine use of calomel in cholera infantum, recommended so highly by some authors, can- not be advised, since the indications can, to say the least, be met by safer and equally efficient remedies. Great value has been attached to the use of bromide of potas- sium, but in our hands it has never given satisfactory re- sults. French authors speak highly of the nitrate of silver. It may be given by the mouth or rectum ; the dose for internal administration is from the one-twelfth to the one- eighth of a grain. The vegetable astringents (Kino, Krameria, etc.) are of doubtful utility during the violence of the attack, but are of service in the diarrhoea which so often protracts convalescence. Stimulants are needed in nearly all cases. It is a com- mon mistake to delay their use too long. Good brandy or whiskey in small doses frequently repeated assuages thirst and lessens vomiting; and in larger doses, these spirits are the most powerful remedies at our disposal with which to combat exhaustion. Ten to thirty drops, repeated as often as required, is the proper dose. It is surprising how large a quantity will sometimes be profitably taken by a child threatened with collapse. Enemata often do good. Laudanum (three or four drops) in a tablespoonful of thin starch-water may be thrown into the bowel three or four times during the day. X Sulphate of copper (one-fourth grain), acetate of lead (one grain), or nitrate of silver (one-fourth grain), may be added to the above enema, if it should fail to restrain the discharges. When the nitrate of silver is used, the anus and the lower portion of the rectum should be washed with a solution of chloride of sodium before the injection is given, as otherwise, even very mild solutions may give rise to severe tenesmus. Mild counter-irritation over the abdomen is often bene- ficial. For this purpose spiced poultices, or camphorated oil, or flannel cloths wrung out of hot mustard-water may be used. During convalescence the child should be carefully watched, as one attack increases the liability to another. W. J. Conklin. CHOLESTEATOMA. The cholesteatoma is a tumor which is composed of cells resembling those of the horny- layer of the epidermis. This tumor was first described by Cruveilhier, and to this pathologist and to Johannes Muller we are mainly indebted for our knowledge concerning it. Cruveilhier gave it the name of tumeur perlie. He described under this name a tumor which was seated on the base of the brain in a girl of eighteen years. The tumor was covered by the arachnoid, and filled the entire base of the skull, in places attacking the brain itself. It had a metallic lustre like that of silver, or of a pearl of the purest water. The surface was not smooth, but covered with numerous protuberances which glistened like small pearls. On the surface only it had this peculiar lustre ; when cut into it had a whitish-yellow color, and was of the consistency of soft wax. The surrounding parts were compressed by the tumor and were separated from it by the pia mater. Cruveilhier concluded that the tumor was developed in the subarachnoid cellular tissue, and, as he was unable to find any trace of organization in it, he concluded that it * The doses given in this article are for a child about one year old. 137 Cholesteatoma. Chorea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. was only a product of secretion held in the meshes of the cellular tissue. Barrul examined the tumor chemically and found some albuminous material, cholesterin, fluid fat, and, from an alcoholic solution, a substance which he supposed was stearin. In another case, cited by Cruveil- hier, numerous cysts were found in the testicle, some of which contained a substance which had a pearly lustre similar to the tumor of the brain. Johannes Muller spoke of these formations as fatty tumors resembling mother-of-pearl and named them cholesteatoma, which name they have since borne in literature. He said he had met with them eight times, and mentions particularly one which he had found in the ventricles of the brain, and which was two inches in diameter. He mentions others which he found in the subcutaneous cellular tissue. There is no doubt that Mul- ler, and after him many other authors, confounded this tumor with the atheroma. The latter may become changed into a shining, refractive mass, in which noth- ing but dried horny epidermis-cells are found, and in this condition it has both micro- and macroscopically almost the same appearance as the cholesteatoma. Bill- roth denies their existence as a special group and classes them all with the atheromas. Virchow, who has described the cholesteatoma more fully than any other author, re- gards them as formed from the connective tissue and in this respect therefore heterologous. The cholesteatoma is essentially a tumor of the cere- brum, and is found here more often than in any other place. Generally it is seated on the base of the brain, either on the pons, medulla, or the inferior surface of the cerebellum. Macroscopically it agrees best with the de- scription given by Cruveilhier. It is very often sur- rounded by a well-defined capsule, and its peculiar me- tallic-like lustre will at once strike the eye. It is seldom smooth and regular on the outside, is soft and easily torn, so that it is generally more or less destroyed in taking out the brain. Microscopically, the cholesteatoma consists of large flat epithelial cells, which were for a long time considered to be tablets of cholesterin. Virchow was the first to show that by the use of proper reagents a nucleus could be made visible in each of these large cells. Some of the cells, when viewed on the side or when there are folds across the body of the cell, resemble fibres. These cells have no special arrangement in their relations to each other, although large concentric masses similar to the pearls in epithelial carcinoma are very often found. The cells will not stain by any reagent; by the use of acetic acid a nucleus can usually be discovered in the middle of the cell. Tablets of cholesterin and amorphous granular matter are very often seen. The tumor seems to be de- void of blood-vessels and connective tissue stroma. Little is known as to the origin and mode of growth of these tumors. Virchow regards them as originating in the connective tissue of the arachnoid. It is possible that they take their origin in the endothelium of the pia mater. Chiari has described one seated in the medulla, in which case it seemed probable to him that the epithelium of the central canal was the starting-place of the growth. Some authors regard them as belonging to the dermoid cysts, and formed, as these are, from residues of embryonic tis- sue. Against this view we have the fact that dermic structures, hair, teeth, or nails, have never been seen in them, nor has a true epithelial structure been seen in the cyst which sometimes surrounds them. We always see the tumor when its growth has been completed, and it represents but an inert mass in the organism. The cholesteatoma is a rare tumor. No cases have been reported of metastases from it, and it is usually an accidental discovery at the post-mortem examination. It may, however, by compressing important parts, prove fatal to life. The most peculiar and striking feature about the tumor is its metallic-like lustre. W. T. Councilman. Tancz, Plasawicy scelotirbe, Corea, Folie musculaire (Bouillaud). The literature of chorea is extremely voluminous, and its history dates back to the middle ages, when it existed chiefiy^n its epidemic form. Hecker1 and others detail the incidents of the various religious pilgrimages to the shrines of St. John and St. Vitus, and the imitative feat- ures of the outbreak of psychical excitement with con- vulsions and jactitations are of the greatest interest. In many respects this form of trouble, apart from its whole- sale character, differs but little from that in which attacks of hysterical chorea major are witnessed to-day.2 Puc- cinatti and other writers have undertaken to fix the identity of sporadic and endemic chorea, and to some ex- tent they have succeeded ; but when we consider the prob- able pathology of the disease from the standpoint of modern investigation, it must be admitted that the psy- chical element is by no means an important one. During the last twenty-five or thirty years, thanks to Kirke, Ogle, Dickinson, Dowse, Jackson, Eisenlohr, and Elischer, the cardiac and embolic connection and its relation with rheumatism have been made very clear, and within a comparatively short space of time the organic variety known as post-hemiplegic chorea, or hemi-chorea, has been fully described by Mitchell, Charcot, Hoffman, and Jack- son. Chorea is a disease which manifests itself in an exceed- ingly irregular manner as to parts affected, degree of violence of expression, and its association or dependence upon other things. It is expressed by a peculiar disor- derly and nearly constant recurrence of muscular con- tractions of an involuntary character, which are not (ex- cept in hysterical cases) at all rhythmical. It has been divided into general chorea, or chorea major, and partial chorea, or chorea minor, and its mode of association still further demands a series of qualifying terms, such as hys- terical, saturnine, the chorea of pregnancy, electric, rheu- matismal, dental, enteric, etc. Symptoms.-Chorea may follow some other affection- one of the ordinary diseases of childhood, for instance-or it may be the sequel of an attack of acute rheumatism ; or again, it may have no basis except a general reduction of vital power with anaemia and its belongings. In such cases the development of the malady is slow and insidious, and the child for a long time presents simply those evi- dences of neural malnutrition which are so common. It is peevish and capricious, and restless in the extreme. Its petty exhibitions of temper render it a nuisance, and it receives its full allowance of punishment. The same caprice of disposition is found in eating-it prefers im- proper food, and at best eats but little. It is listless and dull at school, sleep is disturbed, and frightful dreams produce night terrors and nocturnal incontinence. Its pale face makes more conspicuous the dark spots under the eyes, and its foul breath and dry teeth betoken a derange- ment of digestion. After a while it begins to shrug one shoulder or the other, and twitches its hands, or fumbles the seam of the trowsers, or opens its mouth with a sort of gasping movement, or twitches its lips, or corrugates its brow, or spasmodically closes its eyes ; or does some- thing else that may be regarded as a trick or bad habit. Scolding or whipping does not effect a change of behavior -in fact, it rather aggravates the trouble. In a week or two the movements are more pronounced or general, the arm is swayed hither and thither by the action of the pectoral muscles, or the hand is supinated or pronated, the fingers restlessly cramp, the lips are pursed, and any attempt at speech is attended by hesitation and embarrass- ment, and oftentimes by great indistinctness. The pa- tient breathes in a catchy, quick way, and if the body be stripped it will be found that the action of the inter- costals is uneven. There is rotary swaying of the body, constant shrugging of the shoulders. The leg of one side-usually the right-is affected, and after a while there is greater or less loss of power, so that there is a well- marked drag which is usually more noticeable toward the latter part of the day. All the voluntary muscles are more or less affected, and as a rule those are most involved which are used to the greatest extent in acts which be- CHOREA. Synonyms : St. Vitus' Dance, Danse de St. Guy, de St. With, Myotyrbie(Dartigues), periodical jacti- tation (R. Watt), Choree, Veitstanz, Veitsdands, Vit- 138 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cholesteatoma. Chorea. come automatic. In the form known as laryngeal chorea the thyro-hyoid muscles are affected, and phonation be- comes seriously embarrassed. The tongue, when pro- truded, is found to be the seat of jerking spasms, and when the patient talks he makes a peculiar sucking mo- tion of the lips. Symptoms of spinal sensory irritation mark the prodro- mal period, and we are furnished with a history of pains and sensitiveness of the vertebral spines. Pressure on the cervical region sometimes causes great distress, and especially is this the case when even light pressure is made upon the vertebra prominens. The pa- tient complains of pains in the wrists and ankles, which suggest rheumatism, and the bellies of the affected mus- cles are sore. Spots of cutaneous hyperaesthesia or anaesthesia are sometimes detected. In hysterical chorea the latter are very often present, and I have repeatedly found hemi- anaesthesia upon the left side. The vision is affected, and, as a rule, errors in accommo- dation are found. So common is hypermetropia that it has been advanced as a cause of the disease, and a most absurd therapeutic course, which involved the use of glasses and operations, has been advised by one individual; but Dr. C. S. Bull, of New York, exploded this theory, showing by statistics the frequency of hypermetropia in non-choreic children, and others. In debilitated subjects it is not difficult to get a history of dimness of vision, and sometimes we find pupillary alterations which consist usually in dilatation, and the pupils, as Von Ziemssen has observed, are very sluggish. Electrical response is somewhat altered. Rosenthal2 found an increase in the electro-muscular contractility, with weak currents, in those patients who suffered from unilateral chorea. Galvanic excitability was pronounced, and cathodal opening with weak currents produced con- traction. Benedikt had the same results, and also found that the electric sensibility is much exaggerated, and when the electrode is applied to the cervical or dorsal region, eccentric pains in the limbs are complained of. The presence of cutaneous eruptions is not uncommon. Eczema, as was originally shown by Frankel and myself, bears a very close relation to chorea, especially in children. The movements, as a rule, cease when the patient sleeps, but this is sometimes not the case in pronounced or violent examples. Of one hundred and fifty, eight cases collected by See this was the rule, there being but six exceptions. Dr. Robert Amory Hare3 has conducted some investi- gations which go to show that mono-chorea is associated with elevation of temperature in the affected limb. Most of the conclusions were gross and arrived at by contact, or by the subjective complaints of the patient. When the thermometer was used a difference of four or five degrees was often found between the two sides of the body. The psychical changes in chorea have impressed such observers as Romberg, Skoda, and Maree. This latter writer has referred to cases in which hallucinations were present, and feelings of dread were very pronounced, and Rosenthal mentions an old woman who was unusually garrulous and loquacious, and gave '1 utterance to savage cries." The hallucinations are most often presented in the half-waking state, and are, as a rule, visual. A case in which hallucination of an extremely interesting char- acter was a feature is related by Ritti (Union Medicate, 3me serie, t. xix., p. 721, 1873), the subject being a girl, aged nineteen, who was not hysterical. The hallucination depended upon derangement of all the senses, but principally of sight. She saw cats, bright lights; heard the voices of men close to her; perceived imaginary smells, and tasted poisonous substances, etc. Thore4 reports a case of melancholia in a chlorotic girl, aged sixteen, who suffered from disturbed menses. Six weeks after the commencement of the melancholia she de- veloped chorea which involved both extremities on the left side. She had auditory hallucinations at night, sui- cidal tendencies, more aggravated melancholia, and re- covered, six weeks afterward, when the menses were re- established. I have seen a number of cases in which mental perver- sion was conspicuous. Two cases, in particular, now occur to me. One, an old woman, who had general and very severe chorea, and who for ten or twelve years was a confirmed chronic maniac. The other case was that of a young woman, aged twenty-five, who suffered from hysterical mania. In the first case the autopsy revealed very extensive cortical degeneration. I think, as a rule, the form of mental trouble presented by choreics is that of excitement, and the psychical derangement is more common among adults than children. Some writers speak of a marked loss of memory-this I have never found, except when the chorea was a symp- tom of dementia. The urine of the choreic patient is often copious in amount, and in those cases in which there is rheumatismal complication is apt to be loaded with the urates and phos- phates. Sugar is occasionally found. Franque reports the case of a boy who suffered with chorea major, and whose urine contained sugar after each violent attack. In the intervals it was normal. This connection cannot, how- ever, be regarded as a matter of very great importance. Hanfield Jones, who has repeatedly examined the urine of these patients, thus tabulates the result of his urinary ex- amination : " 1. In tolerably severe cases, during the full sway of the disorder, the urine may be of high specific gravity, 1030 to 1040, contains an excess of urea ; after crystallizing copiously with half its volume of nitric acid, deposits sometimes lithates, sometimes phosphates ; its color is full, and on boiling with one-fourth its volume of muriatic acid it darkens extremely. 2. The total amount of urea and of phosphoric acid excreted in twenty-four hours may be greatly in excess. 3. In convalescence the specific gravity falls considerably, the color becomes paler, there is less darkening when the urine is boiled with muriatic acid, and the amount of urea and phos- phoric acid may diminish to less than one-half. 4. The bodily weight increases during the period of convales- cence. 5. It does not appear that the nervo-muscular agitation determines the increased excretion of urea, as the latter may be very marked in the paralytic form of the malady. The relation of chorea to rheumatism and cardiac dis- ease is one of the utmost importance. In 1839, Bright first insisted upon the recognition of the association of chorea with affection of the heart and pericardium, and in 1849 and 1850 Roth and See systematically described the rheumatismal origin of chorea. They, as well as Roger and Axenfeld, hold the following general views: Chorea may develop in the subject of acute articular rheumatism. The jactitations may appear in the course of an arthritic attack, but rarely when the temperature is high. The chorea may take the place of an attack of inflammatory trouble, and in the same subject the two conditions may alternate. In other cases the two diseases may coexist and be due to the same cause. Axenfeld speaks of the appearance of chorea in connection with the decline of the acute inflammatory symptoms. There is a species of antagonism in the vehemence of the maladies, says he, and the choreic movements, if present at all dur- ing the fever, are of the slightest kind, and limited to a few grimaces of the face. The relation of chorea to heart-disease is generally recognized to occur under three conditions, and these are tabulated by Axenfeld as : 1. When the chorea precedes the heart-disease, a simple chorea without antecedent rheumatic trouble, the cardiac affection beginning from three weeks to three or four months after the commence- ment of the chorea. 2. When the cardiac trouble pre- cedes the chorea, e. g., when an attack of pericarditis is followed in from ten days to three weeks by well-estab- lished chorea. 3. The cases in which the chorea and cardiac affection begin simultaneously, or nearly so. There are a variety of conditions which complicate the disease. Some of these are of an asthenic nature, and others are coincident diseases of infancy. Sometimes these intercurrent affections exercise a most remarkable effect upon the disease-cutting short the choreic attack. There may be, perhaps, a febrile attack of some intensity, 139 Chorea. Chorea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. during which the movements are increased until the fever attains the intensity, when a diminution takes place. When the reaction ceases, the movements diminish or disappear. Sometimes such eruptive fevers as variola, when the force of the poison is exerted upon the nerve- centres, produce an augmentation in the force and a continuance of the disease ; in fact, it is changed perhaps from a simple functional affection to one of a chronic nature. Chorea very often makes its appearance in pregnant women, usually during the early months of utero-gesta- tion, and may last for a few weeks after delivery, or may become a chronic affection. I have seen many cases originating during the latter part of pregnancy, and last- ing for many years ; and I am inclined to regard the affection as a very grave one in many instances. In these cases I am of the opinion that some grave embolic lesion takes place, which is formed by the peculiar condition of the blood in certain chlorotic subjects. In fact, I have several times witnessed the most serious accidents-cere- bral venous thrombosis, and the like-which were due to some such blood-state. The chorea of pregnant women is more apt to be bilateral, and the tongue is involved. This fact was first pointed out by Romberg. It is more common among primiparae, and, according to Axenfeld, is quite likely to be associated with hysteriform and epi- leptiform convulsions, which lead to possible abortions. In one of Linck's cases the movements were worse when the patient was lying down. There is a lighter form than that of which I have spoken, which is quite common and begins during the early months of pregnancy, and the prognosis of which is not especially bad. Hysterical chorea is very rare; that is, the form de- scribed by Charcot and Bourneville, in which it is asso- ciated with the hysteric acces, and is manifested by rhythmical movements. I have not seen more than half a dozen of these cases ; but it is by no means uncommon to find chorea developing in hysterical women, the disease, so far as the movements are concerned, differing little, if any, from the familiar disorder of infancy. The subject of true hysterical, rhythmical chorea will for hours repeat, while apparently unconscious, a suc- cession of movements, let us say of flexion and extension, and while sitting in bed she bows low, recovering herself rapidly, and goes through with this for hours at a time. Adult chorea is an affection often associated with mental decay. The form of old age (Choree des Vieil- lards) is especially so, and it is frequently met with in asso- ciation with dementia. I have encountered cases, the duration of the disease being fifteen or twenty years, and in one instance the patient was upward of seventy years of age. The disorderly movements are quite general, in- volving not only the extremities and trunk, but the muscles of the face, so that the subject makes the most horrible grimaces. In such patients there is nearly al- ways a history of cardiac trouble and old rheumatism. Genetous idiots are very apt to present various dis- orders of motility, among which are automatic move- ments and chorea ; in this instance the chorea probably being associated with cerebral hemiatrophy and difference in development between the two sides of the body. Ireland6 speaks of the association of insanity in children with a chorea which is curable. Electric chorea, which was originally described by Dubini, as a disease of en- demic character, and it is manifested in rhythmical move- ments which last for weeks ; by paralysis and atrophy of the muscles involved in the spasms ; by local epileptiform convulsions, general at times ; by headache and coma, delirium, and, finally, by death. Its peculiar character gained for it the names myelitis convulsiva (Hortel) and typhus convulsive cerebralis (Frua). Delirium and head- symptoms usually follow the first four weeks of the dis- ease, and precede the coma (Radcliffe). The duration of the affection is about that of ordinary chorea. Two very unusual forms of the disorder are known as tarantism and tigretier. Both are varieties of chorea major, and are undoubtedly hysterical or imitative in character. The first, which, so far as I can learn, is unknown to-day, was supposed to be due to the bite of the tarantula. The development of the disease was marked by a period of depression and stupidity; and when the sound of musical instruments was heard, the victims leaped into the air and indulged in a wild species of dance, continuing it until powerless from exhaustion. During the epidemic sexual excesses of all kinds were rife. The tigretier, a disease of modern times, resembles very much the tarantism, and, in fact, both of these are in many respects like those forms of religious excitement which bring with them suspension of inhibitory control and great disorder of muscular movement. We are furnished with examples, both in this country and abroad, and the convulsionnaires in France, and the jumpers of Maine may be instanced. Etiology.-Chorea, as a rule, is a disease of early life, and this may be said to be almost, absolute in regard to chorea minor. The more severe affections, i.e., chorea major and hemichorea, both have, as a rule, some basis of cerebral change. The period, then, at which the disease is most common is between the ages of eight and eighteen ; from eight to twelve it is very common. Congenital cases have been reported by Richter and Fox,6 and Simon has met with it in children a few days old. Of 195 cases re- ported by Haven, 2 were said to be congenital, 11 were less than six years old, 92 between six and eleven, 58 be- tween eleven and fifteen, 22 between fifteen and twenty- one, and 10 between twenty-one and sixty.1 Heller8 also presents a case. In adults we find that cases have been reported at all ages, and, as I have said before, even in ad- vanced life. Some cases begin in childhood and continue through life, and others recur every year for several years and then subside. I have found, and I think my experience is borne out by the statistics of others, that the disease is most frequent during the spring or fall. I have repeatedly seen cases that commenced in October and continued until April or May, but, as a rule, under proper treatment the disease is not so protracted. In such cases I find often a history of eczema capitis, and gastric derangements, and it is not uncommon to find the skin disease and the chorea in association. Sometimes the eczema takes the place of the chorea and marks the period of subsidence. So far as local climatic influences are ob- served, it would seem as if it belonged to cold or temper- ate countries. Axenfeld states, upon the authority of Rufz de Lavison, that it is unknown in Martinique, Guadeloupe, and other hot places ; and I find that, while not unknown in our own Southern country, it is of com- paratively infrequent appearance there. It is certain that the negro is exempt from the disease, as Dr. Mitchell has proved from inquiries he has specially made. I have never seen a case in a negro child. It is more common among the German and American children than among the Irish, so far as my statistics go, and the children of the poor are particularly liable. Many authors agree as to the influence of heredity, and cases are on record where the parents of the patient had been affected. Trousseau9 and Hanfield Jones trace out the development in phthisical families, and Day calls attention to the fact that, among the Jews, it is very com- mon and is often associated with epilepsy, or appears in the children of epileptic patients. I find that it is by no means uncommon, in gouty families, to glean the history of chorea not only in several children of the same family, but to find that their father or mother had been similarly affected. As to sex, it is commonly a disease of females, and the ratio is as three to one. This is especially true when the subjects are between the ages of twelve and fifteen, the time of puberty. Of Pye-Smith's 136 cases, 98 were females and 38 males. Of 62 patients affected between the ages of six and ten, 47 were females and the remainder males; while between the ages of six and fifteen of the 106 cases, 74 were fe- males and the others males. In the disease appearing later in life there is a much greater preponderance of fe- male patients, and this is true even of the anatomical form of the disease. We can hardly consider the form known as post-hemi- 140 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cliorea. Cliorea. plegic, for this, after all, is a distinct affection, and the spasmodic movements are by no means pathognomonic. A degeneration of the pyramidal column, from whatever cause, will be quite likely to give rise to choreiform movements. The influence of fevers, and especially those of a zymotic nature, in the development of chorea, is an im- portant one. Scarlet fever and measles, whooping-cough and diphtheria, often leave after them a most intractable chorea, which oftentimes becomes a chronic affection. Barclay, Bernheim, and others speak of typhoid as a cause or complication. Onanism is mentioned as a cause, but I do not attach much importance to this statement, which appears to find favor with the Germans. Overstudy has undoubtedly much to do with its devel- opment. Some years ago I found by a careful system of inquiries, instituted by means of printed tables, that nearly twenty per cent, of the public school children of New York suffered from some choreiform trouble, which varied from simple limited twitchings to well-marked chorea. Dr. J. Crichton Browne, in a recent record of investigation (see " Report upon Overpressure of Work in Public Elementary Schools," London, 1884), while he found much nervous motor trouble, was of the opinion that chorea was not as common as here, but he admits that his paucity of findings may have been due to the fact that children were taken away from school as soon as affected. Saturnine chorea may manifest itself in suddenly de- veloped convulsive movements of the limbs. Tanquerel speaks of it (" Lead Diseases, a Treatise," etc., by L. Tanquerel des Planches, American translation, 1850, p. 288), the "first form of the convulsive variety," as fol- lows : ' ' The face, or one side of it only, one or several limbs, are agitated by rapid convulsions analogous to those produced by electric shocks. Instead of this effect all the parts may be struck with permanent contraction, remaining a longer or shorter time without interruption." It is usually a form of trouble connected with cerebral disease of a grave type, and is the precursor of vascular rupture. The association of chorea with epilepsy is occasional, and when found is an affection of long standing. I have met with it frequently in children, and almost without exception the attacks of epilepsy involved the limbs of one side of the body ; in fact, there was a hemiepilepsy and hemichorea in association. In two cases there were general convulsions, beginning unilaterally in association with hemichorea. Chorea is occasionally of traumatic origin, and is then, as a rule, dependent upon some grave cerebral lesion or meningeal irritation. Chaveau has reported a case de- pendent upon a cicatrix, and Sayre, Hart, and other writ- ers have found the disease in children who have adherent prepuce. Several years ago Drs. F. P. Kinnicutt and Heine- mann pointed out the relation of chorea to certain states of malarial poisoning, and subsequently Kingsley, of St. Louis, observed cases. For many years I have been familiar with examples of the disease in which the complication of malarial rise of temperature was a feature, and in which the movements were greatly modified by this change. Quinine helped or cured these cases, and occurring, as they did, in malarious regions, I was forced to admit their malarial origin. A form of toxic chorea which I have observed in adults, is the direct result of tobacco. It is usually gen- eral, but may be confined to the muscles of the face. I have seen at least ten cases of this disorder in subjects who used tobacco to excess. The movements were found in association with vague hyperaesthesiae, or rather dys- aesthesiae, a "tightness," a "feeling of tension" of the skin of the face and head, with palpitation and gastric disturbances, and subsided under the use of hypophos- phites and the discontinuance of the habit. In one boy, who was addicted to the practice of cigar- ette smoking, I have no doubt the disease was entirely due to this bad habit. In all of these cases the faeces were redolent of nicotine. Intestinal irritation is a most important cause of chorea, whether such irritation be from intestinal worms or un- digested food. The books are full of cases in which the expulsion of lumbricoides was followed by cure. Tardieu reports a case where a sudden cure followed the expulsion of eight lumbricoides. I have frequently met with ex- amples of the disease which were helped instantly after the rectum had been freed from a ball of pin-worms by a free injection of quassia. It rarely happens that the source of intestinal irritation is a taenia solium, but, strange to say, children are sometimes the subjects of chorea from such a cause. Hanfield Jones speaks of a boy, nine years old, who was sleepless for four days and nights, who was in a state of constant motion, whose lips and teeth were covered with sordes, and who presented every appearance of collapse. A dose of oil of male fern brought away a tapeworm seven yards long, and in a few days the patient rapidly convalesced. I have reported elsewhere a case of this kind, and in this as well as others the peculiarity of the chorea is its sudden development and very violent and general character. The influence of imitation and fright as exciting causes are supposed to play a very great part in the genesis of the malady. In the epidemic form of the disorder there are many historical examples. The danger of association of healthy with choreic children I am convinced is very much exag- gerated, and that when chorea is thus produced it is in hysterical subjects. In a child of weak nervous system a sudden fright may undoubtedly cause much mischief. In an admirable paper Russell, of London, sketches the importance of sensational excitement in a case of chorea. Strange considers the influence of two forms of fright {British Med. Journal, July 16, 1881, p. 69), and he be- lieves that in two-thirds of the cases it is the exciting cause. " Fright may operate in various ways, some simple, some more continuous and complicated. It need not be sudden, though that is generally the case. There is a kind of fear or fright to which children are exposed for long periods of time. Ill-tempered parents, espe- cially the mother, may keep a child in perpetual trepida- tion and dread of punishment for unavoidable disasters. Again, the coming home of a drunken father must often be a source of continual terror to a delicate and sensitive girl. Ghost stories and foolish threats of ' Old Bogies,' and the like, so constantly used by ignorant mothers and nurses, need only to be mentioned to be severely repro- bated." The appearance of chorea in children who have been improperly fed is not always regarded with the import- ance it should be. An excessive meat diet is often responsible for this, as well as other neuroses, notably epilepsy and hysteria. In these cases there is very often a history of broken sleep, night terrors, incontinence of urine, and not infrequently somnambulism. The pathology of chorea has been considered by a number of English and continental observers, the former adhering to the theory of cerebral origin of the affection, while the more modern of the latter believe it to be a spinal affection. Todd, Stenhouse and Kirkes, Broadbent, Ogle, Tuckwell, Hughlings Jackson, and Bastian, all favor the theory that it is an embolic disease, and the corpus striatum is its seat. Though Todd was the first to point out this probable origin of the disease, starting from the standpoint of the unilateral spasm and hemiparesis, it was not until 1870, or therabouts, that Kirkes stated that chorea is the result of irritation produced in the nerve- centres by fine molecular particles of fibrine which are set free from an inflamed endocardium, and washed by the blood into the cavities of these centres. Appreciating the important relationship of the middle cerebral artery to cerebral nutrition, the other investigators I have named came to look upon the corpora striata as the region af- fected. Ogle, Tuckwell, and others have found embolie plugging. Aitken believed the optic thalamus to be af- 141 Chorea. Chorion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sively, as well as the ganglia. There was general con- nective-tissue thickening, and proliferation in the motor tracts of the brain and cord. The morbid appearance found by Ellischer, which has been alluded to, included very extensive degeneration of the nerve elements of the corpus striatum, there being hyperplasia of the connective-tissue, proliferation of the nuclei, especially of the lenticular nucleus, the vessels of which were found to have undergone a thickening of the walls. The cord was also involved, the posterior column being the seat of some sclerosis in the gray mat- ter, which was hypersemic ; and there was a decided nuclear proliferation in the gray substance adjacent to the cells, which were more or less diseased, they being pig- mentated and destitute of nuclei. Besides these there was a sclerosis of the peripheral nerve-fibres, and conse- quent destruction to some degree of their nerve filaments. As to Prognosis, we have to consider the question of duration of the immediate attack, its probable recurrence, and the possibility of a fatal termination. I have already called attention to the two first, and I will simply add that chorea minor is usually a simple and curable affec- tion. In adults this is not the case, for when no other cause can be ascertained, it is unhappily true that the affection is too often indicative of some such gross cere- bral disease as tumor or sclerosis, or is a sequence of arterial rupture. I have seen many cases of the simple affection in chlorotic young women, in fact, in women of thirty to forty, which were readily curable, so this rule even has its exceptions. The danger in fatal cases arises from exhaustion, from the debility caused by the constant excessive motion, and by attendant insomnia. In febrile cases the prognosis is decidedly bad if anything like a typhoidal state super- venes. Numerous fatal examples have been reported. Gris- wold 16 relates a case which proved fatal in sixteen days, and Ogle 11 brought forward sixteen other cases. Dr. Haven, of Boston, has made some very interesting investigations, and has analyzed 200 cases of chorea. From his table it would appear, that the average duration of the disease, in 25 such cases as he could follow up, was 94.5 days. In others it was 77 days, when arsenic was used. Drs. Gray and Tuckwell have also gathered statistics in a number of cases when no treatment was given, and the average duration was from 72 to 76 days in different sets of cases. It is not uncommon to find cases which re- cover in six weeks, and sometimes, under the use of fer- ruginous tonics, the period may be much shorter. The tendency to relapses is quite common ; in fact, Haven found that there was 1 relapse in 22 cases, 2 in 4, 3 in 2, 4 in 1, 5 in 1, and 7 in 1, and 14 of these recurred in the first six months of the year. Von Ziemssen refers to the fact that recurrences are most common at puberty. Of 33 cases of chorea, the notes of which I have kept- and the number -would have been much larger were it not for the fact that many were observed at dispensaries, where the attendance is so irregular and floating-I found that in forty per cent, of the cases there were two re- lapses. The residual paralysis is sometimes, though rarely, quite lasting. If a hemichorea exist for a year, it is quite likely to be associated with some loss of muscular sub- stance. In one of West's cases-a girl-it was found, three months after the movements had ceased, that the left arm was half an inch smaller than the right. In an- other case-who had kept her hands clenched for a long time-there was wasting and contraction. The Diagnosis of chorea should be simple enough, if we throw out of consideration those cases of organic ori- gin, the so-called " post-hemiplegic chorea." The move- ments themselves can hardly be confounded with any others. They are coarse, jerky, and irregular, and in no sense rhythmical. The same cannot be said of the move- ments of post-hemiplegic chorea, in which, besides eccen- tric jactitations, there is usually more or less tremor. The movements of chorea may be in simple cases (I may say always in chorea minor) controlled, in part or wholly. fected as well, but it would appear that there were sen- sory alterations in such connection. A variety of experiments have been made by Raymond and other French investigators. Raymond experimentally caused chorea in dogs by wounding the internal capsule and optic thalamus, pro- ducing chorea of the opposite side. Rosenthal10 experimented for the purpose of producing embolic occlusion, by injecting pollen into the left internal carotid of a choreic dog in whom the movements were most active in the right foreleg. The result of the injec- tion was that the dog became powerless to change his position. Despite the abolition of voluntary movements, however, violent choreic convulsions occurred in the an- terior limbs, in the eyes and tail, and continued for two days, until the death of the animal. Autopsy.-Encephalitis of the left anterior lobe, soften- ing of the left corpus striatum, embolism of the left middle cerebral artery, etc. The conclusion arrived at was that the abolition of function of the motor ganglia was followed by increase of choreic movement and irrita- tion of the co-ordination centre. Might it not be inferred that there was an abolition of inhibitory control, and an increased activity of the reflex activity of the cord ? Other investigators-among themChauveauJ'Carvaille, and Bert-operated upon choreic dogs, cutting the cer- vical cord, and determined that the choreic movements were not dependent upon the connection with the cere- brum or cerebellum. A section made lower down in the dorsal region in two other dogs, resulted in diminution of the movements in the tail and legs. They concluded, therefore, that chorea minor was a spinal affection. Le Gros and Onimus12 further experimented, and were also of the opinion that chorea was a disease of the cord. Excitation of the posterior column exaggerated the move- ments, and freezing this part of the cord produced a diminution in their intensity. The movements were not diminished by section of the posterior root-zone, but only by the partial section of the posterior columns and horns. These observers concluded that the seat of the chorea was in the cells of the posterior horns, or in fibres con- necting them with the great motor-cells. Numerous post-mortem examinations have been re- ported, the most important of which are those of Meynert and Ellischer,13 who found, changes in the peripheral nerves as well as cerebral changes. The English authorities have made many autopsies, and their researches have revealed obstruction of the middle cerebral and smaller cerebral arteries, usually on the left side of the brain. Bastian found, in one case of bilateral chorea, embolic plugging by aggregation of white corpuscles, oblitera- tion of small vessels in the corpora striata, serous effusion in the ventricles, etc. Hughes collected fourteen fatal cases, in which the meninges were either congested or pale. There were effusions and subarachnoid and ven- tricular adhesions of the dura to the skull ; in fact there was nothing distinctive about the findings. In eight of these cases the spinal canal was opened, and in these cases the cord was perfectly healthy, as were the membranes. In one there was slight congestion. In the other four there were adhesions of the arachnoid of ancient date. Softening of the posterior columns and gray matter gener- ally. In one case softening at the level of the third or fourth dorsal vertebra. At best these particular results simply show that fatal chorea may be found with cerebro-spinal textural altera- tion of inconstant character. The observations of a few English writers, among them Bastian, are of great value in pointing to the corpora striata as the chief seat of trouble. The continental investigators are much more accurate and have shed great light upon the pathological anatomy of the disease. Meynert,14 especially, and Schultze 15 have both ably investigated fatal cases. The former found degeneration of a large number of cells of the cortical substance, some being swollen and the others shrivelled. Those of the third frontal convolution were involved quite exten- 142 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chorea. Chorion. by the exercise of the will. Embarrassment and diver- sion of attention seem to aggravate the intensity. The age of the subject is also a determining factor. Those forms of degenerate brain or spinal disease, in which hyperkinesis is a symptom, are very rare in chil- dren ; the exception, perhaps, being cerebral hypertrophy and hemi-atrophy, and here we find errors in development and other concomitant symptoms, which render diagnosis quite simple. In paralysis agitans, we have an affection which re- sembles to some extent certain varieties of adult chorea. We find festination, associated movements, no aggrava- tion by attempt at control, and a " fineness" of the spasms which can hardly be called choreic. In the diagnosis of the particular cases much depends upon our ability to determine the probable nature of the chorea itself. Whether it be due to eqcentric irritation, to anaemia; whether it be a sequence of one of the zy- motic diseases, or whether it is a symptomatic affection, the result of some form of tissue change. These things are important when we come to predict the course of the malady. It will readily be seen how much credit may be gained by recognizing the true nature of a chorea depen- dent upon intestinal worms or other irritative causes, and promptly curing the same by expulsion of the irritating agents. Its cardiac association is also most important to recognize. The Treatment of phorea has probably received more attention than that of any other nervous disorder, and the list of remedies, good, bad, and indifferent, is very long. As I have said, there is very little difference between the duration of the malady in those patients for whom the expectant treatment is ordered, or in others who are sub- jected to a rigorous course of medication of the orthodox kind. In the practice of medicine, masterly inactivity is not always the prudential method of procedure, but in chorea minor I would counsel the simplest treatment pos- sible. Of the vast horde of remedies, I think we can dis- card all but three or four, and I will name them in their order of usefulness: 1, Arsenic; 2, Strychnia; 3, Iron; 4, the Fats. There is a second list of remedies which employs those which reach special conditions, and among these I may mention heat and cold, anthelmintics, sedatives, etc. If we do use either of the remedies of the first order, it must be freely and with the idea of getting their full physiological effects; especially true is this of arsenic and strychnia. In children the dose of the former should be rapidly increased until slight subocular oedema is reached, while the good effects of strychnia are only ob- tained when there is complaint of tension of the back leg- muscles. A bulky solution of strychnia is recommended in preference to drops or granules, both in point of safety and efficacy. In combination with the syrup of the iodide of iron, the latter drug is of especial service in the anae- mia of chorea. To this mixture may be added digitalis, especially in many cases in which cardiac asthenia is a feature. The French writers favor the division of chorea into many forms with relation to the etiological factors. When such forms are clearly made out, of course it be- comes our aim to direct special treatment to the individual cases. In those forms with rheumatismal history, the salicylate of soda, the tincture of cimicifugae racemosa, sulphur and vapor baths and alkalies, are of great service ; hysterical cases are most helped by the valerianate of zinc, cypripedin, or cannabis indica. In many cases the removal of an ulcerated wisdom-tooth is sufficient to effect the dis- appearance of a violent chorea, and when intestinal worms exist, we are to turn to turpentine, kousso, or santonin. Should the movements be so violent, as they often are, to necessitate the use of restraint, I know of no better remedies than hyoscyamine or chloral hydrate. Of the benefit of calabar bean in such case, I have little to say. It has never been of the slightest service in several cases in which I have tried it, and I may say the same thing of belladonna. Axenfeld recommends opium in large doses, but he wisely cautions those who administer it to children. Gery and Fuster recommend the repeated use of chloro- form-in inhalation-several times a day. In some cases the remedies cited above may be used hypodermically, but, as a rule, this is an unnecessarily painful mode of treatment. Arsenic has been used in tliis way. Four or five drops of Fowler's solution may be in- jected daily in the affected member ; and by Radcliffe, Eulenburg, and others, it is said to act more quickly than by the stomach. The use of cold is occasionally of great benefit to the choreic patient. The application of the ether spray to the entire spine every day, for ten or fifteen minutes, or the application of cold by means of the ice-bag, is excellent, especially in violent cases. I have of late applied the needle douche, using several gallons of water. It is of the utmost importance that the patient should be kept quiet, and that muscular exercise should be for- bidden. A few hours' seclusion daily, in a dark room, works wonders, and at other times the patient should be made to assume a recumbent position, if possible. There is no nervous disease which is helped so much by proper diet as this. Fats are essential, and a liberal administration of milk and cream as well as fresh butter are highly recommended. Good substantial soups, raw meat, and condensed nitrogenous nourishment, should be provided to the exclusion of everything else which simply satisfies hunger or gratifies the capricious appetite of the patient. Sea-air is of immense service, and sea-baths, if not too wearisome, are to be advised. Still bathing, of course, is to be preferred to the surf. Moral treatment is of great value in many cases. West, whose sensible ideas of treatment I have always adopted, when possible, calls attention to the emotional perversion in choreic children, and speaks as well of the hebetude and weariness of mind, which seem to disappear with the movements. He considers moral therapeutics inap- plicable to those cases of partial chorea which sometimes, though not often, last through life. The treatment should consist in removing mental' strain, abridging study, and instituting a regular life, proper habits, and in building up the child's will-power. The consciousness of the child, in regard to his infirmities, should not always be awakened, except when it is clearly a bad habit and not the result of disease. Allan McLane Hamilton. 1 Hecker's Epidemics of the Middle Ages. 2 A Clinical Treatise on the Diseases of tjie Nervous System, by M. Rosenthal, p. 390. 3 Boston Med. and Surg. Journal, vol. cxii., No. 14. 4 Annales Medico-Psych., 1865. 6 On Idiocy and Imbecility, p. 242. 8 British Medical Journal, vol. ii., 1873, p. 9. 7 Boston Med. and Surg. Journal, 1881, p. 297. 8 Ein fall von angeborner Chorea, Wiener Med. Wochenschrift, 1876, xxvi., 456. 9 On Functional Nervous Disorders, p. 350. 10 Op. cit., p. 388. 11 Archives Generales de Med., March, 1865. 12 Comptes Rendus, tome Ixx., 1870. 13 Archiv fur path. Anat., Ixi., pp. 485-493. Berlin, 1874. 14 Wien Med. Wochenschrift, 1868, xviii., 227, 244; Wien Med. Presse, 1868, ix., 194-196. 15 Deutsches Archiv fiir Klinischer Med., 1877, xx., 383, 396. 16 Cincinnati Journal of Medicine, 1867, ii., 398. 17 British and Eoreign Medico-Chir. Rev., 1868, xii., 208, 465. CHORION. The term chorion has been used to desig- nate various structures, but its application is now gener- ally restricted to one of the embryonic membranes. This article is confined to a description of the chorion of the mammalian ovum, and accordingly the following defini- tion is given ; The chorion is the whole of that portion of the extra-embryonic somatopleure, which is not concerned in the formation of the amnion. In the case of the human ovum, with which we are immediately concerned, the mesoderm appears very early and forms a distinct layer of tissue underneath the ecto- derm and all around the embryonic mass or area, thus constituting the extra-embryonic somatopleure, of which the part about the embryo, Fig. 651, A 7-Am, constitutes the future amnion, and the rest becomes the chorion, Ch. When the amnion has closed over, Fig. 651, B, the chorion forms a complete vesicle around the embryo. The cavity of the chorion communicates with, and mor- phologically is a part of, the embryonic body-cavity or coelom ; or, as it is also called, pleuro-peritoneal space. 143 Chorion. Chorion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fig. 651, B, shows in a rough diagram an ovum of the third week. The chorion forms a closed vesicle and con- sists of two layers, the outer of which bears villi, the inner is smooth and unbroken. The villi in nature are larger and far less numerous than in Fig. 651. Fig. 652 represents an actual ovum of the same age, the chorion having been opened and spread out, to display its inner surface, and the embryonic structures. The chorion has two very distinct layers, the inner of which is a continuous sheet of mesoderm ; but the outer layer has numerous scattered round openings, each lead- after the stage represented in Fig. 652, but they enlarge very rapidly and develop extremely complex ramifica- tions. At first the development is nearly uniform over all parts of the chorion, but, as is well known, the chorion gradually separates during the course of the second and third months into two parts : 1. The chorion frondosum, which lies in the neighborhood of the insertion of the allantois stalk, and is characterized by the permanence and enormous development of the villi in order to form the placenta. (For a fuller account of the structure of the chorion frondosum, see Placenta.) 2. The chorion lave. Fig. 652.-Human Embryo of about eighteen days, after Coste; the chorion has been opened and spread out. Al, stalk of the allantois running from the chorion to posterior end of the embryo : Am, amnion springing from the side of the allantois and enveloping the embryo; VI, the large vitelline (or yolk) sac still having a broad attachment to the embryo. ing into a hollow villus, which is an cvagination of the outer epithelial (ectodermal) layer of the chorion. Soon after this stage, the connective tissue and blood-vessels grow into the villi, which thus acquire vascular cores. Orth10 has shown that the villi always grow in this singu- lar manner, some branches arising as hollow epithelial buds into which the connective tissue penetrates later. The villi first appear as simple cylindrical protuberances, but their ends soon begin to expand and branch so that their bases appear constricted, Fig. 653. It seems to me probable that the number of villi does not increase much, if at all, which comprises all the remainder of the chorion, and gradually loses its villi by atrophy; the villi of this part are at first broad and thick, but during the latter part of the second month they become filamentous, and are slowly reduced in bulk until, by the end of the third month they have nearly disappeared, and thus the originally shaggy surface is rendered nearly smooth {lave). The shape and branching of the villi must be briefly described. The main stem is thick, wavy in its course, and gives off its thick branches more or less nearly at right angles ; it has been stated that the branches of neigh- 144 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chorion. Chorion. boring villi concresce, but I am inclined to doubt this assertion. Fig. 654 shows one of the terminal branches of a villus of the chorion frondosum at about the twelfth week ; the system of branching and the terminal enlarge- ments are particularly worthy of note. The villi are, of uterine glands, nor are they covered by a membrane of maternal tissue. Both of these views are often advanced, but they are both entirely erroneous (cf. Placenta). The arrangement of the blood-vessels of the villi has not yet been well elucidated ; there is a central arterial trunk which gives off branches to a superficial capillary net- work. For further details see Placenta. Let us return now to the chorionic membrane proper, from which the villi spring. By the end of the third week we find three layers differentiated in the human chorion': 1, the external epitheli- um ; 2, a curious cellu- lar layer; 3, an inner- most stratum of loose embryonic connective tissue. The epithelium (Fig. 655, Ep), consists of simple cubical or low cylinder cells with round nuclei ; the cell- limits are distinguish- able only in very early stages, if at all. The cellular layer is com- posed of a peculiar glistening, highly re- frangent matrix with numerous oval nucle- ated spaces scattered through it; in the spec- imen I have examined it also contains blood- vessels, which commu- nicate with those of the villi. The connective- tissue stratumcontains, so far as I have seen, no blood-vessels and is built up entirely of anastomosing connective-tissue cells. The interpretation of these layers, excepting the epithelial, is difficult. It is possible that the two outer layers, b and Ep, represent the true chorion, and that the inner layer, a, is the mesoderm of the allan- tois growing out over the chorion ; but if this is the case, whence are derived the chorionic vessels ? As regards the homologies with later stages, Langhans supposes the in- Fig. 654.-Chorionic Villus from the Pla- centa of the Twelfth Week (after Ecker). a to b, with the ectodermal epithelium ; a to a, with epithelium removed and showing the internal capillaries. Fig. 651, A.-Diagrams to Show the Formation of the Human Amnion. A, first stage ; B, second stage ; Am, amnion ; Al, allantois ; Ch, chorion, the villi of which are drawn smaller and more numerous than in nature; V, yolk-sac. course, covered by the ectoderm, within which is the vas- cular mesoderm. The ectoderm consists of a single layer of cylinder epi- thelial cells, the nuclei all lying in the base, thus leaving an outer stratum free. This outer stratum, after macera- tion in water, dilute acids, etc., peels off, and has been de- scribed by some authors as a distinct membrane. The ectoderm is the active agent in the growth of the villi, and, as we know from the observations of Orth,10 Koll- mann,11 and others, it may form hollow buds, and this at any period during the life of the placenta. Kollmann's ob- servations (loc. cit., p. 297) on the growth of villi of the fourth week are particularly instructive. The outgrowth of the branches is very rapid and occurs with every degree of participation of the con- nective tissue. The two ex- tremes are : 1, a bud consist- ing wholly of epithelium, which may become a process with a long thin pedicle and a thickened free end, remaining entirely without epithelium ; 2, a thick bud with a well- developed core of connective issue ; such a bud probably grows out as a nearly cylin- drical branch. Between these extremes every intermedi- ate state can be found. The various forms of growing branches may lie close together. Only the tips of the villi touch the decidua; the villi do not grow into the Fig. 655.-Section of the Chorion of Three Weeks, a, inner; b, outer layer of chorion; Ep, chorionic epithelium also extending over the villi, Vi and Vi'; the layer, b, contains a number of blood-vessels nearly all in transverse section. Fig. 653.-Part of Chorion of Fig. 652, more highly magnified; after Coste. Mes, mesoderm; Ec, ectoderm; Ki, villi. ner layers to persist and to be identical with the cellular and connective-tissue layers of the older chorion. (The chorion, from which this section was taken, is from an ovum apparently normal, nearly twenty milli- metres in diameter and supposed to be about three weeks old, or less. The sections were cut in celloidine and stained with alum carmine. The inner layer, a, does not appear in sections from all the parts examined. It con- 145 Chorion. Choroid. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sists of a loose network of granular threads with round nuclei scattered irregularly, and is, perhaps, only a co- agulation product. The layer, b, is very well marked and is directly continuous with the stroma of the villi, which, however, differs somewhat from layer b. The blood-vessels of this layer give off branches to the villi, but in the main villus of the figure, Vi', no blood-vessels are to be seen in this particular section. The figure was drawn with the camera from two consecutive sections, but layer a was added from still a third section. The scattered fragments are bits of villous branches irregu- larly cut and kept in place by the celloidine. The epi- thelium is granular and quite thick, and has round nuclei in its basal portion ; I have observed no cell boundaries around the nuclei.) If we make a section through the chorionic membrane of the placenta of the sixth month we find the following appearances (Fig. 656). The amnion at this time is al- ready united with the chorion forming the covering, Am, of the free placental surface ; its epithelium, Ep, is still distinct. The remaining layers are four innumber: 1, Str, the stroma, or Gallertschicht of the Germans, which constitutes more than half the thickness of the chorion, and passes over without definite demarcation into 2, Fib, the fibrillar layer ; 3, C, the cellular layer, which is some- what irregular in thickness, and 4, Fbr, the so-called fibrine layer. This last is interrupted wherever a villus arises. At each inter- ruption the cellular layer, as indicated in the figure, passes out and becomes continu- ous with the stroma of the corresponding vil- lus. In the section fig- ured only the base of the villus is hit. I suspect that the two layers which are found in the chorion at three weeks, correspond, the outer to the fibrillar layer, Fib, and the in- ner to the stroma lay- er, Str, of Fig. 656, and that the cellular layer and the fibrine layer are new for- mations ; but perhaps Langhans' view, stated above, is correct. The decision must be brought by further investigations. The following are the characteristics of the four layers: 1. Stroma.- This layer is called the Gallertschicht by German writers, and Kolliker strangely describes it as not belonging to the chorion, but as coming between the chorion and amnion ; but there is no reason apparent for regarding it otherwise than as part of the chorion. As mentioned above, it is usually interpreted as connective tissue which has grown out from the allantois. The tis- sue consists of a basal substance presenting a fibrillar ap- pearance, and numerous connective-tissue cells. The latter branch and anastomose with one another; and as pregnancy advances they assume in larger numbers, and with greater distinctness, an elongated shape. In this layer we find also many amoeboid cells, which show out very distinctly in Fig. 656, being all more or less pig- mented, probably from having fed on red blood-globules. Jungbluth discovered a network of capillaries, which ex- ist during the first half of pregnancy, but normally atro- phy later, and which, from his description, appear to lie in the superficial part of this layer, i.e., next the amnion. He also states that in hydramniotic placentae these vessels are persistent, and he connects them with the origin of the amniotic fluid, (cf. Amnion). 2. Fibrillar Layer.-This is the stratum sometimes called (e.g., by Kblliker) the connective-tissue layer of the chorion. It consists mainly of numerous very tine wavy fibres, so arranged as to give the whole a lamellar struct- ure, and to leave numerous oval and elongated spaces, in which cells are packed. The cells are branching, with few processes, or spindle-shaped, etc. Langhans states that in earlier stages this layer is readily seen to consist itself of two layers: 1, the inner main layer, and, 2, the outer (i.e., nearer the chorionic epithelium) thinner layer containing fine capillaries. 3. Langhans' Cellular Layer.-This layer has been the subject of continual misconceptions. Kblliker describes it in the chorion laeve as part of the epithelium ; in the chorion frondosum he culls it the decidua subchorialis. Langhans is apparently the only author who has held cor- rect views as to this layer. It consists mainly of rounded and oval cells similar to, but considerably smaller than, the true decidual cells, for which Winkler, Kblliker, and others have mistaken them. In the eighth month this layer does contain true decidual cells, which ap- parently make their way into the chorion at the margin of the placenta. This layer exists on both the laeve and frondosum, but obtains a greater thickness on the latter than on the former. 4. Fibrine Layer.-This layer is so-named from its re- semblance to the cana- lisirtes Fibrin of Ger- man writers, but it is doubtful whether it is fibrinous. It is prob- ably the product of the cellular layer. It consists of a homoge- neous matrix, which stains very darkly with most histological dyes, and which is permeated by a com- plex network of ca- nals ; a few cells ap- parently lie in these canals, for one sees an occasional nucleus in them. This layer in- creases greatly during the second half of pregnancy, and sends out long columns w h i c h grow out alongside the chori- onic villi until they reach the maternal uterine wall (serotina); in short, this layer is an important constitu- ent of the foetal placenta (cf. Placenta). That it is part of the foetal tissues is shown, according to Langhans, by the fact that when it first appears it lies within the chorionic epithelium. At the stage we are considering, Fig. 656, the epithelium has disappeared over the surface of the membrane ; on the villi it is permanent. The chorion forms a vesicle around the embryo and outside the amnion. The manner in which it forms a closed vesicle is described in the article Amnion. At one point the allantois stalk is inserted into its surface, Fig. 652, hence the embryo is suspended from the chorion. It is supposed that the cavity of the allantois, with its en- todermic lining, extends only tv the chorion; but whether the mesoderm of the allantois grows out over the chorion to form the inmost layer thereof is uncertain but prob- able, especially because the vessels of the allantois cer- tainly ramify over the whole of the chorion, even as early as the third week (Coste). These vessels nearly all atrophy before the sixth month, except the main stems in the placental region, which persist, traversing the stroma and supplying branches to the villi. The size of the chorionic vesicle varies greatly : at first it becomes very large, leaving a relatively enormous space Fig. 656.-Section of Amnion and Chorion of Human Placenta of Sixth Month. 17, chori- onic villi; Fbr, fibrine layer of chorion ; C, cellular layer; Str, stroma, or Gallertschicht; Am, amnion ; Ep, amniotic epithelium. (From a section cut in celloidine. and stained with Weigert's heematoxyline, i.e., potass, bichrom. haimatoxyline, and Weigert's iron solution. The drawing is only approximately correct as to details.) 146 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chorion. Choroid. around the embryo, but after the second month this space is rapidly reduced by the growth of the foetus. His gives the following table : Diameter of Chorion < 1.5 ctm. ; Embryo, 2 to 4 mm. " " 1.5 to 3.0 " " 4 to 10 " " " 2.5 to 4.0 " " 10 to 15 " " " 3.5 to 5.0 " " 15 to 20 " " " 4.0 to 6.0 " " 20 to 25 " Literature.-The literature of the chorion is very much scattered, but singularly replete with errors. Nearly all, if not, with the exception of Langhans, all, writers have held some fundamentally erroneous concep- tions ; this is notably the case with Kolliker, and to a far greater degree with Ercolani, of whose views, concerning the chorion and placenta, hardly a single one original with him can stand. For the accuracy of the greater part of Langhans' observations I can myself vouch ; it is not a little singular that the author who has made the most cor- rect investigations should not be cited generally by the text-book makers. The principal authorities are Kolliker in his text-books and the following : 1 Langhans, Theodore : Untersuchungen uber die menschlichen Pla- centa, His. Archiv, 1877, 188-267, Taf. vii.-viii. 2 Langhans, Theodore: Ueber die Zellschicht des menschlichen Chori- ons, Festschrift fur Henle, p. 69-79, 1 Taf. (1882). 8 Robin, Charles : Memoire sur la Structure Intime de la V6sicule Om- bilicale et de 1'Allantoide, Brown-Sequard, Journ. Physiol., 1861, iv., 305. 4 Dohrn : Ein Beitrag zur • mikroskopischen Anatomie der reifen menschlichen Eihullen, Monatschr. Geburtsk.. No. 26, p. 114. 6 Winkler, F. N.: Zur Kenntniss der menschlichen Placenta, Arch. f. Gynak., 1872, iv., 238. 6 Schroder van der Kolk: Waarnemingen over het maaksel van de menscheligke Placenta en over haren Bloedsomloop, Verh. k. Nederl. Inst., 1851, Derde Reeks, Vierde Deel, 69-180. 7 Schultze, S. B. : Das Nabelbliischen ein constantes Gebilde derNach- gebnrt des ausgetragenen Kindes. Leipzig, 1860. B Ecker's leones Physiologicae. [For the older literature, see 8 Owen's Comp. Anat, and Milne-Ed- wards' Physiologie, T. ix.] 18 Orth, J.: Das Wachsthum der Placenta Fcetalis und Boll's Prinzip des Wachsthums. Zeitschr. f. Geburtsk. u. Gyn., ii., 9-23. 11 Kollmann, J.: Die menschlichen Eier von 6 min. Grosse, His. Ar- chiv, 1879, 279-311. Charles Sedgwick Minot. in which there is an abundance of products-for example, suppurative choroiditis and tumefactions. The former do not destroy the form or function of the eye directly, but bring about their deleterious effects by the organization of their products, or the slow trans- mogrification of the character of the tissues affected ; so that, from injury to these tissues, the eye is no longer able to perform its function as a useful organ. Such, for instance, is the result of plastic inflammation of the cho- roid and ciliary body ; since in many cases the conse- quence of a plastic cyclitis is the formation of bands of connective tissue through the vitreous chamber behind the lens, which by continued cicatricial contraction de- tach the ciliary body and result in the more or less com- plete atrophy of the eye. This may not be the case, however, in other forms of plastic inflammation, as in those which involve the pos- terior segments of the choroid. Here the process may be circumscribed, but the tissue affected will certainly suffer and atrophy, although the eye as a whole may retain its shape, and the tissue which has been spared, its function ; as in choroiditis areolaris, or in choroiditis specifica. In that variety of inflammation in which the product is excessive, as in choroiditis suppurativa and sarcomatous growths, the whole visceral contents of the eyeball may be degenerated and the capsule of the eye destroyed ; or, as in the latter case, the disease may even be transmitted to other localities, and the patient lose his life. But the frequency of occurrence, and the locality and character of all these changes, can better be described under the heads of the several diseases than explained in viewing choroiditis as a whole. We, therefore, refer to the following diseases : Hyperemia of the Choroid.-We sometimes find, without being able to determine the cause, that the cho- roidal blood-vessels contain too much blood, and this state may extend to the greater part of the choroidal ex- pansion or may be circumscribed. Both conditions may be the precursors of a disease in the vicinity, as in the first stages of inflammation or sarcoma, as I myself have had occasion to observe ; or they may be the distant effect of some pathological process going on in a tissue quite removed from the eye. This process may be a cellulitis of the orbital contents, or even an inflammation of the brain, or, in the female, of the genito-urinary organs. Such conditions as parametritis and tumors of the uterus, or pustular conditions of the labia, or of the vagina, and acute vaginitis, may, according to Mooren, of Diisseldorf, and other observers, produce hyperaemia and congestion of the retina and choroid, through the plexus panpini- formis venosus, the vertebral veins, and the cerebral si- nuses. This result we should be utterly at a loss to ex- plain did we not know of the pre-existing and inducing disease. The condition of hyperaemia of the choroid is by no means easy of diagnosis with the ophthalmoscope, and in many cases we may fail, no matter what amount of skill we may possess with that instrument. The black pig- ment-epithelium of the retina, which covers the back part of the eye over its whole extent (except the optic papilla), lying between us and the tissue of the choroid, may be so densely pigmented as to close out our view of the tissues behind it entirely. Even the stellate, pig- mented, connective-tissue corpuscles, already referred to, may be so thick and rich in pigment as to throw a veil over the blood-vessels of the choriocapillaris and Henle's layer of larger vessels, and render their recognition im- possible. However, in subjects whose general pigmentation is not excessive-in blondes and in young persons-we may notice that the choroidal blood-vessels are larger and turgid, especially the smaller ones, giving the whole background of the eye a dark-reddish hue, which we can readily recognize by comparing the conditions of the two eyes, provided they are not both congested at the same time. But we must not forget the anastomosis between the branches of the posterior short ciliary arteries and veins around the optic nerve-entrance, and the interstitial blood- CHOROID, INFLAMMATION OF. The choroid is es- sentially a vascular membrane; in fact, its blood-vessels are so numerous that they give the choroidal tissue cer- tain characteristics which are possessed by but few other tissues of the body. We might therefore conclude d priori that its principal inflammatory processes are those de- pendent upon disturbances of the vaso-motor system and the contents of the blood-channels. Such, indeed, is the 'case ; and we find that, by all odds, the diseases most frequently located in the choroid are those in which the blood-vessels play the important role. However, these are not all ; nor is the whole tissue of the choroid made up of blood-vessels. There are various connective-tissue elements and nerves which in themselves may take on an abnormal condition ; and here the influence of the vaso- motor system is entirely secondary. In the former case the inflammatory process is much more rapid and energetic, involving, in the vast majority of cases, the tissue of surrounding parts. Under this head may be mentioned serous, plastic, and parenchym- atous inflammations of the uveal tract, which almost always drag the surrounding tissues into sympathy with them, and force upon us the necessity of using a com- pound term if we wish by our terminology to include all that is truly present, such as retino-choroiditis, sclero- choroiditis, etc. There is, however, another class of disease processes which we find in the choroid. These are slow, certainly not energetic, and, at least in the beginning, are entirely restricted to a circumscribed locality, implicating no other; such are colloid degeneration or colloid excres- cences from the lamina vitrea of the choroid, and retro- grade metamorphoses in the choroidal stroma, tumors, etc. If we consider the character of choroiditis in the con- crete, we also have two different types : one, that in which the products of inflammation are diminutive in quantity, as in serous and plastic choroiditis ; the other, 147 Choroid. Choroid. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vessels of the optic nerve itself. By reason of this anas- tomosis we may find the papilla of the optic nerve con- gested, in cases of hyperaemia of the choroidal blood- vessels ; which condition then becomes a valuable aid to us in diagnosis. We have subjective symptoms which are of assistance. Patients may tell us that they have flashes of light and rolling clouds in their field of vision, even when they have their eyes shut. Again, such sights as falling stars, or bright, dancing, flitting figures, are signs of congestion of the retina and choroid. We do not, however, refer to those peculiar cloud-like objects, with brilliant-colored outlines, which are seen in phlemoscotoma, or amaurosis partialis fugax, since these are more probably the result of congestions in the brain at the origin of the optic nerve-fibres, or in the visual centres, than any local mani- festations in the eye. These latter pass off quickly, and are followed by severe headache; which is not the case with the former. As with all other vascular tissues, when an inflam- matory process is about to take place, the choroid will cer- tainly be hyperaemic and congested prior to any active inflammatory process in it; and the diagnosis of such a state of things is of great importance, since by energetic means we may be able to abort the disease. Unfortu- nately, we are but seldom called upon to inspect such eyes, since in the great majority of cases the patient never comes until there is an inflammation already existing, and the diagnosis is easy to be made. But in certain cases of brain trouble-it may be in tumors of the brain, tubercular basilar meningitis, or cerebral abscess-a hyperaemia or congestion of the retina and choroid may prove of immense value to us. To show the importance of this condition, Professor Zaufal, of Vienna, relates a case of abscess of the mastoid process in which he was apprehensive of a cerebral complication. Since opening of the mastoid cavity is a serious procedure, in that it is followed by tardy healing, he waited, watch- ing the condition of the background of the eye, and was able to tell just when the brain was becoming affected. He then operated, cleared the cavity of pus, and kept it clear. The patient had a slight brain attack, but he re- covered ; and again, by the condition of the background of the eye, the doctor could foretell the progress of the disease, since the congestion of the retina and choroid commenced to subside before the cerebral symptoms be- gan to wane in intensity. Mooren cites many cases in which his attention was di- rected to the genital organs of females by hyperaemia or congestion of the background of the eye ; as also by con- firmed ocular disease which never would have improved had he not discovered the uterine trouble and advised his patient to have the cause removed. When we have made the diagnosis of hyperaemia or congestion of the choroid, antiphlogistic means and atro- pine are in order. The latter seems able to exert an irri- tating influence on the vaso-motor system of vessels, since it contracts their calibre-as we see in a far greater dilatation of the pupil of the eye after its instillation than could possibly be brought about by a complete paralysis of all the nerves in the eye. (Compare treatment of first stages of serous choroid- itis, etc.) Serous Choroiditis (Choroiditis Serosa).-This form of choroiditis is distinguished by the fact that there is a serous exudation from the blood-vessels of the choroid, depending in quantity upon the momentum with which the disease is ushered into existence. We distinguish two forms, depending upon the rapidity of the process and also upon its extent. One of these is of acute origin, and may culminate in all that train of symptoms to which the term glaucoma has been given (described under Glaucoma). In the other form the dis- ease is not so energetic, and is oftentimes so slow that there is hardly any redness of the eyeball, photophobia, or lachrymation. However, since the exudation almost always extends and infiltrates the retina and the vitreus, we have a cloudiness of these members, with a conse- quent great reduction of sight. The process may be re- stricted to a small area of the choroid, in which case it does but little damage, since in this condition it is easily combated, and passes away without leaving any bad re- sults behind. There is one peculiarity about serous troubles in general in the uveal tract, and this is that the exudation has a ten- dency to accumulate into small nodules ; and when seen in the anterior chamber or on the posterior surface of the cornea, from serous iritis, these appear as small round granules, which are highly characteristic. These granules may also accumulate on the posterior surface of the lens, in serous choroiditis, or cyclo-choroiditis. If the disease extends to a great area of the choroid, which, indeed, is generally the case, we find a diffused opacity of the retina and the posterior part, or rather periphery, of the vitreus. The disease may here stop, and the retina and vitreus clear up ; when, with the oph- thalmoscope, we see nothing left in the background of the eye to indicate that so extensive a trouble ever existed. On the other hand, the patient may not be so fortunate, but may have had his disease started with such a momen- tum that the retina and the whole of the vitreus may be- come so clouded and infiltrated with serum and nodules of lymphoid tissue as to destroy the structure of the latter constituent of the eye entirely. The suspensory ligament may be destroyed, and the lens partially dislocated and cataractous. The cataract is very liable to be of the pos- terior polar variety (Graefe), or may be of the cretaceous form. Under these circumstances the results of the dis- ease will be of permanent damage to the eye, since such defects are never repaired. Even in this extensive form, the choroidal and retinal tissue may not have suffered to a very great extent. When we examine the choroid we may only find small areas in which its tissue has been destroyed, and this prob- ably by pressure from accumulations of nodules in its stroma. Serous choroiditis, so long as it is confined to one at- tack, may leave the eye in a good condition ; and does so in the great majority of cases, provided the inflamma- tion remains of a purely serous character. But after a while the disease may return, and often, time and again ; and then we meet a condition which may be of the gravest consequences. As would naturally be supposed (the con- tents of the eye being so much increased by the extra amount of secretion), the tension'of the eye will be made greater. That is, the eyeball may become harder. This is almost always the case in the beginning, but the intra- ocular tension may vary very rapidly from hard to normal and to soft. From the two abnormal states the eye may recover, and proceed to a healthy condition ; or it may become softer and softer and finally shrink, and become completely phthisical, or atrophied to a small hard stump. A condition, however, of total atrophy is rarely met with if the disease retains its serous character throughout; but this may not be the case. All serous inflammations of the eye are comparatively innocent, not even excepting sym- pathetic serous trouble ; but unfortunately they do not always retain this character, and may take on a mixed form of serous and plastic inflammation. In this case there is much more danger to the eye, since in the sero- plastic form we may have the formation of connective- tissue strings and membranes, which are united to the choroid, and which, by later cicatricial contraction, may detach the retina, or the retina and the choroid and ciliary body, and result in total atrophy of the eyeball. If we examine with the microscope a choroid which has suffered a serous attack, we may find but little to lay at the door of the disease. However, the cells of the stroma of the tissue may be puffy, and their protoplasm seem cloudy, or it may have undergone a fatty degeneration. In this last case there may be minute globules of oil scattered around in a more or less fluid protoplasm. The pigment of the cells may be faded so as to present only a light- brown color, or it may be accumulated into peculiar round nodules-as I have sometimes had occasion to ob- serve with the microscope, but do not find it generally referred to in ophthalmological literature. However, I have never seen what I could consider an increase in the 148 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Choroid. Choroid. tion of rosy pinkness, to a deep-red color-almost blood- red (Stellwag.)-from the anastomosing vessels in the lamina cribrosa. There is one peculiarity which must not be overlooked, regarding an optic nerve thus con- gested. The outlines of the disk (optic nerve-entrance) are distinctly defined, which is not the case in inflamma- tion of the nerve. Moreover, the disk lies in its normal plane, or one which is but slightly elevated above the general level of the retina. If there be increased press- ure, we may notice a spontaneous pulsation of the retinal veins; or this may be brought about by even a slight pressure on the globe of the eye. If the disease has progressed to a stage of exudation (serous), this will infiltrate the choroidal tissue, which will appear cloudy. If it has affected the retina and vitreus, we may have the whole background of the eye clouded. In fact, we shall see little of the background of the eye, for the same reason that the patient experiences a reduction of vision, viz., mechanical obstruction to light returning from or entering the deeper parts of the eye. When the disease has subsided, we sometimes find nothing abnormal; since in slight cases there are no path- ological changes in the eye. In some instances, however, we may find in the choroid whitish spots or areas of vari- ous shapes and sizes, from atrophy of the choroidal tis- sue ; when, with the instrument, the white sclera will be seen shining through the transparent atrophic regions. This is not nearly so often the case as in the plastic varieties of choroiditis; as we shall see under that head more particularly. Prognosis.-The prognosis of all cases of serous choroi- ditis, in which the tension of the globe does not increase to such a degree as to bring about a glaucomatous condi- tion, is good. If the disease is protracted or recurrent, the prognosis is worse the longer it lasts, and also becomes graver with each return of the condition ; for under such circum- stances the tension is almost sure to be diminished more and more, and the eye go slowly into more or less com- plete atrophy. In those cases in which the disease is induced by some vehement influence, such as injuries to the eye, the cho- roiditis may develop rapidly to high degree and as rapidly subside. Where the choroiditis is secondary to some other cause-as disease of other organs, or secondary syphilis, etc.-it is usually of a subacute form, and may either last as long as the inducing cause exists, or may be cured by proper treatment. In those forms in which the condition is the result of some disturbance in the blood-vessels themselves, either in the choroid or in the region of the ophthalmic artery, the choroiditis may have a course similar to that of glau- coma, and, as a rule, develops into that disease (Stellwag). Treatment.-As the very first step in the treatment of all serious disease of the eye, we should insist upon the patient's refraining from anything which places an extra strain on the eye, such as reading, writing, sewing, etc. Even in the mildest forms, this must be insisted on, and the patient be required to remain at home ; since any influence of cold, dust, wind, etc., will certainly be of the greatest moment to him. Alcoholic stimulants are to be carefully avoided, from the influence which they have on the action of the heart and the condition of the intra- ocular blood-vessels. If the first stages of the disease are energetic, the pa- tient must be put in bed, and as much light shut out of the room as possible. Perfect darkness is the ideal in this respect. There is no combination of therapeutic agents which will be found able to replace these two ; and, indeed, we might almost say that perfect rest and perfect darkness, without any other medication, will cure the vast majority of such cases. Hypodermic injections of pilocarpine, in small doses oft repeated, are highly recommended in the earlier stages of choroiditis, or fluid extract of jaborandi by the sto- mach, if the alkaloid is not convenient. I have, while experimenting on various classes of animals, found pilo- carpine (Archie d. Physiol. Institute zu Heidelberg, 1879) number of the processes of the stellate pigmented con- nective-tissue corpuscles, as described by Arlt, of Vienna. There is an increase in the number of round cells and nuclei of the stroma. These may be gathered together into groups, and may be unpigmented or filled with a dark coloring matter. If the process has been long con- tinued or oft repeated, we may find chalky deposits in the walls of the blood-vessels, and other atheromatous changes. In this condition we find the round cells ar- ranged more along the sides of the vessels than dissem- inated through the stroma of the choroid. The vessels of the choriocapillaris are dilated and often tortuous in their course (Arlt), the spaces between them being filled with free nuclei, or fat granules ; the lamina elastica is often much thickened and may have numerous colloid ex- crescences ; but of the nature of these we will speak later. If the disease has run a course which we define as sero- plastic, we shall have evidences of it in circumscribed destructiohs of the tissue of the choroid. These also will be found more fully described under the head of plastic choroiditis. When the eye has become atrophied from serous choroiditis, a section will reveal the vitreus, retina and choroid occupying, it may be, a mere string running from the entrance of the optic nerve-to which it is at- tached-up to the posterior surface of the lens, passing around it and being again attached to the sclero-corneal margin by the ligamentum pectinatum of the ciliary body; the space between the choroid and the shrunken sclera may be filled with a serous or gelatinous mass, but this may also be the case with phthisis bulbi, from other causes than serous choroiditis. Symptoms of Serous Choroiditis.-Of course, in the be- ginning of the disease we may have all the evidences of hyperaemia and congestion of the choroid. Aside from these, after the disease has been established, if we re- member the character of the trouble, we may expect Hyperamia of the episcleral vessels, producing a deep- seated rosy tint around the cornea, as we have in all active inflammatory processes in the interior of the eye. This is accounted for by the anastomosis which exists between the branches of the anterior ciliary arteries and veins, and the episcleral vessels, before the former penetrate the globe and take part in the formation of the circulus arte- riosus iridis major. Increase in tension of the eyeball; since the intraocular contents are much augmented by the serous exudation and transudation of white blood-corpuscles from the walls of the blood-vessels. This is usual; we may, however, find a marked softening of the globe, especially in those cases which are to result in atrophy of the eyeball. Diminution of the depth of the anterior chamber; since in those cases in which the tension is increased by the secretion, the augmentation of the intraocular contents is chiefly from a source behind the lens ; which is therefore pushed forward toward the cornea ; and hence the depth of the anterior chamber is lessened. Moderately dilated and fixed condition of the pupil; since the pressure has rendered the sphincter of the pupil powerless to contract, or has even ro,bbed it of its tonic- ity. The pupil is, however, not so widely dilated as in paralysis of the third nerve ; since the iris is always more or less congested, and the gorged condition of its blood- vessels pushes the pupillary margin of the iris tissue closer to the centre of the eye than the locality in which it is found in paralysis of the oculo-motor nerve alone. Dimness of vision; caused by the infiltration of the retina, as well as the increased pressure upon it, and by cloudiness of the corpus vitreum, which furnishes a mechanical obstruction to the free passage of light to the retina. The ophthalmoscope shows but little in this form of choroiditis, for several reasons. In the earlier stages, as that of congestion, we have already seen that an ophthalmo- scopic diagnosis is a matter of great difficulty, except in blonde eyes. In these, however, we see that the choroidal vessels are enlarged and tortuous. yiie whole back- ground of the eye is of a deeper red color, and the deeper layers of the optic nerve-entrance are also congested, and may present anything from a simple hyperaemic condi- 149 Choroid. Choroid. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and muscarine to cause a profound effect upon the choroidal capillaries and the outer layers of the retina. Cold applications to the eye and forehead are also rec- ommended (Stellwag et al.). Leeches (natural or artificial) to the temple are fre- quently of the greatest value, as also are most reagents for controlling pain. Atropine is of service, unless the tendency is toward glaucoma ; and then it is to be religiously avoided, as a single drop, of even a wreak solution, may bring on an acute glaucomatous attack, and possibly result in destruc- tion of the sight of the eye. Eserine is to be used in all cases of increased tension of the globe ; but if this is of no avail in reducing the ten- sion, then we must consider the advisability of puncture of the anterior chamber, or even of iridectomy. Plastic Choroiditis {Choroiditis Plastica sire Ex- udativa).-Pathology.-The earliest stages of plastic cho- roiditis, such as those of hyperaemia and congestion of the choroid, present the same conditions as in all other forms of active inflammation of this ocular tunic. We are, therefore, unable to diagnosticate its plastic character until it has progressed somewhat; or, in other words, until it has taken on its plastic peculiarities. The condi- tion of hyperaemia and congestion of the choroid, retina, and optic papilla, will be the same that we have already described when speaking of serous choroiditis, and need not be repeated here. The first symptom which gives us an idea of its real plastic nature is the appearance of numerous small, rounded, grayish, or reddish spots over the background of the eye, seen during examination with the ophthalmo- scope. They may be scattered over its whole posterior expanse, may be circumscribed or situated exclusively at the posterior part of the globe, or may be anterior or located near the periphery of the ocular fundus. They may vary in size from a millet-seed to a spot whose di- ameter is several times larger than that of the optic disk (the size of the latter being always used in measuring dis- tances or specifying dimensions when seen in the eye with the ophthalmoscope). The form of these spots has an almost infinite variety, often each one differing from the rest. They most fre- quently appear first in the region of the yellow spot, and then increase toward the optic disk and the periphery of the ophthalmoscopic field of view. They are not very numerous in the majority of cases, although they may be very large. They may, however, reach such a multi- plicity as to cover the whole background of the eye. Their color varies also, but this is rather the result of their position and their age than of any peculiarity of their own. We may find them red or grayish-red in the beginning, or even reddish-white. When they are situated in the deeper parts of the tissue of the choroid, they may have a bluish or brownish-gray color (Stellwag), or even greenish-gray. In their area we may find lumps of dark- colored pigment of various shapes, or this pigment may be collected around the edges of the spots so as to give to them a dark contour. They are often well defined, and again may be gradually fading away into the surround- ing tissue of the choroid ; all of which will depend upon accidental circumstarices, as we shall see later on. At a subsequent stage these plaques become more transparent by absorption of their contents. When they appear white it is from the fact that they then represent atrophic spots in the choroidal tissue, the white sclerotic being laid bare and shining through them. Clinically we distinguish the following forms of plastic choroiditis, viz., choroiditis disseminata simplex, choroiditis areolaris, chorio-retinitis ad maculam luteam, and chorio- retinitis syphilitica or specifica. All of these so-called distinct forms of the disease differ from each other merely by the locality or distribution of the exudation foci, or spots, as we have called them ; with the exception of the variety depending upon lues. This form is accompanied by a peculiar dust-like opacity in the deeper parts of the vitreus, and this opacity also seems, from the peculiar motion which the dusty veil has on sudden movements of the eye, to be suspended in a more or less fluid vitreus. For instance, if the eye has been at rest for some time, the veil is stationary ; but if the optical axis is suddenly changed by looking in an- other direction, the veil does not go through a concomi- tant motion, but lags behind, and slowly follows until it has reached the line of fixation, and then passes it, and seems to bank itself up on the other side. This is, how- ever, not absolutely pathognomonic of syphilitic contami- nation, since there are other diseases of the fundus which produce a similar effect. At the same time, when we find it in connection with plastic choroiditis, we may at once commence our mercurial treatment in earnest; and it is not even necessary to ask the patient about his antecedent misfortunes. We proceed just as we do when we see a gumma of the iris. The plaques, in specific forms, are also apt to be sur- rounded by a pinkish or red contour. Although it mat- ters but little how we classify our cases of plastic choroi- ditis, since we treat them all in the same way, nevertheless it would be as well to observe that there are two varieties of extensive inflammation which modern ophthalmolo- gists distinguish. The first they call choroiditis dissemi- nata simplex. In it the background of the eye is usually densely studded with small plaques of exudation, situ- ated close together. In the great majority of instances these spots do not show any tendency to coalesce, being separated by intervening portions of apparently normal choroid. In other cases these spots may be so densely packed with the products of exudation as to destroy the intervening walls of normal tissue, and we have larger areas scattered here and there, even when the original spots were small. This, of course, depends upon the in- ertia of the disease, and should be described more as one of the results of plastic choroiditis in general, than as possessing any peculiarity in itself, save that of locality and distribution. The other form of extensive plastic inflammation is that in which the disease has been started in larger foci, or smaller ones have coalesced, leaving the choroid spot- ted with larger plaques. This we distinguish as choroi- ditis plastica areolaris. As to its etiology, the remarks made in regard to choroiditis disseminata simplex hold good. There is, however, another form of plastic choroiditis, known as choroiditis plastica centralis, or, as it is often called, choroiditis ad maculam luteam, which deserves spe- cial mention. Although it hardly differs in its path- ological characteristics from the foregoing, it neverthe- less always occurs as a single plaque, or two or three adjoining plaques, just behind the region of the yellow spot. It is a very disagreeable form, since it too often implicates the retina, and since the fovea centralis and the macula lutea are liable to destruction, because the focus of disease behind exerts decided pressure on the retina. If such is to be the case, we have, first, a swell- ing of the diseased spot, and a consequent elevation and stretching of the retinal tissue, when the patifint will say that he sees objects much smaller than they ought to be. This state of vision we term micropsia. It is to be easily explained from the .fact that the image formed on the central part of the 'fundus of the eye, although it is of its usual size, covers fewer of the recipient elements of the macula lutea and fovea centralis ; since they have been separated further from each other by the stretching of the retinal tissue. The sizes of objects are determined by a combined re- sult in the eye : first, by the amount of nervous impulse which must be given to the internal recti muscles in order to fix, at the same time, the two optical axes on the ob- jects ; and also by the number of rods and cones of the retina covered by the image formed in this condition. If the patient has used his customary amount of convergence of the eyes, and determined what the apparent distance is of the object from the retina, he will of course judge of the size of the object by the size of what his retinal image seems to him to be. If the rods and cones are separated further apart than they should be, he will be deceived in the size of the image, and the object will appear smaller than it really is, since it covers fewer nerve-elements than it should. 150 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Choroid. Choroid. When the plaque has run its inflammatory course, it may be that the integrity of the tissue of the choroid has not suffered much, and the result may be a restoration to the normal. In this case the retina will also resume its normal condition, provided the pressure from behind has not dealt too severely with it. If, however, the plaque has had an original inertia great enough to destroy the choroidal tissue and implicate the retina, the whole area will pass into a gradual atrophy, and the subsequent cicatricial contraction of the new-formed connective- tissue will pull the rods and cones closer together than they should be ; then the image formed on the retina will cover too many nerve-elements, and the object will ap- pear much larger than it really is, which condition has received the name of megalopria. Again, we may have the retinal tissue taking active part in the disease process of the choroid to such an ex- tent that its nervous character will be destroyed, the nerve-elements being replaced by connective-tissue. In this condition there will be a blind spot in the retina, cor- responding in extent to the area of the destroyed tissue. This we call central scotoma. We have two distinct varieties of plastic choroiditis: one in which the disease is more energetic in the stroma of the. choroid-as we have just seen in the various plaques of inflammatory products in it-and a second variety, in which the process seems to be restricted to the lamina elastica of the choroid. Besides the senile excrescences from the hyaloidea, which we will later describe, we also occasionally meet a thickening of this layer of the eye, and isolated spots of hypertrophy amounting to nodules, accompanied by dis- tinct signs of irritation. These excrescences are usually small, but they may attain such dimensions as to detach the retina-or at least raise it from its normal plane-in- ducing changes in its structure, either by active inflam- mation in it, or by causing atrophy from pressure in a vicinity immediately surrounding them. It may commence in a wave-like thickening of the elastic layer, with a consequent detachment of the retina ; but this abnormity is usually situated so far toward the periphery of the choroid that a diagnosis with the oph- thalmoscope is extremely difficult. When, however, the waves are enlarged into true excrescences, they present a very peculiar ophthalmoscopic picture, which when once seen will never be mistaken (see Colloid Excrescences from the Choroid). They may only implicate the outer layers of the retina, or may extend a deleterious influence to the whole thickness of that member; in which case they appear over the whole background of the eye in the shape of small pigmented spots, irregularly arranged, but being fewest near the macula lutea of the retina, and in- creasing in number as we pass toward the periphery of the field of view-the equator of the globe. Fortunately they do not produce any marked defect of vision, even when they occur in the back part of the eye, unless they happen to face immediately behind the ma- cula lutea or the fovea centralis of the retina. All the clinical forms of plastic choroiditis show the same appearance of the plaques under the microscope. In the fresher nodules we find a circumscribed accumu- lation of round cells resembling white blood-corpuscles. They are more or less densely packed together into foci, and lie in an amorphous mass of exudation which is traversed by delicate fibrillae of connective-tissue. The larger foci are usually arranged along the larger retinal blood-vessels, from which their contents show every sign of having exuded. The smaller ones accompany the smaller vessels, and even the chorio-capillaris. In the earlier stages the retina will be seen to be intact, all of its layers presenting a more or less normal appear- ance, with the exception that they are somewhat raised over the collections of small round cells in the choroid. Over the larger foci we may find a slight infiltration of the retinal tissue, with no great disturbance of the rela- tion of its elements. The pigmented connective-tissue cells of the choroid are usually pushed aside so that they are arranged around the sides of the foci, when these will appear, both with the ophthalmoscope and with the microscope, to be sur- rounded by a zone of black choroidal pigment. However, we may lind the pigment-cells of the choroidal stroma caught in a focal deposit, and destroyed, so that their pigment will be scattered throughout the focus-account- ing, in a manner, for its color. As the disease progresses or the foci become older, the stage of cell-proliferation is followed by a more or less complete atrophy of the diseased portions of the cho- roid, when the normal tissue will be replaced by cicatri- cial tissue. In the most advanced stages, the choroidal tissue will have completely disappeared, and only con- nective-tissue (cicatricial) will remain. Under such cir- cumstances the spots will appear white with the ophthal- moscope. When all of these changes have occurred in the cho- roidal foci, the retina will have undergone a similar cycle of changes, in that, from being only slightly infiltrated in the earliest stage, it has undergone active inflammation with proliferation of cells, etc., with resulting transforma- tion of its tissue into connective-tissue more or less con- tinuous with the similar tissue of the atrophic foci of the choroid. Here we find the retinal elements pulled toward the foci by cicatricial traction on their radiating connec- tive-tissue fibres. It may be that only the layer of rods and cones of the retina has been destroyed along with the black pigment epi- thelium. In this condition we often find that the granu- lar, retinal, and flocculent choroidal pigment cells have migrated along the radiating fibres of Muller (of the retina) and the perivascular tissue and spaces, so that the retina becomes pigmented somewhat in the same manner as in retinitis pigmentosa ; but we must not confound this pigmentation with that of the latter disease. They are totally different as to cause, effect, and prognosis. There are no characteristic signs visible with the mi- croscope, in the plastic choroiditis which presents itself in the later stages of syphilis, which would induce one to attribute them to the pernicious effects of the disease. None of the much-ventilated bacilli of syphilis have, as yet, been found in the choroid. This form of choroiditis usually yields readily to appropriate treatment of the con- stitutional lues ; but it may leave its traces in the choroid in the shape of plaques and atrophic spots, identical with those of the other varieties of plastic choroiditis which we have just described. However, the peculiar dust-like opacity of the vitreus is usually present. It is freely movable in the earlier stages, but later it is not so much so, and presents itself as thick flakes with filiform processes. The opacity of the retina always shows a grayish hue, and follows the retinal blood-vessels a distance equal to about three or four diameters of the optic papilla. After the disease has passed away, the optic-nerve entrance generally assumes its normal contour, but has a dirty yellow color ; or there may remain a hazy opacity, resembling a halo, around the optic disk. In the severer cases, when the optic nerve and retina have badly suffered, the optic nerve may show a high degree of atrophy, and appear yellowish and sunken, while the blood-vessels which enter the eye within its area are but indistinctly to be seen, or may have disappeared entirely. Symptoms.-As a subjective Symptom, the patient may complain of fixed clouds or defects in his field of vision (scotomata), if he has noticed them ; but he may have them for months before being aware of their existence. They are highly characteristic, and correspond, in point of time, with the exudative foci or aggregations of cells, etc., in the choroid; these foci being plainly visible with the ophthalmoscope, and the individual cells with the micro- scope. He may describe them in a variety of ways, such as thin or thick, white or gray, or dark clouds appearing smoky. Sometimes they may seem brown or even green, as I have recently observed in one of my own cases. They may seem to have various shapes, and even resemble rings in the air ; but they remain in the same place, and in this respect are not analogous to figures produced by particles floating in the vitreus or muscae volitantes. In the case of the thinner clouds, which will correspond 151 Choroid. Choroid. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with plaques in the back part of the eye where the infil- tration has not destroyed the retina, the patient will see objects through the cloud or smoke but indistinctly. Be- hind the thicker or dark clouds, he will not distinguish objects, since in this case the retina has already become too much affected. They may be in different localities of the field of vision, but if a focus exists just behind the fovea centralis, central vision will be suspended, and the patient will not be able to read or see small objects; whereas his eccentric vision may continue good. In extensive exudations it may so happen that the fovea centralis remains intact, when the patient wrill see small objects and be able to read, although his eccentric vision may be defective. There is usually no peripheric limitation of the field of vision (Stellwag), although we may have this too, and es- pecially if the optic nerve has shown any signs of atrophy. Etiology.-Choroiditis plastica is essentially a retino- choroiditis to which an exudation of a plastic character is superadded. The latter may even be secondary and supervening upon a serous choroiditis or a retinitis. Its causes may be straining of the eye with light of too great intensity ; secondary syphilis ; injuries and operations, including sympathetic transpositions from the other eye ; or the transposition backward of an inflammatory pro- cess which had its original seat in the iris. It is believed to occur more frequently in women than in men. There are several peculiarities in the course which the disease follows. It is often ushered in with all the symp- toms of an active inflammation-redness of the eyeball, photophobia, and lachrymation, with severe pain in the eye and around the orbit. It may develop into an intense inflammation in a short time, and these energetic symp- toms may quickly subside as far as the appearance of the eye is concerned ; but the process inside may increase gradually, lasting for a very long time. This is generally the case where the eye has been subjected to some severe injury. Again, the process may cease entirely and leave only its results in the eye, in the form of atrophic plaques in the choroid, etc. In the majority of cases the disease commences very gradually, and may be without any inflammatory symp- toms whatever, and progress to a high degree without the patient knowing that he has an eye-trouble, unless he happens to shut one eye. This may be the case for months and months, when the patient will for the first time con- sult a physician, who finds numerous extensive atrophic patches in the choroid, especially if but one eye is dis- eased. It sometimes happens that when the process has once ceased it commences again. The old foci will become larger and new ones be added until the blood-supply of the eye through the choroid will be so much damaged by atrophy of the choroid that the eyeball as a whole will go into a slow atrophy. Prognosis.-As far as the ultimate results are con- cerned, there is no hope that the exudation plaques will ever disappear, or that the choroid will ever be restored to its normal condition. The same is true of the retina when it has once been brought into a condition of atrophy of any of its parts. If the process stops in the earlier stages, when there is .only an infiltration forming the plaques, this may be absorbed and a moderately intact choroid and retina result. This is, however, rarely the case, and the spots left will remain and produce various disagreeable reflections, blurring the sight of the eye to a greater or less extent. In many cases the disease only af- fects the outer layers of the retina, and destroys them, leaving the inner ones intact-a condition which is de- voutly to be wished for, since then the optic nerve-fibres which pass over the plaques will retain their integrity; and if they pass on to supply some part of the retina which has not been destroyed, they will convey impres- sions from this part to the brain and render such parts of the retina useful. If the disease occurs in young per- sons, it may have a great influence on the development of the eye by destroying the blood channels of both retina and choroid. Such conditions are unfortunate, since their effect will be greater than it would be were the eye already at its complete stage of development. The prog- nosis is never so bad in uncomplicated conditions of plastic choroiditis, as far as total blindness is concerned, as it is when there are extensive superadditions of reti- nitis, cyclitis, and iritis, or when the disease is mixed with acute serous choroiditis. In the latter unfortunate combinations the eyeball frequently goes into complete atrophy, and, of course, the sight is gone forever. Therefore, in stating our prognosis to the patient it is well to be extremely guarded, since, independently of the immediate results of one attack of plastic disease, the eye is always more liable to a second or a third attack, aiid each one is far worse than its predecessor. However, the disease may come to a complete standstill and the eye remain in that condition, or it may clear up very considerably even after we see the unmistakable evidences of localized atrophy of the retina and choroid. We must closely watch the condition of the optic nerve, since, when once an atrophy of its tissue has com- menced, it is liable to progress slowdy until the eye is totally blind. However, after we have watched the background of the eye for some time and seen that no new nodules are formed, and that those already there do not increase in size, we may tell the patient that there is no reason to be- lieve that his eye will get any worse unless a new attack takes place. Indeed, his sight may become much better and he may feel much more comfortable. The first re- lief will be in consequence of the fact that the tissues of the eye will clear up by absorption ; and the second, be- cause he will get more accustomed to his condition, and learn to pay no attention to his disagreeable symptoms. The prognosis is always best where the condition is the result of secondary syphilis. Treatment.-In the treatment of plastic choroiditis we should be careful to watch the symptoms of each stage, and attend to the eye accordingly. If the disease should be mixed with serous choroiditis and the tension of the eye be increased to too great an extent, or if it be com- bined with iritis where there are multitudinous synechiae, or a circular attachment of the posterior surface of the iris to the lens, an iridectomy will be necessary. Whether the disease be specific or not in its origin, we must rely principally upon a thorough mercurial course of treatment, with the free use of unguentum hydrargyri upon the forehead and temple. Small doses of calomel oft repeated, or hypodermic injections of corrosive sub- limate, are to be recommended, but not so highly as the mercurial ointment. If there are active symptoms of inflammation about the eye, we may use atropine, leeches to the temple, and should put the patient in bed in a dark room. Hypoder- mic injections of pilocarpine, and the administration of the fluid extract of jaborandi by the stomach, are useful. If we are certain that the condition of the patient is the result of syphilis, we have no time to lose, but must bring him to the verge of salivation as quickly as possible- taking care to use the tooth-brush effectively and chlorate of potash as a mouth-wash. We should be careful to instruct the patient not to use the sight: to give up all reading, writing, sewing, or, after he has had one attack of the disease, following an occupation in which the eyes are strained in the least. It is well for him to use a pair of dark smoked glasses. Do not give him green or blue glasses, as is so often done, for of all the varieties of light which affect the eye most energetically, those composed of the actinic rays of the spectrum are the very worst. Green and blue, next to violet, are the most actinic of all. If leeches are put on the temple, by all means let the patient remain in bed all the next day, and if he be really too weak to tolerate the natural (which is very seldom the case), let the artificial leech be substituted. These therapeutical agents do no good in cases devoid of inflammation, in which there remains simply the result of previous disease in the choroid. However, here we may employ iodide of potassium, and instruct the patient to use his eyes with the utmost care. Bookkeepers and the like would do well to give up their occupation, although 152 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Choroid. Choroid. they may say that their central vision is as acute as ever -which will be the case when the region of the macula lutea has not been affected. If there should be a second attack we must proceed in the same way as before, but with additional care ; and it is under these circumstances almost imperative that we should put the patient in bed and make the room perfectly dark. If the latter precaution is not practicable, exclude as much light as possible, and bandage up both eyes even though the disease exists in only one of them. Suppurative Choroiditis {Choroiditis suppurativa sive purulentd).-The characteristics of this form of cho- roiditis are great cedematous and chemotic swelling of the lid and conjunctiva, a purulent clouding of the media of the eye, and rapid diminution of sight : and when the ocular capsule remains intact, a greater or less increase in the tension of the eyeball. It is not often possible to diagnosticate the suppurative character of the choroiditis in this form with the oph- thalmoscope, since, the condition of the eye being one of purulent infiltration and clouding of the vitreus, a sight of the ocular fundus is impossible. Nevertheless, when the other symptoms, as given above, are present, we may be able to make the diagnosis with certainty-especially if we have learned what are the causal conditions. All the other symptoms may vary in intensity ; but the rapid loss of sight, with the intense inflammatory condi- tion of the eye, will point.tothis diagnosis and to no other. There may also be intense constitutional disturbances in connection with this form ; high fever and excessive pain in various parts. The lids will be greatly swollen and red ; also very sensitive to the touch, as we find them in diphtheritic affections of the conjunctiva. The cornea may be cloudy, and even the anterior cham- ber, iris, and lens, infiltrated with pus, as also the sclera. If the sclera or cornea has been broken, the exudation is purulent. Pain will generally be referred to the nervus frontalis, and may be very intense. In milder cases, although the loss of sight is just as rapid, all the other symptoms are not nearly so intense, so that the conjunctiva and lids may be only slightly in- jected, and there may be no pain in or around the eye. Between the above extremes all conditions of intensity may present themselves. The causes of this type of choroiditis are more easily traceable than those of any other form, except the specific variety. They are, for the most part, intense and extensive traumata-wounds of all descriptions, chemical irritants, or foreign bodies within the eye; we may also add cys- ticercus. Then, again, operations of all kinds on the eye- ball may induce suppurative choroiditis, and this is espe- cially true in extraction of cataract, when the lens has been dislocated into the vitreous chamber, or a large amount of vitreus has escaped from the eye. Great and sudden changes of intra-ocular tension, where there is an abnormal condition of the blood-vessels, as in retinitis haemorrhagica, or glaucoma of the same type, may produce extensive haemorrhage in the back part of the eye, leading to suppurative choroiditis. It may also be that particles of the lens cortical sub- stance remain in contact with the iris after cataract ex- traction, and produce it ; but in this form the choroiditis will be a continuation backward from a previous sup- purative iritis. In fact, we may have this variety of choroidal disease resulting, as a secondary affection, from almost any in- flammatory process of the various other parts of the eye, or following operations which in themselves seem com- paratively harmless. Sarcoma of the choroid first, and all other forms of tu- mors which are met with in the eye, may produce it. By far the most interesting variety of choroiditis sup- purativa we have in those cases which are the result of metastasis, or are a local demonstration within the eye- ball of a disease which may be far removed from the organ of vision. This may be the case after suppurating wounds (Stell- wag), puerperal processes, measles, scarlet fever, typhus fever, cerebro-spinal meningitis, etc.; or in any condition in which pus is found in any quantity within the blood- vessels ; or it may result from thrombosis or embolism of the choroidal blood-vessels. It also sometimes appears in tubercular processes, both local in the eye, and from tubercular meningitis or general tuberculosis ; but in these it is more probably a late complication, and the result of a degeneration of the tubercular masses. Course.-The course of this form of choroiditis is al- most always very acute, but occasionally we meet cases which are weeks in reaching their point of culmination ; the duration, however, will depend upon the cause from which it springs. If it is the result of extensive trauma, or of chemical reagents, it is very rapid in its course, often destroying the eye in a few hours ; when it may then pass slowly to its termination-blindness ! If, however, we are to have this condition of the cho- roid following an extraction of cataract, it may not be so intense at first; in fact, we may be surprised, on opening the lids some time after the delivery of the lens, to find that the eye is lost from a suppurative condition of the uveal tract, which has previously given but slight indica- tion of its presence, the lids being but slightly swollen and there having been no pain in the eye, because-ow- ing to the open condition of the corneal incision-the tension could not become increased. The variety which occasionally follows perforations of corneal ulcers or abscesses is not so acute nor so intense, especially so far as the subjective symptoms are con- cerned, since the ocular capsule is opened and the intra- ocular tension cannot become excessive. Those which are most variable in this respect are the metastatic and tubercular varieties, since they often oc- cur in the most violent forms, or again in a manner which is far less active than we should expect from the character and extent of the causal influence. So much is the latter the case that we often meet patients in whom the loss of all vision is the first symptom, and the diag- nosis can hardly be made except by ophthalmoscopic ex- amination, or the eye may present the usual appearance of iritis or irido-cyclitis. The last variety is often binocular, whereas the others are not, being confined to only one eye alone. Prognosis.-The prognosis of suppurative choroiditis in all its forms is very grave, for it is extremely rare that any sight will be left in the eye affected. In fact, we find it more often the case that the eye will become smaller and smaller, until it is reduced to a mere stump. We must be satisfied if we can cause the eye to retain its form with a clear cornea, so that it shall not present too great a deformity. It has been often observed that not only has the eye been lost, but the condition of suppura- tion in the eye has led to metastatic meningitis, the patient losing his life. The metastatic variety is the worst of all as to prog- nosis, and especially that from tubercles, since, if the patient escapes with his life, his eye is sure to be phthis- ical. However, there are a few cases on record in which the eye retained a certain limited amount of vision. The method by which the eye shrinks differs in differ- ent cases ; but the condition is very unfortunate in young people, since the lids will be immovable and closed, anil the orbit will not develop equally with its fellow, but will remain smaller. If an artificial eye is introduced it can never give satisfaction, since it must necessarily be too small to appear natural. If no ossification take place in the stump later on, it will remain harmless and need not require any further attention. But if bone form inside of a phthisical stump the whole thing should be removed, because it may at any time cause sympathetic trouble in the other eye, with resultant total blindness. This is also true where the stump contains a foreign body which has been the cause of the original trouble. Such stumps should always be removed. Treatment.-The treatment will, of course, be to get rid of the exciting cause if possible. If the eye has a foreign body in it, remove it. If there be a dislocated lens, let it out; or if an extensive hypopyon, or large cor- 153 Choroid. Chromium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. neal abscess, slit the cornea freely, so as to give an exit for the pus and to relieve the intra-ocular tension. If there be an orbital abscess, open it freely ; etc. But what- ever the cause, the patient should be protected from all irritating influences. This is best done by keeping him in bed in a dark room, and attending to his general condition. If the process is not very energetic the eye may be simply bandaged ; but if this is not the case, no bandage should be applied. If there is great heat in the eye, cold applications may be employed, witl) leeches to the temple. If there is much pain in and around the eye, warm appli- cations will generally be found to give greater relief than cold ; but a single trial will settle this point. In case the pain be not controlled by these agents, of course a judicious use of narcotics may be recommended; but I myself try to avoid these latter. If there is a great accumulation of pus in the back part of the eye, and the tension is found on examination to be increasing, one or two incisions may be made into the sclera and through the choroid, so as to give an outlet for the pus ; as the eye is certainly lost, at least the cuts will do no possible harm, so long as they are not made in the ciliary region. The tension will never become so great as to cause excessive pain after this procedure. If the process is so intense that the eye is more or less certain to become phthisical, cut through the sclerotic behind and put on warm applications to shorten the course of the disease. Or it may be recommended, when we are sure that the ball will become shrunken, to enu- cleate the eye at once, since this will certainly relieve us of all future complications, with but the following excep- tion : It has been found that where the process is ener- getic, and especially where the orbital contents are in- flamed, enucleation has been followed by extension of the disease to the brain, with fatal results. This termination I have never seen, but I have cause distinctly to remem- ber a case in which there was a foreign body in the eye, which I could see with the ophthalmoscope before the media had become cloudy. I advised enucleation, since the body had passed through the ciliary region, and I did not deem it proper to try and get it out. I enucleated the eye, and everything went on nicely for some few days, and I had told the patient he could go home in two days more. I called the next day, and, much to my horror, found him delirious, vomiting, etc., with all the symp- toms of brain complication. I sent him to the hospital, and he remained in that condition for eight to ten days, but finally recovered. No one could doubt that this was at least a case of cir- cumscribed meningitis caused by the enucleation ; and if this result can spring from such an apparently innocent case, it may assuredly follow the operation performed when the orbital contents are in an active stage of in- flammation. There are, moreover, several cases on record of death after the operation ; but they are rare, and I may say that we are often justifiable in assuming the risk for the comfort of the patient. However, this should be ex- plained to the patient or his friends beforehand. If the patient has come to us late, and we can satisfy ourselves from the history that the disease is on the wane, we need do nothing but bandage the eye and tell the patient to take good care of himself. He should wear the bandage until the condition is reduced to that of no inflammation. In other words, put the eye in the best condition to cur- tail the disease. If the disease has progressed far when we first see it, and we find a shrunken eyeball which is not painful, and one which has not probably a foreign body in it, we may do nothing ; but if the stump is painful, either spontane- ously or on pressure, removal of the stump is in order, and must be insisted upon ; because these painful stumps signify that the ciliary nerves have not been destroyed by the suppurative process, and, therefore, always hold the sword of Damocles over the other eye. Under such circumstances it is policy to remove each and every one of these painful stumps, since it is a very small matter to lose such a stump, but an entirely different question, should it render the other eye blind by sympathetic trouble. IK C. Ayres. CHROMIDROSIS Chromidrosis is a disorder of the sweat-glands in which the fluid poured forth is variously colored. In the majority of cases the color is bluish or bluish-black. In some cases a brownish or ochre-yellow colored sweat has been observed. In recent years the oc- currence of a brick-dust red deposit upon the skin has been reported in connection with the sweat secretion. The commonest situation for the occurrence of the dark discoloration is on the lower eyelids. The whole of the face or any part of it may be affected, as also any portion of the body and hands. In men the scrotum has been observed to be affected. The majority of persons affected with chromidrosis have been women, usually neurotic, and often the subjects of hysteria. The disease appears in some cases in connection with some nervous shock. It is occasionally feigned (see Feigned Eruptions of the Skin). These remarks refer to the dark varieties of chromidro- sis. Red or orange chromidrosis occurs commonly in the axillae, although the writer has seen a case occurring on the cheek, and Duhring alludes to its occurring on the neck and elsewhere. The immediate cause of the change of color is not ac- curately known. The darker varieties are supposed to owe their origin to the presence of indican in the sweat, and some have supposed red chromidrosis to be due to the presence of a parasite. In a marked case of yellow unilateral chromidrosis, reported recently by J. C. White ("Trans. Am. Dermatological Association," 1884), the coloring matter was very carefully examined by the spec- troscope without throwing any light on its nature. Arthur Van Harlingen. CHROMIUM. Compounds of chromium are constitu- tionally highly poisonous to the animal system, and, lo- cally, chromic acid and its' soluble salts are intensely irri- tant, and even caustic. Preparations of the mineral are, in modern medical practice, used only for local purposes. The U. S. Pharmacopceial compounds are the following : Acidum Chromicum; Chromic Acid (Chromium tri- oxide, CrO3). This compound is in " small, crimson, needle-shaped or columnar crystals, deliquescent, odor- less, having a caustic effect upon the skin and other ani- mal tissues, and an acid reaction. Very soluble in water, forming an orange-red solution. Brought in contact with alcohol, mutual decomposition takes place. When heated to about 190° C. (374° F.) chromic acid melts, and at 250° C. (482° F.) it is mostly decomposed with the forma- tion of dark green chromic oxide and the evolution of oxygen. On contact, trituration, or warming with strong alcohol, glycerin, spirit of nitrous ether or other easily oxidizable substances, it is liable to cause sudden combus- tion or explosion " (U. S. Ph.). From its powerful chem- ical action, chromic acid should be kept in glass-stoppered bottles. In concentrated application chromic acid is a powerful and penetrating caustic, and is available in sur- gery when a deep and thorough cauterization is de- manded. It should not, however, be applied over an extensive area, lest enough be absorbed to produce con- stitutional poisoning. It is generally used by mixing the crystals with a drop of water to the forming of a paste. The acid is also a powerful oxidizer and antiseptic, thus proving disinfectant, both by destroying low forms of living things, and also by oxidizing foul products of zy- motic processes. But its corrosive properties make the disinfectant virtues generally unavailable. Chromic acid is of use, however, for the preservation of organic tissues in the laboratory, particularly of nerve-structures intended for microscopical examination, since it simultaneously preserves and somewhat hardens, while changing but little histological appearances. It is used for such pur- pose in very weak aqueous solution. Chromic acid should not be prescribed for internal medication, and in prescription for any purpose, the explosiveness of its mixture with glycerin and other oxidizable matters must be carefully borne in mind. PotassiiBichromas, Bichromate of Potassium (K2Cr2O7). This well-known salt is in "large, orange-red, transpar- ent, four-sided, tabular prisms, permanent in the air, odor- less, having a bitter, disagreeable, metallic taste, and an 154 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Choroid. Chromium. acid reaction. Soluble in 10 parts of water at 15° C. (59° F.), and in 1.5 part of boiling water ; insoluble in alcohol" (U. S. Ph.). The salt is severely irritant and poisonous, and is not used in medicine. In weak aque- ous solution it is a convenient preservative for histological specimens, producing similar effects to chromic acid. It is officinal probably because used in solution as a chem- ical test. Eduard Curtis. internally, its action would undoubtedly be more violent than that of the bichromate of potassium. Experiments made on animals show that the action of. the neutral chromates is similar to that of bichromate of potassium, but weaker. They may, however, act as violent poisons. A tablespoonful of the chromate of potassium, taken by mistake for Glauber's salt, caused vomiting within a few minutes, and death in twelve hours (Neese, case of Parochow). Experiments on Animals.-The action of chromic acid and the soluble chromates has been studied by means of experiments on animals (Orfila, Gergens, Priestley, Vul- pian, and others). These substances are fatal to dogs and rabbits in doses of 0.100 to 0.400 Gm. (1.5 to 6 grains). The symptoms produced are, in general, similar to those which have been described. According to Priestley, who experimented with the neutral chromate of sodium, the nerve-centres are at first excited, later depressed. Neph- ritis was observed in animals poisoned by the subcutane- ous injection of chromic acid (Gergens) and neutral chromate of sodium (Priestley). Chromium has been de- tected in the blood, heart, liver, kidneys, and urine of animals poisoned by its compounds. It is probably eliminated in great part in the urine. Treatment.-Emetics will seldom be necessary, but should be administered if vomiting has been slight or wanting. As chemical antidotes, magnesia, chalk, sodic or potassic carbonate may be administered, to convert the chromic acid or bichromate of potassium to a neutral chromate. The stomach should then be washed out to remove the neutral chromate thus formed. The subse- quent treatment should be the same as that employed in cases of poisoning by the metallic irritants in general. Effects upon Workmen.-Workmen who manufacture chromate and bichromate of potassium, especially the latter, are subject to accidents which result from the irri- tant and escharotic action of the salt. This escharotic action is especially manifested by perforation of the car- tilaginous portion of the septum of the nose. In addition to this, painful ulcers are developed upon any part of the body where particles of the powdered salt, or concen- trated solutions, come in contact with the broken skin. The first symptoms usually appear within a few days after the men have commenced work ; sometimes on the first day. A mere tingling in the interior of the nose is first noticed. This is soon followed by frequent sneezing, and later by a serous discharge. There is usually epis- taxis ; sometimes a painful sensation of constriction, and smarting pain in the nasal fossae. If the men are not re- moved from their work, the discharge rapidly increases, becomes opaque, and then greenish, owing to ulceration of the mucous membrane. The septum soon becomes thin, permeated with openings, and is finally totally de- stroyed. All symptoms then cease. The sense of smell is not affected. The ulcers are found especially upon the hands, arms, and feet. If the skin is whole no effects may be observed for a long time. If, however, there is the slightest injury of the skin, the caustic action of the salt is at once manifested, and a painful sore is produced. Unless the workman is promptly removed, this sore bur- rows deeper and deeper-without spreading laterally, how- ever-in spite of all treatment. Cases have been observed in which these ulcers have penetrated to the bone, and even through the hand or arm (Duncan, Baer). These ulcers may occur on parts of the body which are covered with clothing. They have been observed especially about the genitals. Ulcers of the throat and tonsils, resembling closely syphilitic ulcers, have been observed (Heathcote). Treatment.-If the early symptoms, pointing to the nose, are recognized, the patient should be removed at once from his work. Delpech and Hillairet recommend, at this stage, the frequent application of demulcent lotions, and the inhalation of bismuth or starch, and later pow- dered cinchona bark. When perforation is once estab- lished, they recommend lotions of decoction of cinchona bark and frequent inhalation of the powdered bark. When a bit of the bichromate falls on a crack in the skin, the part should be immediately washed with water or a solution of potassic carbonate. If the pain persists, CHROMIUM, POISONING BY. The most important compounds of chromium, from a medico-legal point of view, are chromium trioxide (chromic acid) and the chro- mates. The dichromate, commonly called bichromate, of potassium and chromate of lead have given rise to a considerable number of cases of poisoning. The salts of sesquioxide of chromium are said to be poisonous; but their action, which is known only through experiments on animals, appears to be much less violent than that of the chromates. Potassium Dichromate.-This is a garnet-red trans- parent salt, crystallizing in tables or prisms belonging to the triclinic system, and soluble in from nine to ten parts of water at the ordinary temperature. It is manufactured on a large scale, and is employed for the preparation of the other chromium compounds, and is largely used in the arts, especially in dyeing and calico-printing. Cases of poisoning by this substance have been hitherto acci- dental, suicidal, or the result of its use as an abortive. Symptoms.-Taken internally, in poisonous doses, it acts as a violent irritant. Active symptoms usually come on immediately, or within a few minutes after taking the poison. In the act of swallowing, the bitter metallic taste of the substance will be noticed. This is followed by a sensation of heat and pain in the throat, oesophagus, and stomach. There is usually violent vomiting, and, later, profuse purging. The vomited matters have at first a yellowish color ; later they may be streaked with blood. The pupils are, as a rule, dilated. There are usually cramps in the legs, and abdominal pains. The pulse is feeble ; the countenance pale and anxious ; the skin cold and clammy. The urine is frequently sup- pressed. Death may be preceded by coma or convul- sions. Occasionally the symptoms of gastro-intestinal irritation are slight or altogether wanting. In fatal cases death has usually taken place in from four to twelve hours ; it has been delayed for fifty-four hours. Fatal Quantity.-The amount required to endanger life is not accurately known, but appears to be small. Dis- agreeable effects have been observed to follow its admin- istration in doses of 0.030 to 0.300 Gm. (0.47 to 4.6 grains). A piece weighing 0.32 to 0.65 Gm. (5 to 10 grains), destroyed the life of a child, twenty months old, in nine and one-half hours (McCrorie). Taylor relates a case in which 7.7 Gm. (2 drachms) was fatal, in an adult, in four hours. Owing to proper treatment recovery has taken place after a dose of 62 Gm. (2 ounces). Appearances.-The mucous membrane of the stomach, duodenum, and upper part of the jejunum has been found reddened, swollen, and injected with blood; in some cases destroyed in patches. These appearances are not, however, constant. Ilyperaemia of the kidneys has been reported in a few cases. Nephritis has been observed quite constantly in animals poisoned with chromic acid and soluble chromates (Gergens, Priestley); and it is probable that the suppression of urine, so frequently ob- served in cases of poisoning in the human subject, is due to a similar condition resulting from the direct irritant action of the acid or its salts upon the kidneys. The pia mater has been found injected; the blood in the right side of the heart, and in the cerebral veins and sinuses, fluid and dark, almost ink-like, in color ; the lungs con- gested. Chromic Acid and Neutral Chromates.-Chromic acid is a powerful corrosive poison. It is an active oxi- dizing agent, and, when concentrated, destroys most tis- sues. It is, on this account, used as an escharotic. Its use for this purpose is said to have been followed by repeated vomiting and diarrhoea, abdominal pains, symptoms of collapse, and even death (Mosetig, Bruck, Netzel), Taken 155 Cli romium. Cicatrix. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. it may be moderated by emollient poultices. Solutions of subacetate of lead, nitrate of silver, and lactate or acetate of iron, have been recommended. In cases of ulcerated throat Heathcote has obtained satisfactory re- sults by sponging the throat with a solution of nitrate of silver (0.130 Gm. to 30 c.c. water). Chromates of Lead.-These include chrome yellow (the normal chromate), chrome red (a basic chromate), and chrome orange (a mixture of chrome yellow with chrome red). These substances are very much used in the arts as pigments, and, within a few years, have given rise to several cases of poisoning. Dr. von Linstow has reported the cases of two children, aged respectively one and three-fourths and three and one-half years, who were poisoned by eating a number of small yellow objects which had been used for decorating a cake, and which consisted of gum tragacanth colored with chromate of lead. In about five hours both were seized with violent vomiting, which continued for some hours, and great prostration. The vomitus was at first yellow in color. The children complained of much thirst and were very restless. There was no diarrhoea and no complaint of pain. On the following day the younger child had some diarrhoea and convulsions, which continued till death, which took place in about forty-eight hours after the in- gestion of the poison. On the third day the elder was list- less and stupid. The skin of the breast and abdomen was erythematous ; the temperature in the axilla was 39.5° C. (103° F.). On the fourth day the pulse was irregular and the temperature increased. There was great thirst and difficulty of swallowing. On the fifth day he passed into a state of collapse and died. At the post-mortem exam- ination the blood-vessels on the surface of the brain were found strongly injected ; the lungs and brain congested. There was beginning fatty degeneration of the liver. In the case of the younger the mucous membrane of the stomach was swollen, especially on the cardiac half, and was marked throughout with red points. Near the car- diac orifice it had a pale yellow color. In the case of the elder the oesophagus was injected ; its mucous membrane was disintegrated and purulent throughout. The mu- cous membrane of the larynx and upper part of the trachea was purulent and partially disintegrated. The mucous membrane of the stomach was loose and easily rubbed off, and in some places disintegrated. At the cardiac end the color was pale red, at the pyloric end brownish-red. The mucous membrane of the duodenum was ulcerated, loose, and easily rubbed off. At its upper part it was strongly injected, and in one place perforated. Both kidneys were rich in blood, and on section showed small pus-drops, which apparently came from the calices. The poison could not be detected in any of the organs. The amount of chromate of lead swallowed by both chil- dren was about 0.0252 Gm. (about two-fifths of a grain). The action of the chromate of lead in these cases resem- bles that of chromic acid and the soluble chromates rather than that of a salt of lead, and suggests the probability of a decomposition of the chromate of lead within the body. The use of chromate of lead for coloring articles of food, especially confectionery, appears to be quite ex- tensive. H. B. Hill in 1873 analyzed 77 samples of candy, both white and colored. Of the colored specimens 21 were colored yellow, 12 orange, and 7 green. In 36 of these 40 samples the pigment consisted wholly or in part of chromate of lead. Six of the green samples were colored with a mixture of chromate of lead with Prussian blue (" Mass. State Board of Health Report, 1873," page 390). In 1881 the writer found that chromate of lead was still used as a pigment for confectionery (" Report of the Board of Health of the City of Boston, 1880-81," page 41). Many cases of chromate-of-lead poisoning have oc- curred among workmen as a result of inhaling the dust given off in the process of weaving cloth or yarn colored with chrome yellow or chrome orange. The pigment is so loosely applied to the fabric that it is easily detached and diffused through the room (Smith, Leopold. See also "Mass. State Board of Health Report, 1872," page 311). Most of these cases have been unmistakable cases of chronic lead-poisoning, One of the cases reported by Leopold, however, and which proved fatal, resembled in some respects the cases of Von Linstow. The patient was a child a few weeks old, who lived during the day in the room in which its parents were employed in weaving yarn colored with chromate of lead. The child died in six or eight days after the beginning of the symptoms. At the autopsy perforation of the stomach was found. The poison could not be detected in any of the organs ex- cept the lungs, in which 0.0036 Gm. of chromate of lead was found. In one of the cases reported by Smith chromium was detected in the urine, but lead was not. It appears that chromate of lead may give rise either to acute poisoning, owing probably to its decomposition within the body, in which case the symptoms and post- mortem appearances resemble in many respects those of chromic-acid poisoning; or to chronic poisoning, in which case the symptoms are unmistakably those characteristic of chronic poisoning by the salts of lead in general. William B. Hills. CHRYSAROBIN (Chrysarobinum, U. S. Ph. ; Ph. G.), sometimes misnamed chrysophanic acid, is the crystalline substance of which " Goa powder" principally consists. Goa itself is a crumbly powder found in considerable quantities in canals and cavities of the wood of Andira Araroba Aguaiar; Order, Leguminoscc, Papilionece, a large Brazilian tree. It has long been used in Brazil, from where its employment has spread through Portuguese com- merce to India and the East. Its general European and American employment is comparatively recent. Goa, or Araroba, is a pulverulent substance, contained in long and large canals in the older wood of the trunks, and also in large irregular cavities in the same, formed by erosion or degeneration of the wood itself. It is obtained by cutting and splitting up the trees, and scooping or scraping out these canals and cavities. It is considerably irritating to the skin and mucous mem- branes, and severe inflammation of the face and eyes of those who collect it is not unusual. Lachrymation and sneezing are readily produced by sifting or handling the powder. Crude Goa is a coarseish powder, mixed with lumps and fine bits and fibres of wood, varying from dull yellow (when fresh) to reddish-brown, or even a ,greenish or violet-brown color, with the other properties of its purified product as described below. Besides small amounts of sugar, gum resin, and cellular tissue, it contains, as was first shown by Professor Attfleld, eighty-five per cent, of a yellow crystalline substance, which he supposed was chrysophanic acid, but which Lieberman afterward proved to be a mixture consisting mostly of a peculiar substance, chrysarobin, having many points of resemblance to the above-mentioned acid, and, in fact, capable of being transformed into it. The im- pure Chrysarobin of the Pharmacopoeia is thus de- scribed : "A pale orange-yellow, crystalline powder, permanent in the air, odorless and tasteless, almost in- soluble in water, only slightly soluble in alcohol, readily soluble in ether and in boiling benzol. When heated to about 162° C. (323.6° F.) it melts, and maybe partially sublimed. On ignition it is wholly dissipated. In solu- tions of alkalies it is soluble with a yellowish-red or red- dish-yellow color, which is changed to red by passing air through the liquid. Sulphuric acid dissolves it with a deep blood-red color ; on pouring the solution into water, the substance separates again unchanged." Chrysarobin taken internally is an active irritant to the alimentary canal, causing violent and persistent catharsis and vomiting. It is eliminated partly unchanged and partly converted into chrysophanic acid by the kidneys, which glands are extremely irritated by it, and haema- turia and interstitial nephritis may follow. It is, how- ever, here, never given internally, its use being confined to local applications as an irritant and parasiticide in chronic psoriasis, pityriasis versicolor, and tinea ton- surans. It produces an active acute inflammation, which as it subsides leaves the original malady in an improved condition. Chrysarobin stains both skin and clothing badly. The ointment (Unguentum Chrysarobini, U. S. Ph., strength, -^j) is of a suitable strength for inunction. 156 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chromium. Cicatrix. It is doubtful if the value of this remedy compensates for the danger and disagreeableness attending its use. Allied Plants.-The genus Andira contains sixteen or more species of South American trees, several of which perhaps contribute a part of the Goa of commerce ; for a notice of the order, see Senna. Allied Dkugs.-Chrysophanic Acid of Rhubarb and some other drugs, Cashe.w nuts, Cantharis, Poison Ivy, Poison Sumach, Croton Oil, and other intense vegetable and animal irritants ; also, Tartar Emetic externally used. W. P. Bolles. and send out epidermal wandering cells. These wan- dering cells spread over the granulations of the wound, and increase by proliferation and division, forming a deli- cate epithelial membrane that gradually diminishes in thickness toward the middle of the wound. This trans- parent, glistening pellicle can almost always be seen to spread inward on all sides from the edges of the wound. But it is sometimes observed to advance centrifugally from an "island" of epithelium in the midst of the wound. In this case it is possible that there may be a connection with the adjoining skin, not visible macro- scopically. Usually the cells originate from sweat-glands, sebaceous follicles, or epidermis, that have survived the original injury. Sometimes they are derived from new cells scattered on the granulating surface by design, as by the application of skin-grafts, or by accident, the cells falling unobserved on the wound while the dress- ings are removed. Beneath this pellicle, numerous small polygonal nucleated cells, separated by soft transparent or granular intercellular substance, are irregularly ar- ranged in the meshes of embryonic blood-vessels. The cells are either white blood-cells or wandering connective- tissue cells. The blood-vessels are derived from those of the adjoining part by the channelling of protoplasmic sprouts. The tendency of this tissue is to develop into the white fibrous tissue found in old cicatrices. Many of the young cells are destroyed in this process, the rest be- come at first spindle-shaped, and finally acquire the characters of connective-tissue cells. The intercellular substance, at first not very abundant, becomes fibrillar and separates the remaining cells more widely. The whole cicatrix is now denser and drier than at first. Then the fibrillar intercellular substance contracts and condenses still further, the process only terminating when dense white fibrous tissue is formed. The contraction pulls on the neighboring parts, causing more or less wrinkling near the scar and drawing the adjacent tissues from their places. The blood-vessels also undergo changes. Many of them disappear entirely, and those which per- sist form a delicate anastomosing network of capilla- ries and small vessels communicating with those in the normal tissues on all sides of the cicatrix. The whole process is analogous to the development of embryonic tissue into adult connective-tissue. In course of time, the cicatrix becomes loosened from its adhesions by the formation of adipose tissue beneath it. It becomes flexi- ble, pliable, and easily movable, losing its adhesions to fasciae and bone in many cases. Lymphatics and nerves also reappear, and in old cicatrices there are sometimes found a few elastic fibres. But cicatrices never contain hair, papillae, sweat-glands, or sebaceous follicles, except when they remain from the original tissue, not having been destroyed by the injury or disease that has preceded the cicatricial process. Cicatrices of mucous membranes are similar to those of the skin. They are more apt to be the cause of serious trouble, on account of the greater fre- quency of damaging contractions, producing strictures of the mucous tubes, as of the oesophagus or urethra. Cicatrices of the glands are composed of fibrous tissue. Wounds of nerves and muscle are at first united by cica- tricial tissue, but regeneration often occurs in these tissues under favorable circumstances. Cicatrices remain for a long time of low vitality. They require to be kept warm and dry, and to be carefully protected from violence. Slight blows, friction of the clothes, exposure to cold, are sufficient to produce neural- gia of the cicatrix or ulceration, especially if there have been any defect of cicatrization. They are also apt to give way when the neighboring parts are stretched, and sometimes extensive wounds are reopened by undue ten- sion on the delicate scar. Recent cicatrices may break down under the influence of exhausting disease or exces- sive use of mercury. Cicatrices produce certain changes in adjoining parts of the body, and are liable to defects and diseases. Excessive formation of cicatricial tissue sometimes oc- curs, usually in places where it produces unsightly de- formities. It has been most often noticed after plastic operations, as the operation for harelip, and after wounds CHURCH HILL ALUM SPRINGS. Location.-A sub- urb of Richmond, Va. Access.-By the various lines of railways centring at Richmond. Analysis (J. C. Booth, M.D.).-One pint contains : Grains. Chloride of sodium 0.578 Sulphate of potassa 0.305 Sulphate of soda 0.243 Sulphate of magnesia 10.758 Sulphate of lime 11.104 Sulphate of ammonia 0.980 Persulphate of sesquioxide of iron (i. 408 Bisulphate of sesquioxide of iron 10.419 Sulphate of protoxide of iron 3.023 Persulphate of alumina 9.116 Silica 1.303 Phosphoric acid trace Total 53.337 G. B. F. CICATRIX (Synonyms: Cicatrice, scar; Lat., cicatrix; Ger., Narbe ; Fr., cicatrice). The new tissue formed in the healing of wounds or during the process of repair of loss of substance by disease or injury is a cicatrix. Old cicatrices are usually whiter than the normal skin, but may be pink or bluish, and are often pigmented. Usually depressed, smooth, and glistening, they may be elevated, or, more rarely, on a level with the surrounding skin. They may be rough and scaly, or covered with broad or narrow bands of denser tissue, dividing the sur- face into irregular ridges and hollows. These unsightly scars are especially apt to follow lacerated wounds and wounds caused by fragments of wood, metal, or other irregular substances. Pigmentation is generally found to follow when gunpowder or fragments of coal have been embedded in the skin. Where the wound has been cov- ered by soft, flabby, weak granulations, the cicatrix is almost always blue. Pigmentation is especially found in cicatrices of chronic and syphilitic ulcers. Once fully formed, cicatrices are a permanent part of the body, growing with its growth, so that, if they oc- cur of a certain relative size in a child, this relation will be found to persist in the adult. When small, cicatrices occasionally wear out and entirely disappear, but this never happens when the cicatricial tissue is at all abun- dant. Cicatrices are thus of great importance in estab- lishing identity. They also frequently furnish reliable information of previous disease, as in the case of cica- trices following syphilitic lesions of the skin, suppurating bubo, or suppurating joint-diseases. The structure of cicatrices, the same in all parts of the body, is best studied after superficial wounds. When a wound of skin and subcutaneous connective-tissue has just healed, the young cicatrix is redder, firmer, less pli- able and yielding than the surrounding parts. It may be on a level with the adjacent skin, or elevated above, or depressed below it. Its shape and size depend chiefly on those of the original gap in the tissues which it fills in, but partly on the developmental process of contraction, which begins in many cases before cicatrization is com- plete. The new scar is composed of granulation tissue or embryonic connective-tissue covered by a thin pellicle of epithelium. It contains no papillae, nerves, lymphatics, muscle, or glandular tissue. In most cases the epithelial cells have been derived from the rete Malpighii of the surrounding skin. During the process of cicatrization its cells form new nuclei, and increase in size and number, 157 Cicatrix. Cinchona. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the eyelids, particularly vertical wounds. It some- times follows piercing the lobe of the ear for ear-rings. It is to be avoided only by securing primary union of operation and other wounds. Pressure and counter-irri- tation sometimes diminish the excessive cicatrix, but more reliance is to be placed on excision of the redundant tissue and gaining primary adhesion of the subsequent wound. Cicatricial contraction is concerned in the causation of several of the defects and diseases of scars. It is a nor- mal process, and often begins before cicatrization is com plete. It is produced by the shrinking of the intercellular substance of the fresh cicatrix in its transformation into white fibrous tissue. In granulating wounds contraction begins early and assists in the closure of the wound by approximating its surfaces. The layer of granulations is rarely more than a few lines thick, and wound cavities are rarely entirely filled in by granulations. If we scrape away the granulations, we soon reach a layer of contract- ing cicatricial tissue, and it is the force of this acting on the walls of the wound that does most toward obliterat- ing the cavity. When this contraction is resisted by mechanical appliances, as is sometimes done to prevent deformity, the wound may remain open for months and obstinately refuse to heal until the apparatus is discarded. In this case the tension on the blood-vessels of the cica- trix so lowers its vitality that the completion of cicatriza- tion is almost impossible. When it does occur the scar is particularly liable to ulceration from the slightest causes. The same result occurs naturally when the force of the contraction is exerted on bones or other tissues that do not yield. The amount of contraction depends on the quantity of new cicatricial tissue and the resistance of the neighbor- ing parts. Wounds healed under antiseptic dressings, and by first intention, are followed by much less shrink- ing than when allowed to granulate and suppurate. Where there is little subcutaneous connective-tissue the neigh- boring parts retain better their positions, and far slighter deformities follow than when great freedom of motion is allowed, as in the neighborhood of joints and in extensive superficial wounds. The cicatrices of burns and scalds, wounds in the flexures of joints, and lacerated wounds usually produce the greatest deformities. The remark- able contractions that follow burns are not due to any peculiarities in the structure of the cicatrix, but to the great amount of new tissue and the facility with which the surrounding tissue yields. Slight contractions at the flexures of joints may seriously interfere with their func- tions and greatly impair the usefulness of the limb. It is impossible to describe the varying deformities produced by cicatricial contractions here. After burns, the hand may be bent upward on the forearm, while the fingers are twisted in the most fantastic ways or buried in the palm of the hand. Joints may be dislocated, bones deeply indented and arrested in development. The arm may be immovably fastened against the side of the body, or the lower limbs so distorted that the erect posture and walk- ing are impossible. Neglected burns of the face and neck produce still more sad and disfiguring deformities. The head, twisted to one side, may be drawn downward so that the chin is fixed on the breast, while the force of the cicatricial contraction still unexpended extends further, sometimes producing eversion of the lips and distortion of the mouth, or ectropion. The result in some cases is that even articulation is affected, while the horrible dis- tortion of the- face and mouth, permitting the saliva to dribble away, causes the sufferer to be a subject of pity or aversion. In many cases disfiguring and disabling con- tractures follow burns and wounds treated with the ut- most care. They are only to be avoided by securing, where possible, the primary union of the wound. Cica- trization must be hastened by the application of skin- grafts, and careful attention to bring about the most rapid healing of the wound possible under the circumstances. Splints and bandages are sometimes of service in pre- venting deformities, if properly employed during and after cicatrization. But untoward results occasionally are seen, contraction beginning when the apparatus is laid aside, weeks or mouths after the completion of cicatriza- tion. Or the wound may remain obstinately open while contraction is prevented, and healing will occur only at the expense of more or less extensive deformity. For the relief of deformities resulting from cicatricial contrac- tions, apparatus may be used to stretch the scar, or vari- ous operations may be performed. The plastic operations have produced, in some hands, very satisfactory relief, but they are uncertain in their result, and sometimes fail en- tirely. Occasionally no relief for an injured and distorted member can be obtained, and if it is painful or cumber- some, there may be no resource but amputation. Weak cicatrices are frequently found when, during cicatrization, the granulations have been inflamed or pale and flabby. They are most common in the lower extremities and over the bones. They are particularly apt to ulcerate, and to be ultimately the seat of epithelial carcinomata. They often occur where no contraction of surrounding parts has occurred in cicatrization. Here the tension on the blood-vessels has left ill-nourished the flabby granulations, and at the end of long periods of te- dious waiting the ulcer has finally closed. Ulcerated cicatrices require the same treatment as chronic ulcers- rest and stimulation. Cicatricial bands and masses may do serious damage when they contain or compress important vessels or nerves. Obstinate oedema of parts supplied by the blood- vessels may follow, but is seldom dangerous. It is fre- quently seen, after operations on the axilla, in conjunction with sufficient loss of motion at the shoulder to seriously interfere with the after-usefulness of the arm. Paralysis of motion and sensation, and unpleasant formications sometimes occur when nerve-trunks are compressed by cicatricial tissue. The only remedy is to dissect out the flattened nerve from the dense cicatrix, hoping that it may be subject to less pressure in its new position. When nerves are divided and their ends contained in cicatrices, besides the loss of motion and sensation the cicatrix is apt to be painful. The nerves are sometimes found to be bulbous, or the seat of fibrous degeneration. Here a portion of the nerve may be excised, or the end dissected out of the cicatrix. This does not always re- lieve the pain, and then it must be treated on general principles as neuralgia. In this category may be men- tioned those cicatrices that are blamed for the causation of epilepsy. What connection lies between the two has not been satisfactorily established. It is only certain that in some cases excision of the cicatrix is followed by disappearance of the epileptic symptoms. ' Cicatrices also suffer from inflammation, wounds, con- tusions, and tumors. Inflammation occurs in the same way as in other con- nective-tissue. Abscess often occurs in recent cicatrices as a result of retention of some foreign body, or of infec- tion. Cicatrices of wounds made in operations for tuber- cular diseases frequently develop abscess at the end of two to four weeks from the time of the operation ; and in other cases suppuration is probably due to the presence of infectious germs. Tetanus in one recent case followed abscess in a cicatrix of the foot caused by the retention of a small fragment of shoe-leather. Wounds of cicatrices usually heal readily. Dr. A. C. Post has drawn attention to the rapid cicatrization occur- ring in secondary plastic operations. Cicatrices sometimes undergo degenerative changes, leading to the formation of elevated, scaly, itching nod- ules, called keloid. This is a fibrous or fibro-cellular tu- mor, often of a pink color. The only treatment is exci- sion, and the keloid is very apt to recur. It follows even slight cicatrices-for example, those of acne and chicken- pox. It is more frequent, however, in cicatrices of burns and lacerated wounds. Carcinoma of cicatrices may be either primary or sec- ondary. Primary carcinoma is usually of the epithelioma variety. It occurs most commonly in cicatrices situated over bones, and following burns and gunshot wounds. It usually appears in cicatrices that have been much irri- tated or exposed to pressure and ulcerated, and presents no unusual phenomena. 158 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cicatrix. Cinchona. Secondary carcinoma in cicatrices usually develops in three weeks or six months from the time of operation. It may appear in the cicatricial tissue, but usually in nodules in the subjacent or surrounding connective-tissue. Sarcoma is also found occasionally in cicatrices, and if removed by operation is apt to recur in the cicatrix. Wm. G. Le Boutillier. angled, with throat'either glabrous or velvety ; limb five- parted, valvate, lobes spreading, with hairy margins. Stamens five, inserted upon the tube of the corolla, with sometimes short filaments and included anthers, some- times long and exserted. Ovary inferior, two-celled, style slender, sometimes short and included, sometimes exserted two-parted. Ovules numerous, capsule ovoid, oblong, or subeylindrieal, tvzo-celled, dehiscing septi- cidally from the base upward. Many-seeded. Seeds shield-shaped, margined with broad and long, ragged, scarious wings, albumen fleshy, cotyledons ovate, radicle terete. Leaves opposite, petioled, stipules interpetiolar, deciduous, glandular at the base. Like certain other Rubiacece, more or less dimorphism prevails. Of the neighboring genera, Cascarilla (not the source of Cascarilla Bark) is distinguished by the thicker corolla- lobes, with stout papillae instead of slender hairs upon their margins, and by pods which split from above down- ward. In Remijia the lobes of the calyx are larger, the inflorescence is lateral, and the dehiscence generally downward ; in Pimentelia the calyx is still larger and the flowers are in dense axillary clusters, dehiscence also downward, etc. In none of these related genera, except- CINCHONA, U. S. Ph. (Cortex China, Ph. G. ; Quin- quina, Codex Med.; Peruvian Bark ; Germ., Chinarinde ; Old name, Countess's or Jesuit's Bark, etc. ; Spanish name, Quina). The term Cinchona, when used alone in phar- maceutical language, is restricted to barks above a certain standard of alkaloid strength, and sometimes also to those of particular species or countries. Thus, in the United States Pharmacopoeia it is described as "the bark of any species of Cinchona containing at least three per cent, of its peculiar alkaloids." In the German Phar- macopoeia, cultivated Cinchona barks are required of not less than three and a half per cent, of alkaloid, etc. In England and France, certain species only are officinal under their respective names, there being no general term in authorized use, unless Quinquina of the Codex may be considered so in France. In most countries, in addi- tion, two or three of the most valued varieties of bark ■are singled out for especial recognition under descriptive names ; like red, yellow, pale, etc., bark, as will be no- ticed further below. Botanical Source. - The genus Cinchona, which furnishes the above, is the type of one of the tribes of the order Uubiacece (Cinchonea), and was named by Lin- naeus for the Countess Ana of Chinchon, wife of the Viceroy of Peru, who, in the early part of the seven- teenth century, was treated with the bark herself, and introduced its use into Spain, and from there to the rest of Europe. But, from some cause not certainly known, the great botanist spelled the name without the h in the first syllable, which belonged to the Countess's province and title, and his error has been perpetuated in almost every country to this day. There have been a number of individual and reasonable protests against this slight upon the benefactress's name, and rather recently, Mr. C. R. Markham, an enthusiastic quinologist, has written an •earnest and gallant plea for a return to correct spelling, in a " Historical Study and Memoir of the Lady Ana," etc., published in 1874. But in spite of these protests, the jus- tice of which is universally recognized, it appears likely to continue to be misspelled as before. Perhaps, if Spain were a more influential country, either in politics or science, the sense of right in the matter might be more easily aroused. The genus is naturally a very interesting one, on account of its immense economical importance, but besides this it is also fascinating to botanists on ac- count of its very close affinity with the other genera of its tribe and the hopelessly puzzling questions which its division into species brings up. There is little doubt that the dividing lines between them have less permanent value than those between the majority of contiguous species and genera. The number of species of Cinchona is variously estimated to be between four and more than fifty. No two authorities agree exactly, but the major- ity, at present, place it between thirty-five and say forty. Bentham and Hooker, whose authority in botanical mat- ters is generally followed in these articles, estimate it at thirty-six, while the champion of the minimum number is Kuntze, who, after studying the cultivated cinchonas in Java and India, came to the conclusion that all forms were varieties of not more than four separate species. His view, although worthy of attention, has not been ac- cepted by others. It is probable, however, that division into few species and many varieties is likely to be the correct and final one. The Cinchonas are all evergreen trees or shrubs, many of them very large and handsome, with simple opposite leaves, and terminal panicles of pretty and fragrant, white, pink, or sometimes purplish flowers. The technical description of the genus, abridged from Bentham and Hooker, is as follows: Calyx tube turbinated, pubescent, limb five-toothed, persistent. 'Corolla funnel-shaped, pubescent, tube cylindrical or five- Fig. 657.-Cinchona Calisaya, one-third natural size. (Bailion.) ing Remijia, have any of the valuable alkaloids of Cin- chona been found ; some of them are not even bitter. Exclusive of the countries into which Cinchona has been artificially introduced, and in some of which it bids fair to be naturalized, its geographical range for so large a genus is a restricted one, being confined to the higher slopes and valleys of the Cordillera ranges of the Andes. It extends in a long open crescent from about the tropic of Capricorn to near the Caribbean Sea. The most northerly point is S.S.W. from Caracas, where C. cor- difolia and C. tucujensis (Karsten) have been observed; the most southerly is in the interior of Bolivia. Westerly it does not extend down the Pacific slope of the moun- tains ; easterly its boundary is less defined, but it does not generally extend beyond the Cordillera ranges. The width of this belt varies from fifty to two or three hun- dred miles. Cinchonas flourish only at a considerable altitude above the sea. The better species are not found at all below about two thousand feet above, and from this elevation to about ten thousand may be taken as the vertical limits of the genus, although one or two species exceed these in each direction. The best barks are gen- erally found between five and eight thousand feet above. 159 Cinchona. Cinchona. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. As the distance from the equator is increased, the average altitude materially lessens. These tropical mountain re- gions have a moist and changeable climate, with frequent alternations of sunshine, showers, and fog, and a mean temperature of from fifty-four to sixty-eight degrees. Oc- casional frosts and hail-storms occur in the higher regions, but do not injure the more hardy species ; but warmth and moisture in general are the characteristics of the climate. Of the, say thirty-six species of Cinchona, nearly all have some trace of one or more of the four alkaloids which constitute the active principles of the useful barks, but more than half of them in so small quantity as to make them at present practically worthless. Of the re- maining twelve or fifteen species the majority again furnish barks useful only to manufacturers of Quinine, and the others supply the officinal barks of different countries. These will be first noticed, and the less valuable ones afterward merely mentioned by name. 1. Cinchona Calisaya Weddell, discovered in 1847, is the source of the " Yellow Cinchona" or Calisaya {Cin- chona Flava, U. S. Ph., etc.), which has been the most prized sort for upward of a century. It is a fine large Cinchona {Cinchona Rubra, U. S. Ph., etc.). The leaves are large, five or six, or even sometimes twelve to eigh- teen, inches long, oblong, somewhat pointed, dark green, turning bright scarlet as they fall. The veins make often nearly a right angle with the mid-rib. Fruit longer and narrower than Calisaya, from two to four centimetres (three-fourths to one and one-half inch). This species in- habits now (excepting where it has been cultivated) only a limited area upon the western slopes of Mount Chim- borazo near Guayaquil, and is becoming more and more scarce in its native woods. It is, however, most easily and extensively cultivated in India, where it is indeed the most important of the cultivated Cinchonas. 3. Cinchona officinalis Hooker (not Linn.), with beauti- ful carmine-red flowers and small capsules, supplies in part the Pale Cinchona (Cinchona Pallida Cortex) of the British Pharmacopoeia, now no longer officinal here. It is a very variable species, and grows in Ecuador and Peru. Besides the above officinal species the following are mentioned as supplying an important amount of barks which go to the manufacture of quinine for manipulation. C. Lancifolia Mutis, C. cordifolia Mutis, supply Co- lumbia Bark. C. Macrocalyx Pavon, supplies Palton Bark. C. pitayensis Wedd, supplies Pitayo Bark. C. peruviana Howard, and other species, supply Lima Bark. C. tucujensis Karsten, supplies Maracaybo Bark, etc. For a careful table of the principal cinchonas and their products, the reader is referred to the article Cinchona of the Pharmacographia. Cultivation.-The introduction of these plants into other countries, especially India, Ceylon, Java, and Ja- maica, has been one of the most interesting experiments in arboriculture of recent times, and is the subject of a very extended modern literature. After one or two un- successful attempts the first plants were landed in Ba- tavia (Java) in 1854, by the Dutch botanist Hasskarl, as the result of an expedition made into Bolivia for this express purpose ; the plants were planted in Wardian cases and forwarded by a Dutch frigate to their destina- tion. In 1860 Mr. Markham, before mentioned as the champion of the correct spelling of the name, undertook the management of an English expedition for the same purpose, and with the assistance of Spruce, Pritchett, Cross, and others, collected large quantities of seeds and plants of the best species and shipped them to India. In connection with this admirable enterprise the greatest care had been used in seeking out exactly similar condi- tions of soil and climate in India, for the home of these new-comers, and in preparing for their reception. In 1861 the first plants were placed in a Government gar- den prepared for them in Ootocamond, in the Neil- gherry Hills, near the southwest coast of India, and shortly after another plantation was made in the Hima- laya Mountains, in Sikkim, in the northern part. The young trees in these two places flourished exceedingly, were rapidly propagated by cuttings, and in seven years were to be counted by millions, and their bark had be- gun to enter the market. Cinchona is now cultivated, besides the locations mentioned above, in other parts of India, in Ceylon, in Jamaica, Mexico, and finally in its own home in South America. The cultivated barks have appeared in the market in rapidly increasing quantities each succeeding year, and bid fair before long to rival in quantity, as they already do in quality, the natural sup- ply of South America. Collection.-1. Of native barks. This is carried on by native collectors called Cascarilleros, under the direc- tion of speculators or agents of trading companies, who form them into gangs and send them far into the forests for this purpose. The work is often exceedingly labori- ous-roads, or rather mule- and foot-pathshaving to be cut many miles before the desired region is reached. The expedition may last one or several seasons, and provisions must be carried, and sometimes gardens planted near the scene of their labors. As the Cinchonas have become more and more exterminated in the vicinity of civilized places, these journeys have become proportionately more Fig. 658.-The Red Cinchona Tree, Cinchona Succirubra. (Bailion.) tree, with a straight trunk and a spreading leafy crown. The bark is thick, whitish, and fissured upon the trunk, and dark and smooth upon the branches. The leaves are light green, obovate, blunt, five or six inches long, taper- ing at the base into the petiole. The flowers in large loose panicles are about half an inch across, light pink and fragrant. Capsule short, ovate, about one and a half centimetre (one-half inch) in length. The species is very variable in size, shape of leaves, and even in the quality of its product. Var. Josephiana is a small one, with narrower leaves and whitish flowers. Its bark is of little value. Var. Ledgeriana, on the other hand, also a shrub, discovered by M. C. Ledger in 1851, has proved in cultivation to be the richest variety known. The seeds of the shrub were obtained by Mr. Ledger's servant in 1865, and afterward sold to the Dutch government and planted in Java. It has small white flowers, and rather pointed leaves. Calisaya and its varieties inhabit the southern portions of the Cinchona area, occurring in Bolivia and southern Peru, N.E. of lake Titicaca, at an elevation of upward of five thousand feet. It is exten- sively cultivated in Java, India, and Ceylon. 2. C. succirubra Pavon, also a large fine tree, with a brown bark and pubescent branches, furnishing Bed 160 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cinchona. Cinchona. ject of numerous acrimonious disputes. One of the prom- inent figures in its early use was Robert Talbor, of England, who succeeded in curing many eminent per- sons with a secret remedy, which, after his death, was shown to be a vinous preparation of Cinchona. From the latter part of the century until now, Cinchona, or its active principles, have been in constantly increasing use. The cultivation of the trees, first established in Java in 1854, and in India in 1861, has insured the abundance of what promised until recently to be a scarce and diminish- ing drug. Description.-It is difficult to word any general de- scription by which Cinchona barks may be distinguished from those of many other trees. Their external ap- pearance, color, texture, surfaces, fracture, vary greatly in different specimens. Of odor they generally have none or little ; their taste is simply bitter, or bitter and astringent. In color, upon the inner surface or fracture, they are grayish-yellow, buff, yellowish-brown, or deep brownish-red ; externally they may have the same color if the cuticle has been removed, or they may be blackish- brown, grayish, or gray if it has not. Several common species of lichens usually grow upon their surfaces, and color them either light gray or almost black. Mossed, and generally renewed, barks are free from these, and of a yellowish-brown or brown color. Some species have smooth, others exfoliating barks. Cinchona bark is generally very brittle, its fracture is fibrous but short, seldom splintery, breaking nearly as easily transversely as lengthwise. It comes in pieces of every size, from fine chips to long quills or slabs half a metre or more (two or three feet) long; from thick trunk bark one centi- metre thick or more to the quills of slender twigs. The recent introduction of the cultivated barks of the Eastern hemisphere has greatly multiplied the diversity of appearance, by offering genuine Cinchonas of well- known species so different in appearance from their South American predecessors that no one would suspect them to belong to the same family. The mossed, re- newed, scraped, and other artificial forms of bark are of exceedingly diverse appearance. In the living barks the color is internally pale yellowish or whitish-green, the buff and red shades only appearing after exposure to the light and air. They can also be modified to some extent by the details of drying, and the exact shade of the fa- vorite red and yellow barks is often attained by the ex- ercise of judgment in this respect. The structure of the Cinchona barks in general presents some peculiarities which are of use in distinguishing them from barks of other trees, and from each other. The most important of these is in the shape and arrangement of the liber-cells, which are shorter and stouter than is common (from ten to twenty times as long as their diameter), spindle-shaped, with blunt-pointed ends and very thick walls. They are never arranged in large, long, tough bundles, as is the case with stringy barks, but are usually either entirely separate, each surrounded by thin-celled parenchyma, or in groups of two to three or a few more cells. In some species these cells or groups are distributed irregularly in the liber, in others arranged in radiating lines be- tween the medullary rays. The peculiar fracture of the Cinchona barks is explained by this structure. The arrangement of the ducts and laticiferous vessels, the ap- pearance of the cork, the presence and distribution of the " stone-cells" with calcium oxalate crystals or other concretions, the formation of exfoliating surfaces as in Calisaya, and other details, have been very carefully studied by numerous observers, and furnish, in some in- stances, the means of distinguishing species from each other. But with all the aid of external and internal ap- pearance, it is only the best-defined species that can be with certainty told from each other. There are several well-defined trade varieties of this drug which are en- titled to special description. First, Calisaya, Yellow Cinchona (Cinchona Flava, U. S. Ph. ; Cinchona, Cortex, Br. Ph. in part; Quinquina jaune royal, Codex Med., etc.). This, the most prized kind of all, is the bark of Cinchona Calisaya Weddell and its varieties. It has been in use about a hundred long and laborious. As soon as the bark collectors have reached a place where the trees seem to be abundant enough, they erect temporary huts, where their provisions, and afterward their bark, are stored. When a tree is se- lected for cutting, the underbrush is cleared away and the principal roots laid bare. The trunk is then beaten to re- move the dry, corky layer, which is thrown away, and the inner bark is then separated in large strips, as far in both directions as the operator can reach. The tree is then felled, and the process repeated upon the larger limbs and branches; from the smaller branches it is separated entire, that is, without removing the cork. It is then dried, either in the sun or over a fire in the huts. That of the larger branches and trunk is laid in piles so as to prevent the pieces curling as they dry, and is usually packed separately and known as " Flat Bark," while the thinner bark of the smaller branches is allowed to curl in rolls as it dries, and called, to distinguish it, " Quill Bark." When dried it is tied up, or wrapped in hides, and carried on the backs of mules or Indians many long miles through the woods before civilized roads or villages can be reached. From the gradual extinction of the older trees the amount and size of " flat" specimens has been diminishing for a number of years, until typical pieces of flat "Crown" have become about obsolete, while handsome red and yellow barks are costly beyond their real value. 2. The collection of Indian and other cultivated barks is effected in several ways': The first and simplest con- sists of separating the entire bark of the young trees and allowing it to dry in quills-this, as in South America, kills the plant and is consequently not economical. Some- times only a portion of the bark-from one side of the trunk, or a short ring-is taken in such a way as to spare the tree, and the remaining portions similarly removed in succeeding years. The above barks in both cases are classed as "natural." In the latter methods a second growth of bark is formed upon the places where the first has been removed, which after a few years is itself col- lected, and constitutes the "renewed" bark. By careful treatment the trees will bear repeated partial strippings (the cambium not being injured), like the cork-oaks of Spain-and these " renewed " crops appear to grow better with repetition. Sometimes the bark, either "natural" or renewed, is swathed in protecting sheaths of straw or moss, wrapped around the trunks. The barks which have been so covered are known as "mossed" barks. Finally, a desirable mode of collecting is by shaving or cutting the outer and middle portions of the bark, with a sort of spoke-shave, and not touching the innermost cam- bium portion at all. This method, which does not im- pair the growth of the tree at all, procures the older part of the bark, which, in C. succirubra at least, is the richest in alkaloids, and promises to be the best method for the present, while the extent of the Cinchona orchards is limited. It is needless to say that the Cinchonas of India and Java, obtained by these various methods, do not bear the slightest external resemblance to the classic barks of the older commerce. History.-Of the early use of Cinchona in Peru, by the Indians, there is nothing positively known, although the fact that its first reported employment was directed by "native" doctors tends to indicate it. On the other hand, it is said not to be employed by them at present, nor in recent historical times. The first reported use of this remedy is by the Spanish Corregidor of Loxa, Don Juan Lopez Canizares, in 1630 ; but its trial on the now famous Countess of Chinchon, mentioned early in this article, is the earliest case of undoubted authenticity. She was taken, in 1638, of intermittent (?) fever, and the same Don Lopez sent to her physician some of the bark, with assurance of its efficiency. It being tried, and curing the Countess, upon her recovery she procured a quantity of it and used to distribute it among the sick. Next year it reached Spain, and shortly after was carried by Jesuits and priests to other parts of Europe, so that, by the mid- dle of the century, it was known in the principal cities of the Continent. Through jealousy, at first of the Jesuits, and then of several of its earliest advocates, the new rem- edy met with considerable opposition, and was the sub- 161 Cinchona. Cinchona. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. years, and like several of the others occurs in the thick plates obtained from the trunks and in quills. The for- mer is one of the most distinctive of Cinchonas. It has a bright, brownish-yellow color, a very fine fibrous struct- ure, and a very short fracture. Its internal surface is smooth, and marked with fine wravy lines ; externally it is rough, with shallow, rather irregular depressions caused by the separation of its corky layers. It consists entirely of the inner bark, the outer having been re- moved by the beating and other manipulations it has undergone at the hands of the Cascarilleros. Its liber- cells are generally separate or in bundles of two or three, and evenly distributed through the whole thickness in radiating lines between the medullary rays. The pieces vary from mere fragments to half a metre in length, and run up to one centimetre or more thick ; their texture is soft and uniform. Large, handsome, and rich specimens of this Cinchona are becoming more and more rare. It comes from Bolivia. Calisaya Quills are now more com-, mon. They are three or four centimetres (one and a half inch) in diameter, and from ten to fifty or more in length. External surface smooth, gray, or brown in color, longitudinally furrowed. Inner surface brownish- yellow, finely striate ; fracture, purely fibrous. Ledger's bark is from a variety of G. Calisaya. It comes only in quills, which are with difficulty distinguished from those of the typical quilled Calisaya. A very corky bark is one of the Indian cultivated varieties, probably of G. Cali- saya, very rich in alkaloids. They may both be classed with yellow or Calisaya Bark. The Pharmaceutical de- scription of Calisaya is as follows : " Yellow Cinchona of commerce is in flat pieces or in quills. The fiat pieces vary in length and width, are from one-sixth to two-fifths of an inch (4 to 10 mm.) in thickness, almost entirely deprived of the brown, corky layer, compact, of a tawny-yellow color ; outer surface marked with shal- low, conchoidal depressions and intervening, rather sharp ridges ; inner surface closely and finely striate ; the trans- verse fracture showing numerous very short and rigid, glistening fibres, which are radially arranged, and rarely in small groups. The powder has a light, cinnamon-brown color, and a slightly aromatic but persistently bitter taste. "The quills are either single or double, varying in length from one-half to two inches (1 to 5 ctm.) in diameter ; the bark is from one-sixteenth to one-eighth of an inch (1.5 to 3 mm.) in thickness ; it is covered with a grayish cork, marked by longitudinal and transverse fissures, about one inch (25 mm.) apart and forming irregular meshes with raised edges. The inner surface is cinna- mon-brown and finely striate from the bast-fibres. "The true Yellow Cinchona Bark should not be con- founded with other cinchona barks of a similar color, but having the bast-fibres in bundles or radial rows, and breaking with splintery or coarsely fibrous fracture." Red Bark, Red Cinchona (Cinchona Rubra, U. S. Ph. ; Cinchonas Rubrce Cortex, Br. Ph.; Quinquina Rouge, Co- dex Med.), is the product of Cinchona Succirubra Pa von, of Ecuador. It is also one of the earliest known barks. Flat Red Bark is exclusively from South America, the cultivated product being always in quills or chips. It is easily recognized by its large size and thickness, its deep, dull red color, its smooth surfaces, and its fracture. Tlfis is smooth in the outer one-fourth or so of the di- ameter of the bark, and rather coarsely fibrous in the inner portion. The liber-cells are of a beautiful deep red color, arranged in radial lines, and rather more num- erous and contiguous than those of Calisaya. The sur- face is seldom exfoliated. Red Quill Bark. This may be either South American or Eastern. It is the most important and abundant of the East Indian product. The quills vary from one to four centimetres (one-third to one and a half inch) in diam- eter, and may be twenty-five or fifty long. Externally the bark is rather smooth, gray; internally, it is dull brownish red. The officinal description of Red Cinchona is as follows : "In quills and in flat or inflexed pieces, varying in length and width, and from one-eighth to one-half of an inch (3 to 12 mm.) in thickness ; compact: of a deep brown-red color; outer surface covered with numerous suberous warts and ridges, or longitudinally and some- what transversely fissured ; inner surface rather coarsely striate ; transverse fracture short-fibrous ; the bast-fibres in interrupted, radial lines ; the powder deep brown-red, slightly odorous, astringent, and bitter. "Red Cinchona should not be confounded with other Cinchona barks, having an orange-red color, and break- ing with a coarse splintery fracture. Thin, quilled Red Cinchona of a light red-brown color, should be rejected." Pale Cinchona (Quinquina gris de Loxa, Codex Med.). This is not so well defined a sort as the two just described. It is indeed doubtful if it is the product of a single species, although usually attributed to G. Officinalis. It comes in quills, generally rough and transversely fissured, often twisted or bent, gray externally, yellowish-brown within. Besides the above there are a dozen or more varieties of generally inferior Cinchonas which are not employed di- rectly in medicine, but purchased by manufacturers as source of the Cinchona alkaloids. Columbian, Huanaco, Carthagena, New Granada, etc., barks are examples. They do not come, uniformly, from the same species. All the above descriptions and all the estimates of the value of barks by their appearance, have become of very much less importance within the past few years, since the culture in India, on the one hand, has greatly modified their appearance, and the process of valuation by assay of their active principles, on the other, has given a far more accurate method of learning their quality. Constituents.-The medical properties of Cinchona are diie almost entirely to its bitter alkaloids, of which four-quinine, quinidine, cinchonine, and cinchonidine- are in common use, and will be treated in full below. Be- sides these, there are a dozen or more other alkaloids, more or less resembling them, which either occur in very small proportion, or are only found in particular varieties or specimens, and there are also a number of acid and neutral constituents. It further contains the usual vege- table substances, woody fibre, starch, sugar, etc., and about three per cent, of ash. The proportions of these various ingredients, as is to be expected considering the numberless varieties of the drug, are subject to very con- siderable variation. One or more of the four principal alkaloids just mentioned, are found in every bark of any value ; usually two or three of them are associated to- gether, and not infrequently the entire four co-exist in the same specimen. As a rule, the barks of particular species of Cinchona regularly contain a predominance of some one or another of them, as Calisaya of quinine, Red Bark of cinchonine, Pitayo Bark of quinidine, etc. The older pieces from the same tree are apt to be richer in quinine, the younger in cinchonine. Cultivation and ma- nuring increase the alkaloids, and "renewed" barks in general run better than the "natural" ones. The bark of the root is richer than that above ground. Finally, the alkaloids cannot be seen in situ with the microscope, and the real value of barks cannot be judged of by their appearance. The principal seat of the alkaloids-at least in C. succirubra, where it has been carefully studied-ap- pears to be in the cellular tissue just external to the liber, so that the scraped and shaved barks of the Indian plan- tations are better than the entire ones from the same. In C. calisaya, however, it is abundant in the bast itself. These alkaloids are not free, but are combined in nature with one or more acids, probably mostly cinchotannic and kinic. Other parts of the trees, especially the leaves and flowers, contain a small proportion of them. They have, so far, only been found in products of the genus Cin- chona, and its near relation Remijia (see Allied Plants); their occurrence in the latter being a recent discovery. South American barks are sometimes injured by too much heat used in drying, which decomposes their alka- loids, but further than this, they appear to be entirely permanent, so that long keeping does not damage them materially. The following list shows the principal substances so far found in undoubted Cinchonas. At the end of the article (Allied Plants) a few more will be mentioned, which have been discovered in Remijia and other " false " barks. 162 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cinchona. Cinchona. Name. Discovery. Composition. Source. Approximate Proportions. Quinine. Pelletier and Caventou, 1820. C20H24N2O2. In all the best Cinchonas, especially C. Calisaya, Ledgeriana, officinalis, laneifolia, pitayensis, etc., associated with cincho- nine, etc. In good flat Calisaya from 2 to 4 per cent. ; Quill Calisaya, % to 2 per cent. ; in good Red Bark, X to 3 per cent.; in common Cinchonas, X to IX per cent. Cultivated Barks often run much higher. Extreme figures are : in C. officinalis, 9.1 per cent. ; C. succirubra, 9.8 per cent.; C. Ledgeriana, 13.61 per cent. The Pharmacopoeia re- quires not less than two per cent. Quinidine. Henry and De- londre, 1833. Same formula. C. pitayensis and other good species. One or two per cent., largely obtained from " Chinoidine." Cinchonine. Pelletier and Caventou, 1820. C]9H22N2O2. Red Bark, C. succirubra, also in most of the others, common and abundant. Good South American Red Bark, from 1 to 3 per cent. Calisaya less than one per cent. ; Pitayo Bark, one per cent. Cultivated Red Bark, from one to five or six. Extreme figures: Red Bark 9.8 per cent. Cinchonidine. Homocinchonidine. Quinamine. Cinchamidine. Aricine. Cusconine. Cusconidine. Vuscamine. Cuscamidine. Paricine. Winckler, 1847. Hesse, 1877. Hesse, 1872. Hesse, 1881. Pelletier and Coriol, 1829. Hesse, 1877. Hesse, 1877. Hesse, 1880. 1 Hesse, 1880. f Winckler, 1844. Same formula. C^H^NjOo. C19M24N2O. C20H26N2O. ^23^^2C^2^4* ^23^^26^2^4* Not analyzed. Not analyzed. C. tucujensis, also in other species. South American Red Bark. C. Ledgeriana, officinalis, etc., also in Remijia. From the mother-liquor of Homocinchonidine. Fre- quently present in com- mercial Cinchonidine. C. pubescens, etc., Arica or Cusco Bark. Accompanying the above. C. pelletieriana ("Cusco Bark"). C. succirubra (Hesse, 1877). In red cultivated barks, from 3 to 4 per cent.; extreme, 5.2 per cent. Also obtainable from " Chinoidine." 1. Alkaloids. 2. Acids. Name. Discovery. Composition. Source. Approximate Proportions. Cinchonic Acid. Kinic Acid. Chinovic Acid. Cinchotannic Acid. Hoffman, 1790. Hlasiwetz. Berzelius. c7h1206. C34H38O4. In all Cinchonas and many other plants. A widely dis- tributed vegetable acid. In cultivated Cinchonas; probably more general. Al- so in Tormentilla. All Cinchonas. From five to eight per cent. From one-half to three or more per cent. 3. Neutral and Miscellaneous. Name. Discovery. Composition. Source. Approximate Proportions. Chinovin. A gluco- side. Cinchona Red. Lignoin. Cinchocerotin. Water. Pelletier and Caventou. 1821. Reuss, 1812. Reichel, 1856. Kerner, 1859. O o > o • I s a w : co S ° « • Cinchonas, Remijias, and other Cinchonece. All Cinchonas, especially the red. Cinchonas - doubtful sub- stance. Calisaya. z One or two per cent. From two to fourteen per cent. Nine to eleven per cent. In addition to these may be mentioned Chinoidine {Chinoidinum, U. S. Ph., Chinioidinum, Ph. G.), the black extractiform mass obtained by evaporating the mother-liquor of Quinine, etc. It consists of the inferior alkaloids in an impure state, and decomposition products, such as Quinicine, Cinchonicine, etc. The following comparative resume of the differential characters of the principal alkaloids is taken from Fliick- iger's monograph. Essentially the same is found in the Pharmacographia, as well as in Husemann's Pflanzen- stoffe, to all which the writer is greatly indebted for the above details. a. Hydrated crystals are formed by: Quinine, Quini- dine. Not containing water of crystallization: Cincho- nine, Cinchonidine, Quinamine, Homoquinine.* b. Abundantly soluble in ether; Quinine, Quinidine, Quinamine. Slightly soluble in ether; Cinchonidine, Cinchonamine.* Very sparingly soluble in ether : Cin- chonine. c. Levogyrate solutions afforded by: Quinine, Cin- chonidine. Dextrogyrate solutions afforded by : Quini- dine, Cinchonine, Quinamine. d. Thalleioquin is afforded by: Quinine, Quinidine, Homoquinine. Thalleioquin is not afforded by; Cin- chonine, Cinchonidine, Quinamine. e. Fluorescence is displayed in the acid solutions of salts of: Quinine, Quinidine, Homoquinine. No fluo- rescence is displayed by : Cinchonine, Cinchonidine, Qui- namine. The officinal alkaloids are thus described in the Phar- macopoeia : " Quinine.-A white, flaky, amorphous or minutely crystalline powder, permanent in the air, odorless, having a very bitter taste, and an alkaline reaction. Soluble in about 1,600 parts of water, and in 6 parts of alcohol at 15° C. (59° F.); in 700 parts of boiling water, in 2 parts of boiling alcohol, in about 25 parts of ether, in about 5 parts of chloroform, in about 200 parts of glycerine, and also soluble in benzin, benzol, water of ammonia, or in diluted acids, which latter it neutralizes. When heated to 57° C. (135° F.) it melts, and at the temperature of the water-bath, loses about nine per cent, (about two molecules) of its water of crystallization, the remainder being expelled at 125° C. (257° F.). On ignition, the al- kaloid burns slowly without leaving a residue. The so- lution of Quinine in diluted sulphuric acid has a vivid, blue fluorescence. Treated, first, with fresh chlorine water, and then with a slight excess of water of am- monia, Quinine produces an emerald-green color " (Thal- leioquin). Quinidine is not officinal. It crystallizes in large four- sided prisms, of bitter taste and alkaloid reaction. It ♦ Alkaloids of Cuprea (Remijia) Bark, not in Cinchonas proper. 163 Cinchona. Cinchona. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dissolves in 2,000 parts of cold water. The sulphate is officinal. Cinchonine.-"White, somewhat lustrous prisms or needles, permanent in the air, odorless, at first nearly tasteless, but developing a bitter after-taste, and having an alkaline reaction. Almost insoluble in cold or hot water, soluble in 110 parts of alcohol at 15° C. (59° F.), in 28 parts of boiling alcohol, 371 parts of ether, 350 parts of chloroform, and readily soluble in diluted acids, forming salts of a very bitter taste. At about 250° C. (482° F.) it melts and turns brown, with a partial subli- mation. On ignition, the alkaloid is dissipated without leaving a residue." Cinchonidine is not officinal. It also crystallizes in large, shining, but anhydrous prisms. It is less bitter than the others, and requires about 2,500 parts of water for its solution. The sulphate is officinal. In order to separate the alkaloids, their natural salts must be decomposed, as they are not wholly soluble. This is effected in several ways. In one series it is done by macerating the powdered bark in acidulated (sul- phuric or hydrochlorate) water, which replaces the kinic salts with soluble sulphate or chloride, etc., precipitating the crude alkaloids with quick-lime, re-dissolving in acid- ulated water or other solvent, and purifying by animal charcoal, crystallizing, etc. In another method the ki- nates are decomposed by an alkali instead of an acid (lime), and the free alkaloids extracted by petroleum, ben- zin, or other mineral oils, alcohol, etc., and purified by washing, re-crystallization, animal charcoal, etc. The separation of the alkaloids from each other is done by taking advantage of their different solubilities, and the formation of salts, by treating them with the different acids. This is only a merest outline of the process, but as it is done wholly by large manufacturing chemists, the details are not of general interest. In the United States Pharmacopoeia are given processes for recovering the al- kaloids in bulk, and also for quinine separately, for the purpose of assaying the officinal barks.* Finally, all Cinchonas are now bought and valued at prices based upon such analysis. Action and Use.-Of the minor constituents : the in- ferior alkaloids in general have the same action as qui- nine, only somewhat weaker, but quinidine is claimed to be fully as good. Quinamine and one or two others are different in kind as well. Kinic acid is pleasantly sour, and has about the same properties as malic or citric acid. Chinovic acid is almost insoluble and tasteless. Cinchotannic acid is astringent, like other tannins-its iron salts are green. Chinovin is a bitter glucoside, and probably adds distinctly to the tonic value of the bark. On these, and perhaps other ac- counts, the extracts, tinctures, etc., of the barks them- selves are, possibly with reason, considered to be better tonics than solutions of the alkaloids only. With this preliminary sentence Quinine will be taken in the follow- ing paragraph as representing Cinchona, as it does in all its definite physiological powers. Its solutions lessen protoplasmic (amoeboid) movements in general. They are also, when concentrated, moderately destructive to the lower forms of life, and, probably by virtue of this quality, diminish or arrest alcoholic, lactic, and some other fermentations, as well as preserve, for a time, meats, butter, urine, etc., from putrefactive change. On these accounts it has had some employment as an antiseptic, a* a wash for diphtheritic conjunctivitis, as a dressing for ulcers, as a gargle in pharyngitis, and as an injection or spray in coryza. Its value in hay-fever has been some- what similarly explained, and its power over intermit- tent may yet be shown to be due to its poisonous action upon some living germ causing that disease. But the germ has not yet been surely found. Quinine appears to materially diminish the activity of the white blood- corpuscles. This is offered, with plausibility, as an ex- planation of its recognized value in certain inflammatory and suppurating fevers, like pyaemia or erysipelas. Quinine in solution is readily absorbed from the stom- ach, and begins to appear in the urine (with which it is eliminated) in from half an hour to an hour ; but if un- dissolved, or in old hard pills, it may pass through the bowel unchanged if the stomach should happen to con- tain no acid. It is a good plan, if powdered quinine has been taken, and the stomach is inactive, to follow it with some weak acid ; lemonade would do. From other mucous membranes it is absorbed more incompletely, from gran- ulations and ulcers generally still less, from the whole skin practically none at all. Clear, or in strong solu- tion, it is a mild irritant; given subcutaneously (in solu- tion) it is painful, and may be followed by inflammatory indurations, and even abscesses and sloughs. The physiological action of quinine upon the higher animals or man, does not explain to any great extent its therapeutic value, and on this account will be only briefly summarized. Restlessness, tremblings, vomiting, stupor, paralysis, dyspnoea, blindness, coma, and convulsions, also death, by failure of respiration, are the symptoms observed after enormous doses given to the lower animals. In man, a feeling of cerebral pressure or headache, ringing or other noises in the ears, are present after large doses, and blindness or some disturbance of vision occurs occa- sionally. These symptoms are temporary, and generally pass off with the elimination of the drug. Occasionally they may persist for a considerable time. Poisonous doses in man produce effects similar to those named above as observed in animals. The tinnitus aurium is always present after a full antipyretic or anti-intermittent dose ; it is probably due to an intensely congested condition of the middle and inner ear.* It is thought to increase cerebral congestion, but after large doses the reverse appears to be the case, the brain sharing in the general debility of the circulation. The action upon the spinal nerves is not very definite, upon the intestinal tracts slight or entirely wanting, upon the circulation, in large doses, to reduce it, and finally, none of these actions is recognized as the basis of its value. It diminishes waste of tissue, and the nitrogen in the urine. Uses.-Besides those incidentally noticed above, are the following : In the first place, and by far the most important, stands that for which it was originally used, and in which it has fairly driven out of employment every rival-its curative power over intermittent fever. Excepting the mercurials and iodine for syphilis, there is not in the medical repertoire a drug that comes so near being a practical specific as this. As a prophylactic, as a palliative, as a cure, it is wonderfully successful; and in the cachexia of malarial poisoning, and the peculiar ten- dency to chills and febrile attacks which many persons who have been exposed to it have, long after the acute symptoms have gone by, and after they have perhaps lived for years in a non-malarial region, nothing affords such marked relief. As a prophylactic, it is taken to the extent of about two decigrams daily, by those exposed to malarial influences. In the treatment of intermittent al- ready developed, the best time to administer it is from eight to four hours before the expected chill; a full anti- pyretic dose, say one gram (gr. xv.) should be given, or the same amount may be taken in two or three portions close together. It acts best when associated with some purgative treatment. Smaller doses should be continued for some time after the chills have been overcome. In severe or malignant types of the attack, very large doses, one or two grams, are sometimes indicated at once, and should be repeated in a few hours. Quinine is also useful in neuralgias, especially if of a remittent or periodic type, medium-sized doses being required. Another important use to which it has been latterly much put, is to reduce the temperature in septic, typhoid, and other fevers. Although it has no effect upon the normal temperature, except in enormous amounts, in those conditions in which the bodily temperature is four or six degrees above the normal, a full dose of quinine * " Dr. Kirchner found in rabbits, cats, and guinea pigs which had been poisoned with quinine or with salicylic acid, very great congestion of the middle ear and of the labyrinth, with bloody exudation, and with, in some cases, the ear-drum swollen into a bladder-like body by serous ex- udation." Quoted by Wood: Therapeutics, p. 05. * Under article Cinchona. 164 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Clncliona. Cinchona. will generally reduce it from one to three degrees and keep it down for several hours, and remove the dangers and inconveniences of the excessive heat. It is, however, a physiological process only, and does not otherwise modify or shorten the run of the disease. Alcohol and cold bathing are most frequently used, in connection with it, for this purpose. It is also used occasionally in childbirth. In slow and protracted labor, when the pains are dull and infrequent, but especially in long labors, where the patient is nervous and tired out, when the pulse is weakening and becom- ing frequent and the pains dying away, a large dose of this substance frequently acts like a charm. Ergot often fails in such cases until the quinine has been given, when the pains return with renewed strength and continue to the end. It will not, however, start a labor not begun, nor produce an abortion. As a tonic, quinine, or some Cinchona preparation, is in universal use. In small doses it appears to act like the simple bitters-improving the appetite, digestion, and nu- trition. When there is nervous debility, it is especially useful, otherwise Gentian is in most cases better. Finally, it is used, in common colds, muscular rheumatism, sci- atica, and nearly all febrile diseases, with varying benefit. Administration.-It is not now given in substance. A dose of good powdered bark sufficient to break up an intermittent chill, or reduce a high temperature two de- grees would include twenty-five or thirty grams (25-30 Gm. = 3 vj. ad vij.) of useless wroody tissue-a small tea- cupful. A tonic dose would be a heaping teaspoonful, etc. The following Galenical preparations are officinal : 1. From "Cinchona," that is, any cinchona "having three per cent." or more of crystallizable alkaloids, is made : Infusion (Infusum Cinchona, U. S. Ph.). Cinchona,* six parts ; aromatic sulphuric acid, one part; water, enough to make one hundred parts ; percolate. A fair preparation, but not much used. Dose, as a tonic, thirty cubic centimetres (30 c.c.= 1 j.). '2. From Yellow Cinchona : Extract (Extractum Cinchona, U. S. Ph.). An alco- holic extract, kept moist by means of glycerine, for pills, etc. ; about six or seven times as active as the bark. Dose, as a tonic, thirty centigrams (0.30 Gm. = gr- v.) Fluid Extract (Extractum Cinchona FluidumAL S. Ph.); strength, |. On the whole the best of all the preparations, although not a favorite, representing the entire yellow bark. Tonic dose, two cubic centimetres (2 c. c. = 3 ss). Tincture (Tinctura Cinchona, U. S. Ph.); strength, -j1^. The proportionate dose of this preparation, to obtain the same amount of cinchona, should be tw enty cubic centimetres (20 c.c. - 3 v.), but the usual amount given is less than half as much. It is not much used. 3. From Red Cinchona : Compound Tincture of Cinchona (Tinctura Cinchona Composita, U. S. Ph.), Huxham's Tincture of Bark. This elegant and universally used tonic is prepared from the Red Cinchona, for its color, and on account of old tradition. Its composition is : Red Cinchona 10 Bitter Orange Peel 8 Serpentaria 2 Glycerine 10 Alcohol and water (eight and one), enough to percolate one hundred parts. None of the above preparations are suitable for any- thing more than the tonic uses of cinchona, nor should they be employed when any high degree of accuracy is desired. They have, over the separate alkaloids, what- ever advantage may be due to the presence of the in- ferior alkaloids, the chinovin, and the acids of the crude bark. Where any definite, physiological effect is desired, the alkaloids themselves should be given. Their exceedingly bitter taste has led to numerous devices to conceal it. Among the most successful are : gelatine capsules, which will hold one or two decigrams (one to three grains)-the French " Cachets de pain," in which about twice as much can be sealed,-sugar- and gelatine-coated pills, which are manufactured in enormous quantities, and can easily be made extemporaneously, etc. Several other methods of administration are also used with a view of lessening or disguising the taste. Taken in milk or suspended in a weak alkaline solution, say of bicarbonate of soda, it will be found to have a somewhat less bitter taste. One of the best vehicles for disguising it is ammoniated glycerrhy- zin, one part in three or four of, say sulphate of quinine, rubbed carefully together, and the powder taken either dry or moistened at the instant of swallowing. The bit- ter is hardly noticed. It is often given also in the syrup, fluid extract, or an elixir of liquorice, all of which answer the purpose fairly. If they are bought separately, and the alkaloid salt put in each dose as wanted, the device is better. Quinine itself is less bitter than its salts, and may be given if desired on this account. For rapid absorp- tion, however, a solution either in spirit or in acidulated water is the most suitable. An amount of diluted sul- phuric acid equal to the quinine (or cinchonine, etc.) to be dissolved, is rather more than sufficient to insure it. Bisulphate of Quinine dissolves without additional acid. There is no disguising the taste of these solutions. Officinal Alkaloids, etc.-Quinine (Quinina, U. S. Ph.), the pure alkaloid, is used mostly in pharmacy to make other preparations, as : Citrate of Iron and Quinine (Ferri et Quinina Ci- tratis, U. S. Ph.), containing twelve per cent, of Quin- ine, much used as a tonic. Dose, thirty-five centi- grams (0.35 Gm. = gr. v.). Solution of the above (Liquor Ferri et Quinines Ci- tratis, U. S. Ph.), containing six per cent, of quinine, used in pharmacy to dilute still further in dispensing and to make the Bitter Wine of Iron (Vinum Ferri Amarum, U. S. Ph.), whose formula is as follows : Solution of Citrate of Iron and Quinine. 8 Tincture of Sweet Orange Peel 12 Syrup 36 Stronger White Wine 44 100 This is the most elegant form in which tonic doses of quinine and iron can be given, where the wine is not an objection. Tonic dose, ten or fifteen cubic centi- metres (10-15 c.c. = 3 ijss. ad 3 iv.). And finally Quinine is employed in the formula for the Syrup of the Phosphates of Iron. Quinine, and Strychnine, called also syrup of the triple phosphates, (Syrupus Ferri Quinines et Strychnina Phosphatum, U. S. Ph.), as follows : Phosphate of Iron 133 Quinine 133 Strychnine 4 Phosphoric Acid 800 Sugar 6,000 Distilled Water to make 10,000 parts. It contains one and three-tenths per cent, of Quinine, and one twenty-fifth of one per cent, of strychnine. It is a favorite and much used nervous tonic. Dose, four or five cubic centimetres (= f 3 j.) Salts of Quinine.-Of these more than a dozen are in the market, but only four or five are much used. There is not much choice between these, and their selection is mostly a matter of habit. The sulphate is in almost universal use here ; the hydrochlorate and other more soluble ones in Europe. The officinal ones, with their solubilities in water, are given below : Sulphate (Quinina Sulphas, U. S. Ph.), 1 in 740. Bisulphate (Quinina Bisulphas, U. S. Ph.), 1 in 10. * When not otherwise specified, use Yellow Cinchona. The acid is added to aid in extracting the whole of the alkaloids. 165 Cinchona. Cinnamon. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Hydrochlorate (Quinines Hydrochloras, U. S. Ph.), 1 in 34. Hydrobromate (Quinines Hydrobromas, U. S. Ph.), 1 in 16. Valerianate (Quinines Valerianae, U. S. Ph.), 1 in 100. They are all, except the bisulphate, much more solu- ble in alcohol than in water. It has been claimed that the two last have additional qualities, due to the action of the bromine and valerianic acid bases, but the gain for these respects is not very important. The other officinal alkaloids and salts are : Sulphate of Quinidine (Quinidines Sulphas, U. S. Ph.), solubility, 1 in 100. Cinchonine (Cinchonina, U. S. Ph.), insoluble. Sulphate of Cinchonine (Cinchonines Sulphas, U. S. Ph.), 1 in 70. Sulphate of Cinchonidine (Cinchonidines Sulphas, U. S. P1l), 1 in 100. Chinoidin (Chinoidinum, U. S. Ph.), the black re- sidual extract obtained by boiling down the mother- liquors of Quinine, etc., insoluble. It is inferior to the above alkaloids in every respect, and seldom used. Now that they are so cheap, there is scarcely any rea- son for saving it. Doses of Quinine and its Salts.-Theoretically, there is a little difference in the strength of the above, but not much account is taken of this in practice. The Val- erianate is not given in the larger doses. In intermittents, from one-half to one and a half gram (0.5 to 1.5 Gm.= gr. viij. ad xx.) are given, either in one or two doses, a few hours before an expected paroxysm. Small doses are continued after the chills have been broken up. As an antipyretic, nearly the same amount is required, but given at one dose. To stimulate the uterus seventy-five centigrams (0.75 Gm. = gr. x. ad xij.). In erysipelatous and suppurating fevers, twenty-five centigrams (0.25 = gr. iv.) or so two or three times a day. As a tonic, one decigram (0.1 Gm. = gr. j. ad ij.), three times a day ; for neuralgias and headaches, twice as much. For hypodermic use, which is apt to be followed by ab- scesses and should be seldom resorted to, the bisulphate is the suitable form ; a saturated solution in distilled water being injected. Sulphate of Quinidine has the same dose as Quinine Salts. Sulphate of cinchonidine about one and a half, and cinchonine twice as great a dose. Quinetum is a mixture of all the alkaloids of East In- dian Cinchonas, extracted and precipitated together, and is used as a cheap febrifuge in India. Warburg's Tincture, which has had a great reputation in India in the treatment of malarial fevers, is a com- pound in which Sulphate of Quinine is the principal in- gredient. It contains besides Aloes, Rhubarb, Angelica, "Confection" of Damocratis, * Elecampane, Saffron, Fennel, Prepared Chalk, Gentian, Zedoary, Cubes Myrrh, Camphor, and Agaric ! Allied Plants. - The genus has been sufficiently dwelt upon in the beginning of this article. Of the re- lated genera, three have been mentioned, and there are several more whose barks were, during the last century and the early part of this, occasionally imported into Europe, either as experiments or as substitutes for true Cinchonas. They are all now entirely obsolete, excepting one, which is entitled to further notice. This is the genus Remijia, separated from Cinchona, in 1829, by De Can- dolle on account of having a capsule which splits from above downward, axillary instead of terminal inflores- cence, and other botanical details. The Remijias are slender, hairy or pubescent shrubs or small trees, with Cinchona-like leaves and flowers. There are thirty spe- cies, all South American. Unlike the free Cinchonas, they flourish well in comparatively low countries, even down to within a thousand feet of the sea-coast, and on this account could probably be much more widely culti- vated than the former. Two species, R. Purdeiana, a small shrub with rusty- woolly branches, and especially R. pedunculata, with glistening silky hairs on the younger parts, both natives of Bolivia, yield some of the Cinchona alkaloids. Their barks appeared in the market about fifteen years ago, and were designated by Professor Fliickiger " Cinchona cu- prea," from their reddish-brown color, which he aptly compared to tarnished copper. " Cuprea" bark occurs in Bat or channelled pieces and quills, or more usually in irregular and smallish frag- ments, generally peeled or scraped on the outer side, so as to remove the cuticle. It is very hard, and has the peculiar reddish color mentioned. It was imported, a few years ago, to such an extent as to materially cheapen quinine and the true cinchonas. At present it is not quite so abundant. The bark varies a good deal in qual- ity, besides being the product of at least two separate species. The following alkaloids have been observed in it: Quinine, from none to two per cent., generally from one-half to one or a little more ; quinidine, cinchonidine, 0.8 per cent. ; and several new alkaloids: homoquinine (1880-1882, by several observers), cinchonamine (1881, M. Arnaud in R. Purdeiana), conquinamine, etc. The acid of Cuprea is also said to be different from cinchotannic. These barks are never used in pharmacy, but go entirely to the manufacturers for the separation of their quinine. The order Rubiacecs is a large and interesting, but mostly Tropical-American, family. Only a few of its species are of extensive use, but some of these are of the greatest value. The following list includes the most in- teresting or familiar : 1. Cephalanthus, button bush, comes in our swamps ; pretty. 2. Uncaria, the source of the astringent Gambir, or pale catechu. 3. Cinchona, quinine, etc., yielding bark. 4. Remijia, quinine, etc., yielding bark. 5. Houstonia; one species is the pretty star flower of the meadows, in the spring. 6. Coffea; several species furnish Coffee. 7. Cepheslis; one species furnishes Ipecacuanha. 8. Rubia ; one species furnishes Madder. 9. Galium; several species used in vesical catarrh, etc. Allied Drugs.-In their control of intermittent fever and malarial poisoning, the cinchona alkaloids are sui generis. The great number and variety of drugs which were used for this disease before their introduction, and since, by those who are either prejudiced against, or by idiosyncrasy unable to take them, proves this. As none of them have any special value in this direction, they are not worth mentioning in detail; but berberine, buxine, among alkaloids, and a whole host of simple bitters and aromatics-Cascarilla, Thoroughwort, Quassia, etc., as well as the fragrant eucalyptus, may be referred to. As an antipyretic, its most important rivals, among drugs, are alcohol and several modern artificial alkaloids, of which " antipyrine" appears to be the most valuable. (See An- tipyrine, also Antipyretics, in vol. i.) Cold baths and spongings are better antipyretics even than quinine. As a bitter tonic: the berberine and buxine series of drugs, and the simple bitters. See Barberry, Box, and espe- cially Gentian. Inoxytocic power, it compares with Ergot. As an anti- septic and germicide, it ranks low, but may be compared with others in use. (See the article on Antiseptics in vol. i.) IK P. Bolles. CINCINNATI. The accompanying chart, representing the climate of the city of Cincinnati, O., and obtained from the Chief Signal Office in Washington, is here in- serted for convenience of reference. A detailed explana- tion of this, and of the other similar charts published in this Handbook, together with suggestions as to the method of using them, may be found under the heading Climate. * An Indian compound, containing itself many ingredients. 166 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cinchona. Cinnamon. Climate of Cincinnati, 0.-Latitude 39° 6', Longitude 84° 30'.-Period of Observations, December 1, 1870. to December 31, 1883.-Elevation of Place of Observation above the Sea-level, bo^feet. 'Meat A AA 6 g * "ce « If E§ "s se Jl bfS < Degrees. 34.4 37.8 43.5 54.6 65.7 72.4 78.3 77.8 67.8 57.6 44.4 36.8 54.6 76.1 56.6 36.3 55.9 B C n K F 1 » II temperature of months at the hours of Mean temperature for period of ob- servation. ! ! : : : : £ Average maximum temperature p • : : : g । for period. Average minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. 1 | Greatest number of days in any : : : : : singlemonthonwhichthetem- : ; : : : -••j-i-i---cj'oti perature was below the mean 1 monthly minimum temperature. Greatest number of days in any : : ; : : singlemonthonwhichthetem- : : : : : ; perature was above the mean ■ monthly maximum temperature, January.... February... March April May June July August September . October .... November.. December.. Spring Summer.... Autumn.... Winter Year ' 7 A.M. , Degrees. ' 31.2 I 33.4 38.8 49.2 60.1 69.5 73.5 76.5 62.2 52.2 40.5 33.5 3 P.M. Degrees. 38.4 42.6 48.9 61.0 72.8 80.7 84.9 82.5 74.9 64.1 49.2 40.7 11 P.M. Degrees. 33.9 37.6 43.0 53.8 64.3 72.4 76.6 74.5 66.5 56.5 43.5 36.4 Highest. Degrees. 48.6 46.5 51.4 60.2 70.6 79.0 81.6 79.5 76.1 64.2 48.5 47.4 58.5 78.4 62.2 40.6 57.7 Lowest. Degrees. 26.5 27.1 37.2 47.9 61.0 70.0 74.4 71.2 63.7 52.4 37.7 25.2 52.1 73.7 53.4 31.1 53.0 Degrees. 27.4 32.6 31.8 47.1 57.0 65.2 70.5 67.6 60.6 52.4 38.8 32.0 Highest. Degrees. 69.0 73.0 77.0 85.0 94.0 98.5 103.5 101.0 95.0 86.0 75.0 72.0 1 Lowest. Degrees. 47.0 59.0 60.0 75.0 82.8 89.5 90.0 87.0 80.0 73.0 62.0 52.0 Highest. Degrees. 25.0 25.0 35.0 40.0 48.0 58.8 67.0 62.3 58.0 43.3 30.0 26.0 Lowest. Degrees. -10.0 - 1.0 1.0 18.0 35.0 49.0 58.2 55.0 41.0 27.0 5.0 - 8.0 J L M IV O n S hyde, and also exists ready formed in conjunction with benzoic acid, to which it is closely related, in many balsams, as, for instance, the balsams of tolu, of Peru and of benzoin. It can also be formed synthetically. Cinnamic acid is a colorless crystalline body, without taste or smell, freely soluble in alcohol, but feebly only in water (one-tenth per cent.). Cinnamic acid is non-poisonous, and is said to resemble salicylic and benzoic acids in antiseptic power. It has been suggested as a practical antiseptic for use in surgical dressings. Lint, jute, etc., may be charged with the acid by soakage in an alcoholic solution. Sodic cinnamate is a salt freely soluble in water, and has been proposed as a substitute for cinnamic acid of greater convenience because of such free solubility. So far as the writer knows, exact observations on the anti- septic power of this salt are still wanting. Edward Curtis. CINNAMON {Cinnamomum, U .8. Ph. ; Cinnamomi Cortex, Br. Ph. [Ceylon] ; Cortex Cinnamomi, Ph. G. ; Cannelle de Ceylan, Codex Med.). The present U. 8. Range of temper- ature for period. | Mean relative hu- 1 Average number of fair days. Average number of clear days. Average number of fair and clear days. Average rainfall. Prevailing direc- tion of wind. Average velocity of wind, in miles, per hour. January... February.. March April May June July August.... September. October.... November. December.. Spring Summer... Autumn... Winter.... Year 79.0 74.0 76.0 67.0 59.0 49.5 45.3 46.0 54.0 59.0 70.0 80.0 93.0 54.5 90.0 83.0 113.5 72.3 69.4 61.8 59.2 58.8 64.3 64.4 66.2 66.4 66.0 68.4 72.0 60.9 65.0 66.9 71.2 66.0 10.2 9.8 11.9 11.8 13.4 12.9 13.2 12.8 10.8 11.3 11.4 10.9 37.1 38.9 33.5 30.9 140.4 4.8 5.9 6.1 8.2 8.8 6.3 9.2 10.5 11.2 10.7 7.2 6.0 23.1 26.0 29.1 16.7 94.9 15.0 15.7 18.0 20.0 22.2 19.2 22.4 23.3 22.0 22.0 18.6 16.9 60.2 64.9 62.6 47.6 235.3 Inches. 3.54 3.71 3.96 3.24 3.50 5.22 4.29 4.17 2.17 3.11 3.48 3.97 10.70 13.68 8.76 11.22 44.36 From S. W. N. W. N.W. N. W. S. E. S. W. S. W. N. E. S. E. S. E. S. E. N.W. N.W. s. w. S. E. N. W. N. W. Miles. 6.4 6.9 7.5 6.7 5.8 5.6 4.8 4.3 4.8 5.3 6.0 6.1 6.7 4.9 5.4 6.5 5.8 hyde, and also exists ready formed in conjunction with benzoic acid, to which it is closely related, in many balsams, as, for instance, the balsams of tolu, of Peru and of benzoin. It can also be formed synthetically. Cinnamic acid is a colorless crystalline body, without taste or smell, freely soluble in alcohol, but feebly only in water (one-tenth per cent.). Cinnamic acid is non-poisonous, and is said to resemble salicylic and benzoic acids in antiseptic power. It has been suggested as a practical antiseptic for use in surgical dressings. Lint, jute, etc., may be charged with the acid by soakage in an alcoholic solution. Sodic cinnamate is a salt freely soluble in water, and has been proposed as a substitute for cinnamic acid of greater convenience because of such free solubility. So far as the writer knows, exact observations on the anti- septic power of this salt are still wanting. Edward Curtis. CINNAMON (Cinnamomum, U .S. Ph. ; Cinnamomi Cortex, Br. Ph. [Ceylon]; Cortex Cinnamomi, Ph. G. ; Cannette de Ceylan, Codex Med.). The present U. S. Pharmacopoeia includes under the same term Ceylon or true Cinnamon, and the better grades of Chinese Cinna- mons-the Cassias of the market, giving a separate de- scription to each. The French and English, as just noted, require the former, while the German describes the latter only. There is no difference whatever in their medical properties if the percentage of oil is the same, the prefer- ence being based upon fineness and delicacy of flavor, in which the Ceylon product is superior. The appearance of the barks is quite distinctive, but only an experienced nose can tell the difference between their oils. The prices are as three or four to one. The " cinnamon" of house- hold use is almost always "cassia," and the poorer grades at that. The principal Cinnamon trees are as follows : 1. Cinna- momum zeylanicum Breyne; Order, Lauracea (Lauri- neat), a smallish evergreen tree, with smooth, slightly quadrangular, green or pale brown branches, and short- petioled, opposite, light green, three- or five-nerved leaves. These are ovate-oblong, blunt-pointed at the apex, rounded at the base, and entire. The flowers are in cymose clusters at and near the ends of the twigs ; they are small and inconspicuous, whitish green, regular, peri- ginous. The perianth is six-parted : Androecum of nine stamens and three staminodes, the outer six glandular at the base. Anthers four-celled, opening by uplifted valves. CINCINNATI ARTESIAN WELL. Location, Cincin- nati, Hamilton County, O. Analysis (E. S. Wayner).-One pint contains: Grains. Carbonate of magnesia 1.018 Carbonate of lime 2.167 Chloride of potassium 0.409 Chloride of sodium 64.950 Chloride of magnesium 2 267 Chloride of calcium 2.782 Sulphate of lime 3.409 Iodide of magnesium 0.024 Bromide of magnesium 0.032 Oxide of iron 0.046 Silica 0.061 77.165 Gases. Cubic in. Sulphuretted hydrogen 0.97 Carbonic acid 1.29 This artesian well is situated at the Cincinnati Gas Works. It has a depth of 1,245 feet, with a continuous flow of water. G. B. F. CINNAMIC ACID AND CINNAMATES. Cinnamic or phenyl-acrylic acid (C9HeO2) results from oxidation of oil of cinnamon, the oil being chemically cinnamic alde- 167 Cinnamon, Circulation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ovary, one-celled, one-ovuled. C. zeylanicum is a native of the hills and woods of the island of Ceylon. It has also been long cultivated in the same island, and it is from these cultivated plants that all the true cinnamon now comes. It has also been introduced into other islands of the Indian Ocean, and into the mainland of Asia, as well as into the West Indies, but it produces in these places inferior barks. On the cinnamon plantations the trees are trimmed down to make them send up sprouts from the base ; these are allowed to grow until they are about two years old and three or four centimetres in diameter, when they are cut, and the bark is peeled off in pieces about thirty centimetres (one foot) in length. These strips are then put together in rolls and allowed to wilt for a day or so, when they are separated and each piece is laid upon a suitable stick around which it will fit, and the outer cellu- lar layers of the bark are scraped off and rejected. The quills of inner bark so prepared constitute cinnamon, and are rolled together in successive layers until a solid cylin- der about a metre long and one and a half or two centi- metres thick is formed (one yard by half or three-fourths of an inch), of sometimes a dozen layers of brittle, splin- tery bark. The cultivation of Ceylon cinnamon is de- clining, and part of the supply comes from the neighbor- ing mainland of India. Cinnamomum Cassia Blume, is a larger tree with thicker bark, narrower three-nerved leaves, and a fine varieties of cinnamon come, in general, from the places whose names they bear : the Ceylon variety from that island, where also its oil has been distilled for a hundred years, and also from parts of India. Cassia (Chinese cinna- mon) from China, chiefly from Canton. The description of the two articles from the Pharmacopoeia is appended : " Ceylon cinnamon is in long, closely-rolled quills, com- posed of eight or more layers of bark of the thickness of paper ; pale yellowish brown ; outer surface smooth, marked with wavy lines ; inner surface scarcely striate ; fracture splintery ; odor fragrant ; taste sweet and warmly aromatic. " " Chinese cinnamon (Cassia Bark) is in quills about one twenty-fifth of an inch (1 millimetre) or more in thick- ness ; nearly deprived of the corky layer ; brown, outer surface somewhat rough ; fracture nearly smooth ; odor and taste analogous to that of Ceylon cinnamon, but less delicate." The oil is contained in oil-cells, not very different from the other parenchyma cells. Besides these, inferior grades are imported, with thicker, less fragrant bark, as well as other products of the trees. See Allied Drugs. Composition.-The single ingredient of value in cinna- mon is the essential oil {Oleum Cinnamomi, U. S. Ph., etc.), of which the yield from the dried bark is from one- half to one per cent. It is usually imported from Ceylon, although occasionally distilled here. It is a golden-yel- low liquid, becoming brown on ex- posure, of delicate but powerful cin- namon odor, and an aromatic, burn- ing taste. Sp. gr. about 1.035. Its composition is given as cinnamic aldehyde and hydrocarbons ; the for- mer constituting the heavy, and the latter the light portions into which it is easily separated by distillation. Oil of cassia (Chinese cinnamon), imported from China, resembles the above, but its odor is a little cruder, and its taste more pungent, with a sweetish flavor. Sp. gr. a little higher. Both these oils are heavier than water ; the only method of distinguishing them from each other is by smell and taste ; their medical properties and composition are iden- tical, although there is a great dif- ference in their prices. Cassia con- tains also tannic acid in consider- able amount. Use.-Cinnamon (Cassia) is an agreeable spice in general use all over the world. In medicine and pharmacy it is employed as an aromatic (carminative, cor- rigent, etc.) and as a flavor. For these purposes it is one of the best of its class-agreeable tasting, not very irritat- ing, stimulant and tonic to the stomach, and mildly astrin- gent. As a carminative it may be given alone in powder, in the dose of a gram or two. It is oftener, however, com- bined. The following preparations are those in which it plays a principal part : The Oil {Oleum Cinnamomi, U. S. Ph., etc.) one of the best. Dose from one to five drops. It may be given in spirit, sugar, syrup, or mucilage, or united with bitters or other medicines. Cinnamon water {Aqua Cinnamomi, U. S. Ph.), prepared from the oil (strength about nAnr) is used as a vehicle. Spirit or " Es- sence" {Spiritus Cinnamomi, U. S. Ph.), a ten per cent, solution of the oil in alcohol, is convenient. Dose two grams or so (2 c.c. = 1R.. xxx.). Tincture of Cinnamon (strength^, Tinctura Cinnamomi, U. S. Ph.), made from the bark, contains the oil and the tannic and coloring mat- ters ; is slightly astringent as well as carminative. Dose from five to ten grams (5 to 10 c.c. = 3 j. ad iij.). Aro- matic Powder {Pulvis Aromaticus, U. S. Ph.) is a mixture of spices ; its composition is cinnamon, 35 ; ginger, 35 ; cardamom, 15 ; nutmeg, 15. It is more stimulating than Cinnamon alone. Dose, the same as of Cinnamon. From this powder a fluid extract {Extractum Aromaticum Flu- idum, U. S. Ph.) is made in the usual way. Dose the same. Fig. 660.-Flower and Section; enlarged. Fig. 659.-Ceylon Cinnamon Tree. Flowering branch ; reduced. (Bailion). pubescence upon the ultimate branches and the under surfaces of the leaves. It is usually considered to be a native of China, where, as well as in Java and India, it is extensively cultivated. It is supposed to be the source of the better grades of Chinese Cinnamon. Like the fore- going it is very variable, and several doubtful species of Cinnamon-yielding trees are referred to it. "Cassia" bark is collected in various ways, the better sorts being generally peeled or scraped, but sometimes it includes the entire thickness. It always runs thicker than Ceylon cin- namon, and comes in separate quills-never rolled into solid sticks like that. History.-This is one of the oldest of drugs, and fre- quently mentioned, not only in such authorities as Galen, Diascorides, and Pliny, but also in several of the books of the Old Testament. Moreover, both cinnamon and cassia appeared to be known and to be essentially the same articles as we know by these names. Of course they were precious and costly. In Chinese writings they were mentioned more than thirty centuries ago.* The two * For further particulars see the Phannacographia. 168 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cinnamon. Circulation. Allied Plants.-Fifty species have been enumerated in the genus, many of which should probably be merged together. They inhabit tropical Asia and the Pacific isl- ands. Camphor is furnished by one of them. The order Lauracea is an immense one of nine hundred, mostly tropical and fragrant trees. The following species are of medical interest • Cinnamomum, several species : Cinnamon, etc. Cinnamomum Camphora Nees : Camphor. Nectandra Rhodiaci ; Bibiru Bark, not aromatic. Sassafras officinale Linn : Sassafras. Laurus nobilis Linn : Bay Laurel. Our spice bush, Lindera Benzoin Baillon {Benzoin Linn), in the same family, has a pleasantly spicy bark ; it is occasionally used as a family medicine. Allied Drugs.-The fruits,* twigs, leaves, and other parts of the cinnamons are used for cheaper purposes than the barks, mostly to adulterate the powders of the latter. The oil from the leaves has the odor and com- position of that of cloves. Cinnamon may be taken as a type of the aromatic car- minatives, and may be compared with all those drugs whose chief constituents are non-poisonous essential oils. Often the products of whole botanical families are nearly or quite of this class, and may be profitably compared together. Such groups will be found in the Umbelliferce, sec Anise ; the Labiates, see Peppermint ; the Myrtacece, see Cloves ; the Rutacea, see Oranges, etc. In a more distant manner it may be compared with others in which there is a natural combination of aromatic and bitter, see Magnolia, or essential oil and pungent resin. See Ginger for Seitamineae {Zingiberea). The following are often used as carminatives or stomachic stimulants : Mustard, and other Grudfercs, Red Peppers, Nutmeg, Valerian, and many others, besides alcohol and other •ethereal stimulants. Creasote is sometimes used for somewhat similar effects upon the stomach. IE P. Bolles. kept continuously at,a point above the normal ; but it is notorious that such a system leads to the deposition of fat, more food being eaten than can be oxidized, and that anaemia, rather than plethora, is the constant attendant of obesity. The symptoms universally ascribed to plethora : red- ness of the face, throbbing of the cerebral vessels, sing- ing in the ears, vertigo, etc., are rather due to products of imperfect digestion, some of which, it has been shown by recent researches, especially of Lauder Brunton, may be positively poisonous. In an article entitled " A Contri- bution to the Study of Ana?mia," published in the Archives of Medicine for October, 1882, I make use of the following language, which I have since seen no reason to alter: "As to the existence of plethora I am extremely skeptical. I have never seen any morbid condition what- ever that could be ascribed solely to an excessive number of red cells in the blood. I recognize a condition com- mon to hearty eaters of animal food, which has been called plethora, but attribute its symptoms, for the most part, to albuminoid indigestion, and would classify it under the head of lithsemia. This condition has been admirably described by Fothergill." Experiments have been made on animals with the object of establishing an artificial plethora. Panum, by direct transfusion from one dog to another, found that the blood might be increased even eighty per cent., but that the plethora thus induced was only of temporary duration. Von Recklinghausen (" Deutsche Chirurgie "), who quotes this and other similar experiments, and admits their nega- tive results, yet acknowledges that he is a believer in plethora in the human subject, which belief he bases upon a dilated condition of the entire vascular system and the presence of hypertrophy of the heart, without demon- strable lesion of the cardiac valves, of the arteries, or of the kidneys. It must be conceded, however, that such instances are extremely rare, and, besides, no data are given to show that the quality of the blood, in such cases of vascular dilatation, is normal, as well as its quantity increased. Anaemia.-This form of general disorder consists of a diminution in the quantity or quality of the blood, or of both combined. The typical form of anaemia is that caused by haemorrhage, and the degree of systemic dis- turbance is in direct ratio to the suddenness with which the blood escapes from the vessels. A sudden haemor- rhage of one half kilogramme (1.339 lb. troy) will cause syncope in the adult. If it continues unchecked, the pal- lor of countenance increases and assumes a bluish tinge ; the eyes become sunken ; the pulse grows small and flut- tering, the skin cold ; attempts at vomiting are frequent and rouse the patient from the syncopal state ; the skin is bathed in perspiration ; yawning and sighing are fre- quent ; great restlessness and jactitation supervene, and death is preceded by general convulsions. The symptoms of acute loss of blood, and its frequently fatal termina- tion when not more than one-half the normal amount has been lost, are due to sudden ischaemia of the nerve-centres. The contraction of the vessels in consequence of loss of blood, is not uniform in the vascular districts of the body. Thus wfliile the vessels of the skin contract upon their diminished contentsand produce a death-like pallor, those of the abdomen permit of the accumulation of a large quantity of blood, which tendency to stagnation in this region is constantly being added to by the enfeebled ac- tion of the heart. A time soon arrives when the amount of blood leaving the heart at each systole is too small to supply the respiratory and circulatory centres of the me- dulla, and symptoms of asphyxia set in. The treatment empirically adopted after haemorrhage is in accordance with the latest knowledge concerning its results, and con- sists in elevating the extremities and lowering the head, rubbing the extremities in the direction of the heart, and the transfusion of blood or of an indifferent saline solution, the quantity of which need by no means equal that which has been lost from the vessels. In acute anaemia from haemorrhage, the quality of the blood remaining in the vessels is normal, at least for a time. If the patient recover, the blood during the stage CIRCULATION, DISORDERS OF THE. Disorders of the circulation may be general or local. In the former variety the amount of blood in the entire vascular system is increased or diminished with reference to a supposed normal standpoint, while in the latter the quantity circu- lating in individual vascular districts may be increased or •diminished, the amount in the whole circulation having undergone no alteration. An excess of normally consti- tuted blood is known as Plethora. A diminution of the quantity or quality of the blood, or, as most frequently happens, of both combined, is known as Anemia. An •excess of blood in one or more vascular districts is called Hyperjemia, while a subnormal amount of blood in one •or more vascular districts is called Ischaemia. Plethora.-Of late years the term plethora has been less and less employed, until, at the present day, it is almost obsolete, and the question may wrell be asked whether such a thing is possible as a deviation from the standard of health, having for its sole foundation too great a quantity of blood in the vessels. A certain amount of blood is adapted to the vessels of every individual and may be termed the vascular capacity. It is roughly esti- mated at one-thirteenth of the weight of the body. It may vary to a certain extent within the limits of health, ■owing to the fact that the vessels, instead of being rigid, unyielding tubes, are capable of contracting and dilating, under the influence of the nervous system, and, perhaps, independently. A permanent condition of plethora pre- supposes a constant paresis of the vaso-motor system throughout the body, as well as a continued power of di- gesting and assimilating the most nutritious articles of food. The transient state of the vascular system of every healthy individual after a hearty meal, is what has been described as the permanent condition of the plethoric. It is well known that the vascular tension is increased during digestion, and that this tension is speedily reduced by an abundant excretion Of urine, and it is conceivable that by a system of constant feeding the blood-pressure may be ♦ The so-called "Cassia buds," 169 Circulation. Circulation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of convalescence will be found on examination to be rel- atively deficient in red corpuscles, owing to the fact that the former volume of the blood is restored by the absorp- tion of water before repair of its cellular constituents sets in. Later, there is an abundant new formation of red corpuscles, which may be demonstrated by chromometric methods to be deficient in haemoglobin. Finally, each corpuscle, by the acquisition of haemoglobin, attains the normal standard. In anaemia, the result of disease, the deficiency affects, as a rule, both the number and quality of the red corpuscles, although the degree in which each is reduced is very variable. A remarkable exception to this rule is found in cases of idiopathic (so-called perni- cious) anaemia. In this affection the reduction in the num- ber of the red corpuscles far exceeds that observed in any other disease. The normal number of red corpuscles is at least 5,000,000 per cubic millimetre, whilogjn idiopathic anaemia there may be only 500,000 per cubic millimetre ; that is to say, nine-tenths of the red corpuscles have dis- appeared. Nevertheless, and this constitutes a pathog- nomonic feature of this affection, the value of each cor- puscle, as shown by the haemoglobinometer, may be twice as great as normal. Five hundred thousand corpuscles may have the functional value of one million. Attention has been recently called to this feature of idiopathic anae- mia by S. Laache, of Christiania, who attributes it to the greatly increased size of the red corpuscles in this dis- ease. I have recently been able to confirm Laache's state- ments in two typical cases of idiopathic anaemia. Idiopathic anaemia and chlorosis are often described as closely allied affections, but the above-mentioned fact of the increased value of each corpuscle in idiopathic anae- mia, constitutes a salient point of difference. In chloro- sis the percentage of reduction of haemoglobin is, as a rule, decidedly greater than that of the number of the red corpuscles. Ilayem and others have studied cases of chlorosis in which, with a normal number of red corpus- cles, the haemoglobin was reduced fifty per cent.; that is to say, 5,000,000 red corpuscles have the functional value of 2,500,000. Local disorders of the circulation comprise the various forms of hyperaemia, active and passive, and are produced by a variety of causes, the chief of which are chemical, mechanical, thermal, electrical, and nervous. Certain chemical substances, on account of their prop- erty of directly producing active hyperaemia, are known as rubefacients. The most commonly employed of these, in medical practice, are mustard, turpentine, and ammo- nia. The application of cold is first followed by a pale- ness of the surface, due to contraction of the vessels, but on ceasing the application the part in question becomes the seat of a decided hyperaemia. The effect of heat va- ries with its mode of employment. Dry heat, when not sufficient to injure the structure of the tissue, produces direct hyperaemia. Moist heat, on the other hand, pro- duces a tonic contraction of the smaller vessels, which persists for a considerable length of time. The applica- tion of hot water, of the temperature of 43.3° C. (110° F.), is one of the best means of stopping the oozing of blood from stumps, as well as the more profuse intra-uterine haemorrhages of post-par turn or other origin. The action of mechanical causes is illustrated by the collateral fluxion which follows the ligature of an artery, as well as by the determination of blood to the abdominal vessels after the removal of pressure from their surfaces, as in tapping for ascites. Increased atmospheric pressure causes a slow- ing of the pulse and increase of the blood-pressure. The effect of diminished atmospheric pressure is in proportion to the suddenness with which the system is subjected to it. The greatest effects produced by alterations of at- mospheric pressure are observed in the case of workmen employed in bridge building. Too sudden an exit from the caissons in which they may have been breathing an air compressed from three to five atmospheres, is fol- lowed by a series of symptoms of which the most striking are haemorrhages from the nose, ocular conjunctiva, and ears, and haemoptysis. In addition there may be nausea and vomiting, intense neuralgic pain, syncope, and even paralysis from rupture of diseased cerebral vessels. These and other symptoms may become more or less chronic in such workmen, forming a complex to which has been given the name of Caisson Disease. Syncope may occur during the application of Junod's boot to an entire lower extremity, and is explained by the anaemic condition of the brain that is produced by the sudden derivation of so large a quantity of blood. The effect for the time, in the central nervous system, is the same as blood-letting. Sudden derivation ' of blood to the venous side of the circulation, and consequent gen- eral arterial ischaemia, are caused by embolism of the pul- monary artery, as also by multiple embolism of smaller pulmonary vessels-air and fat embolism. In such cases there is dilatation of the right heart, an accumulation of blood in the abdominal veins, with emptiness of the left heart and arterial system. The pulse disappears rapidly and the heart stops in diastole. The lungs are peculiarly subject, from their exposed situation, to active hyperemia from a great variety of causes, such as the inhalation of the ■ irritant vapors of chlorine, bromine, ammonia, and carbonic oxide. In cases of stenosis of the glottis and trachea, the effect of the inspiratory effort is to rarefy the subnormal quantity of air admitted into the alveoli, and, consequently, to diminish the normal pressure upon the capillaries. Hence, in great part, arises the active con- gestion which constitutes so grave a complication in this class of cases. Of the various forms of active congestion, the most im- portant are those which can be directly traced to disor- dered function of the nervous system. Thanks to the labors of Bernard and others, it is well known that the contractility of the blood-vessels is under the control of nerve-fibres, which are distributed for the most part through the medium of the sympathetic system. Section of the cervical sympathetic is followed by increased red- ness and heat on the corresponding side of the head and face, from dilatation of the blood-vessels, to the muscu- lar coat of which its fibres are distributed. Electrical ir- ritation of the nerve, on the other hand, produces con- traction of the same vessels. Similar facts have been observed with regard to the splanchnic and certain cere- bral nerves, such as the trigeminus, the lingual, and the ischiatic. On the other hand, there are certain nerves the irritation of which, instead of being followed by ischae- mia, as in the cases just mentioned, produces active hy- peraemia; such are the chorda tympani and the nervi erigentes penis, from the sacral plexus. These latter facts have given rise to the theory of an active dilatation of vessels from irritation, as well as a passive dilatation from paralysis, and hence a division of arterial hyperemia of nerve origin into a neuro paralytic and a neuro-tonic variety. The division, however, is not clearly defined. Under the head of neuro-paralytic congestion, are in- cluded cases of injury of the sympathetic, of which the most remarkable example has been reported by Mitchell, Morehouse, and Keen.1 It was a case of gunshot wound of the right cervical sympathetic, and was followed by cerebral symptoms, contracted pupil, ptosis, lachryma- tion, and unilateral flushing of the face on slight exertion. Jonathan Hutchinson attaches a certain degree of diag- nostic significance to signs of sympathetic disturbance in cases of fracture of the clavicle. These consist of con- traction of the pupil, narrowing of the palpebral fissure, and increased heat of face on the side of the injury. Of non-traumatic forms of neuro-paralytic congestion, the best known is hemicrania or migraine ; although the affection is generally of mixed form, the stage of hyper- temia being usually preceded by one of ischaemia. " The first, or ischaemic stage, is due to an irritation of the cer- vical sympathetic, evidenced by pain on pressure over the middle and superior cervical ganglia. The vessels of the head and face on one side are in a state of tonic contrac- tion ; the countenance is pale, the eye sunken and the pupil dilated, while the temperature is lower than that of the corresponding region of the other side. The source of irritation may be in the cilio-spinal region of the cord, from which proceed fibres to the cervical sympathetic, and may be evidenced by tenderness over the spinous pro- cesses of the lower cervical and upper dorsal vertebrae. 170 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Circulation. Circulation. There may be irritation of the medulla, the principal vaso-motor centre of the body, giving rise to tonic con- traction of the vessels in distant parts of the body ; hence arise chilly sensations and coldness of the extremities, with suppression of perspiration, and a small, contracted, radial pulse. The second stage presents all the symp- toms of paralysis of the cervical sympathetic, or its spinal centre. The face, on one side, shows increased redness and heat; the conjunctiva is injected, the pupil con- tracted, and the vessels of the retina dilated. The pulse may also be retarded, in a marked degree, from irritation of the pneumogastric. There may also be increased sweating of the head and face. In some cases of mi- graine, one or other of these stages predominates, to the almost total exclusion of the other, and the treatment is adapted to the prevailing condition. Thus, in the neuro- tonic form, benefit has been derived from remedies which dilate the blood-vessels, such as nitrite of amyl. Nitro-gly- cerine would be also worthy of a trial in this variety. On the other hand, in the neuro-paralytic form, ergot has been used with advantage by Eulenberg. Among the empir- ical remedies may be mentioned iron, quinine, caffein, the bromides, narcotics, and last, but by no means least, the constant galvanic current. Local hyperemia is generally the attendant of neu- ralgia, as is well illustrated in neuralgia of one or more branches of the trigeminus. When the supra-orbital branch is affected there are, in addition to the pain, swelling and redness of the conjunctiva, forehead, and cheeks, and increased lachrymal secretion. When the infra-orbital is attacked, there is congestion and increased secretion of the nasal cavities and mouth. In certain cases the hyperaemia may even proceed to inflammation with its various consequences, as in herpes zoster and, perhaps also to be here classified, acute pemphigus. The phenomena of shock are best explained by the theory of a reflex paralysis of the splanchnic nerve, hav- ing as its result an enormous accumulation of blood in the abdominal vessels, and a corresponding anaemia of the central nervous organs, while, in addition, there is also a reflex paralysis of the pneumogastric. Carbonic oxide poisoning, experimentally induced, has caused an accumulation of blood in the abdominal ves- sels, the amount of which may equal fifty per cent, of the entire volume. In the cold stage of intermittent fevers, in sea-sickness, and in the algid stage of cholera, there is an accumulation of blood in the central organs. The sphygmographic tracing of the pulse in these three conditions is remark- ably similar, and shows decidedly increased tension. Disorders of the circulation are most frequent in that condition of the nervous system known as irritable weak- ness, with which a certain degree of anaemia is frequent- ly, though not invariably, associated. I have frequently examined the blood of individuals, generally females, who had been supposed to be anaemic on account of the unstable equilibrium of their circulation, with the result of finding the number of blood-corpuscles absolutely normal. The term anaemia is too loosely applied to such cases ; they are cases of neurasthenia, with which an- aemia may or may not be associated. An organ or system that has been overtaxed, whether it be the brain, the digestive system, or the genito-urinary system, remains for some time, perhaps permanently, in such a condition that, upon a normal demand for blood to the organ, there is an excessive supply. Passive congestion, or venous hyperaemia, is due to a diminished vis a tergo, or to an obstruction to the out- flow of blood from an organ. The former cause is op- erative in the various forms of hypostatic congestion, in which the enfeebled action of the heart is unable to en- tirely overcome the effect of gravity. In anaemic condi- tions, in which the heart-muscle is insufficiently nourished, perhaps the seat of fatty degeneration, there is a tendency to accumulation of blood in the dependent parts ; also in cases of prolonged dorsal decubitus, as in typhoid fever, in which the posterior portions of the bases of the lungs are peculiarly prone to this form of congestion, which may constitute a serious complication of the disease. Of the second variety of passive congestion, that due to obstructed outflow' of blood, a type is to be found in mitral stenosis or insufficiency, the first effect of which is pulmonary congestion; later, the hepatic veins become hy- persemic, and, finally, with increasing failure of the right heart, the entire venous system becomes engorged. A physiological cause of venous congestion is the press- ure of the pregnant uterus, causing the varices of the lower extremities often observed during pregnancy. It is probable, however, that a weakness of the venous walls, either congenital or acquired, may contribute to their production, since they are absent in many cases. The same remark is applicable to the dilatations of the haemor- rhoidal veins-haemorrhoids,-which are favored by he- patic obstruction and constipation. There is, however, a special predisposition to congestion of these vessels, since they are destitute of valves, and the blood, after travers- ing them, has to pass through a second capillary system in the liver. The tributaries of the left spermatic vein are also predisposed to congestion and dilatation-vari- cocele,-because this vessel, instead of opening into the vena cava at an acute angle, as is the case with the vein of the right side, empties at a right angle into the left renal vein. The pressure of adjacent tumors is a fre- quent cause of venous congestion. When the compres- sion affects the superior vena cava, as is often the case in mediastinal growths, a remarkably dilated and tortuous condition of the superficial veins of the chest and abdo- men results, owing to the collateral circulation being car- ried on by these channels. Interesting cases of compres- sion by gummata are reported by Bristowe {Lancet, Feb- ruary 28, 1885). The effect of venous congestion is most manifest in the extremities of the body, such as the finger-ends, the toes, the cheeks, ears, and tip of the nose ; that is to say, in those parts in which there is a highly developed capil- lary network, and in which, according to some eminent anatomists, there are probably also direct anastomoses between the arteries and veins. Such direct anastomosis has been proved to exist in the ear of the rabbit. Ischemia.-The acute local anaemia of one or more vascular districts, in contra-distinction to that which is part of a general condition shared equally by all the organs, is known as ischaemia. The causes of this con- dition are, many of them, palpable and manifest, such as the action of cold, the pressure of tumors, the traction of cicatrices, the application of ligatures, thickening of the coats of arteries, the formation of thrombi in their lu- mina, and the arrest of emboli. The more obscure cases are those dependent upon contraction of the vessel-walls from irritation, either direct or reflex, of the vaso-motor nerves. The effect of the obstruction or obliteration of an artery depends upon the freedom of its anastomosis with the neighboring vessels. In the great majority of cases these suffice to completely re-establish the circula- tion. By some authorities it is supposed that the vasa vasorum, and even the newly-formed vessels in the co- agulum which follows the ligature of an artery, may take part in restoring the circulation. If the vessel ob- structed be a terminal artery, that is, one without anas- tomosis, the effect is generally the formation of a w'edge- shaped area of necrosis, known as a haemorrhagic infarction. The anatomical details of this process are described in another part of this work, under the head of Embolism. Of ischaemia of nervous origin, one of the most strik- ing examples is the form of angina pectoris known as angina pectoris vasomotoria. With a perfectly healthy heart, there is a more or less general arterial spasm, mani- fested by pallor of the visible parts, and sensations of numbness and coldness, soon followed by pericardial pain radiating to the left shoulder and upper extremity. These attacks are relieved by agents which dilate the vessels, such as nitrite of amyl and nitro-glycerine, re- cently introduced in the treatment of this affection by Dr. William Murrell, of London. Raynaud has described a form of arterial spasm of the upper extremities, which he terms local asphyxia. It occurs in w'eakly indivi- duals on exposure to cold, most frequently on rising in 171 Circulation. Circumcision. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the morning, and manifests itself at first by pallor and numbness, perhaps by altered sensations, such as those produced by the crawling of insects, or even by severe pain in the ischaemic parts. There is also great muscular weakness in the same regions. Bluish spots soon make their appearance and gradually extend and coalesce until the entire limb may assume a cyanotic hue. The affec- tion is generally bilateral. The arterial spasm may last several hours, and then pass away with sensations of increased pain, or of burning heat; or, on the other hand, it may result in symmetrical gangrene. It is relieved by friction and warmth, and the best curative measure is the constant galvanic current. The affection just described resembles, in some of its features, chronic poisoning by ergot. The disordered sensation of the skin is common to both, and constitutes so marked a feature of ergotism that the term Kriebelkrankheit has been popularly applied to it in Germany. It is probable, however, that the path- ology of the two affections is different. In the former, the condition is, as Raynaud described it, one of primary arterial spasm, while in ergotism, the contraction of the arteries, which undoubtedly exists, is regarded by most experimenters as secondary to a venous engorgement. This view is supported by the presence of enfeebled ac- tion of the heart and the absence of increased arterial pressure. Brown-Sequard has demonstrated that irritation of the nerves of the kidney, crushing the kidney, the suprarenal capsule, or the nerves proceeding to it from the coeliac ganglion, will produce anaemia of the pia mater spinalis, and simultaneous paralysis of the posterior extremities. The latter symptom was hence supposed to be due to ischaemia of the spinal cord, and the same theory of ischaemia of the nerve-centres was applied to the cases of reflex paralysis described by Romberg, Graves, and others. At the present day, however, these cases are preferably explained as due to a direct inhibitory action upon nerve-centres, proceeding from the irritated region. In conclusion, reference may be made to the fact that there are certain physiological irregularities in the dis- tribution of the blood, interference with which may lead to grave functional, and even inflammatory, disorders. Thus, during digestion, there is an active hyperaemia of the abdominal organs, predisposing to sleep, through derivation from the brain, and causing disinclination to mental exercise. Nevertheless, under the influence of the will, or independently of it, through the emotions, blood may be summoned to the brain, even though at the same time it be imperatively demanded in much more extensive vascular districts, and the mental work be per- formed to the detriment of the digestion. The same re- marks are applicable to the function of menstruation, for the proper performance of which repose of mind is quite as important as that of the body. Frederick P. Henry. 1 Injuries of Nerves. S. Weir Mitchell, M.D. operation as performed in Algiers, is given by Tarneau, in Gazette des Ilbpitaux, 1855, and referred to by Hamdy, in his monograph on circumcision, which also gives much valuable information of the history of the operation (Hamdy, " De la Circoncision "). The age at which the op- eration is performed, varies in different places. The He- brews operate on the eighth day, as is also done in Algiers, while generally the Arabians wait until the tenth or thir- teenth year, the age of puberty. The operation consists essentially of three parts: circular section of the ex- tremity of the prepuce, tearing of the remainder of the prepuce to the corona, and denudation of the glans, and suction of the wound and penis by the operator. Haemor- rhage is arrested by styptics, powdered coral, or generally tannin ; and simple dressings are applied to prevent the inner layer of the prepuce from again covering the glans penis. As the operation has too frequently been per- formed by unskilful and dirty hands, serious complica- tions and fatal results have often followed. Cases of death from excessive haemorrhage and inflammation can be found in the literature of the operation, as well as of various untoward complications, for example, wounds of the glans penis or urethra. Much has been said, too, of the danger of transmission of syphilis in the disgusting third part of the operation, whether from the operator to the patient, or occasionally from the patient to the operator. The prepuce consists of two folds of integument, sepa- rated by very loose connective-tissue, that cover and pro- tect the glans penis. They meet and become continuous at the preputial orifice or end of the foreskin, which is usually the narrowest part of the prepuce, although suf- ficiently large in adults to allow the prepuce to be re- tracted so as to expose the glans. At birth the prepuce is longer than the penis, and its orifice narrow, often preventing exposure of the glans, so that a greater or less degree of congenital phimosis is pretty constant. The inner surface of the prepuce at this time embraces the glans closely, especially at the corona where there is generally a little circle of adhesions. Sometimes the pre- puce and penis are adherent over a much greater extent of surface, either in little patches at various parts of the glans, or from the corona to the meatus. The adhesions are generally easy to subdue, partaking more of the na- ture of agglutinations than of firmly organized tissue. They are apt to be the source of local irritation, and to cause the retention of the secretion of the glands of Ty- son, or smegma praeputii. It occasionally happens that the prepuce is imperforate, a condition that soon makes itself manifest and is easily recognized. The child passes no urine, and a soft, fluctuating, transparent tumor forms slowly on the penis. As the tumor grows it pulls upon the skin of the scrotum and pubes, and an inspection shows that there is no preputial orifice. An incision must be made as soon as possible to allow the escape of urine, but circumcision had better be deferred to a later period, when it may be unnecessary to do more than trim up unsightly flaps. In childhood there are not many changes in the prepuce; the few erections rupture a part of the congenital adhesions. Attacks of balanitis or posthitis may result from the decomposition of retained smegma and give rise to contraction of the preputial ori- fice, or new adhesions between the prepuce and the glans. A child with phimosis and an unhealthy local condi- tion may have no symptoms, and at puberty, with the changes that occur in the penis, the phimosis may disap- pear. But if there are dysuria, or reflex symptoms aris- ing from the phimosis, operative interference is essential, not only to relieve the immediate trouble, but as a pro- phylactic against various conditions apparently depend- ent on it, as varicocele, hernia, some cases of masturba- tion, etc. (See article Phimosis.) At puberty the glans increases in size, erections become more frequent and strong, and usually destroy any remaining adhesions, while they dilate the preputial orifice so that the phimosis disappears. If any adhesions still persist they are strong and firm, and may prevent the development of the glans, and be the cause of painful erections, tenderness of the penis, etc., as well as of other symptoms more or less evi- dently dependent on the local condition. Such a con- CIRCUMCISION. (Synonyms: Posthectomy; Lat., Circumcisio ; Fr., Circoncision; Ger., Beschneidung j) Circumcision is the partial or complete removal of the prepuce or foreskin. The operation is performed as a religious rite, and as a hygienic or therapeutic measure in congenital or acquired phimosis, and some other dis- eases of the prepuce and penis. Among females in Arabia, Egypt, Nubia, and some other portions of Asia and Africa, travellers have observed a similar custom, consisting of amputation of the labia minora or mutila- tion of the clitoris. As a religious rite, circumcision is a practice of great antiquity and geographical extent. While most com- monly performed among the Hebrews and Arabians, it is frequently observed by travellers in other portions of Asia and Africa where the origin of the custom is easily traced, and it is also seen in parts of South America, in the islands of the Pacific Ocean, in Madagascar, and in other places where no clue to its origin has yet been discovered. The Hebrews are supposed to have derived their knowl- edge of circumcision from the Arabians or Egyptians, most probably the latter, among whom the practice originated, according to Herodotus. An interesting account of the 172 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Circulation. Circumcision. dition is best remedied by circumcision, and, indeed, it is a question of considerable interest and importance whether it is not desirable to perform circumcision at an early age as a hygienic and prophylactic measure. The outer lamella of the prepuce is continuous near the corona glandis with the integument that covers the body of the penis. One should remember the elas- ticity of this integument and the laxity of its subcutane- ous tissue, and avoid undue traction upon it in perform- ing circumcision, or it may happen that when the skin has been drawn forward and amputated, an unexpectedly large surface of the prepuce will be found denuded, or there may be a circular wound near the middle of the penis while the parts covering the glans have entirely escaped the knife. Such an accident is usually a sur- prise to the operator, and may be followed by disagree- able deformities from subsequent cicatricial contraction. Under the circumstances, the best course to pursue is to relieve the phimosis for which the operation has been undertaken, by a dorsal incision, without removing any more integument, and after careful arrest of haemorrhage, to approximate the edges of the circular wound as well as possible by sutures and endeavor to secure primary union. The inner surface of the prepuce is reflected for- ward from the corona glandis to the orifice of the forer skin. In its ordinary condition, protected from friction, and lubricated by the natural secretions of the part, it is soft, pliable, moist, and1 so much resembles a mucous surface that it is usually referred to as the "mucous membrane," in distinction from the "skin" or outer layer of the prepuce. This layer, and not the skin, is usually affected in phimosis. The constriction is usually at the meatus, although it may be anywhere between there and the corona. The fraenum praeputialis is a small triangular fold of the inner layer of the prepuce, is inserted near the meatus of the urethra, and when too short, may interfere with retraction of the prepuce, pulling the penis downward and producing pain. On each side of it, near the median line, are the arteries of the fraenum. When these are divided in circumcision they may be the source of troublesome haemorrhage ; accordingly, the operator is directed in most of the text-books to avoid them if pos- sible. Where the frenum is short, it is better to disregard this precept and divide the frenum thoroughly, or remove a portion of it, and be prepared to place fine catgut liga- tures on the arteries that bleed. A considerable number of operative procedures have been suggested and practised by different surgeons, hav- ing in view the more accurate removal of the redundant prepuce, and the coaptation of the wound surfaces. They fall into three classes : preliminary incision of the prepuce, dilatation, and amputation of the prepuce with- out previous incision or dilatation. The preliminary in- cision is usually made on the dorsum of the prepuce, as far back as the corona, and the two flaps thus formed are carefully trimmed away. The incision may be made with a pair of blunt-pointed scissors or a bistoury. The bistoury may be inserted into the preputial orifice on a director, or the point may be protected by a little lump of wax and the bistoury passed with the side to the glans as far as the corona, then, turning the back to the glans, the point is pushed through the foreskin, which is divided by drawing the bistoury forward. The trimming of the flaps may be facilitated by the use of curved for- ceps applied so as to leave out the portion that is to be removed. Instead of making this division the prepuce may be dilated and cotton stuffed between the prepuce and penis, but this is a tedious and sometimes impossible process, and has no advantages beyond the greater facil- ity of applying needles and sutures in the prepuce, so as to render the coaptation of the surfaces more accurate. The incision, however, is of great value, especially where there is reason to believe that a constricted prepuce con- ceals a venereal sore that cannot be disinfected. Here a comparatively small incision allows the sore to be ex- posed, and after it has been disinfected or has cicatrized, the unsightly flaps may be trimmed off. In such cases it often happens that so much tissue has been destroyed by the ulcerative process that there is no excess of tissue when the wound has healed. The most simple and rapid method of circumcision is by a transverse incision, made obliquely from behind forward and above downward, in the direction of the margin of the corona glandis, the glans being carefully protected from the cutting instru- ment. The prepuce may be drawn forward with the fingers or with forceps, and the glans may be protected by Ricord's forceps or the handles of a pair of scis- sors or other instrument applied obliquely. To insure division of the prepuce at the proper place, if the eye cannot be trusted, it is well to mark with ink or iodine on the prepuce at -the point where the corona glandis underlies in a natural condition of the parts, and to make the section a very little in front of this level. Ricord made the mark two lines from the corona, and after ap- plying forceps transfixed the prepuce with needles along the line so as to secure accurate apposition of the two preputial layers after removing the prepuce. Other sur- geons, however, sometimes remove more or less of the two layers. Dieffenbach and Redreau removed all the mucous surface, leaving enough of the outer to partially cover the glans. After the prepuce has been drawn for- ward and divided, the forceps or other protecting instru- ment is removed, and the integument slides back on the penis, while the inner layer of the prepuce still covers the glans. This may either be turned back if there is no constriction, or divided as far as the corona by cutting or tearing on the dorsum. The two flaps thus formed may be left or trimmed away ; it is generally preferable, with a pair of curved scissors and forceps, to cut away evenly on all sides, leaving about a quarter of an inch. At the same time that this layer is turned back any ad- hesions are carefully broken, or if firm, cut through, doing as little damage to the penis as possible. All haem- orrhage should be carefully arrested, fine catgut ligatures being used for the purpose. The edges of the two layers are then united by sutures, which may be either of fine silk or of catgut. A continuous catgut suture is very useful, but if many stitches are used there is apt to be considerable swelling of the parts from the contusion and handling. In young children it is not necessary to use sutures, as the dressing prevents the inner layer from again covering the glans, and retains the parts in suffi- ciently close apposition for union to take place readily. If silk sutures are used they should be removed on the fourth day. Instead of sutures, the parts may be held together by serresfines, but these are apt to fall off as the patient recovers from ether, and may excite erections. If they are used they should all be removed by the end of twenty-four hours. Before the operation an attempt should be made to disinfect the parts, and antiseptic dress- ings should be applied. In children it is impossible to prevent the soiling of the wound by urine, but in adults, with care, pretty thorough asepsis may be preserved. After urine has been passed the wound should be thorough- ly cleansed with some disinfecting solution, and a new dressing applied. In children, cold-water compresses and weak carbolic acid solutions, or a light dressing of iodo- formized gauze are as useful as any elaborate dressing, and may be frequently renewed. The operation should not be performed without some anaesthetic, and cocaine hydrochlorate, if administered hypodermically, has given satisfactory results. The in- jections should be made at five or six points in the cir- cumference of the penis, and should be made into the skin. I'he amount necessary varies, but may be esti- mated at from thirty to fifty minims of a four per cent, solution. The patient should be in a good light, and it is well to see that the bladder is empty, as children are especially apt to urinate before recovering from ether, and thus soil the wound. If there is a purulent discharge from the contracted meatus, an antiseptic solution should be injected under the prepuce so as to make it as clean as possible, and the dorsal incision should be practised. In some cases, especially where there is danger of haemorrhage, the patient suffering from haemophilia, the ecraseur, the galvano-cautery, or caustics have been substituted for the knife or scissors, but they can hardly be recommended. 173 Circumcision. Cirrhosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The operation is liable to be followed by the ordinary diseases of wounds, but as it is frequently performed by unskilful hands, it has, perhaps, had more serious se- quelae than other equally simple operations. As already stated, it occasionally happens that too much integument is taken away, in consequence of which there are inflam- mation and suppuration, and finally a contracted cica- trix. Too little integument is more often removed, and the phimosis returns after cicatrization. The glans pe- nis or urethra may be injured, and severe haemorrhages and deforming cicatrices may result. Occasionally, in tearing adhesions, the glans penis is much damaged, with the same result. Severe inflammation, and even death, may be the consequence. Severe and fatal haemorrhage may occur from small vessels of the prepuce or from ar- teries of the frenum, or from wounds of the glans penis. From various causes the subsequent inflammation and suppuration may be very severe. Jacobi (" Diphtheria") gives a number of cases in which the wound has been the seat of the diphtheritic process in epidemics of diphthe- ria, and Hueter (" Chirurgie ") mentions fatal cases from phlegmonous erysipelas and gangrene. Gangrene of the penis and retention of urine may also result from tight bandages, or from a thread of circular dressings becoming detached and buried in the swollen tissues at the corona. The latter are exceedingly difficult to discover and remove from the tissues, in which they may sink deeply. Re- tention of urine is usually reflex, and should be relieved by the use of soft catheters. Primary union may fail from infection of the wound with chancroidal virus, the infection usually becoming evident about the third day. Free cauterization is necessary, either with the Paquelin cautery or by means of some of the acids. Excessive inflammation or erections may delay the union of the wound. Erections are very common, and in the swollen and tender condition of the part usually very painful. To prevent them it is well to keep the patient on a low diet, and to prevent constipation. Of drugs, bromide of potassium, lupulin, opium suppositories, suppositories or urethral injections of iodoform, camphor, etc., are used. The best success is generally obtained from the use of opium suppositories and iodoform urethral injections. Union may also be prevented by patients who mastur- bate, so that the inefficacy of the operation as a cure for that trouble becomes very apparent. The oedema of the parts on the second or third day after the operation is generally due to rough handling during the operation. The clamp may be applied too tightly, or the parts be much contused in placing numerous sutures. The indications for the operation are, in children, con- genital phimosis when accompanied by hydrocele, or her- nia, balanitis, preputial calculi, " ballooning" of the pre- puce in voiding urine, or by general or special reflex symptoms which may depend upon the local condition, as dysuria, convulsions, epilepsy, spasmodic contrac- tions. In adults the operation is indicated for the same set of troubles as in children, and for phimosis dependent upon inflammation, excited by venereal sores, gonorrhoea, etc., as well as for simply redundant prepuce without phimosis, when there are any local irritation or reflex symptoms, as spermatorrhoea. The operation should be postponed when the parts are in a condition of acute inflammation, except when there is a sanious discharge from the meatus. In this case, as there is probably a sloughing sore or severe inflamma- tion, the dorsal incision should be first practised to en- able local measures to be efficiently applied. The opera- tion should not be done when the patient is known to be a " bleeder," or when very feeble and anaemic, or suffer- ing from febrile or severe constitutional disease, unless, indeed, there may be some very urgent symptoms. Here, generally, the complete circumcision should be deferred, and the dorsal incision practised. It is still a mooted point whether hygiene demands cir- cumcision at an early age. It is certain that many cases of varicocele and hernia are due to the straining in mic- turition and the handling of the penis by young children. In general, however, congenital phimosis does no harm, and disappears at puberty. On the whole, it seems best to await some local disorder, or consecutive trouble, and to urge circumcision at the first sign of local irritation, or when general symptoms appear in connection with a phi- mosis. Wm. G. Le Boutillier. CIRRHOSIS. Synonyms.-Sclerosis, Chronic Inter- stitial Inflammation, Fibroid Induration, Granular In- duration, Fibroid Substitution, Chronic Fibrosis ; Ger., Cirrhose; Fr., Cirrhose. Definition.-Cirrhosis is a chronic inflammation af- fecting the interstitial connective tissue of the different organs. The term Cirrhosis, being derived from the Greek, Kipfros, "tawny," is not a happy one, inasmuch as it de- signates a feature that is peculiar to but one organ when affected by the disease, namely, the liver, and is by no means characteristic of every case or stage of the affec- tion in the liver. Sclerosis, from aKKypos, "hard," is better, but until recently its application has been restricted to affections of the nervous system, and it is frequently employed to designate indurations of other than intersti- tial tissues. History. - The morbid changes resulting from the process which we now term cirrhosis, were known to the ancients under various names, and were confounded with various other affections. Laennec was the first to employ the term Cirrhosis. He applied it to the interstitial in- flammation of the liver, because of the peculiar color of that organ when involved; but he suggested that the same pathological change might occur in other organs. Rokitansky and Gubler regarded hepatic cirrhosis as a chronic inflammation, but Kiernan and Hallman were the first to recognize an increase of the interstitial connec- tive tissue as an essential feature. Cruveilhier, writing on apoplexy in 1820, refers to a thickening of the inter- stitial connective tissue of the brain, but the pathology of the change to which he referred has been studied chiefly by Valentiner, Zenker, Charcot, and Vulpian. Pathology.-The morbid process may be divided into three distinct stages, the first of hyperaemia, the second of hyperplasia, and the third of contraction. The hyper- aemia of the first stage is simple and more or less pro- tracted, or often repeated, It is marked chiefly by the presence of an abnormal amount of blood in the organ, slowing of the blood-current, and increase of intra-vascular tension, with distention of the vessels. These conditions soon lead to a transudation of white blood-corpuscles, which accumulate in great number in the external coats of the vessels, between the fasciculi of the fibrous tissue, and in the lymph-spaces. The connective-tissue corpus- cles now acquire an increased assimilative power, and ap- propriate a part of the nutritive material so abundantly provided. A multiplication of the connective-tissue cor- puscles is the result, and thus the second stage is initiated. The history of the process from this time on, is the his- tory of the growth of any newly formed fibrous tissue. The neoplastic cells are called fibroblasts. According to Senftleben, Tillmanns, and Ziegler, they originate from the leucocytes as well as from the fixed connective-tissue corpuscles. Other investigators, among whom are Weiss, Baumgarten, and Bottcher, deny that the migrated cells take any part in the process; while Cohnheim, Ebert, and others claim that the fixed tissue-corpuscles remain entirely passive. , In regard to the formation of fibrous tissue from these cells, there are two prominent theories. According to the older and simpler view, the fibroblasts, at first round, by gradual extension soon become oval, then spindle- or club-shaped, and finally are transformed into delicate fibrous bands, their nuclei disappearing du- ring the course of development. The view adopted by Ziegler, Tillmanns, and others, who claim to have wit- nessed the steps of the process, is that the fibroblasts soon become spindle-shaped, club-shaped, or branched, by elongating and sending out arms ; that these arms fuse with similar prolongations from other cells until a mesh- work is formed. From the borders of the cells thus united, and in the homogeneous intercellular substance, fibrillae develop, and as these multiply and unite with each other, the new fibrous tissue is formed. 174 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Circumcision. Cirrhosis. A reticulated tissue is developed very rarely, and al- most exclusively in the supra-renal capsules and the liver. While the growth of the neoplastic tissue is in progress, and starting with the first appearance of fibroblasts, nu- merous new blood-vessels are formed. They are chiefly offshoots and prolongations of vessels already in the neighborhood, and their walls consist of but a single layer of endothelium. As soon as the fibrous tissue has become thoroughly or- ganized it begins to contract. This contraction consti- tutes the third stage of the process, and is identical with the shrinkage that occurs in cicatricial tissue everywhere. The bands of young tissue crowd closely together, become dense and firm, and gradually compress the parenchyma- tous elements and the blood-vessels upon which they de- pend for nutrition. The extent and duration of the several stages of cirrho- sis depend ultimately upon the cause of the disease and the intensity and duration of its action. They also vary greatly in different localities. The affected organ under- goes important changes peculiar to each stage of the dis- ease. In the first stages, owing to the increased amount of blood, it is slightly enlarged and increased in weight. The capsule at the same time becomes tense. When in- cised, the cut-surface is of a deep red color, and blood flows freely from it. With the occurrence of cell-infiltration and hyperplasia, the size of the organ is' more markedly increased; the capsule becomes smooth and more tense, and on section the surface is still of a deep red color. In the third stage, as contraction advances, the size of the organ diminishes, the red color gradually subsides, and the capsule becomes thick and tense. For a time the parenchymatous structures retain their vitality and color, and, on section, are somewhat more prominent than the interstitial tissue, giving the organ a mottled appearance ; but later they too become anaemic. In the brain the tis- sue becomes more opaque, so that the white substance re- sembles the gray. The contraction that accompanies the third stage may reduce the organ to less than half its normal size, the density being increased to a corresponding degree. Cap- sulated organs usually become granular on the surface, or more or less deformed, owing to the thickening and subsequent contraction of the fibrous bands that bind the capsule to the organ. In many instances depressions and grooves on the surface indicate the parts where the dis- ease is most advanced. When the disease is the result of syphilis, these scars are usually very irregularly dis- tributed throughout the organ. Causes.-Cirrhosis is caused by a chronic irritation. This may be of a mechanical or of a merely functional nature ; it may be active or passive, and varies greatly with the organ affected. In the liver it is due almost ex- clusively to the action of alcohol, syphilis, or malaria, although it has been claimed to be transmitted from an inflammation of the gall-bladder, or to arise from the free use of sugar and spices, or poisoning by phosphorus. Valvular lesions of the heart lead to a form of cirrhosis in the liver, as well as in the kidneys and spleen. In the lungs it is due to the irritation of tubercles, chronic bron- chitis, or the inhalation of dust, carbon, silica, metals, etc. In the brain it is most commonly due to alcohol or syphilis, but is believed to result also from prolonged maniacal excitement. Syphilis produces it in all organs ; malaria chiefly in the liver, kidneys, and spleen. A chronic inflammation of a serous membrane may result not only in a fibrous (sclerotic) thickening of the mem- brane itself, but may extend to the interstitial tissue of the organ which it envelops. So a chronic catarrh may ex- tend from the mucous membrane that is affected to the interstitial tissue of the organ to which it belongs. A hypertrophy of the interstitial tissue of an organ almost always occurs in the vicinity of tumors and foreign bodies located in them. Many other influences are reported to have caused the disease in different organs. Among these are, the action of microorganisms, chronic poisoning by various metals and drugs, excessive heat and cold, ex- posure to wet, and long residence in warm climates. In rare instances it has been believed to have been congen- ital. Microscopic Appearances. - The earlier stages of cirrhosis have been studied for the most part experimen- tally, and the statements respecting them are based largely upon the phenomena observed during the course of in- flammations of analogous fibrous tissues. If we examine a thin section of an organ in a late stage of the disease, we observe, instead of the delicate bands of supporting tissue, bands from twice to many times the normal thick- ness, separating the parenchymatous structures by wide intervals. Here and there rows or clusters of round or spindle-shaped embryonic cells are seen, lying between the fibrous bands. The blood-vessels are converted into thick-walled channels, chiefly by the thickening of their external tunics, but sometimes also by an increase in the thickness of the internal coat. As complications, we observe extensive fatty, calca- reous, or pigmentary infiltrations of either the parenchyma or the new-formed fibrous tissue, cysts, haemorrhagic de- posits, or abscesses. Excretory ducts, when present, are frequently dilated into fusiform cavities by the retained fluids, or are entirely obliterated by pressure. Very Fig. 661.-Cirrhosis of the Kidney. From a specimen in an advanced stage of the disease, showing great increase of interstitial tissue at the expense of the parenchyma, dilatation of tubules, fatty degeneration of lining epithelium, etc. At the right side, and at the top, small cysts are represented ; at the left a Malpighian tuft, and above this a portion of an indurated blood-vessel. (From an original drawing.) rarely the amyloid degeneration accompanies the disease. Other complications, peculiar to the organ affected, are occasionally observed. Cirrhosis occurs primarily or secondarily in all organs of the body. When secondary, it is generally the result of parenchymatous disease. The organs most frequently involved are the liver, kidneys, lungs, spleen, the brain and spinal cord, nerve-trunks and ganglia, the heart and other muscles. The lymphatic glands, pancreas, testicle, ovary, and mamma, as well as the walls of large arteries, are sometimes involved, and the pylorus is thickened as a result of chronic gastric catarrh. By an analogous process, a fibroid thickening of the skin (scleroderma) occurs, capsules form around foreign bodies or sub- stances acting as such, and the fibrous tissue surrounding organs in a state of chronic inflammation is thickened ; but such changes as these do not properly come under the head of cirrhosis. The induration may invade an entire organ to an equal degree, or may be limited to certain parts ; and the differ- ent stages are frequently coexistent. Dual organs are usually symmetrically affected, but only one may be in- volved, or both may be affected to a different degree. In the nervous system, we meet with both symmetrical and asymmetrical scleroses. The irritation which produces a cirrhosis generally 175 Cirrhosis. Clavicle. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. reaches the organ through the blood. As a rule, there- fore, the disease appears first around the blood-vessels or in their tunics-in most instances, in the smaller arteries. In the liver, it commences around the terminal branches of the portal or hepatic veins, less frequently perhaps, around the smaller bile-ducts. It is therefore confined chiefly to the inter-lobular spaces, but may extend into the interior of the lobules. In the brain and cord, it is found mostly in the gray substance ; in the kidney chiefly in the cortical portion. Results.-Associated with a cirrhosis there is always some complication of the parenchymatous structures. In the earlier stages an organ may functionate vicariously, on account of the hypersemia that is present. In the later stages, however, the functional elements frequently atro- phy, or undergo fatty degeneration and absorption. The fatty degeneration is sometimes so rapid, especially in the lungs and supra-renal capsules, as to lead to caseation and necrosis or calcification. The functional activity of the organ is then lessened in proportion to the amount of induration, and the effect upon the health of the in- dividual depends upon the organ that is involved. In secreting organs, the secretion is diminished ; or, continu- ing, is retained by cicatricial closure of the ducts and causes the formation of cysts. As a consequence of fibrous induration the blood-vessels lose their elasticity, thus greatly impeding the circulation of the part and pro- ducing important changes, both local and general. Other effects, more remote or peculiar to the organs involved, are fully described in the chapters on diseases of these organs. James AL. French. softens decidedly by warming, and burns with a bright clear flame. The odor, while having a general resem- blance to that of musk, is less diffusible and far more dis- agreeable. Civet is insoluble in water and only slightly so in alcohol; not wholly so even in whrm ether and chloroform. Its constituents, according to Boutron- Charlard, are volatile oil, solid and liquid fats, yellow coloring matter, resin, mucus, ammonia, oxide of iron, and lime and potash salts. It is happily no longer used in medicine. Formerly, it had some employment as an antispasmodic in the nervous derangements for which musk has had deser- vedly greater popularity. It is a little used still as a basis of perfumery, and for scenting bait for game. Allied Substances, etc.-See Musk. IE P. Bolles. CIVIL INCAPACITY. The chief interest of the phy- sician in the civil incapacity of the insane arises from the probability that he may at any time be asked his opinion on the capacity of a person he has treated or examined. To answer such inquiries, requires some general knowl- edge of the legal tests. For there is not any one distinct degree of mental aberration which can be mentioned as being, in view of the law, sufficient to render void any and all of the sufferer's past dealings. The legal idea of insanity and the standards by which a person may be ad- judged so insane that he may be committed to guardian- ship or custody for the future, are mentioned under In- sanity ; and those by which he is deemed exempt from the punishments of the criminal law, under Criminal Ir- responsibility. But these topics do not cover the field. Cases frequently occur in which some single act or deal- ing-a contract, a deed of property, a will or the like-is impeached on the ground that the chief actor at the time of entering into it was mentally incapacitated from bind- ing himself by its obligations. And the principle under- lying what the courts have said as to such cases is, that in general they will not hold persons bound by civil engagements, who at the time of making them did not possess the mental ability requisite for comprehending dealings of that nature. Very different degrees of men- tal capacity are requisite for different dealings ; and if the person possessed enough for comprehending the act under review, what he has done will be sustained, al- though he may have lacked ability for some more com- plicated acts ; while if he did not, his act is liable to be set aside although, for lesser dealings, he may have evinced mental ability. Civil capacity is judged relatively to the demands of such dealings as the one which the trial seeks to impeach. The most numerous cases are those in which heirs con- test a will on the ground of insanity of the testator. Here, if allegations of fraud or undue influence used to induce the making of the will can be added, evidence of mere weakness of mind may suffice to complete the case ; for a weak-minded person will be more easily overcome than one in full mental health. But where the objection to the will is simply that the testator lacked testamentary capacity, proofs of enfeebled intellect, hallucinations, perversity, erratic or gross personal habits, may be ac- cumulated day after day without reaching the point necessary for setting it aside. The legal criterion of mental incapacity for making a will is: Was the tes- tator disabled by abnormal condition of the brain, from recollecting his property and the persons among whom he would naturally distribute it, with sufficient clearness to decide upon intelligent dispositions ? The law does not require of testators that they should bestow their property wisely. Folly is not insanity ; neither is igno- rance. To sustain a suit for setting aside a will on the ground of incapacity only, the medical evidence should be clear of some disturbed action of the brain, adequate in kind and degree to embarrass the testator in remem- bering that he had property and that his execution of his will would determine its disposal upon his death. How- ever long, complex, and morbid the narrative of symptoms of derangement may be, if the court or jury may reason- ably believe that the testator had an intelligent recollec- CITRIC ACID. Citric acid, H3C6H5O7.H2O, is the agreeably flavored acid of lemons and limes, and occurs also in other fruits, such as the cranberry, currant, straw- berry, and raspberry. It is officinal in the U. S. Phar- macopaeia as Acidum Citricum, Citric Acid, and occurs in " colorless, right-rhombic prisms, not deliquescent except in moist air, efflorescent in warm air, odorless, having an agreeable, purely acid taste, and an acid reaction. Soluble in 0.75 part of water and in 1 part of alcohol at 15° C. (59° F.), in 0.5 part of boiling water, in 0.5 part of boil- ing alcohol, and in 48 parts of ether. It is nearly in- soluble in absolute ether, chloroform, benzol, and benzin. When heated to 100° C. (212° F.) the acid melts and gradu- ally loses 8.6 per cent, of its weight. At a higher tem- perature it emits inflammable vapors, chars, and is finally dissipated without leaving more than 0.05 per cent, of ash" (U. S. Ph.). Citric acid is the most agreeably flavored of the sour so-called organic acids, and makes, in aqueous solution, a grateful artificial lemon-juice. In concentrated solu- tion the acid is irritant, but not corrosive nor specifically poisonous. A six per cent, solution of citric acid in water about equals in strength good lemon-juice, and if, before solution, a drop or two of the essential oil of lemon be triturated with the crystals of the acid intended for making a tumblerful of draught, the imitation of genuine lemonade flavor will be quite perfect. Such artificial lemonade can be partaken of with the same freedom as the natural article. Edward Curtis. CIVET (Civette, Codex Med.), a sienna-brown, oint- ment-like, unpleasantly odorous substance, obtained from two species of Viverra ; Order, Carnivora, Viver- rina. The first, Viverra Zibetha Linn., the Indian Civet Cat, is from the warmer parts of Asia. The second, V. civetta Schreber, the African Civet Cat, is a native of Africa and Southern Europe. Both are kept in confine- ment for their peculiar secretion. This is formed in a sac-like gland, situated in front of the anus, in both sexes, between it and the external genitals, and is collected from the domesticated animals, either by saving it as it is discharged, or by scooping it out of the glands with a small spoon. When first gathered it is semi-liquid and brownish-yellow, but by keeping, it becomes considerably darker and harder. It is a nasty-smelling and dirty-look- ing substance, usually mixed with hairs and other im- purities. Its taste is sharp, bitter, and disgusting. It 176 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cirrhosis. Clavicle. tion of his property, and of the persons who might naturally be, or whom he intended to make, the objects of his bounty, and was able to comprehend the disposi- tions which the will contains, the will should not be set aside for incapacity. When the controversy is upon the validity of a con- tract, a conveyance of property, or the like, the medical criterion varies somewhat in form, but is the same in principle. The test is : whether the actor in the transac- tion possessed, at the time, mental ability to comprehend in a reasonable manner, a transaction of that nature ; if a deed, could he comprehend that he owned the property, that he might, if he chose, continue to own and enjoy it, and that his giving the deed would pass it away ; if an agreement, could he comprehend the legal obligations of mutual contracts, and the duties or payments which the one he was about to make would impose upon him. If such ability existed, the transaction may well be sus- tained in law, although the party suffered under delusions upon independent subjects, or under general feebleness of intellect. The principle of law is well established that insanity of a person brought to trial for crime, or coming into court as party to a suit, may be ground for deferring his trial, or for excusing delay or irregularity in his proceed- ings. The general test in cases of this class seems to be : whether the person understands the nature and impor- tance of his rights involved in the litigation, and the ne- cessity and adaptation of the proper legal remedy, so that he is competent, not indeed, to give the wisest possible directions as to the conduct of the proceeding, but to exert an intelligent will in selecting and instructing attor- neys and counsel, according to the ordinary course of a judicial proceeding. Upon the one hand, it is not enough to win for a party to a trial the indulgence accorded by the law to the insane, to show by testimony of physicians that he is weak-minded, or that he is disabled for other duties of life ; or that he has at some former time been to stand a trial. If at the time he is able to understand the general nature of the charge or controversy, the author- ity of the court to inquire into and punish the offence, or enforce the demand if proved, and the relation between services of counsel and the interests of the client, the trial may lawfully proceed ; it is not necessary that he should reason wisely in regard to the business, or that his plans or purpose in regard to the course to be taken should be prudent. The foregoing are not all the questions of the kind which may arise. They are the most frequent; but others are easily supposable. What, for instance, is the measure of that degree of insanity which avoids the marriage of the subject or which may warrant a divorce in jurisdic- tions where insanity is a ground ; or which affects the power of an officer, so that his vice or substitute may act in his stead, or a vacancy be declared ; or renders a per- son incompetent as a witness or unworthy of credit; or disables a woman from giving such a consent to sexual intercourse as will reduce the man's act from rape to se- duction ; or warrants the removal of the subject from a trusteeship or guardianship ? The rule for determining the degree of insanity varies, according to modern views, with the nature of the purpose for which it is needed. The inquiry is twofold : 1. What degree of mental ability is required for the performance of the act in question? 2. Did the person possess mental ability in the required degree ? The first is a practical question, to be determined by common-sense and business experience, with some general aid from the law. The second is a question of mental pathology, within a physician's peculiar province, and to be determined by applying his professional knowl- edge of insanity to the symptoms characteristic of the case. But the effort must be, in general, to indicate, not what is insanity absolutely, but what constitutes it rela- tively to the purpose of inquiry. And the spirit and tendency of modern decisions are adverse to establishing fixed and uniform tests, even with reference to a particu- lar object of inquiry ; and favorable to allowing each case to be decided upon its own circumstances. Benjamin Vaughan Abbott. CLARENDON SPRINGS, VERMONT. Location and Post-Office, Clarendon Springs, Rutland County, Vt. Access.-By Delaware & Hudson Canal Company Railroad, Saratoga & Champlain Division, to West Rut- land Station, about three miles from springs ; or by sev- eral railroads to Rutland, seven miles from springs. Analysis (by Professor A. A. Hayes, State Assayer of Massachusetts).-One gallon, or 235cubic inches, of water contains : Cub. in. Carbonic acid gas 46.10 Nitrogen gas 9.63 Grains. Carbonate of lime 3.02 Muriate of lime Sulphate of soda Sulphate of magnesia 2.74 One hundred cubic inches of the gas which was evolved from the water consists of : Cub. in. Carbonic acid gas 0.05 Oxygen 1.50 Nitrogen 08.45 Therapeutic Properties.-As a remedy for dyspep- sia, liver derangements, urinary affections, and cutaneous diseases, this water has proved beneficial. The springs are situated among the hills of Vermont; at an altitude of 1,000 feet, on the west side of Tinmouth River. From three springs-the large, lower, and north- there is a flow of 600 gallons per hour. The water is led to the hotel by pipes, being a delightful bathing water. The climate is delightful, the temperature rarely being oppressively warm during the day, while the nights are always cool. The scenery about the springs, situated as they are among the hills at the base of the Green Mountains, whose peaks are prominent features in the landscape, is of peculiar beauty. The drives in the neighborhood, over excellent roads, afford many charming views of this picturesque region. There are churches and schools in West Rutland. Hotels.-The Clarendon House, accommodating one hundred guests, and three cottages, also accommodating one hundred guests, fronting on a fine park tilled with shade trees. History.-These springs are said to have been discov- ered in 1776 by " Asa Smith." It was revealed to him in a dream that they would cure him of a scrofulous com- plaint from which he was suffering. He searched, found, and was cured. George B. Fowler. CLAVICLE, JOINTS OF. Jointing with the sternum and with the acromion process of the scapula, the clav- icle acts as an " outrigger," holding the scapula and hu- Fig. 662.-Clavicle as seen from above. merus away from the body for free motion, and placing the shoulder-joint in the best position for resistance. Fig> 662 shows that in every position the head of the hu- merus is held advantageously with reference to transmit- ting shocks to the strong glenoid fossa of the scapula, they being finally delivered through this and the acro- 177 Clavicle. Cleft Palate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mion process to the clavicle. Strong ligaments are there- fore needed to fix the bone at either end. It is more ad- vantageous that these be attached a short distance from the ends of the bone and only secondarily connected with the joints (see Fig. 661). The rhomboid ligament is a strong and thick band which attaches the sternal end to the first costal cartilage, and the coraco-clavicular liga- ment (separable into trapezoid and conoid bands) unites in a similar way the acromial end to the coracoid process of the scapula. Besides these ligaments, the bone is held in place by the cervical fascia and the costo-coracoid membrane. The strength of these attachments is sUch that dislocation of the clavicle is rather rare, occurring in about three per cent.- of the dislocations of the upper ex- tremity. Movement at the joints is arthrodial, and though limited, it takes place in all directions. Almost all mo- tions of the arm or of the thorax are associated with some slight movement in these joints, and it is not there- fore surprising to find that when they become inflamed, which is quite rarely, they seldom become anchylosed. In the sterno-clavicular joint the original capsular liga- ment is developed into an anterior and a posterior band, and a strong bundle (interclavicular ligament) passing from clavicle to clavicle over the episternal notch. An interarticular cartilage divides the joint into two synovial cavities. It is believed to represent the episternal bone skin is thickened, polished, and horny. At times it may be just the contrary, as is the case in soft corns. Occur- ring on parts that are naturally more or less moist, as be- tween the toes, maceration takes place, and the result is usually a soft corn. Upon the outer surface of the foot and toes, the usual site of these formations, the corn be- longs commonly to the hard variety. The usual size is that of a small pea. Corns are caused by pressure or friction, and in most cases may be referred to improperly fitting shoes. The shape of a corn is conical, with the base external, and the apex pressing upon the papillae. It consists of an accumulation of the cells of the horny layer, which are closely packed together, the centre and apex being dense and horny, forming the so-called core. The corium upon which the corn presses may be either atrophied or hyper- trophied, usually the former. In order that treatment be successful and the cure per- manent, the feet are to be properly fitted. Shoes are to be comfortable, neither too tight nor too loose. If pressure is removed, corns will in most instances disappear spon- taneously. In all cases, however, treatment is to be adopted. This is always satisfactory when the cause has been removed ; the cause persisting, the benefit is likely to be but temporary. In an affection so common as corns the plans of treatment recommended are innumer- able. A simple and popular method of treatment con- sists in shaving off the outer portion by means of a razor or sharp knife, and then applying a ring of felt, wadding, or like material over the region of the corn, with the hol- low part immediately over the site of the core. This ring-like plaster should be worn for some time, in order that the part may be relieved of all pressure and friction. As a preliminary measure the parts should be soaked in hot water or applications of poultices made ; in this man- ner the corn is somewhat softened and more easily pared off. It is also possible, in many cases, to extract the whole corn by gradually dissecting it out; the after-treatment being the same as above. In some cases touching the base of the cavity, from which the corn has been dissected out, with a drop of a solution of caustic potash will pre- vent a return. The application must be made with care, a solution of not more than five per cent, strength being employed. Another method of treatment is by a solution of salicylic acid. The menstruum may be either alcohol or collodion, preferably the latter. A solution of ten to fifteen per cent, strength is ordinarily required. This is painted on the corn and hardened skin night and morning for several days ; at the end of this time the parts are soaked in hot water, and the mass readily comes away. No preliminary preparation is necessary. This remedy forms the basis of most of the patent corn cures. Soft corns may be treated with the solid stick of nitrate of silver ; or the methods described above may be employed. Henry IK Steluayon. Fig. 663.-Joints of the Clavicle. The left sterno-clavicular joints shown in section. (interclavicle) of monotremes, rodents, and other animals. Being attached below to the cartilage of the first rib, it materially strengthens the joint and at the same time forms an elastic cushion which breaks the force of shocks transmitted from the arm. When dislocation occurs here, it is usually produced by the sternal end of the cla- vicle being forced forward by a sudden pushing back of the shoulder. It has been occasioned by suddenly seiz- ing a child by the arm and dragging it backward, and in the foetus, at term, by the manipulations of the ob- stetrician or even by the natural forces of labor. The de- formity arising from Pott's disease of the spine may cause the sternal end to be forced inward and press upon the important structures which lie near the joint behind, viz., the great vessels and the trachea. This is one of the joints liable to be affected in pyaemia. Effusions point and discharge in front where the capsule is thinnest. Syphilitic arthritis is not uncommon here. The acromio- clavicular joint is weak, the apposition of the surfaces being slight, and the capsular ligament (divided into su- perior and inferior bands) thin. It is of some assistance in the diagnosis of injuries about the shoulder to remem- ber that the line of the articulation falls exactly within a continuation of a line drawn through the middle of the anterior surface of the humerus. An interarticular fibro- cartilage sometimes exists within this joint also. Frank Baker. CLEAVERS; Goose-grass (Galium Aparine Linn.); Order, Bubiacece. This is a small herb, with slender, branching, weak stems, leaves in whorls, and minute flowers. It is a native of Europe and America, growing abundantly in low swampy places. The dried herb is an old remedy for chronic urinary troubles, and is usually classed among the diuretics, al- though it does not have much power in that direction. Enough relief is afforded now and then by drinking its decoction, to induce patients with chronic cystitis, or en- larged prostate accompanied by frequent micturition, to continue its use a long time. The hot water with which it is made is not without effect. Tannic, citric, and rubi- chloric acid*, are noted as constituents of this drug; none of them, probably, have much to do with its efficacy. It may be given in decoction ; dose indefinite. Allied Pi.ants.-Galium is a large genus. The spe- cies are generally small herbs, with very weak, reclining, square, often spiny stems ; rosettes of narrow leaves and small, white, greenish, or yellow four-merous flowers. They often contain coloring material. The genus is a very natural one, and its species not well defined. All are mild and inefficient in their medical properties, and CLAVUS. Clavus is a small, circumscribed, flattened, deep-seated, horny formation. Ordinarily a corn has the appearance of a small callos- ity, a modification or variety of which it really is. The 178 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Clavicle. Cleft Palate. quite a number have been in use. Galium mollugo Linn., Caillelait blanc, and Galium luteum Linn.; Caille-lait jaune are official in France. Several other species have been used (as what has not ?) in epilepsy, hysteria, eczema, etc. The nearest interesting genus to Galium is Rubia-the madder plant-which resembles it closely, but is a larger, stouter herb. For the order Rubiacea, see Cinchona. Allied Drugs.-See Couch-grass. IF. P. Bolles. bones appear as an appendage to the vomer, being held or assisted in position by fibrous, cartilaginous, and mucous tissues. This island of intermaxillary bones and tissues, which is so very noticeable in double hare-lip, especially when associated with double split, or fissure of the alveolar circle, has been a source of deep study to histologists as well as to pathologists. The former have spoken of it as analogous to the premaxillary bones in some of the lower ani- mals, and yet it has been very difficult to de- tect, in the youngest foetal human upper jaw, the differ- ence between the intermaxillary portions and the lateral or true portions of this bone. However, we know that this so-called island does contain what may be termed the true intermaxil- lary bones and the temporary and permanent incisors, in cases of complete double cleft having only the middle ones perfect, the lateral incisors often being imperfect or entirely absent. This condition of the incisors I have ob- served in cases in which it be- came necessary to remove the island. Such instances of re- moval are fortunately rare. Singular as it may seem, Fer- gusson states that this line of separation, just spoken of, can- not always be traced in the well-developed foetal skull; yet the suture remains quite dis- tinct in the palatine portion of this bone until a late period of adult life. The surgeon is obliged to take somewhat into consider- ation the structure of this island or the intermaxillary substance, in determining the line of treat- ment to adopt. Cleft of the hard palate, as well as hare-lip directly through the mesial line of the in- ter-maxillary bones and soft parts, is very rare. Tait says two specimens are known. I have seen one case of median hare-lip. Sir William Fergusson states that he has never seen a case. Maternal impressions are often suggested as a cause of this deformity. We can give but a very slight endorse- ment to this view of the ques- tion. / A. < A Congenital cleft of the hard V 4 and soft palate may be exceed- ingly simple, only the uvula, as seen in Fig. 664,* being impli- cated, or it may, in different degrees, be confined to the soft palate, or it may extend forward to, or into, the alveolar ridge, Figs. 665 and 666, as taken from two of my own cases, or it may double fissure the alveolar cir- cle, Fig. 667.* The fissure is oftener situated in the roof of the mouth, so that the vomer is to be seen in the middle of the split, Fig. 667.* At times the vomer is fastened to one or the other side, Fig. 668, generally to the left, and this location of it is always a source of embarrassment in operating. It is here that a combination of the Fergusson bone opera- tion and the Warren operation-the former on the side CLEFT PALATE. By cleft of the hard and soft pal- ate we mean a fissure of greater or lesser degree existing in the roof of the mouth, including, it may be, the al- veolar ridge in front, and extending back to the extreme end of the uvula. These clefts are of two kinds, congen- ital and acquired, the former being by far the more fre- quent. Pathology.-As to the congenital form, nature does not complete her work as originally intended, and while we can consistently endorse the views of those who think it entirely due to the want of a meat diet and of sufficient phosphates of lime on the part of the mother, still there are many other factors to be considered. H. E. Dennett, D.D.S., of Boston, has stated that " till flesh-eating animals take as much of the bone with the flesh they eat as they can break with their teeth suffi- ciently fine to swallow, and all have good dental organs." Several years ago the lions in the Zoological Gardens of London were fed upon flesh containing too large bones for them to break and swallow. The young born while this method of feeding was pursued, it was observed, had cleft palates and lived but a short time. The lions were then fed upon small animals, whose bones they could break easily, and the young born afterward had perfectly formed palates. It is safe to assert that the same causes which produce rickets in children have also a like effect in producing cleft of the hard palate. Hereditary tendency has been mentioned by some authors, and this I have observed in the history of some of my own cases. Mr. Lawson Tait, F.R.C.S., in his paper on " Cleft Palate," ' has very briefly, in somewhat differ- ent words, referred to this patho- logical condition, and is very strong in his belief that in certain localities it is quite endemic, and that, in his experience, heredity had been a great factor. He says he has known cleft to miss as many as three generations, and then appear in an hereditary form. The late Dr. Gurdon Buck has reported a number of interesting cases of hereditary cleft occurring in his practice, upon which he operated with success. I lay much stress upon asking the parents questions bearing upon these points. Intermarrying is an element to be considered in the study of the pathology of these cases. (See Fergusson's " Surgery.") In a majority of cases in which the fissure is single, it is to be found on the left side, and the deviation of the two segments of the alveolar circle is fortunately, in these cases of single split, seldom great. My experience has been that in double fissure through the alveolar ridge, the vomer often has its only support below in the inter- maxillary projection, that is, the intermaxillary bone or Fig. 666. Fig. 664. Fig. 667. Fig. 665. Fig. 668.* * From Mason, On Hare-lip and Cleft Palate. 179 Cleft Palate. Cleft Palate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. free from the septum, and the latter on the opposite side, sliding the periosteal flaps-meets the emergency best. To break the vomer, as I did in some of my earlier cases, is not always a success, and we are more likely to get necrosis, especially of the septum. It is well known that many infants born with this de- fect die within a short time after birth, when the cleft is of a marked character. Mr. Tait says that one-half of the children born with extensive clefts die within a few days after birth from starvation, and thinks we might be able to save many of these children if we could help them to suck by early giving them a roof to the mouth, and, therefore, advocates doing the operation for closing the hard palate as early as the third week. My personal experience does not show so high a rate of mortality. When speaking of treatment, I shall refer to this again. Children born with cleft palate cannot nurse, nor can they, in many instances, use the large rubber nipple of the nursing-bottle with complete success. Mason in his excellent work, mentions the large flat nipple, made so as to fill the roof of the mouth while nursing, as of great use. When the children must be fed with a spoon, a great care devolves upon the mother or nurse. Among my cases I have the notes of two, son and daughter in one family, where the mother, for nearly two years, in each instance, was obliged to give nearly her entire time to their care as regards feeding, before they could help themselves. In neither of these cases was an early operation done for closing the double hare-lip. Fig. 666 shows condition of the son. Cases allowed to grow on without interference beyond the second year, are those that show the loss of voice and the nasal tone in so marked a degree. This often proves a source of great annoyance in after-life, keeping the pos- sessor from society, and from the study of the professions. It is interesting, as we study the history of this subject, to note the views of different surgeons who have pub- lished their cases, as to the proper time for operation, es- pecially in reference to the recovery of the voice. I have now done the operation so many times, in patients of from twenty months to nineteen years of age, that I am entitled to speak from experience, and am convinced that our most successful cases are those upon which we oper- ate early, and before the child has made any great effort to speak. In fact, these cases should not be encouraged to talk early. Most children make an earnest effort to talk at the end of the second year, and by that time the opera- tion should have been performed. From the observations I have made of efforts of other surgeons to close the cleft as early as the second or third month of infant life, and from reading and experience, I am not in favor of going so far as this in the direction of early operating. Young children do not bear the loss of blood well, and although we may make use of the galvano-cautery knife to divide the tissues and avoid haemorrhage, yet the shock is such as to add to our mortality list, and, besides, union often fails in these early attempts. Of this, however, I am certain, that in all these cases of cleft palate complicated with single or double hare-lip, the operation upon the soft external parts should be done as soon after birth as possible. With the large nipple and perfect lips to surround it, or simply by the use of the spoon, the child can be fed very well. The union of the soft parts does aid, I am convinced, in bringing together the bony vault of the mouth, a result which is very desir- able. Then again, it does, to a certain extent, carry the child out from the domain of idle curiosity and observa- tion, and thereby lessens the burden of the parents. Some of these children will die before reaching the age of two years, not because of imperfect mastication, but because they are bound to bear their ratio of death with the rest of the infant family. In double hare-lip, while the treatment of the island or intermaxillary bone has been dwelt upon very clearly by the various writers, I am sure that of all the different complications, it is in this that experience is of the great- est value, and that every case presents one or more pecu- liar features. To save the island when possible is, I think, good surgery. There can be no doubt that it pre- vents the child-like contraction or appearance which is so striking in some adult faces where it has been removed. I think the cases are few in which, in saving the island, the operator can go on and unite both sides in the same operation. As to the manner of closing the single hare-lip, there can be little difference of opinion. The law is indexible that to produce a good result the vermilion border of the lip must be always on a line projecting a little, if possible. If not, an apparent notching occurs in the vermilion bor- der. Regarding the mode of dealing with the island, as my experience goes, if I cannot save the bone, I try to save the healthy skin covering it, be it ever so small, and to shape it in such a way that by angle, curve, or square, I can fit it either into, between, or to one side of the upper lip, using that to form daps, the small portion aiding in its way to give an appearance of fulness to the face or upper lip. In one of my cases, sent me by Professor Bigelow, of Albany, there existed that dreadful deform- ity, such as is seen in a small number of cases only-for which we should be thankful-in which the island pro- jected upward almost like a horn toward the nose. There was quite a surface of healthy skin covering it, and I de- termined to save all. Accordingly, I first took from the septum, with curved bone-forceps, a V-shaped portion of bone, and then broke the island into position on a level with the alveolar ridge of the upper jaw, and held it there for a period of ten days, with com- press and adhesive plaster. Two weeks later, I freshened the edge of the fissure on the left side, also the edge of the skin covering the island, and then brought the flap or upper lip up to it, holding it there with two silver pins. Good union was obtained (see Fig. 669). Two months later, and when the child was not quite six months old, I treated the fissure on the right side in a similar manner, and got a perfect result. Unfortunately for the completion of the operation for closure of cleft of the hard palate, this child died of cholera infantum just at the end of its second year, and at a time when the parents were ready and anxious for the final operation. The saving of the island gives a better septum for the nose, as is reasonable to conclude in comparing this case with another in which the island was removed. Master B , aged six months, had a double hare-lip with the intermaxillary bone so prominent that it was deemed best to remove it entirely. This was done at the first operation : a lateral incision was made from the angle of the nose on each side outward into the cheek, and then the two flaps forming the upper lip were brought together, perfect union being thus secured. Later on, and in his second year, two operations were required for closing the cleft in the hard and soft palates ; but his voice did not im-< prove as I had hoped. I did not see him for nearly three years, when he was brought to me, and on examination I found the upper lip had no union with the septum or vomer, and that through this opening the air escaped in so great a volume as to partially account for his defective speech. These cases are difficult to remedy. Master C , aged four years, presented almost as frightful an appearance as Master B . We operated upon him the same number of times, saving the inter- Fig. 669. 180 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cleft Palate. Cleft Palate. maxillary bone, and obtaining a result, as to appearance and voice, nearly perfect. Just here I wish to speak of the necessity of operating upon the soft parts in such a manner as not to leave any scar behind. On this point Mr. Lawson Tait says : " To avoid these scars I use ordinary seamstresses' needles, strong, and threaded with a few inches of silver wire double. I introduce each needle through the lip (in the plane of its surfaces), about half an inch from the pro- labium, and bring the point out at the middle of the cut surface. I then introduce the needle at the correspond- ing point of the opposite cut surface, and bring it out at the root of the ala of the nose. Thus, when both needles are in situ they form a St. Andrew's cross, the point of intersection being the centre of the wound. The needles are then pushed home up to their eyes, the wires twisted firmly together, the points cut off close to the skin, and the stumps retracted into it. Thus all possible scarring is avoided." In my article on Hare-lip I shall speak more fully on this subject, having little reason to regret the use of the ordinary silver hare-lip pins. In these operations 1 do not hesitate to make use of chloroform, and especially in children under ten years of hundred times), did not leave a record as to results upon the voice, the restoration of which is the principal object sought for in doing so difficult an operation. That it is a severe operation there can be no doubt, especi- ally when the attempt is made to close a complete cleft. That repeated failure in doing it, in some cases, has been my experience, I am willing to admit; yet in these cases, with one or two exceptions, I have finally conquered, and in none was the patient left any the worse for the future trial of an obturator. That cases do get on in life with- out any operation being done, and are then improved by Fig. 671. use of an obturator, is now a well-established fact. How- ever, these cases are not always so benefited. A gentleman with whom I am acquainted, aged seventy, was operated upon when a child for hare-lip, by Guthrie, and then given to the dentists for relief when eighteen years of age. He has never been in the least improved by the use of obtu- Fig. 672. Fig. 673. rators, and life lias ever been to him a sorrow. It is with great difficulty that he can be understood. That we ought to be careful not to promise too much I am fully aware, and yet encouragement should be given when there is hope, and the attempt should be made to relieve these unfortunate children. It must be remem- bered, too, that some cases are stub- born, and require great courage and perseverance on the part of the sur- geon. I have never yet been obliged to stop an operation because of haemor- rhage, but I have known it to occur at times in a severe manner. Once I was compelled to postpone an opera- tion on account of the great and rapid secretion of mucus, it being so abun- dant that the bronchi filled to an alarming extent, and suffocation seemed imminent. In the second attempt I put the patient for twenty-four hours upon full doses of tincture of belladonna, which had the desired effect of dry- ing the throat and checking the free secretion of mucus. The subject of cleft palate is one that has occupied the minds of our best surgeons both in this country and in the old world, and each can claim a good degree of success. It is not necessary at this point to enter into the details of the history of the opera- tion. It is enough to know that Billroth, Lawson Tait, Fig. 670. age. Before it is given everything should be in readi- ness, and each assistant should be instructed as to his work; then, as the little one comes under the influence of the anoesthetic, the operation should be begun with promptness. It is true, many of these children are of feeble make-up, but the cases are few in which one need feel at all anxious in giving the chloroform from a small plain napkin, plenty of air being allowed. It is possible that these cases may yet be the proper ones for rectal etherization, but in our present uncertain state of knowl- edge as to results, I would not use or recommend this method. The subject of cleft of the hard and soft palate is one not so well settled in the minds of surgeons as to exclude further elucidation, and, while it is hardly safe for one to attempt to advance much that is new, I am convinced that a more careful examination of our cases, and reports of the same, one, two, or more years after an operation has been performed, are needed. It will ever remain a source of regret to the profession that such successful operators as Warren and Fergusson (the latter operating over three Fig. 674. 181 Cleft Palate. Cleft Palate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Francis Mason, T. Smith, Goodwillie, Prince, and many others of our own time, have given the matter careful consideration. It is an operation in which experience is of service as to dexterity, as to time consumed in doing it, as to teaching parent or nurse how to im- prove the speech afterward, and also, I be- lieve, as to the time of selecting the case for operating. 1 think that, if we could get honest statistics, we should find the best time for operating to be immediately after the first dentition, or when the child is about two years old, and that previous to this no attempt should be made to encourage the child to talk. Then there is not so much danger of acquiring that nasal twang which is so difficult for an older person to over- come. The rule stated above should also apply to cases of incomplete cleft, in which there is no hare-lip. The acquired form of cleft is the result of a variety of diseases and accidents. Of the former the most frequent is constitutional syphilis in the adult. In children it is usu- ally the result of a fall while running with something in the mouth, as a bean-blower, pencil, or pen, the force being such as to drive the article through some part of the roof of the mouth. These forms of fissure are strictly behind the alveolar ridge, and, as a usual thing, not large. They will be con- sidered more fully when speaking of treatment. Staphylorraphy is an operation suited especially for closing a cleft of the soft palate, also such as are associ- ated with but slight fissures of the hard. Osteoplasty is essentially the bone or Fergusson opera- tion. I have combined the two in closing a complete cleft of both hard and soft palate, and have had no reason to regret it, although it is a severe op- eration. The child's bowels having been moved the day before, no solid food should be given on the morning of the operation. I was once greatly embar- rassed in a case in which the nurse had given the child a large plateful of oat- meal gruel, which it continued to vomit during the entire operation. Chloroform may be given, and when the anaesthetic takes effect the White- head gag, which I consider the best, should be introduced as shown in Fig. 670. The operator should have ready a number of sponges, with at least a dozen good sponge-holders, long enough to reach well back into the pharynx. It is necessary, too, to have near at hand a bowl of cracked ice, in which to dip the sponges to use in controlling haemorrhage. The surgeon requires as his assistants, one to give and watch faithfully the anaesthetic, another to sponge, a third to hand the instruments and assist gener- ally, and two others to clean, dry, and hand sponges. The operation should be performed in front of a good light, and the patient's head should rest on a firm pillow. Some operators speak very favorably of letting the child's head hang over the table, the blood being sponged out as it collects in the posterior part of the pharynx. The essential steps of the operation are as follows : First. Standing on the right side of the patient with forceps or tenaculum, Fig. 671, the operator grasps the lower end of the uvula, on the left side, and, with long, sharp-pointed, narrow knife, Fig. 672, freshens well the edges of the fissure, not hesitating to take away plenty of tissue, and frequently doing it without remov- ing the instruments ;-in which matter, of course, much will depend upon the bleeding, and how well the child is under the influ- ence of the anaesthetic. Second. With an awl-shaped in- strument, Fig. 673, holes are bored through the bone near the edge of the cleft, for passing the sutures (see Fig. 670). Third. Similar holes, two on each side, are drilled through the bone along the alveolar ridge, sufficiently in front, and not so far back as to in- terfere with the important blood-ves- sels, and then, by means of the chisel, Fig. 674, the paral- lel portion of bone is pressed, or rather forced, toward the median line for the purpose of closing the cleft in the hard palate with bone and periosteal substance. Fourth. The blue and red silk threads forming the sutures are then passed alternately in the following manner, as shown in part in the ac- companying illustrations: A blue thread is first passed through the anterior hole previously made in the left side of the cleft, by means of the long curved needle, Figs. 675 and 676, and the free end is drawn out singly by long forceps ; next a red thread is passed in the same manner through the hole opposite in the right side of the cleft, the loop being drawn through, and in this is engaged the free end of the blue suture in order to draw it through the hole on the right side, thus completing its passage, as seen in Figs. 677, 678, 679, and 680. In this way as many sutures as are needed are passed, the red and blue alternating. Fifth. Tying the sutures is next done by means of the slip-knot. A half-knot is thrown around the free end of the suture, Fig. 680, and then by the use of the fingers or instrument, Fig. 681, the knot is pressed tightly down against the edges of the cleft-which are thus brought together-and tied twice, as shown in drawing from life, Fig. 682, the suture being drawn to one side of the fissure and cut short with curved scissors. This closes the entire split completely in one opera- tion. Sixth. This is a very important step in many opera- tions. It consists in dividing the tissues at the point where the greatest tension exists. In examining my patients I was impressed early with the ob- servation that, when they at- tempted to swallow and when they breathed with the mouth open, the two sides of the fis- sured soft palate very nearly, if not quite, come into apposition, except just opposite the hamu- lar process and at the junction of the hard and soft palates ; and, at the same time, there is thrown up on the posterior wall of the pharynx a transverse ridge formed by the superior constrictor, the latter aiding to prevent the passage of air or food up into the posterior nares. This observation led me to make the lateral incisions in the soft palate only at the point of greatest tension, and, that being the ten- don of the tensor palati, to buttonhole it, as we may say, with a short blunt knife (Fig. 683, after Fergusson). Fig. 678. Fig. 675. Fig. 679. Fig. 680. Fig. 676. Fig. 681. Fig. 682. Fig. 677. 182 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cleft Palate. Cleft Palate. The relief afforded by this procedure is at once marked, but at times the haemorrhage is decided, and, therefore, I believe the platinum knife of the galvano-cautery is the best instrument to use, and probably better than the wire suggested by Dr. David Prince for this part of the opera- tion. This is essentially the same procedure as that of dividing what Mr. Lawson Tait so ably describes in his paper as the circumflex fascia belonging to the tendinous insertion of the tensor palati muscle, a failure to divide which so often causes non-union of the hard and soft palate. Dr. David Prince, in a paper on "Pala- toplasty," very clearly and ably discusses this subject. Fig. 682 shows the appearance of the mouth when the combined operations have been performed ; the lateral alveolar inci- sion having been well packed with strips of iodoform gauze. This step I consider essential, as it prevents the too quick union of this free incision, which is apt some- times to occur. It is well to repack the in- cision on the third, fourth, fifth, or sixth day, the judgment of the operator deter- mining the exact time. When simple staphylorraphy is to be per- formed, the steps are much the same ; the use of the awl and chisel in bringing the edges of the bone together, should, how- ever, be omitted, and, where the hard palate is implicated, the Warren-Langenbeck peri- osteal operation of sliding the covering of the bone as needed, should be performed. This is done by first making an incision through the mucous membrane and periosteum with a blunt edged instrument or cautery-knife ; then with peri- osteal elevators (Fig. 684), the tissues should be lifted from the bone and toward the mesian line, the point of the instrument being carried posteriorly near to the pos- terior palatine arteries. This procedure, as Mr. Tait has observed, raises the vessels from their bed without injur- ing them. The point of the raspatory must not be intro- duced into the canal containing these vessels. Mr. Tait believes that if the muco-periosteum of the hard palate be elevated with a raspa- tory from the semi-lune of the palate bone, the tendinous attachment of the tensor palati will be raised with it, and thus paralyzed, thereby doing away with the necessity of any such division of muscles as is practised by Pol- lock or Fergusson, and dimin- ishing the risk of the pin-hole orifice at the junction of the hard and soft palates. After this, if tension of the soft pal- ate be present, divide as before spoken of. The length of time of leav- ing in the sutures is of im- portance. Tait leaves them in fourteen days and uses silver wire. Prince uses silver wire. Mason uses silk, and in many instances lets them ulcerate out. Other surgeons have sug- gested and used horse-hair. I have always used silk and re- move some stitches by the sixth day, having them all out by the tenth. Colored silk is best. In removing them it is well to put the patient under the influence of chloroform. Use long forceps and sharp- pointed curved scissors (Fig. 685). A word as to the incision of the poste- rior pillar of the fauces as mentioned by Mr. Bryant. I have observed that there is a great difference in the space between the anterior and posterior pillars of fauces of different individuals, and where the soft parts are found to be very tense, the posterior pillar may be divided ; but we are warned by Mr. Tait, that atrophy of the soft pal- ate is likely to follow this operation, an outcome which is to be regretted. This condition I have noticed in one of my own cases. Many cases require two and three operations, but we should not be discouraged. Contrast a good result with the frequent necessity of changing the obturator and the care required in looking after it. Fig. 686 shows the little pin-hole opening (in some cases larger), which may often be closed by the persistent use of some caustic, such as nitrate of silver or nitric acid. Dental engines may yet be of service in performing this opera- tion, but at the present time they have not been used to any great extent. Training the voice after the op- eration is of great importance as regards the final result. Great pa- tience is required, and we must not expect improvement to follow immediately. A year, or even a longer time may be required. With children I have had greater trouble in teaching the pronuncia- tion of ch, as in church, chicken, etc., than that of any other sounds. Dr. Henry J. Bigelow, of Boston, has in a very able manner pre- sented the following views as to teaching the children to talk after the operation has been performed. He says : " Some years since I devised a short series of exercises for a patient I had operated upon. It begins with the only consonant which a patient can usually best articulate, namely, ' t' in ' tar,' and gradually leads to the rest, constantly referred to the acquired ' t' as a point of departure. The great difficulty in pronouncing correctly with a cleft palate is in distinguishing the nasals from the mutes ; thus, p and b from m ; pap or bab from mam ; t and d from n ; tat from nan ; k and g (hard) from ng. ' Tar' is well pronounced by most beginners with an ob- turator. When the beginner can pronounce ' stark ' and ' car ' he has the key to most of what here follows. The above words should be practised carefully ; not ' start ' and 'tar,' but 'stark' and ' car,'and should be spoken loudly, or, as the elocutionists say, ' exploded.' 1. tar artar kar ark gar kar 2. kar arkar arkgar kgar gar 3. kar arkar arkdar kdar dar 4. kar arkar arkpar kpar par 5. kar arkar arkbar kbar bar 6. kar arkar arklar klar lar 7. kar arkar arksar ksar sar Practise all the above with the following vowels : 8. o as in coke. Thus, instead of kar, akar, etc., ko-oko-oklo-klo-lo. 9. a (long) as in cake. 10. i as in kite. 11. e as in keep. 12. u as in suit. 13. kar arkar arngar arkar arngar kar ngar 14. tar artar arnar artar arnar tar nar 15. par arpar armar arpar armar par mar bar mar Fig. 683. Fig. 686. Fig. 684. Practise reading loudly from a book : dar mar sar rar2 " In the case of children beyond twelve years of age, and particulary with adults, I would perform the operation for closing cleft palate, if for nothing more than to afford comfort in eating. Regarding the treatment of the acquired form of cleft, I should, in all cases of traumatic origin, operate by Fig. 685. 183 Cleft Palate. Climate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. forming the periosteal flaps. In cases in which there is con- stitutional syphilis present, I should hesitate somewhat, believing that in the majority of these cases the obtura- tor does best. I believe there are few operators who have accumu- lated a greater number of instruments, such as needles, etc., for passing the sutures in doing this difficult opera- tion, than myself, yet I thoroughly believe there is no more practical way than by the simple method described in this paper. A. Vander Veer. 1 British and Foreign Medico-Chirurgical Review, July, 1870. 2 From Boston Med. and Surg. Journal, February 7, 1884. CLEVELAND. The accompanying chart, representing the climate of the city of Cleveland, O., and consti- tuting one of a series of'similar charts obtained from the Climate of Cleveland, Ohio.-Latitude 41° 30', Longitude 81° 42'.-Period of Observations, November 1, 1870, to De- cember 31, 1883.-Elevation of Place of Observation above the Sea-level, 650 feet. A AA 4 C I) £ F G II 1 Mean temperature of months at the hours of 1 Average mean temperature de- a 3 g S o - 3 8 ■ Mean temperature for period of ob- servation Average maximum temperature for period. Average minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. Greatest number of days in any single month on which the tem- perature was below the mean monthly minimum temperature. Greatest number of days in any single month on which the tem- perature was above the mean monthly maximum temperature. January... February... March April May June .. July A ugust September.. October .... November.. December.. Spring Summer.... Autumn.... Winter Year 7 A.M. Degrees. 24.7 25.4 31.0 42.5 54.9 64.7 69.2 67.0 59.5 49.2 36.5 28.2 3 P.M. Degrees. 29.4 31.6 87.1 48.7 62.4 72.3 76.8 75.6 68.8 58.0 42.0 32.1 11 P.M. Degrees. 26.3 28.3 33.9 44.2 57.1 65.8 69.9 68.8 61.9 52.0 38.0 29.5 Degrees. 26.8 28.4 34.0 45.1 58.1 67.6 71.9 70.4 63.4 53.0 38.8 29.9 45.7 69.9 51.7 28.3 48.9 Highest. Degrees. 39.5 37.0 43.1 53.0 65.6 70.4 74.2 73.8 71.7 59.0 43.0 40.4 51.0 72.5 56.9 80.9 50.5 Lowest. Degrees. 17.3 15.5 27.8 39.6 51.9 64 3 68.7 66.9 59.5 47.4 31.6 19.8 42.2 68.3 48.3 22.9 45.9 Degrees. 32.8 37.7 42.1 53.3 66.4 74.0 79.0 77.9 72.2 63.2 47.2 37.2 Degrees. 19.1 22.5 28.2 37.6 49.6 58.2 64.1 62.5 56.7 47.3 33.6 25.3 Highest Degrees. 70.0 72.0 76.0 85.0 92.0 96.0 96.0 98.7 98.0 87.0 72.5 68.0 Lowest. Degrees. 39.0 47.0 55.0 70.0 74.0 85.5 86.4 81.5 78.0 74.0 53.0 45.0 Highest. Degrees. 8.0 18.0 1 22.0 38.0 39.0 51.1 60.0 58.0 49.8 36.8 26.0 23.0 Lowest. Degrees. -17.0 -11.2 -2.0 15.0 28.3 40.0 49.6 45.6 38.0 26.0 Zero -12.0 23 23 27 24 26 20 23 24 26 23 23 23 30 22 22 19 28 19 18 20 15 20 21 26 J K L. M N O K S ment of chronic catarrhal conditions, bcin^ taken inter- Range of temper- ature for period. Mean relative hu- midity. Average number of fair days. 1 Average number of clear days. Average number of fair and clear days. Average rainfall. Prevailing direc- tion of wind. Average velocity of wind, in miles, per hour. nally, but the springs have lost much of the reputation they formerly enjoyed. T. L. S. CLIFTON SPRINGS. Location and Post-office, Ontario County, N. Y. Access.-By New York Central and Hudson River Railroad, Auburn branch, to Clifton Springs. Analysis.-The sulphur springs are numerous, and have the following constituents, as shown by an analysis, made of one quart of water, by the late Dr. Chilton, of New York ; Grains. Sulphate of lime 17.30 Sulphate of magnesia 4.12 Sulphate of soda 1.94 Carbonate of lime 2.42 Carbonate of magnesia 3.28 Chloride of sodium 2.32 Chloride of calcium 1.02 Chloride of magnesia 1.02 Organic matter a trace, hydrosulphuric and carbonic acids abound, but the quantity having materially lessened while being conveyed to New York, the proper amount could not be ascertained. January.... February .. March April May 1 June July August .... September. October.... November. December . Spring 1 Summer... Autumn ... Winter Year 87.0 83.2 78.0 70.0 63.7 56.0 46.4 53.1 60.0 61.0 72.5 80.0 94.0 58.7 98.0 89.0 115.7 77.9 73.8 74.5 66.4 64.3 68.4 70.1 68.5 69.9 69.2 73.2 77.9 68.4 69.0 70.8 76.5 71.2 8.4 11.7 12.2 12.9 13.2 13.6 15.7 13.4 11.4 10.3 9.5 9.5 38.3 42.7 31.2 29.6 141.8 2.8 4.7 4.3 7.3 10.0 8.7 9.6 12.2 9.4 8.7 3.3 2.0 21.6 30.5 21.4 9.5 83.0 16.4 16.5 20.2 23.2 22.3 25.3 25.6 20.8 19.0 12.8 11.5 59.9 73.2 52.6 39.1 224.8 Inches. 2.50 2.62 3.16 2.49 3.17 4.33 4.21 3.41 3.91 3.14 2.63 2.83 8.82 11.95 9.68 7.95 38.40 From S.W. W. w. N.E. S.E. S.E. N. S.E. S.E. S.E. S.W. S.W. S.E. S.E. S.E. S.W. S.E. Miles. 10.7 10.3 10.8 9.2 8.3 7.9 7.3 6 8 8.7 9.8 11.3 10.9 9.4 7.3 9.9 10.6 9.3 ment of chronic catarrhal conditions, being taken inter- nally, but the springs have lost much of the reputation they formerly enjoyed. T. L. S. CLIFTON SPRINGS. Location and Post-office, Ontario County, N. Y. Access.-By New York Central and Hudson River Railroad, Auburn branch, to Clifton Springs. Analysis.-The sulphur springs are numerous, and have the following constituents, as shown by an analysis, made of one quart of water, by the late Dr. Chilton, of New York : Grains. Sulphate of lime 17.30 Sulphate of magnesia 4.12 Sulphate of soda . 1.94 Carbonate of lime 2.42 Carbonate of magnesia 3.28 Chloride of sodium 2.32 Chloride of calcium 1.02 Chloride of magnesia 1.02 Organic matter a trace, hydrosulphuric and carbonic acids abound, but the quantity having materially lessened while being conveyed to New York, the proper amount could not be ascertained. Chief Signal Office, in Washington, is here introduced for convenience of reference. A detailed explanation of this, and of the other similar charts, will be given in the article entitled Climate ; where also the reader may find suggestions as to the method of using these charts. IL R. This analysis is nearly the same as that of the White Sulphur Springs of Virginia. Therapeutic Properties.-These waters are calcic- sulphur, applicable to cases requiring sulphur-water treat- ment and to patients affected with bladder trouble. Clifton Springs is situated in the fine farming region of Central New York, eleven miles west of Geneva, on Seneca Lake, and the same distance east of Canandaigua, on Lake Canandaigua. The climate is pleasant and free from severe storms. The surrounding country has a quiet pastoral beauty, and is traversed by good roads in all di- rections. There are churches of various denominations, and good schools in the village. Hotels.-The Clifton Springs Sanatorium is a large building, four or five stories high, Slaving a frontage of two hundred and thirty-five feet, with an east wing one CLIFTON is a town in Gloucestershire, England, a .short distance from Bristol. It was formerly much frequented by invalids, coming to drink and bathe in the warm springs there situated. The water of these springs issues from the rock at a temperature of about 76° F. It contains only about 6.28 parts of solids in 10,000, these consisting chiefly of carbonate and sulphate of calcium, chloride of sodium, and nitrate of magnesium. The waters were at one time highly recommended in the treat- 184 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cleft Palate. Climate. physician who is, at least to a certain degree, versed in the kindred sciences of Meteorology and Climatology, and who is of necessity fairly well grounded in matters of general hygiene. A knowledge of climatology suffi- cient to render the reader an expert in that science, or in the selection of health-resorts for his patients, cannot pos- sibly be imparted in the course of a brief article in a Handbook. Such information must be sought in special treatises upon Climate, upon Meteorology, and upon Climatotherapeutics. The reader desirous of becoming more fully informed in these matters may be safely re- ferred to the pages of Parkes's " Practical Hygiene ; " to Dr. Hermann Weber's treatise on " Climatotherapy" in Ziemssen's "Handbuch der Allgem einen Therapie ; " to the articles on " Climate," " Meteorology," and " Atmos- phere," in the "Encyclopaedia Britannica," or to such special treatises as Hann's " Handbuch der Klimatologie," Loomis's " Meteorology," Lombard's " Traite de Clima- tologie Medicale," Dr. J. Burney Yeo's "Climate and Health-resorts," Blodgett's " Climatology of the United States," etc., etc. Finally, in the consideration of climate as applied to the proper selection of health-resorts the old and time-honored (not to say time-worn) maxim ' ' Experi- entia docet," is ever to be borne in mind, and the phy- sician who has travelled and has had personal experi- ence of various climates and of various health-resorts, should be at an advantage as compared with his stay-at- home brother, who can base his judgment solely upon "hearsay" evidence. We say such an one should be at an advantage, and we say so advisedly ; for it is not every one that travels who is capable of observing, and an un- fortunate experience in the matter of accommodation, the encountering of exceptional days or seasons of bad weather, etc., etc., will often pervert the judgment so as greatly to invalidate the opinion respecting a particular region or place held by or pronounced by one who has visited it; and to such a degree, unfortunately, as to ren- der the testimony of such an one not only useless to the inquirer but even misleading as well, and therefore worse than useless. So, too, of course, an exceptionally fortu- nate experience at some health-resort may operate to pro- duce in the mind of the traveller, and in the minds of those depending upon him for their information, an un- duly favorable judgment respecting the merits of the place he has visited. Prolonged residence at, or repeated visits to, the town or region in question, will do much to obviate the risk of such erroneous and misleading impres- sions, and the element of "personal error" can also be reduced in force by comparing together the reports of a number of visitors, and can be still more nearly eliminated by consulting reliable figures giving the result of an ex- tended series of meteorological observations. To assist such persons as are little versed in the signifi- cance of climatological figures toward attaining a proper comprehension of their true meaning, and to enable them in this way, so far as possible, to realize, without actu- ally experiencing, the peculiarities of Climate, or the "habitual weather" of the health-resorts discussed in the pages of this Handbook is, as has already been stated, the main object at which the writer has aimed in the presentation of the present article. The charts which so commonly accompany the descrip- tions of the individual health resorts are intended to sub- serve a double purpose. In the first place they are to serve as a corrective of the element of ' ' personal error " enter- ing so largely into the accounts of travellers, nay even of residents (to say nothing of those informants whose statements are colored by their personal and pecuniary interest in the resorts of which they speak); but, over and above this object for their frequent introduction, such charts are intended to assist in comparing the climate of one place with that of another. It will be observed that full climatological charts are in many instances to be found under the names of places which can hardly, by any stretch of the imagination, be regarded as belonging within the category of health-resorts. For example, in the first volume the reader will find a chart showing the climate of Boston, and in the present volume charts for hundred feet deep, and a west wing three hundred feet deep. It contains an elevator, gymnasium, and baths of every description. Guests for treatment at this establish- ment are under the care of six physicians, and are placed on a strict regimen as to diet, exercise, and bathing. In addition to the Sanatorium there are numerous boarding- houses and a small hotel. G. R R. CLIMATE. Very few of the many definitions of the word climate, which are to be found in such treatises on this subject as he has examined, have appeared to the writer of the present article to be altogether satisfactory. Weber and Loomis both agree in comprising under the term the totality of all those conditions of the atmosphere which affect organic life, while the first mentioned of these two writers also includes in his definition the influences exerted upon plants and upon animals by the soil and by the water of the regions in which they are found. That the soil and the presence or absence of large or small bodies of water are of importance, and are to be taken into consideration in estimating the features of the climate of any particular place or region, there can be no manner of doubt ; but their importance would* seem to the writer to be chiefly due to the effects exercised by them upon the atmosphere, at least when we consider them from a strictly climatological point of view. The study of cli- mate, in the strictest sense of the word, is, therefore, limited to the study of atmospheric conditions; the science of Climatology treats of these conditions or phe- nomena, and of their causes, and in particular of their geographical distribution and the manner in which they are found more or less constantly associated together in different regions and at different places upon the earth's surface. It is closely allied to Meteorology, which treats in a more detailed manner of the ultimate causes of cli- matological phenomena, and of the methods which have been adopted for observing and for recording these phe- nomena. The definition of climate given by Dr. Julius Hann at the beginning of his " Handbuch der Klima- tologie " is a very convenient one, and may be roughly summed up in the two words, " habitual weather." Thus what we mean by the climate of a particular place is the, prevailing and characteristic weather of that place. A detailed and full description of the various elements which go to make up that totality of combined meteoro- logical phenomena known as climate it is by no means the intention of the writer to lay before readers of the present article : for such explicit and minute instruction on this topic he would beg leave to refer them to longer, more strictly scientific, and more able treatises. His main object is simply to supply in this place a moderate amount of comparatively sketchy and superficial informa- tion as to the various climatological phenomena and factors, which shall serve as a guide to the better and more thor- ough understanding of the articles describing individual health-resorts which appear in the pages of this Hand- book, and to do this with a view to assisting such phy- sicians as are not especially interested in climatology in forming a due estimate of the advantages and disadvan- tages possessed by each such health-resort, and in select- ing among them those best suited to the invalids who may place themselves under their care and guidance. Further information of the same sort, but bearing more particu- larly upon the effects upon the human organism produced by different varieties of climate, and by different meteoro- logical factors of one and the same climate, will be found in the article entitled Health-Resorts, in which article will also be found some general remarks concerning what is known as Climatotherapy, to wit, the treatment of dis- ease by means of climatic influence. The special bene- fits likely to be derived by invalids at each health-resort described in this Handbook, are, in most instances, re- ferred to in the course of the article treating of each such resort. The very important question of the selection of a resort suited to the case and to the circumstances of a particular invalid, can be in a measure determined by consulting the general-article on Health-Resorts, together with a certain number of the special articles ; but the proper answering of such a question is only possible to a 185 Climate. Climate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Chicago, and Cincinnati, and his curiosity may have been aroused to learn just why these places should have been mentioned in a " Reference Handbook of the Medical Sciences." These charts, and others like them, are intro- duced solely for purposes of comparison, and to assist, for instance, a resident of Boston, or one by experience famil- iar with the climate of that place, in forming some sort of realizing sense of the climate of, let us say, Charleston, S. C., or of Jacksonville, Fla., through comparing the chart of Charleston, or of Jacksonville, column by column and figure by figure, with the similar chart showing the same factors of climate at Boston. More detailed infor- mation respecting these charts, and fuller suggestions as to the chararacter and scope of the knowledge derivable from the figures standing in their various columns, will be presented to the reader toward the close of this article. A classification of climates will not be attempted in this place, neither is it proposed to give an account of the geographical distribution of various climates. For such classification, and for information respecting the geogra- phy of climate the reader must be referred to such special treatises as have already been mentioned in the early part of this article, as well as to the brief remarks upon these two topics which are to be found in the general article en- titled Health-Resorts, which appears in a later volume of this Handbook. The balance of the present article shall be devoted (A) to a brief discussion and elucidation of the factors of climate, and to the bearing which they have upon the due comprehension of the climatic features of individual health-resorts ; (B) to the explanation of the cli- matic charts presented in the course of the articles de- scribing such resorts, or inserted for purposes of com- parison under the titles Boston, Chicago, New York, Philadelphia, etc. A. Factors or Elements of Climate.-The chief elements of climate which call for consideration on the part of the physician are as follows :- (a) Temperature. (b) Humidity. (c) Wind. (d) Rainfall. (e) Amount of cloudiness. Less worthy of consideration are :- (/) Atmospheric pressure. (y) Electrical condition of the atmosphere. (h) Chemical composition of the atmosphere. Of great importance in its effect upon the human organism, but closely related to and dependent upon a, b, c, and f, is the evaporation, or evaporating power, of the atmosphere. (A) The chemical composition of the atmosphere being subject, when regarded from a purely climatological point of view, to very slight and unimportant variations, it will not be considered in this article. For information con- cerning it the reader is refered to the article entitled Air. (g) The electrical condition of the atmosphere is con- stantly varying at one and the same place of observation, and is of little or no interest to the student of comparative climatology. (/) As for the atmospheric pressure, although it is subject to daily and to annual variations at all parts of the earth's surface, and although the consideration of these periodical, and still more so of its non-periodical variations, is of the greatest interest to the student of meteorology (the variations of the latter class in particu- lar on account of their causative relation to winds and storms); nevertheless, to the climatic physiologist and the climatotherapeutist the weight of the earth's atmos- pheric envelope may be said to be of very little interest, excepting only in the consideration of such considerable variations as can only be experienced by ascending to re- gions standing at a very considerable elevation above sea- level. At such places, for example upon the summits of lofty mountains, or upon plateaus and table-lands having an elevation of some four or five thousand feet, the ef- fects upon the human organism attributable to simple re- duction in the atmosperic density may be differentiated, at least in the case of new-comers, from the effects pro- duced by other modifications of climate depending in part only upon such diminished atmospheric pressure. More will be said concerning the nature of these effects, in the articles entitled, respectively, Health-Resorts and Moun- tain Climates. Such being the opinion of the writer re- specting the relative value of this element of atmospheric pressure, he has omitted all mention of this factor of climate in the charts obtained by him from the Chief Signal Office at Washington. For all practical purposes a sufficiently close approximation to the average atmos- pheric pressure at each health resort may be attained by calculation, in accordance with the rules and tables to be found in meteorological treatises, whenever we know the height above sea-level and the latitude of such place. The figures for elevation above the sea-level and for lati- tude are givenin all the charts just referred to ; and, wher- ever there seemed to be occasion for so doing, and he has been able to do so, the writer has also been at pains to state them in the accounts of individual health-resorts for which he was unable to present full climatic charts. In justification of this total omission of barometrical data from his charts, the writer takes the liberty of quoting the following passage from Dr. Julius Hann's " Hand- buch der Klimatologie : " " It is necessary to remark with emphasis," says Dr. Hann, "that detailed statistics of the conditions of the atmospheric pressure prevailing at a single place give us no definite information at all respect- ing the climate of that place, and that such data are of value only when they may be compared with similar data from other places standing at the same elevation above sea-level; and even then give us no direct information respecting climate itself, but rather serve as a basis for the explanation of the distribution of other factors of climate." * Evaporation, or the evaporating power of the atmos- phere, depends, as has already been stated, upon (a) temperature, upon (&) humidity, upon (c) the presence or absence of wind, and upon (J') atmospheric pressure. Other things being equal, the higher the temperature the more rapid is the rate of evaporation ; so, too, will evaporation be greatly facilitated when the air is in mo- tion, that is when a wind is blowing, and it tends to in- crease in rapidity in proportion to the force of the wind. It is hardly necessary to say that evaporation goes on more vigorously when the air is dry than when it is moist, and that it ceases altogether in the presence of an atmosphere which is Completely saturated with moisture and can therefore drink up no more from the bodies with which it is in contact. It is not, however so generally known that a diminution in the density of the atmosphere, from whatever cause proceeding, increases proportionately its power for absorbing moisture, that is so far as such diminution in density itself is concerned : but it should be remembered in this connection that "as air expands under a diminished pressure its temperature consequently falls, and it continues to approach nearer to the point of saturation, or becomes moister " ("Encyclopaedia Britan- nica," Art., Meteorology). Of two places having, at the same moment, the same degree of elevation of tempera- ture, and having their atmosphere in the same condition so far as regards its degree of saturation, or its relative humidity, and so far as regards its rapidity of motion, or the amount of wind blowing at the time, that one will present the phenomenon of the more rapid rate of evapo- ration where the least atmospheric pressure prevails. The great importance of the relative evaporative power of the atmosphere in estimating the peculiarities of special cli- mates from a medical point of view must, of course, be evident to the reader who is familiar with the physiolog- ical functions of the skin and of the lungs, as well as of the mucous membrane of the entire respiratory tract. Concerning the amount of ozone contained in the at- mosphere under varying meteorological conditions, and * " Es war notig zu betonen, dass detaillierte Angaben uber die Luft- druckverhaltnisse eines einzelnen Ortes uber das Klima desselben nichts aussagen, und dass Luftdruckangaben erst Wert erhalten, wenn man sie mit denen anderer Orte in gleicher Seehbhe vergleichen kann. Anch dann sagen sie direkt nichts uber das Klima selbst aus, sondern bilden nur, die Basis zur Erklarung der Verteilung der andern klimatischen Faktoren."-Hann, tec. cit., pp. 46, 47. 186 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Climate. Climate. the proportion of this ingredient to be found in the air of different places and of different regions, nothing will be said in this place beyond the mere mention of the fact that this gas is supposed to be more abundant in sea-air and in the air of seacoast stations, and also in the air of mountainous regions, than it is in the air of plains or low- lying regions situated at a considerable distance from the sea. It is also believed that ozone is especially abundant in the air of regions covered by a growth of pine woods. Some remarks as to the result of recent investigations concerning the nature, the prevalence, and the effects of this as yet imperfectly understood ingredient of the earth's atmospheric envelope are to be found in the sup- plement to the American edition of Parkes's " Practical Hygiene," where, also, the reader will find comments upon the electrical condition of the air supplementary to those contained in the body of that most useful work. We now come, at last, to those of the factors of climate enumerated above, which occupy a place in the charts for the elucidation of which this article is especially written, viz., to the important factors of (a) temperature, (ft) hu- midity, (c) wind, (d) rainfall, and (e) cloudiness. (a) Temperature.-This is perhaps the most important of all climatological factors, and the one deserving most careful attention at the hands of a physician desirous of familiarizing himself with the study of climate, and of fitting himself to be a judge between the respective mer- its and claims of different health-resorts. What is it that such an one wishes to know respecting the tempera- ture of a particular health-resort ? He must know, in the first place, what is the total amount of heat to which a person would be exposed who should propose to pass an entire year, or a season, or a month, at that place. This amount of heat would be most nearly expressed by the figures giving the average temperature of the place for the year, for the season, or for the month. Secondly, as being of equal, if not of greater, importance to the in- valid proposing to sojourn at that place, his physician would wish to know the amount of variability in tem- perature liable to be experienced at that place, and the rapidity of occurrence as well as the extent of the ha- bitual or possible variations. Thirdly, he would wish to be informed respecting the utmost limits of heat or of cold to which his patient might be exposed in case the year, season, or month selected as the time of his visit by the latter should turn out to be one remarkable, either for its unusual heat or for its unusual cold. Included under the second of the three sub-headings given above, as constituting one of Wiehabitual variations of temperature, is the difference between the day and the night temperatures, or what is commonly called by French writers upon climate the " variation nyctheme- rale " (from vv^, night, and v^pa, day). The importance to the invalid of this feature of climate cannot well be overestimated, and many untoward results and accidents are frequently attributable to its neglect. (b) Humidity.-This factor of climate is in all cases one which demands a degree of attention as great, or at the least very nearly as great, as properly belongs to the subject of temperature. Indeed, for a certain class of invalids the humidity of atmosphere prevailing at a given health-resort is a matter of more consequence than is the temperature of that resort; more important than the average temperature ; nay, even in the opinion of some authorities, a matter of greater import than is the variability of temperature, be the variations of the latter never so frequent, never so great, and never so sudden and sharp in their onset. The connection which subsists between the humidity of the atmosphere and its capacity for absorbing moisture from bodies, both animate and in- animate, with which it is in contact, is necessarily a con- nection of the closest possible description ; the greater the humidity, the less is the evaporating power of the atmos- phere. It is in consequence, chiefly, of its most intimate relation to this evaporating power, to this capacity of the atmosphere for absorbing additional moisture, that the humidity of the atmosphere plays so important a role in the study of climatotherapeutics and of the physiological effects of any and of all varieties of climate. It is a much disputed question, nowadays, among writ- ers upon climatotherapy whether the actual amount of aqueous vapor contained in the atmosphere, or what is known as the " absolute humidity," is of most impor- tance in estimating the physiological and therapeutical effects produced by such an atmosphere, or whether these effects be not more directly dependent upon the ' ' rela- tive humidity " of the atmosphere, that is, upon the de- gree to which its vapor-containing capacity is satisfied. Neither the absolute nor the relative humidity figures of a particular climate can tell us much concerning the ef- fects of that climate tipon the different forms of organic life, and in particular upon the human organism, when they are considered apart from the data for temperature and for the velocity of the wind. An interesting discus- sion respecting the relative importance of the absolute and of the relative humidity of the air, when both are considered from a physiological and therapeutical point of view, is to be found on pages 36 and 37 of Hann's " Handbuch der Klimatologie," where the writer of that work takes issue on this point with W. Steffen, of Davos Platz, and claims that, of the two, the relative humidity is of more importance to the climatologist and to the cli- matotherapeutist than is the absolute humidity. This opinion of Dr. Hann is shared by most writers upon cli- mate, and to the author of the present article, the posi- tion taken in this matter by Dr. Hann and by those who agree with him, would seem to be incontrovertible. The absolute humidity of the atmosphere may be ex- pressed either in figures giving the weight in grains of the amount of moisture suspended in a cubic foot of such atmosphere, or else in figures, showing, in fractions of an inch the height to which the suspended moisture raises the mercury in the column of a barometer. The relative humidity is expressed in figures, showing the percentage of saturation of the atmosphere ; thus, when the relative humidity is said to be seventy-five, we know that the amount of moisture actually contained in the atmosphere is seventy-five per cent, of the amount which it is capable of containing. What this amount actually is depends chiefly upon the temperature of the air, as warm air is capable of holding in suspension a larger amount of aqueous vapor than cold air. Rules and tables for the conversion of the figures showing relative, into those showing absolute humidity are to be found in Parkes's " Practical Hygiene" (fifth English edition). The hygro- metric table published on pages 526 and 527 of Blodgett's " Climatology of the United States" will also be found serviceable by those desiring to calculate both the rela- tive and the absolute h umidity from observations of the dry and wet bulb thermometers. Better and fuller than either of these are, doubtless, the series of ' ' Hygrometric Tables " (sixth edition, 1877), published by Mr. Glaisher, and both referred to and quoted by Dr. Parkes in the work just mentioned. By means of such rules and tables any reader who is desirous of so doing may readily cal- culate the absolute humidity figures for any of the places described in this Handbook from the figures showing the relative humidity in the charts accompanying the ac- counts of such places. (c) Wind.-The greater or less prevalence of wind at any place selected by an invalid as a health-resort is a matter of no little importance, as is also the character of the wind or winds there prevailing. The direction from which they blow is chiefly of importance as determining the character of the winds, and the influence which this element of direction will have upon their character must depend of course upon the situation of the place where they are felt.* So far as it has been possible the bearing of such situation upon the character of its winds has been referred to and explained in the account of each im- portant health-resort described in this Handbook. As one of the elements of their character, the velocity or force of the prevailing winds is, for obvious reasons, en- titled to very careful consideration. The other elements in the character of a wind deserv- * A knowledge of the direction of the prevailing winds is often of ser- vice as a guide to the selection of the quarter of any particular town in which the invalid should be advised to take up his residence. 187 Climate. Climate. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing of special attention are its temperature, its humidity, and the nature of the chemical or particulate substances which it is liable to bring with it. These things are de- termined by the direction from which the wind comes, and by the surfaces over which it has passed, and conse- quently upon the topographical relations and the geo- graphical situation of the place where the wind is felt. (d) Rainfall.-The total amount of rain falling at any place during the course of a year, a season, or a month, is of less importance to the invalid who resorts thither for the benefit of his health, than is the distribution of such total rainfall. The humidity of the atmosphere can by no means be measured by the amount of the rainfall. Thus, the annual rainfall at London is only about one-half as great as it is at New York, while the relative humidity at the former place is notoriously much greater than it is at the latter. The number of rainy days is very much larger at London than at New York. This single exam- ple may suffice as a warning to the reader against esti- mating the comparative climatic advantages of two places by the figures for total rainfall which each may present. Nevertheless, as a general rule, it will be found that a place showing a very small total rainfall will possess a much drier atmosphere than will another place where the amount of the total rainfall is exceptionally large. For the invalid, however, as already remarked, the distribution of the rainfall is a far better index to climate than is the amount of such rainfall; and this is so, not merely on account of their relative effect upon humidity, but also because of the very unequal determining influence ex- erted by each of these factors of rainfall upon the amount of time which the invalid may safely and comfortably pass in the open air. The influence exerted by the nature of the soil upon the degree to which the rainfall of a particular place may affect the humidity of the atmosphere at that place, must never be lost sight of by the student of climatology as applied to the important matter of health and of health- resorts. The amount of moisture precipitated in the form of snow, and the effect upon climate produced by the snow- fall of a particular place, will be discussed in the article entitled Mountain Climates. O Amount of Cloudiness.-The greater or less degree of cloudiness prevailing in the sky at any place, is well worthy of careful consideration at the hands of the cli- matotherapeutist, not only as affecting the temperature and the variability of temperature at that place, and as in- Climate of New York, N. Y.-Latitude 40° 43'. Longitude 74° O'.-Period of Observations, November 1, 1870, to Decem- ber 31, 1883.-Elevation of Place of Observation above the Sea-level, 35 feet. A A V B < D E F 1 ® II Mean temperature of months at the hours of Average mean temperature de- duced from column A. Mean temperature for period of ob- servation. Average maximum temperature for period. Average minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. Greatest number of days in any single month on which the tem- lierature was below the mean monthly minimum temjierature. Greatest number of days in any single month on which the tem- perature was above the mean monthly maximum temperature. 7 A.M. Degrees. 3 P.M. Degrees. 11 P.M. Degrees. Degrees. Highest. Degrees. Lowest. Degrees. Degrees. Degrees. Highest. Degrees. Lowest. Degrees. Highest. Degrees. Lowest. Degrees. January ... February .. March 27.4 28.2 33.7 33.4 35.2 41.1 29.5 30.7 35.7 30.1 31.3 36.8 39.8 36.3 43.8 25.2 23.2 28.9 36 40 45 i 9 23.1 25.9 31.3 64.0 69.0 72.0 41.0 49.0 53.0 17.0 17.5 22.0 -6.0 -4.0 3.0 20 18 24 30 19 28 April 43.8 >1.9 45.2 46.9 53.6 41.3 56 3 40.5 81.0 61.0 40.0 20.0 18 26 May, 56.0 <74.3 56.9 59.0 64.8 53.5 68 5 51.8 94.0 78.0 43.0 34.0 26 23 June 65.8 73.9 66.3 68.6 70.7 64.2 77 1 60.7 95.0 87.5 53.5 47.0 24 26 July August 71.2 69.4 78.6 77.2 71.3 70.2 73.7 72 2 76.4 75.5 71.9 70.6 83 80 4 66.3 64.9 99.0 96.0 88.0 87.0 61.0 63.0 57.0 53.0 25 21 16 22 September. October .... November.. December.. 62.4 52.3 39.7 30.7 70.2 60,3 45.9 35.9 63.4 54.1 40.9 32.3 65.3 55.5 42.1 32.9 72.2 59.8 48.3 40.7 60.8 49.7 37.3 25.1 74 65 50 41 4 4 9 59.5 49.7 37.3 28.6 100.2 88.3 74.0 66.2 70.0 71.0 58.0 47.0 50 0 44.0 32.0 22.0 36.0 31.0 7.0 -6.0 24 21 19 19 19 20 20 26 Spring Slimmer . . Autumn ... Winter Year ... .... 47.5 71.5 54.3 31.4 51.2 52.7 74.0 59.2 33.1 52.9 44.6 70.7 52.0 29.0 48.6 J K L. M N O B S timately connected with the rainfall the relative humid- O direc- nd, h' 1 1 . C cC s* a I I clear d 3 jlocity miles ity, and the evaporative power of the atmosphere, but also as regulating the quantity of direct sunlight which falls upon that place. The intensity of the sun's rays is chiefly dependent upon their inclination, and varies there- fore with the latitude and with the time of day at which ge of te ire for pt £ c 5 1 rage n >f fair da C-Q W S 60- rage n fair and ys. g o railing ion of wi rage v wind in r hour. s 5 o a <D a. < O'O ◄ £ O'*- i ◄ such intensity is measured. It also depends very greatly nnnn the habitual diathermancy of the atmosphere: for Diches. From Miles. this reason places having a considerable elevation above January... February.. 70.0 73.0 69 0 72.4 72.0 67 6 11.6 10.5 13 5 7.6 8.0 7 5 19.2 18.5 21 0 3.50 3.23 4 07 W. N. W N w 9.7 10.8 11 3 sea-level may usually be expected to enjoy a high degree of intensity of sunlight, as the depth of the atmospheric April 61.0 64.8 12.4 7.6 20.0 3.25 N. W. 9.7 layer over such places is necessarily less than the depth of May June July 60 0 48.0 42.0 65.0 68.9 70.4 13.0 15.3 15.5 9.7 7.3 7.5 22.7 22.6 23.0 2.74 3.32 4.46 S. W. S. W. s. w. 8.5 7.9 7.5 the layer covering places of less elevation. Low latitude, great elevation above sea level, and freedom of the atmos- August.... September. October ... November. December. Spring .... Summer... Autumn... 43.0 64.2 57.3 67.0 72.2 91.0 52.0 93.2 71.1 72.8 69.7 69.6 72.4 65.8 70.1 70 7 12.4 12.1 12.8 11.5 12.8 38.9 43.2 36.4 9.8 8.8 10.2 8.4 6.2 24.8 24.6 27.4 22.2 20.9 23.0 19.9 19.0 63.7 67.8 63.8 4.62 3.90 3.12 3.34 2.97 10.06 12.40 10.36 s. w. s. w N. W. N. W. w. N. W. S. W. N. W. 7.3 8.8 9.0 10.0 10.0 9.8 7.6 9.3 phere from watery vapor, from mist, fog, and cloud, in- volve a high degree of intensity of insolation ; the opposite conditions involve a low degree of this important factor of climate. A discussion of the physiological and therapeutical in- fluences of the sun's light it is not proposed to give in this Winter .... Year 75.0 106.2 72.3 69.7 34.9 153.4 21.8 98.6 56.7 252 0 9.70 42.52 W. N. W 10.2 9.2 place. For information on this point the reader is referred to such special treatises as Parkes's ' Practical Hygiene, timately connected with the rainfall, the relative humid- ity, and the evaporative power of the atmosphere, but also as regulating the quantity of direct sunlight which falls upon that place. The intensity of the sun's rays is chiefly dependent upon their inclination, and varies there- fore with the latitude and with the time of day at which such intensity is measured. It also depends very greatly upon the habitual diathermancy of the atmosphere: for this reason places having a considerable elevation above sea-level may usually be expected to enjoy a high degree of intensity of sunlight, as the depth of the atmospheric layer over such places is necessarily less than the depth of the layer covering places of less elevation. Low latitude, great elevation above sea level, and freedom of the atmos- phere from watery vapor, from mist, fog, and cloud, in- volve a high degree of intensity of insolation ; the opposite conditions involve a low degree of this important factor of climate. A discussion of the physiological and therapeutical in- fluences of the sun's light it is not proposed to give in this place. For information on this point the reader is referred to such special treatises as Parkes's " Practical Hygiene," 188 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Climate. Climate. or Weber's Climatotherapy in Ziemssen's " Handbuch," etc. In a general way, however, everyone is familiar with the different effects upon the human organism in health and in disease which are produced respectively by bright, sunshiny, and by dismal and cloudy weather. The proportion of cloudless or partly cloudless days oc- curring throughout the course of a year, season, or month is, therefore, for many obvious reasons, an important ele- ment in estimating the therapeutic value of any health- resort. We have now enumerated and very superficially dis- cussed those of the factors of climate which demand special attention on the part of the physician, and which the writer has endeavored to present in the course of the special articles upon individual health-resorts. Anything approaching a full discussion of these climatic elements, and still more of the ever-varying degree and manner in which they are found associated together, and in which they combine to produce that totality of phenomena known as the climate of a particular place it is quite out of the question to attempt within the limits belonging to an article in a handbook. Many of these factors or ele- ments of climate will be found set forth in the figures of the large climatic charts which we shall now proceed to discuss and to explain ; others which could not be pre- sented to the reader in these larger charts are to be found in certain instances set forth'in the figures of smaller and supplementary charts, or are, in some cases (and of ne- cessity but briefly), alluded to in the body of the text de- scribing individual health-resorts. B. Explanation of Larger Charts with Direc- tions concerning their Use.-To render simpler the explanatory remarks concerning the larger or Signal Office charts which are about to be presented to the reader, two of these charts, representing some of the cli- matic factors of New York City and of Charleston, S. C., are here introduced. , The character and extent of the information derivable- from these charts will be discussed in order for each sep- arate column. Column A.-The figures of this column show us the average temperature at early morning, at the middle of the afternoon, and at that hour of the evening beyond which few healthy persons remain out of doors, and be- yond which no invalid should remain out of bed. These three hours (7 a.m., 3 p.m., and 11p.m.), convenient as they happen to be in estimating temperature from a sani- tary point of view, are nevertheless not chosen on this ac- count, but simply because they also happen to be those selected by the Signal Service Bureau for the taking and Climate of Charleston, S. C.-Latitude 32° 47', Longitude 79° 56'.-Period of Observations, January 5, 1871, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, 13 feet. January.... February... March April May June July August September. October November.. December.. Spring Summer.... Autumn.... Winter Year January... February.. March April May June July August.... September. October ... November. December. Spring Summer... Autumn... Winter .... Year Mea 1 7 A Degi 45 48 53 61 69 80 78 72 63 53 46 - n ten at M. ees. 7 5 4 0 8 5 7 2 7 2 4 9 K A iperature the hours 3 P.M. Degrees. 53.7 57.5 63.2 69.4 76.8 84.4 87.2 84.9 80.4 71.6 62.0 55.7 of month of 11 P.M Degree 49.2 51.9 56.8 63.0 70.9 77.5 80.6 79.4 74.9 65.8 56.2 50.2 in - s s. 2 0 1 1 33822 S Average mean temperature de- > A c S § s g 5 g ees. 5 6 8 4 5 8 8 8 0 8 2 .9 .9 .1 .6 .0 .9 O I Mean ten for peri servatic Highest. Degrees. 58.3 57.3 62.5 67.5 76.3 81.7 84.9 82.9 80.7 72.0 60.6 57.9 67.7 ' rd 53.6 । 67.2 K J iperatu od of o n. Lowe Degre< 38.2 48.2 52.1 60.4 68.8 78.1 79.1 78.9 72.6 62.0 53.5 43.4 62.6 79.6 61.5 47.2 64.4 S re b- t. 'S. § o o es. 3 1 8 6 8 2 7 3 8 7 5 7 7 7 5 9 C 6 1 1 s g-g E 5 Degrees. 58.4 62.0 67.1 72.2 80.1 86.6 90.2 87.9 82.4 75.5 65.0 60.1 E U ; : : : : : w Average minimum temperature M * : I 1 1 1 o for period, k * . . I I Absolute tempera period. Highest. Degrees. 80.0 78.0 85.0 87.0 94.0 100.0 104.0 97.5 94.0 93.0 82.0 76.0 3 naximum ture for Lowest. Degrees. 67.0 67.0 73.0 81.0 86.0 89.1 92.0 91.0 87.0 81.0 73.0 65.0 I Absolute temper period. Highest. Degrees. 33.0 39.0 41.0 47.0 61.0 69.0 76.0 73.0 68.0 54.0 38.0 34.0 :::::: ..11 +1 minimum ature for Lowest. Degrees. 23.0 26.0 28.0 32.0 47.0 60.0 67.0 62.0 54.0 39.0 28.0 13.0 : Greatest number of days in any : : ! 1 ! : jejeMtowMk.MwtcMio single month on which the tern- a 3 : : : I : perature was below the mean K • monthly minimum temperature. J. Greatest number of days in any ) 1 : : : 1 - wmh-W single month on which the tem- M ; : : I : : perature was above the mean ® monthly maximum temperature. fl c o if Is 57.0 52.0 57.0 55.0 47.0 40.0 37.0 35.5 40.0 54.0 54.0 63.0 66.0 44.0 66.0 67.0 91.0 ► § 0) 75.4 71.8 69.6 71.0 72.2 73.1 74.3 76.6 76.6 76.5 74.7 74.4 70.9 74.7 75.9 73.9 73.8 1 o o 10.5 9.1 10.8 11.3 13.5 14.3 14.6 14.5 10.5 10.0 10.5 10.7 35.6 43.4 31.0 30.3 140.3 1 . Is 0) o oS Q G) © 9.5 11.2 12.7 12.0 11.8 9.5 10.4 9.2 10.5 14.0 11.5 11.7 36.5 29.1 36.0 32.4 134.0 0 1 s c 1 * 2 s o U ce Is, c^. cS O'O >0.0 10.3 13.5 13.3 15.3 13.8 15.0 13.7 21.0 24.0 22.0 22.4 72.1 72.5 57.0 52.7 74.3 3 c I <D be £ - Inches. 3.77 3.65 4.47 5.03 4.70 5.05 7.18 7.46 6.44 5.00 3.51 3.64 14.20 19.69 14.95 11.06 59.90 § h's £ From N. S. W. S. W. s. w. s. w. s. w. s. w. S', w. N. E. N. E. N. E. s. W. s. w. s. w. N. E. s. w. s. w. II 5g >s ti ~ h > o <1 Mil 8 8 8 8 8 7 8 7 7 UI UlC LUXlipUl dllli V dll L11C11 IVgUldl O Id 11UUS, To illustrate the way in which the figures of this column can be used in comparing the climate of one place with that of another, let us suppose that the reader is a resi- dent of New York City, and that he is desirous to know, and, so far as possible, to realize without experiencing the exact degree of elevation of temperature characteris- tic of an average March day at Charleston. Looking at the 7 a.m. column on the March line of the Charleston chart, he finds there the figure 53.4. On reference to the New York chart he finds that this temperature of 53.4° Fahrenheit is nearly ten degrees higher than is the 7 a.m. temperature of an average April day at home ; that it is even higher, by a degree and a half, than is the tempera- ture which he is in the habit of experiencing at New York during the warmest part of the afternoon of an April day ; and that it is but two and six-tenths degrees lower than the usual New York temperature at 7 in the morning of a day in the month of May. At 3 o'clock in the afternoon the average March temperature at Charleston is but one degree and one-tenth lower than the average temperature at the same hour of a day in May at recording of the temperature at all their regular stations. To illustrate the way in which the figures of this column can be used in comparing the climate of one place with that of another, let us suppose that the reader is a resi- dent of New York City, and that he is desirous to know, and, so far as possible, to realize without experiencing the exact degree of elevation of temperature characteris- tic of an average March day at Charleston. Looking at the 7 a.m. column on the March line of the Charleston chart, he finds there the figure 53.4. On reference to the New York chart he finds that this temperature of 53.4° Fahrenheit is nearly ten degrees higher than is the 7 a.m. temperature of an average April day at home ; that it is even higher, by a degree and a half, than is the tempera- ture which he is in the habit of experiencing at New York during the warmest part of the afternoon of an April day ; and that it is but two and six-tenths degrees lower than the usual New York temperature at 7 in the morning of a day in the month of May. At 3 o'clock in the afternoon the average March temperature at Charleston is but one degree and one-tenth lower than the average temperature at the same hour of a day in May at 189 Climatic Relations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. New York; while the late evening temperature (the 11 p.m. temperature) of an average March day at Charles- ton is almost precisely that found at the same hour of an average May day at New York City. Column AA.-In this column we find the average tem- perature of each month, of each season, and of the year, deduced from the figures standing in the three subdi- visions of Column A. To illustrate the use of this column in comparing the climate of one place with that of another, let us take the average mean temperature of the Spring season at Charles- ton and compare it with the seasonal averages to be found in Column A A of the New York chart. Charles- ton's average Spring temperature is 64.9° F.; this figure shows an average temperature at that place during the season in question which is no less than 17.4° F. higher than is the average for the same season at New York ; which is also 10.6° F. higher than New York's average Autumn temperature ; and is but 6.6° F. lower than New York's average Summer temperature; while it differs but little from the average temperature characteristic of the month of September at the latter place, viz., the tem- perature of 65.3° F. Column B.-The figures of this column are of use as showing in some degree the variations of temperature oc- curring throughout a series of years, and as indicating the average temperature of the warmest month, or season, or year, and also the average temperature of the coldest month, or season, or year which were respectively expe- rienced at the place of observation throughout the course of the entire period covered by such observations. For example, on the March line of the left-hand subdivision of Column B in the Charleston chart we find the figure 62.5. Tips indicates that out of the whole number (13) of March months occurring between January 5, 1871, and December 31, 1883 (to wit, the total period of observa- tions, as stated at the head of the chart), there was at least one month of March having for its average tempera- ture 62.5° F. and that no other one of the thirteen months of March was warmer than this one. The right hand subdivision of this same column (Column B), shows us, on the March line, a temperature of 52.1°, as the lowest monthly average temperature for the month of March, which was experienced at Charleston, between January 5, 1871, and December 31, 1883. On referring to the New York Chart we find that the first mentioned of these two figures (62.5° F.) is but 2.3° F. lower than the figure giving the average temperature of the warmest month of May experienced at New York City during the same period of observations (viz., 64.8° F.), while the cold- est of the thirteen months of March at Charleston (av. temperature 52.1° F.), was but 1.4° F. colder than the coldest of the thirteen months of May (av. temperature 53.5° F.) observed at New York City during the same period of time. Other interesting facts respecting climate can also be deduced from the figures standing in the two subdivisions of this column B, but time does not permit a reference to them in this place, and, now that enough has been said to show exactly what the figures of this column represent, any reader can deduce such facts for himself, either from the study of a single chart or from the comparative study of any two or more charts. Columns C and D.-The figures of column C are those of the average daily (and not of the average monthly) max- imum temperatures. For example, in the Charleston chart the figure 67.1 on the March line of this column gives us the average of the daily maximum temperatures of all the March days occurring throughout the entire period of observations ; that is, in this case, of 31 x 13 = 403 March days (the month of March having of course 31 days, and there being 13 such months comprised within the total period of observations). This figure represents, therefore, very accurately, the height which the maxi- mum thermometer may be expected to attain at Charleston on what may be termed a normal March day. The cor- responding figure (52.1), in the same line of Column D, is the minimum figure, derived by a similar method of cal- culation, and it tells us that 52.1° F. is the point to which the minimum thermometer may fairly be expected to fall during the twenty-four hours comprising in like manner what we have just termed the normal March day of Charleston. A very little reasoning will show anyone that by deducting this second or minimum figure (52.1° F.) from the first or maximum figure (62.5° F.), the fig- ure of the remainder (62.5 - 52.1 = 10.4) will be that showing the average daily variation of temperature at Charleston during the month of March. A column show- ing this average daily variation for each of the twelve months of the year does not appear in the charts, but can readily be calculated in the manner indicated above, and its figures will be useful to the reader in estimating the equability of each climate for which a Signal Service or full chart is presented, and for comparing the equabil- ity of two or more of such climates. The average monthly variation of temperature, the maximum and min- imum monthly variations, and the maximum and mini- mum daily variations cannot any of them be deduced from the figures of these two columns (C and D), nor yet from the figures appearing in any of the other columns. The writer regrets this not a little, as all these five differ- ent kinds of temperature variation are well worth know- ing in estimating the equability of a particular climate, and for comparing the equability of one climate with that of another. This and other defects in his charts, he will endeavor to remedy by the introduction of supple- mentary tables and figures (whenever attainable), into the accounts of individual health-resorts, at least, in all cases where it appears to him important to do so. Columns E and F.-As is sufficiently well indicated by their headings, the figures of these two columns show the extremes of temperature for each month ex- perienced throughout the entire period of observations. They show the possible extremes to which the climate is liable. For example, in the case of the New York City chart, we see that at least once during the course of the thirteen years and two months, from November 1, 1870, to December 31, 1883, the mercury attained the height of 72° F. on a March day ; that it was never known to rise beyond that figure during all the thirteen months of March observed ; that it never failed to attain the height of at least 53° F. ; that one of the thirteen months of March (and possibly more than one) had for its ab- solute minimum temperature the comparatively high figure of 22° F., and that the mercury fell upon at least one occasion during a March month as low as 3° F. ; and that it never fell below this figure during the month of March throughout the entire period of thirteen years of observation. These two columns (E and F) in the chart of a health resort may be considered as the "columns of chances": they do not tell the invalid what temperatures he may expect, but only what ex- tremes of temperature it may be his good or his evil for- tune to encounter. Columns G and II.-As their headings will show, these two columns, taken in connection with Columns D and C, convey much useful information respecting months characterized either by an exceptionally persistent high temperature or by an exceptionally persistent low temperature. Column G in the New York chart tells us, for example, that twenty-four days have been known to occur, during a single March month at that place, upon each of which days the mercury fell below 31.3° F. ; while Column H informs us that on twenty-eight days of a single March month the thermometer rose above 45.9' F. From Column F we have already learned that the mercury never fails to fall considerably below 31.3° F. (viz., as low as 22° F.) during every March month, while it has been known to fall very much lower (viz., to 3° F.). From Column E we have learned that the mer- cury never fails, at least once during the month in ques- tion, to attain an elevation of 53° F. ; while it has been known to reach the far higher figure of 72° F. In what has just been said it is taken for granted that a period of observations extending over thirteen years is long enough to give reliable information concerning what have already been alluded to as climatic " chances." For places having so variable a climate as is that of New York City, such a thirteen-years period is hardly long enough to determine 190 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, ciimltic Relations. with entire accuracy these ' ' chances " of climate. For places whose climates are more unvarying, such a period of observations would be more nearly sufficient for this purpose in proportion to their greater invariability. Two columns showing respectively the average number of days in each month upon which the minimum ther- mometer fell to a point slightly above the mean monthly minimum, and upon which the maximum thermometer attained an elevation slightly below the mean monthly maximum, might well have been introduced into these Sig- nal Office charts, and would assuredly have been of great service as aids to a fuller and more accurate appreciation of the ''habitual weather" of each place. The writer regrets the omission of such additional columns from the chart forms sent by him to be filled out at the Chief Sig- nal Office in Washington. Their insertion, however, would undoubtedly have considerably increased the amount of time and labor requiring to be expended in the filling out of each chart (an amount already so great as to call for about eight hours work on the part of two men), and would have materially increased the sum gener- ously paid by the publishers for the 41 charts obtained directly from Washington by the writer. It is but just to remark, however, that these suggested columns were not omitted for this reason, and that the writer alone is responsible for such omission. Column J.-The figures of this column are derived from those of Columns E and F. Their value is but tri- fling in estimating variability of temperature. In com- paring one chart with another they will sometimes be found serviceable. Column K.-The heading of this column speaks for it- self. Columns L, M, and N.-The figures presented in these three columns give us a kind of information respecting the climate of a healtn-resort which is of the greatest possible interest and value to the climato-therapeutist, for reasons which have already been set forth in the body of this article. The terms ''fair" and "clear" standing at the head of the columns, require to be accurately under- stood, however, in order that the full meaning of the fig- ures may be comprehended. The following explanation of these terms was furnished to the writer by the Chief Signal Bureau at Washington, where the blank forms of the charts now under discussion were filled out. "Clear, fair, and cloudy days, are deduced from ob- servations taken at 7 A.M., 3, and 11 p.m., Washington time, in the following manner by the Signal Service. " Clouds, by observations, are recorded on a scale of 0 to 10 : 0 to 3 clear, 4 to 7 fair, and 8 to 10 cloudy. By days from the three (3) observations; 0 to 8 clear, 9 to 22 fair, and 23 to 30 cloudy." This method of estimating "fair" and "clear''days from the average of observations made at three fixed hours of each day, and at three such hours only, is mani- festly imperfect as affording an indication of the number of hours of sunshine experienced throughout a day. The factor of cloudlessness in any climate could be far more ac- curately estimated by having a greater number of obser- vations taken during each day, or by the use of a self- recording sun-thermometer, and by recording the actual number of hours of sunshine as well as the proportion of hours of possible sunshine upon which the sun actually did shine. The density of clouds and their sun-obstruct- ing power is also disregarded in these observations, which record simply the area of sky surface obscured by cloud. Nevertheless relative cloudlessness can be approximately determined by comparing columns L, M, and N in one chart with corresponding columns in another. Columns O, R, and S.-The significance of the figures standing in these columns has already been pointed out in the body of this article. The data of the last three columns require to be pre- sented in a more detailed manner, in order to attain any- thing like an accurate comprehension of the climate of a particular place ; thus, especially in the case of a health- resort, we should wish to know the average number of rainy days as well as the average duration of storms of rain or snow, in addition to the average amount of the rain- fall; and we should also be greatly assisted in judging of the climatic merits of such a resort did we know not merely the prevailing direction of the wind and its aver- age velocity, but also the relative frequency of occur- rence and the relative force of the winds blowing from different points of the compass. The subject-matter to which, at its beginning, it was declared that the present article should be confined, has now been treated as fully as the limits of the article will allow; and, while conscious of its many and great defi- ciencies, the writer will, nevertheless, be well satisfied if he has succeeded in awakening any degree of interest in the science of climatology in the minds of any of his readers, and if he has also succeeded in making at all clear to them the main points which must be kept in view in estimating the merits (so far as their mere climate is con- cerned) of the many health-resorts now claiming the at- tention of the medical world, and, finally, in elucidating the somewhat formidable array of figures presented by the larger climatic charts contained in this Handbook. Huntington Richards. CLIMATIC RELATIONS OF CONSUMPTION. From the period when De aeribus, aquis et locis was written to the present time, when each year sees a number of new publications devoted to the special virtues of particular health-resorts, it has been generally accounted true that Hippocrates was right when he wrote, * ' Whoever de- sires to understand medicine thoroughly can by no means neglect the study of the seasons with their variations, of the winds, both as to heat and cold, and those peculiar to certain regions, and of the properties of different waters." The bearing of these words has, by writers of every age, both historical and scientific, been noticed in connection with diseases in general, but, especially, with regal'd to phthisis, which has prevailed among every race of men of whose history we have authentic records. At the present day so frequently do we read and hear of one region after another being free from consumption, and of this and that health-resort being veritable air-cures for tuberculosis that, could we accept the statements of their advocates, " the conclusion would follow that well-nigh all of them are detached fragments of the original Para- dise, replete with all that can make life enjoyable, and walled round from the incursions of death." Dr. W. H. Walsh says : ' ' Probably the earth offers few known spots more favorable to the tuberculized British patient than Nubiq ; yet the native Nubians on their own soil are oc- casionally destroyed by phthisis." New Zealand is popu- larly believed to give perfect immunity from phthisis, and yet rheumatism and pneumonia prevail there, and partial mortality returns give more than ten per cent, of deaths as being caused by consumption. Dr. E. M. Wight writes of the inhabitants of the Cumberland table- land in Eastern Tennessee, as a " people without consump- tion ; " while local physicians sing the praises of the Laurentide forest and lake region of Northern Ontario, as having a Canadian population free from phthisis. So the records read, but actual facts cruelly banish the illusion, and, concerning them all, we have finally to admit the truth of the statement of Dr. Bennet, who, while praising the towns of the Riviera, is yet forced to say: ''The perpetual spring, the eternal summer, the warm, southern, balmy atmosphere described to the reader in such glowing terms, only exist in the imagina- tion of the writers." While, however, it is well to admit at the outset that perfection of climate, as regards immunity from consump- tion, is not to be expected, there has, nevertheless, been too much taught us by the healthfulness of the inhabitants of, and by the experience of invalids in, regions having certain climatic characteristics, to prevent us perceiving that there are certain meteorological conditions more con- ducive to freedom from phthisis than are others ; and it will be our aim to point out what these are, and where they exist in highest perfection. The opinion of Hippo- crates, thousand of years old, regarding diseases in gen- eral, was but repeated and added to by Mr. John Simon, C.B., Chief Medical Officer of the Local Government 191 CHmalie ReiaHon^ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Board of Great Britain, when, in 1867, he wrote : " That vastly fatal disease (phthisis), if we are to have proper knowledge of its causes, must be studied from many dif- ferent points of view." His investigations show it to be a disease "which undergoes development in proportion as men are unwholesomely gathered together in indoor in- dustries ; " and again he says, "it is shown to be a dis- ease which develops itself in proportion as men are dwell- ing upon a humid soil." Dr. II. I. Bowditch, of Boston, arrived at a similar conclusion as long ago as 1862, re- garding the intimate connection between dampness of soil and the prevalence of consumption ; and the Secre- tary of the Provincial Board of Health, Ontario, Canada, has pointed out that in two contiguous health districts of the province, one of which is a plateau, and notably free from malaria, and the other, a flat malarious district, the deaths from consumption in 1881 were, in the first, 8.5 per cent, of all deaths, or 1.02 per 1,000 ; and in the other, 12.7 per cent., or 1.64 per 1,000. From these various statements, based upon statistics, it must be plain that meteorological conditions per se form but a part, and apparently a small part, of the factors entering into the question of the causation of consump- tion. Assuming the truth of these statements, it will be necessary to adopt some comprehensive method of treat- ing the subject, from the evident fact that there are many elements of a heterogeneous character entering into it. Simon asserts that in discussing the prevalence of phthisis, its hereditary relations, and the nature of the mor- bid process which accompanies it, cannot be overlooked. If the scrutiny of so keen-sighted an observer saw this to be true seventeen years ago, the discoveries of the last few years, which have been such as to make ' ' tuber- culosis now rank with anthrax, as the most perfect in- stance up to date of etiological knowledge " (tide Review, American Journal of the Medical Sciences, July, 1884), will make his statements greatly more evident. This being the case, it is apparent that there are briefly to be considered : 1. The nature of the cause. 2. How its development is aided by (a) heredity, (5) vitiated air, (c) moisture of soil, and (d) atmospheric con- ditions. 3. The climatic conditions counteracting its develop- ment, and favoring a return to health of the phthisical. 1. The Nature of the Cause.-Assuming that un- til experiments, greatly more extended than have yet been instituted, shall have proved the incorrectness of the zymotic theory of tuberculosis, it may be taken as estab- lished, the qualities of the bacillus tuberculosis in relation to external influences affecting its development may be noticed. Koch observes that, while the sputum of tubercu- lized patients almost invariably contains bacilli, and that very frequently these bear spores, the former existing ex- ternal to the body for many days, and the latter for many months, yet they are not likely to be borne on the air until they have become exsiccated. Owing to this sensibility to temperature, their growth requiring a temperature be- tween 29° and 42°C. (85° and 108° F.), their fastidiousness as to the composition of the soil, being cultivated only in blood serum, the important conclusion as regards infec- tion is arrived at, that the bacilli of tuberculosis are limited to a parasitic mode of life in animals, and cannot grow out- side of the body under the conditions found in nature. It has further been established that the inhalation of a spray, containing bacilli in suspension, by guinea-pigs, rats, and mice, inoculates these various animals with the disease, and that the extent of the tuberculization depends on the length of time between their inoculation and death. From the peculiarities of the bacillus tuberculosis as re- gards its development, it becomes evident how little in- fectious the disease is compared with some other zymotics, and how the spread of the disease is made possible, almost wholly, by the inhalation of the atmosphere of apartments which the phthisical have inhabited. 2. How the Development of the Cause is Aided. -That there are conditions favoring the development of tubercle there can be little doubt, and among these in this connection may be mentioned (a) Heredity.-Koch tells us that the character of the- pathological lesion depends on the number and localiza- tion of the bacilli, and on the power of resistance of the tissues of the patient. Dr. H. F. Formad illustrates this difference in power to resist by asserting that the scrof- ulous habit, or a tending to take on a tuberculous in- flammation, exists in certain animals, as rabbits, etc., through a structural narrowness of the lymph-spaces of the connective-tissue, and that similar tissue exists in scrofulous individuals. Clinical evidence in this, as in many other diseases, as well as inoculation experiments, has placed the fact beyond doubt of there being a rela- tive susceptibility or insusceptibility to infection, or, in other words, hereditary and induced tendency to disease. (d) Vitiated Air.-It is hardly necessary to draw the conclusion, justified by the qualities of bacillus tuber- culosis, that the impure atmosphere of crowded apart- ments, where consumptives are present, must receive and retain greater numbers of bacilli than if it were fre- quently renewed, and that those exposed will be more likely to inhale them. There are other elements, how- ever, which greatly promote the inoculation of the in- mates of such apartments. The insufficiency of oxygen, the excess of carbonic acid, and the volatile emanations from those inhabiting the place, and the frequently viti- ating action on the lungs of air containing much dust and insufficient moisture, all tend to induce anaemia, catarrh, and other derangements, which not only lessen the resisting power of the system to disease, but also, by colds and catarrh causing congestion of the mucous tract, produce just such conditions as form a nidus favorable for the reception and subsequent growth of bacillus tuberculosis. (c) Moisture of Soil.-Of all the climatic conditions which promote phthisis Dr. Buchanan's investigations show this to be the greatest. Thus he found that after the completion of improved systems of land drainage, the percentage of deaths from phthisis in every town whose statistics are given decreased; this decrease amounting in some, as Ely and Rugby, to forty-seven and forty- three per cent. This remarkable decrease being the re- sult of drainage, it becomes of interest to consider its modus operandi. Dr. Th. J. Turner, formerly Medical Inspector, U. S. N., has abundantly shown the influence of damp air on the health by comparing the sickness and death rates, especially from consumption, on vessels in the United States and British navies, in some of which the old custom of daily washing down the decks was practised, while in others this was performed much less frequently. He asserts that breathing the impure damp air has been the chief cause of phthisis ; and that it is the damp air, rather than the limited amount of air, is shown from the fact that the air-space per man in both classes of vessels was much the same. Sir Alexander Armstrong, of the British Navy, says : " There can be no more fer- tile source of disease among seamen, or, indeed, other persons, than the constant inhalation of a moist atmos- phere, whether sleeping or waking ; but particularly is this influence injurious when the moisture exists between the ship's decks, where it may be at the same time more or less impure, and hot or cold, according to circum- stances." Inasmuch, however, as the bulk of population live on the land, it is necessary to inquire into the influences affecting them in this regard. Ordinarily it may be considered that the relative humidity of the air for health should lie between 70 and 75, at the ordinary tem- perature of 66° F. When it is greater than this, as with a damp soil and low temperature, the heat is very rap- idly abstracted, the action of the skin in its secretion of urea and carbonic acid is checked, and the internal organs, and notably the lungs and air-passages, are congested, having increased work thrown upon them, and are, more over, subjected to the same chilling influences as the skin. Hence colds and catarrhs are generated, and conditions favorable, as we have seen, to the development of the specific bacillus are produced. That damp soil serves to keep the superambient atmos- phere damp, is seen in the fact that drainage raises the 192 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, climatic EZlatlonZ* temperature of the soil, and, therefore, of the contiguous air. This has been proved by Parkes, who found that the mean average temperature of thirty-seven experi- ments gave, at seven inches below the surface, an in- crease of 10° F. in a drained and cultivated soil, over that at the same depth in an adjacent bog. The wet land re- mains cold on account of evaporation from it producing cold, as water has a high radiating power and a high specific heat, and through the conduction of heat down- ward in a soil, deprived of a circulation of air, taking place slowly. Inasmuch as every increase of about 23° F. of tempera- ture doubles the capacity of air for moisture, it is not difficult to see how the soil, by keeping the contiguous air at a low temperature, must to the same extent keep it damp by lessening its capacity for moisture, and thereby produce the evils already referred to.* Such saturated atmospheres being the air, which morn- ing and evening envelopes the inhabitants of wet lands, which is breathed in cold sleeping-rooms where the moist- ure condenses on the walls, too often damp from the foun- dations upward, with the latter enclosing saturated air in the unventilated spaces between the floors, would seem to supply a combination of conditions, with the associated fact of dampness increasing the tendency of air to retain volatile and organic matter in it, favoring the facility for the reception of the germs of tuberculosis and the lessen- ing of the power of the system to resist disease. Other atmospheric conditions dependent upon the' moisture of the atmosphere may be mentioned here. One of these is that the diathermancy of the air is in- creased or diminished according as the air has little or much moisture in it; and that proportionately to the diathermancy the day temperature rises rapidly, and the night temperature, through radiation, falls just as rap- idly. Thus Denver, at 5,200 feet of altitude, shows an average daily range of 30° F., and even with this differ- ence dew but seldom forms. Though this latter fact will indicate the low relative humidity of the air, there can be but little doubt that such extreme and sudden changes must injuriously affect persons other than the most ro- bust. At these high-altitude health-resorts it is carefully ordered that consumptives either wrap themselves well before remaining out in the night air, or remain within doors or under shelter during the evening. Notwith- standing these, the greatest drawbacks to such dry cli- mates, the fact nevertheless remains that a comparatively small change of temperature in a moist atmosphere pro- duces subjective sensations often greater than do much greater changes where the air is dry. Though under or- dinary circumstances it can hardly be said that hot cli- mates are favorable to phthisis, yet it may well be that the endeavors made to keep the body cool by seeking out shady retreats and protecting their houses by trees to shelter them from the sun's rays, create damp atmos- pheres in the latter, which, through favoring fungoid growth, may promote phthisical tendencies in the popu- lation. 3. The Climatic Conditions Counteracting its Development, and Favoring a Return to Health of the Phthisical.-The nature of the cause of the disease indicates, in great measure, in which direction these favorable conditions must be looked for. Most writers, in their remarks on the failure of all climates to produce a cure in cases of consumption, have failed to sufficiently discriminate between hereditary and induced phthisis. It is manifestly unfair to expect that any in- fluence, such as a perfect climate-w'ere such to be found -would be sufficient to undo what generations have pro- duced of imperfect structural development of tissue ; and, on the other hand, before pronouncing against air cures for consumption, it is only just to carefully weigh the in- fluences under which people, without consumption, have lived. When, in the latter case, it is found that such people have lived in a climate which made an out-door life almost perennially possible, and when their occupation has been either pastoral or agricultural, it becomes apparent that we have the plainest rules set forth to guide us, both for the prevention and treatment of consumptives. Though experience has shown that no climate can be called per- fect in regard to every condition, yet a careful analysis of the reports of the many air cures and other health-re- sorts, along with morbidity and mortuary statistics, in- dicate very clearly the special qualities we are to look for in those climates favorable to the prevention or treat- ment of consumptive diseases. Of these qualities the following, viz., purity, dryness, temperateness, and brightness may be considered the most important. It is unnecessary to point out that these four qualities of the atmosphere of a healthy climate are inti- mately related in their causes, one to the other, since no one quality of climate can be discussed in other than a rel- ative sense. (a.) Purity of the Atmosphere.-This not only means that the air ought to contain the normal amounts of its two principal constituents, but also, that there shall not be an undue amount of carbonic' acid in it, since this serves but to indicate the presence of large amounts of organic matters undergoing combustion. [An exception to this rule may be pointed out in the case where the air, at considerable mountain heights, according to Professor R. Angus Smith, contains more than the usual amount of carbonic acid. In this case it may fairly be assumed that the excess is due rather to a rapid oxidation of existing organic matter than to its being greater than that on lower levels.] From this gauge of purity it follows, that the air of badly ventilated rooms, of the cabins, and especially the berths of ordinary vessels, of all, except the openest and cleanest of towns, and of that in proximity to marshes and other large deposits of decaying vegetable matter must be equally avoided, since each instance in- dicates the progress of organic combustion, either chem- ical, physiological, or zymotic. The latter form of com- bustion is of great importance in this connection, since it is indicative of conditions favorable to the development of bacillus tuberculosis. From these considerations open spaces, as in the open fields of most cultivated districts, sea-side abodes with good sanitary surroundings, and mountain-air resorts of moderate elevation and tempera- ture are the places to be sought out by the phthisical. Another reason why such localities are to be sought out is, that in them ozone is freely developed, and adds not only to their stimulating effects on debilitated systems, but also lessens zymosis. (b.) Dryness of the Atmosphere.-If it be true that purity of air is one of the essential conditions if consumption is not to be produced, it is just as true that dryness of the atmosphere is one of the conditions upon which we have to depend for retarding the progress, and, much more, for effecting the cure of the disease in its early stages. These curative conditions are not only freedom from the dampness of soils, but also the direct effects of dry air upon the tuberculizing process in the lungs. These latter are seen in the experience of the phthisical in high altitude climates, as that of Davos and Colorado, from which it would appear that there is less secretion from respiratory mucous membranes, due to less irritation of the air-passages either from the dryness of the air in- spired, or the decreased activity of the tuberculous agent in lung tissue. As stated by a gentleman now living in Colorado : "Expectoration is usually less here than in the East ; I suppose first on account of dryness, and second on account of a peculiar mildness or balminess of the air. My tender throat seldom feels here that raw, rasping damp air that one gets in England and the East, . . . We seldom have dew here; had more in Davos I think." Another effect is in the universal experience that people resist the cold better in dry, even though at very low temperatures, than in moist atmospheres. (c.) Temperateness of the Atmosphere. -By this it is under- stood, first, that a climate ought not to be subject to great extremes of heat or cold ; and, second, that the changes from heat to cold, or vice versa, ought not to be either rapid or extreme. The experience of robust persons residing * Too painfully accurate is the distich from Morte d'Arthur- " The white mist like a face cloth to the face Clung to the dead earth, and the land was still." 193 Clo7es.1C Relatlons- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. long in India, or subtropical America, shows the debili- tating effects of great heat on the physical system ; while the sufferings of delicate people in cold climates indi- cate the strain produced by low temperatures. Frequent and extreme changes are, however, the special points of interest in relation to temperate climates, since on these must greatly depend the relative humidity of any locality. From Glaisher's tables it appears that the capacity of a given volume of air is doubled for about every 23° F. of increase in temperature; from which it follows that an atmosphere which at noon, with a temperature of 70° F., shows a relative humidity of 50, will, at sundown, with a temperature of 47° F. be saturated ; or if, as is often the case, the relative humidity at noon be 75, saturation point will be reached as the temperature approaches 60° F. Re- membering that it is radiation of the earth's heat with the declining sun that lowers the temperature, and that this radiation, as well as the amount of heat absorbed by the earth during the day, is largely regulated by the amount of vapor in the atmosphere, it is perfectly plain that we must expect rapid and great daily changes in dry climates, and much less rapid changes in moist cli- mates. From these considerations it must be apparent that tables of mean annual relative humidities, as ordi- narily given in works on special health-resorts, have no practical value in determining the fitness of a locality for consumptives. Keeping these facts in view, it becomes a matter for careful study to determine wherein lies the happy mean between dry climates, with great daily range, and moist climates, with small daily range of temperature. In a general way, it may be said, that between the two ex- tremes lie the conditions most favorable to health. The experience of persons on arid wastes, and in rooms which, ill-ventilated, are heated by hot-air furnaces, without any means for supplying moist air, shows that there is a limit at which dry air becomes inimical to health from its irri- tating qualities, and by its abstracting moisture from the mucous membrane. The injurious effects of damp air are too well known to require illustration here. Before leaving the question of the temperateness of the atmosphere, some remarks are required regarding the in- fluence of winds on health. They may most properly be considered here from their power to affect the tempera- ture of the body. That they play a most important part in purifying the atmosphere cannot be doubted, while the fact that they are promotive of health, through the pleas- ant sensations they may produce, is equally evident. But their beneficent influences are dependent upon their de- gree of temperature, moisture, and their force. Regard- ing temperature, it is well known that winds of low tem- perature are injurious in proportion to their force, from the rapidity with which they abstract heat from the body. So marked is this fact that the degree of reduc- tion of temperature compared with the force of wind, has become the subject of experiment, and has been reduced to a definite law. Major Chas. Smart, U.S.A., has deter- mined the rate at which the mercury of a thermometer falls in the calm from a standard temperature, when subjected to different degrees of temperature for given lengths of times ; and, also, the increased rate of fall when exposed to certain temperatures, plus wind and moisture. Thus, the ratio borne by the fall when exposed to wind, as compared with the fall in the calm, the latter being taken as unity, is : sons, a source of injury to consumptives, from its causing clouds of dust and sand to be blown along, which, being inhaled, becomes very irritating to affected lungs. Such effects are said to be especially noticeable in those re- puted resorts of consumptives, Australia and New Zea- land, and have been mentioned by Marcet as being the cause of sore throats during dry days at Cannes. From facts such as the foregoing, it is apparent that the preva- lence of certain winds must affect very greatly the char- acter of the climate of different localities, as regards their claim to being health-resorts. (d.) Brightness of the Atmosphere.-This quality, which in large measure bears a direct relation to dryness, must for several reasons be considered an important element in its bearings on the subject. That the amount of sunshine is not always the gauge of the healthfulness of any local- ity, is seen in the mortality and disease statistics of tem- perate North American regions; since from some of these it appears that November is among the healthiest months of the year, although having the smallest amount of sun- shine. The absence in some measure of winds, such as those of March, and the low average daily range of temperature, must .be credited with this favorable result. Brightness, or diathermancy of the air, which is used to express the intensity of sunshine, may be said to be in direct proportion to the relative humidity of the air. From Jourdanet's and Denison's tables it appears, that the intensity of sunshine increases directly with the alti- tude. This intensity is measured by the difference be- tween the temperature in sun and in shade, and has been represented by the following rule of Denison, viz.: One degree greater difference between temperature in sun and shade for each rise of 235 feet. The experiments of many others, as Piazzi Smyth on the Peak of Teneriffe, and of Vacher and others at Davos, abundantly prove the inten- sity of the sun's rays in high altitudes. This intensity, as is readily understood, is associated with the fact that there is sunshine in such localities on almost every day throughout the year. That sunshine has, when the heat is not too great, most beneficial effects upon man, as upon most living animals, is too commonplace a remark to require reasserting. Some of the ways by which such good influences are exerted, are well known. Dr. Thaon, in his "Clinique Climatologique," has well summarized these influences. He remarks, that solar heat increases all the functions of animal as well as vegetable life ; the blood circulates with greater rapidity, respiration is in- creased, peripheral circulation is more active to the ad- vantage of internal organs, which thus free themselves from stagnant blood charged with excrementitious prin- ciples. Light, also, as seen in vegetation, plays a most important part through its active rays. • ' It reddens the blood, it cures chlorosis in the same manner as it restores the color to plants bleached in darkness." Slight consideration must make it apparent that the numberless variations in the combinations of these fac- tors cannot fail to create climates with equally varying characteristics ; nor can we fail to remark that the same locality throughout the year, is subject to equally numer- ous changes in the combinations. Further, when it is remembered that the conditions of phthisical persons, de- pending upon hereditary or induced causes, are infinite in their differences, we are not surprised that the question of what climate will best suit individual cases becomes of extreme difficulty as well as importance. The sex of persons, their ages, their education and tastes, their companionships, their attendants, their pecu- niary abilities, the progress of the disease, etc., may all be questions of equal, if not more, importance than that of climate-so susceptible is the physical well-being to aesthetic and psychical influences. The question of climate as regards the prevention of phthisis, is of greater importance by far than that regard- ing its cure. Experience has shown that in every climate consumption has increased with the increasing population, and, therefore, the first step in its prevention, as in its cure, is to see that the sanitary surroundings of people in their homes, and when employed in their daily avoca- Wind at X mile per hour increases fall 1.42 over 1.00. " 1 " " " " 1.71 " 5 " " " " 2.63 " 10 " " " " 3.18 " " 14 " " " " 3.39 " "20 " " " " 3.60 " The moisture in this case is not estimated in its effects, but it is a factor of extreme importance in the reduction of temperature. Not only is heat abstracted in propor- tion to the force of the wind, but also in proportion to its degree of moisture, for the reasons mentioned in connec- tion with moisture in general. The force of the wind further becomes, at certain health-resorts in certain sea- 194 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cioTe"?0 Re,atlo"8' tions, are of the most perfect nature possible. But, inas- much as it has become the mode to draw distinctions be- tween climates fitted for the phthisical at different stages, it will not be improper for us to give some directions, which experience has proven to be of some value in the treatment of consumption. In all early stages of the disease, before haemoptysis has occurred, bright, dry climates, where the air is in- vigorating, as at varying heights rising to five thousand feet above the sea, where the rarefied air allows of greater lung expansion, and where life with active exercise in the open air may be engaged in, are those which seem likely to produce most gratifying results. Owing, however, to the extreme daily range of temperature, protection from the night-air in well-ventilated dwellings or in tents, is markedly indicated. That height is probably no great element in the cure, except so far as it is the gauge of brightness and dryness, is seen in the almost uniformly good effects of surveying and camping-out in the bracing air of the northwestern prairies, as of Montana and the British Territories. Such, too, are the experiences of consumptives at the far-famed health-resorts of the whole Riviera, in the winter season. When pronounced hae- moptysis has taken place both theory and experience con- tra-indicate treatment by high altitudes, with their rarefied air, unless by the most gradual ascents. Jaccoud illus- trates the first by patients going to the mountains direct by rail from Paris, only to have a haemorrhage occur on their arrival, to be stopped immediately on their descend- ing again. In such cases the bracing air of the North- western prairies would seem to be of the greatest value. When the disease progresses but slowly, high altitudes with their tonic influences and effects upon digestion and nutrition, seem to produce good effects. In cases with much cough and bronchitis, the inland lake districts on the Laurentides of Canada, with their immense evergreen forests of cedar, hemlock, and pine, supply conditions eminently tonic and soothing, from the fact of the temper- ature being equalized by the evaporation from the lakes, and from the trees, thus preventing violent winds and ex- treme daily range of temperature ; while the cool waters flowing from the northern watershed into the innumerable small lake-basins, make the air cool and invigorating in the midst of summer, and afford the opportunities for camp life, with unlimited facilities for fishing and hunt- ing, thus giving variety and exercise without the danger of fatigue, often incident to hill climbing. The average height of these lakes is about one thousand feet above the sea. Much may be said concerning the stimulating influ- ences derived from the ozonized air, and the salt breezes blowing from the ocean. These must, however, be asso- ciated with a mild air, otherwise the dampness and fogs of the coast cannot fail to injure all except early cases, in which general debility is chiefly present. In such cases the coast from Boston southward during the summer, and the Gulf of Mexico during the winter, seem to best fulfil the indications. Los Angeles, etc., on the Pacific Coast may, with good cause, be considered in this connection. The equable character given to the climate of the Pacific Coast by the return equatorial current flowing from the north to join the parent stream at the equator, has of recent years given it many claims to prominence in the treat- ment of consumption. In many respects the climate of Southern California supplies America with a resort in a fair way of becoming as famous a winter-resort for in- valids as the far-famed Riviera of the Mediterranean ; and, if lacking in some of the historic interest attaching to the latter, surpasses it in a freedom from the unsanitary conditions too often present in these old towns. Any attempt to enumerate the almost infinite number of health-resorts whose special claims have, even in America, but especially in France, Italy, Germany, Spain, England, Scotland, Switzerland, Algiers, Australia, and Tasmania, been set forth by special advocates, would be as impossible as it is unscientific ; and it will only be by a careful review of the many conditions in connection with each case, that satisfactory results are at all likely to be arrived at as regards its treatment. P. IL Bryce. CLIMAX SPRINGS. Location, Climax, Camden Co., Mo. Access.-By Warsaw Section of Missouri Pacific Rail- road to Warsaw, thence by stage. Analysis (H. W. Wiley).-One pint contains : Grains. Carbonate of lime 0.651 Chloride of sodium 4.451 Sulphate of lime .' 0.707 Iodide and bromide of potassium 0.319 Iodide and bromide of magnesium 1.250 Oxide of iron, alumina, and silicon 1.000 Organic and undetermined 0.424 8.802 Gas. Cub. in. Carbonic acid 3.45 Therapeutic Properties. - These waters are re- markable as containing the iodide and bromide of potas- sium and of magnesium in greater proportion than any others at present known, either in Europe or in America. These springs flow into a basin, about twelve feet deep and forty feet in diameter, in a cave thirty feet under ground. They are situated in the Osage Mountains, at an elevation of 900 feet, amid attractive scenery. Excel- lent accommodation for guests. 'G. B. F. CLOVES (Caryophyllus, U. S. Ph. ; CaryophyUum, Br. Ph. ; Caryophylli, Ph. G. ; Girofle, Codex Med.). These are the dried flower-buds of Eugenia Caryopliyllata Thunberg. Order, Myrtacea. This is a beautiful, fra- Fig. 687.-Clove Tree, flowering branch one-third natural size (Bailion). grant tree, with a fine pyramidal crown, thirty or forty feet high, and with bright crimson flowers. The branches are numerous, slender, horizontal, the leaves opposite, lanceolate, pointed, entire, dark green, and shin- ing and covered with glandular dots. Flowers in ter- minal clusters, articulated. Calyx brilliant crimson, with a long, solid, flattened, cylindrical tube (receptacle of Bailion) in the upper part of which the minute ovary is imbedded, and four thick, spreading, triangular lobes. Petals also four, cream-colored, orbicular, arched, in the bud imbricated in a perfectly globular head ; stamens very numerous, ovary minute, two-celled, many ovuled, imbedded in the fleshy calyx mass ; style slender, single. Fruit oval, crowned with the four conniving calyx teeth, one-seeded. (The mother cloves of the market.) Length of flower about one and a half centimetres (half an inch), of fruit about two and a half centimetres (one inch). The tree is supposed to be a native of the Moluccas, from which it has been exterminated. It is abundantly culti- vated in Amboyna, Sumatra, Penang, and also in the West Indies and South America. The use of cloves is of 195 Cloves. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ancient date, being even mentioned in Chinese records of more than two thousand years ago (Fliickiger). It was also early known in Europe (fourth century). Cloves are now imported from the Moluccas, Java, and especially from Zanzibar. The collection is made just before the buds expand, usually by hand, each bud being separately plucked by the gatherer, who stands upon a movable lad- der or platform for the purpose. Sometimes they are beaten off the tree. Drying is effected in the sun. Dried cloves have lost all their natural brilliancy of color and become very dark brown, and also hard and brittle ; upon section they show numerous large oil-cells and re- ceptacles, those of the " stem" being of enormous size. The entire struc- ture of the flower can be easily made out by softening a clove in warm water. Cloves contain a larger proportion of essential oil than any other crude vegetable substance ; when fresh and good, from fifteen to twenty per cent, has been obtained. The Oil of Cloves. (Oleum Caryophylli, U. S. Ph., etc.), is a heavy oil, clear when first dis- tilled, and consists principally of Eugenol with a hydro- carbon. Upon standing it becomes yellow, and finally brownish red. Specific gravity, 1.050. They also contain a neutral crystalline principle, caryophyllin, and some others. Uses.-Cloves are an aromatic stimulant and carmina- tive of the Cinnamon class, and may be used for the same purposes, but are rather more irritating. Dose from half a gram to one gram (0.5 to 1 Gm. = gr. viii. ad xv.). Preparations : The oil represents the whole value of the spice. Dose, four or five drops. Oil of cloves was long a favorite benumbing application for toothache, until the use of creosote and other better things was discovered. It is in extensive use for clearing microscopical sections and for other purposes. Allied Plants.-The genus is a very large one, but does not supply any other article of general interest. The order Myrtaceat is also one of the larger groups, including eighteen hundred, mostly odorous shrubs and trees of tropical regions. A number furnish well-known aro- matics. Melaleuca Leucadendron Linn. : Oil of Cajuput. Eucalyptus globulus Label!, and other species ; The Australian Fever Trees, Eucalyptol. Myrtus: The Fragrant Myrtles. Myrcia Acris D. C. : Oil of Bay. Pimenta officinalis Lindley : Allspice. Eugenia Caryophyllata Thunberg ; Cloves. Allied Drugs.-See Cinnamon. JU P. Bolles. plane. To these four simple forms some authors add other forms : Talipes cavus, where the arch of the foot is increased, and talipes planus, its opposite, where the sole rests upon the ground, the arch being diminished. Recently, Shaffer, of New York, has described another class, that of non-deforming club-foot. Any combination of the simple varieties gives us the compound form ; talipes equino-varus and equino-valgus, and calcaneo-varus and calcaneo-valgus. Schematically these different forms may be pictured as follows : Lateral. Varus. Valgus. Simple. Antero-posterior Equinus. Calcaneus. Vabieties. Compound. Equino- Calcaneo- Varus. Valgus. Varus. Valgus. Other forms. Cavus. Planus. Non-deforming. Relative Frequency.-In obtaining information con- cerning the relative frequency of the different forms, much difficulty is experienced, owing to the different nomenclature, notably for varus and equino-varus, used by those making statistics on the subject. From Tam- plin's table, published in the London Medical Gazette for October, 1851, and covering 1,780 cases of club-foot, both congenital and acquired, 764 of the former were recorded to 1,016 of the acquired form. By these tables it is shown that by far the larger number were of the acquired variety, the proportion, as stated by Adams, being as 3:2. Of the congenital variety, the tables show a pre- ponderance of cases of talipes varus, but no distinction is evidently made between the simple varus and the com- pound form, talipes equino-varus. The tables are ap- pended : Fig. 688.-Clove, and Section of Fruit (An- thophyllus).' Congenital. Cases. Talipes varus 688 Talipes valgus 42 Talipes calcaneus 19 Talipes varus of one foot and valgus of the other 15 Total 764 Of the 688 cases of talipes varus, 182 affected the right foot only ; 138 affected the left foot only ; 363 affected both feet, and 5 cases were complicated with other de- formities. Of the 1,780 cases, 1,016 were non-congenital ; 999 were distributed as follows : Cases. Talipes equinus 491 Talipes valgus 181 Talipes eq-varus 162 Talipes calc, and calc-valgus 110 Talipes equino-valgus 80 Talipes varus 60 Talipes varus of one foot and valgus of the other 5 Acquired. CLUB-FOOT; TALIPES. Definition. - Under the generic term Club-Foot or Talipes, are included all cases of deformity of the foot, whether on an antero-posterior or transverse plane, and which are presented in a depart- ure from the normal relation of the foot to the leg, or of the foot to itself. This abnormal relation may consist of a flexion, extension, inversion, or eversion, Synonyms.-Ger., Klumpfuss ; Lat., Pes contortus; Fr., Pied bot; It., Piede torto ; Sp., Pie truncado. Varieties.-Club-foot is most conveniently divided into two classes, namely, the simple and compound, and of the former wre have four typical forms. These are talipes varus, talipes valgus, talipes equinus, and talipes calcaneus. The first form, talipes varus, is characterized by an elevation of the inner side of the foot, the sole be- ing turned inward, and the anterior portion of the foot adducted. In talipes valgus, its opposite, the outer side of the foot is raised, and the sole everted. Talipes equinus presents itself as an elevation of the heel, the foot being in a position of extension, the patient walking on the ball of the foot. In talipes calcaneus the toes are raised, the foot being in a position of flexion, and the patient walk- ing on the heel. The two first-mentioned deformities occur on a lateral, the two latter on an antero-posterior Total • 999 Reeves, in an experience of ten years at the Royal Orthopaedic Hospital, London, gives equino varus as the most frequent congenital form, and also states that the primitive forms of club-foot are rare as congenital de- formities. Sayre, in his work on Club-foot, and also in the article in his work on Orthopaedic Surgery and Dis- eases of the Joints, gives no statistics as to relative fre- quency, but states that the simple forms of club-foot are very rare, the deformity being nearly always a combina- tion of two forms. F. Busch gives equino-varus as the most frequent form. Duval has recorded 1,000 cases of club-foot, and of these 574 were congenital; 364 of these wTere in males and 210 in females. His statistics as to relative frequency are very valuable, and are as follows : Cases. Bovs. Girls. Equinus and Equino-varus 417 2i5 202 Varus 582 302 230 Valgus 22 14 8 Calcaneus 9 6 3 Extreme Calcaneus 20 13 7 Adams, in his work on Club-foot, gives talipes equinus as by far the most frequent non-congenital deformity. 196 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cloves. Club-Foot. Little states that he has seen two cases of congenital equinus, as does also Brodhurst. Tamplin discredits en- tirely the congenital origin of pure equinus, and states that he had not seen a case. Detmold has reported 167 cases of club-foot, and states that of these 93 occurred in both feet. Gross remarks that the congenital variety rarely affects both feet in an equal degree; that in his own experience the single'forms wrere considerably greater in number. Lannelongue has collected statistics at the Maternity Hospital (Paris), covering a period of ten years, from 1858 to 1867, inclusive. He has shown that in 15,229 births, 8 children were born with club-foot, which gives a proportion of about 1 case in 1,903 births. As yet the influences of climate and social position have not been determined. It probably occurs more frequently among the poorer classes. From the foregoing statistics, which have been consid- ered sufficient, the following facts may be deduced : 1. The greater relative frequency in males. 2. That the varus types are the most frequent. 3. That the right foot is affected more frequently than the left. 4. That both feet are more frequently affected than a single one. 5. That the purely primitive forms are rare. Etiology.-There are two classes of club-foot, namely, the congenital and acquired, and in studying their etiol- ogy, we shall consider the former class first. In no de- partment of medicine is there so much that is mysterious and unexplained, as is involved in the causation of de- formities of congenital origin. From earliest times they have been the subject of a vast amount of labor and in- quiry, and while these investigations have resulted in many speculations and a few facts, the theories estab- lished by them still leave much to learn concerning the real origin of this class of cases. The question is beset with difficulties from the onset, from the fact that the life of the foetus in utero is not subject to any direct scientific means of investigation, and wre are compelled to study the subject from such aids as comparative phys- iology, embryological data, and post-partum existence and diseases furnish us. Could we positively admit the question of diseases of the foetus, such as pertain to post- partum existence, the problem would be relatively simple. Many authors, notably Little, have, from the similarity in the deformities of the congenital and acquired paralytic forms, assumed this ground. Outside of the similarity in the appearances of the deformities, this view is not ten- able, for it has not been proven that a foetal myelitis or meningitis has existed. The microscope has not, as yet, demonstrated changes taking place in the foetal brain or cord, such as occur in infantile, cerebral, or spinal pa- ralysis. An electrical examination shows very markedly differing reactions in the muscles of the two forms, and patients suffering with congenital club-foot can, by the exercise of volition, use the muscles of the leg and foot, while such is not the case in the acquired form. These differences, together with the external appearances of the parts affected-the one cold, flaccid, and atrophied ; the other of normal surface temperature, plump, and of rounded contour-indicate an entirely different causation of the deformity. Heredity, with its mysterious influences, physical and psychical, also enters into this complex question, and is undoubtedly a factor in the etiology of many cases. Did space permit, many instances might be quoted as illustra- tive of this. From these we can as yet deduce no better explanation of its influence than the transmission of per- sonal configuration. Arrest of development has also been assigned as a cause for the production of congenital club-foot. Although many cases occur in which there is a co-existence of such deformities as spina bifida, hare-lip, and cleft palate, with club-foot, yet the feet themselves show no arrest of devel- opment, but only the same change of plane as is shown in the cases born without these co-existing deformities. Changes in the tarsal bones, principally the astragalus and os calcis, have been described by many authors, but by none more thoroughly than by Adams and Hueter. These changes consist in alterations in the form and plane of these bones, but they are by no means constant, and differences of opinion are held as to their being primary or causative, or secondary, as results of the deformity itself. The most recent investigations tend to maintain the latter theory. It has also been found that use of the deformed foot largely increases the malposition and form of the tarsal bones. A. Luecke also considers the osseous structures as the seat of primary lesion in club-foot. He and others have shown that at a certain period all foetuses are club- footed, and Luecke claims that by the constant movement of the child in utero th£ articular surfaces are so modified by the attrition produced as to enable the child's feet to assume a normal position before birth ; any interference with these movements would, however, prevent this at- trition, and the child would be born club-footed. Against this ingenious theory it may be argued that use increases the deformity after birth. Why it should act differently before is not easy to understand. We also know that in acquired cases, such as are due to spastic paralysis, for instance, want of use does not so change the articular sur- faces as to cause permanent club-foot, tenotomy in many cases restoring the foot to its form and function. Per- haps of all the theories advanced, that which ascribes congenital club-foot to abnormal intra-uterine pressure, due to lack of amniotic fluid, has received the largest num- ber of adherents. Most of the older writers, and many modern ones, prominently Volkmann, Kocher, Vogt, Banga, and Parker, are among its most noted advocates. Here it is maintained that the foetal foot is permanently fixed in one position by the intra-uterine pressure, and consequently, at birth, the child is club-footed. It has, very reasonably, been argued against this view, that if a decreased amount of amniotic fluid and consequent ab- normal pressure were productive of club-foot, other organs which had been subjected to the same pressure would also be deformed. Yet such is not the fact, clubbed hands, legs, and thighs being among the rarest of deformities, very seldom complicating the pedal mal- formation. It has also been shown that many children have been born club-footed where no appreciable differ- ence in the quantity of liquor amnii, judging from pre- vious labors, could be ascertained ; and we have recently seen a case of double equino-varus in a twin, the other child showing no deformity whatsoever. Billroth states as follows ; " The typical form of this congenital deformity appears to indicate that it depends on a disturbance of a typical (symmetrical ?) development of the lower extrem- ities ; for if foetal disease, disturbance of an irritative na- ture, or abnormal pressure in the uterus were at fault, cases would probably differ. " He also quotes Eschricht as showing that at the commencement of their develop- ment the lower extremities lie with their backs against the abdomen, the hollows of their knees being against the belly ; so during the earlier months the legs must rotate on their axes, and the toes which pointed backward must point in the opposite direction. If the embryonic extrem- ities lie so close as to appear united under a common skin, or be really united, the above-mentioned rotation of the limbs cannot take place, and in this deformity (siren) the feet are turned directly backward. This rotation on the axis, which was arrested in the above case, does not take place fully in club-foot, the rotation in the foot is not fully accomplished. Billroth states further, that ac- cording to this, congenital club-foot would come among the cases of obstructed development; about its cause, he concludes, we know as little as we do of other deformities of the same class. H. W. Berg, of New York, in a very original article, gives failure of rotation as the cause of congenital equino- varus. He has studied the subject from specimens seen at the New York Hospital, and Wood's Museum of Belle- vue Hospital, and describes the changes in the position of the lower extremities at different periods of foetal life. He shows that in early life the whole leg is rotated out- ward, and this outward rotation is accompanied by an ex- aggerated varus and, still later, an equino-varus. This diminishes as the rotation to the normal position pro- gresses, but he states that even when the rotation of the 197 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. leg has been entirely completed some of the varus still remains, and calls attention to the very slight varus of the new-born. In addition he states that equinus is often seen in foetuses of two, three, and four months. This he does not always find, and it disappears in the course of the normal growth of the foot. He concludes that in the early stage of foetal life varus or equino-varus is physio- logical. He does not think pressure necessary to the pro- duction of the deformity, its cause consisting, in his opinion, of a non- or retarded rotation inward of the lower extremity. We consider this theory of non- or retarded rotation as of such importance from an etiological stand- point, that we quote his account of its mechanism in full. He says : "As soon as the joints are formed we find the thigh rotated outward as far as possible, and flexed upon the body. The leg is flexed upon the thigh, but not completely, for this is prevented by the extreme outward rotation of the thigh, which brings the inner border of the leg in apposition with the abdomen of the child. We have, then, the inner border of the thigh and the tibial border of the leg pressed against the abdomen of the f cetus, the legs crossing each other a little below their middle. All of the intra-uterine pressure, therefore, is thus brought to bear directly upon the outer border of the thigh and leg, corresponding to the fibular border of the leg, and also upon the dorsum of the foot. The result of this is that the foot is rotated in and extended (equino- varus) until the sole is almost on a line with the inner border of the leg, and lies against the body of the foetus, while the dorsal surface of the foot is on a convex-curved line with the outer border of the leg, to adapt itself to the concave wall of the uterus. This, I believe, is a stage in the normal development of every healthy foetus ; and wTere the extremities to remain in this position, all chil- dren would be born club-footed. But nature provides against this by the inward rotation of the extremity, which gradually takes place, carrying the leg away from its position against the abdomen of the foetus ; and when this rotation is completed we find the extensor surface of the thigh flexed and in relation with the body of the child, while the legs are flexed upon the thighs, the inner or tibial borders facing each other. Now the soles of the feet lie against the uterine walls, and the intra-uterine pressure is exerted directly upon them. This produces extreme flexion of the foot upon the leg, together with an outward rotation of the foot ; this movement, from the constitution of the ankle-joint, accompanying extreme flexion. Thus is antagonized the varus or equino-varus existing hitherto. It is evident, then, that upon the com- pleteness of the internal rotation or torsion which takes place in the lower extremity, depends the rectification of the early varus of the foot. Should this rotation not take place at all, or be incomplete, the foot will continue to maintain its early relation to the body of the foetus and uterine walls, and the child will be born more or less club- footed. If this be so, we should expect to find in club- footed children that the extremities are rotated outward. And this we do find upon examination. In all of the cases of congenital club-foot (equino-varus) which I have seen since my attention has been directed to this subject, I have found that the thigh and leg, as a whole, were rotated out, and the tibia bent at its lower part, so that the feet were approximated to each other in addition to being in the clubbed position. All this is seen to be the result of non-rotation of the leg." In 1884, two years after Dr. Berg's article appeared, Drs. Parker and Shat- tock published a pamphlet on " The Pathology and Eti- ology of Congenital Club-foot." Their theory, as shown in their argument, is as follows : ' ' Our argument is that the feet of the foetus occupy various positions during the period of intra-uterine life, and that this occurs in order that the joint-surfaces, the muscles, and especially the ligaments, be developed so as to allow of that variety of positions and movements which are afterward to be natural to the foot ; and we hold that, when anything (mechanically) prevents the feet from assuming these positions at the proper time, or maintains them in any given position beyond the limit of time during which they should normally occupy such position, a talipes results. The variety of talipes will depend upon the date of its production ; its severity will be in direct ratio to the me- chanical violence at work. If the inversion of the foot, which is normal during the earlier months of foetal life, be maintained beyond the normal period of time, the muscles and ligaments will, as a consequence, be adap- tively short on one aspect of the limb, and too long on the other; a normal position of inversion will finally become a deformity. Talipes calcaneus is, we believe, produced in a similar manner; it occurs, however, later during intra-uterine life, when a flexed position of the foot is normal. Being thus less fundamental in character, it is also less severe as a deformity than varus." To any one who has read Berg's monograph, it will appear surprising that no mention of it is made by Parker and Shattock. This is all the more remarkable in that Berg had fully anticipated not only all that they have ad- vanced, but had followed these data and observations to their legitimate logical conclusions, which for some oc- cult reason Parker and Shattock have avoided. Had they cited Berg's paper, we would have been forced to the conclusion that they had attempted to prop up the old fanciful mechanical theory with the support of real em- bryological data. We have endeavored to give as succinctly as possible the different theories in vogue concerning the etiology of congenital club-foot. They may be briefly summarized as follows ; 1. The theory of pathological changes affecting the child in utero. 2. The theory of mechanical forces acting upon the foetus in utero. 3. The theory of heredity. 4. The theory of arrest of development. 5. The theory of non- or retarded rotation. In conclusion we would state, that it certainly would seem most reasonable, with our present knowledge of the subject, to ascribe the causation of congenital club-foot to the last-mer^tioned theory, which has at least for its credit the fact of its being demonstrable, rather than to those which for their foundation either have only the similarity to conditions produced by disease after birth, or are entirely fanciful. Etiology of Acquired Forms.-By far the larger number of cases of club-foot occur as acquired forms, and of these infantile paralysis (polio-myelitis anterior) produces the greatest number. Without entering into a lengthy description of this dis- ease, which can be found in any of the text-books on nervous diseases, and also in another portion of this work, it will be sufficient to state that it usually occurs during the period of dentition, beginning with fever and gastro- intestinal disturbance, with or without convulsions, and is followed by paralysis more or less severe. This paral- ysis is followed by a rapid improvement in many of the muscles involved, those of the upper extremity and trunk usually recovering first, while those of the lower ex- tremity remain unilaterally affected. The paralysis is fol- lowed by atrophic changes, loss of electro-muscular con- tractility, especially to the faradic current, and deformities, of which club-foot is the most frequent. For a long time it was taught that the deformities produced by infantile paralysis were due solely to the loss of power in one set of muscles, and the preponderating action of their antago- nists. Thus, in consequence of this loss of balance in the muscles supporting the leg and foot, were produced the altered relations which give rise to the various forms of acquired club-foot. Delpech taught that a muscle could be in a condition of permanent or tonic spasm, and the ppponents being paralyzed, the deformities were produced. That this view is faulty has been proven by more recent researches. Hueter first called attention to the fact that, owing to the position assumed by the paralyzed limb, its weight caused contractions, and that the so-called antago- nistic contractions were not at all muscular actions, but were due to atrophy and lack of growth. Volkmann, in his now classical lecture, has gone very thoroughly into the mechanism of the production of club-foot due to in- fantile paralysis. He has shown that, owing to the super- 198 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot, Club-Foot. incumbent weight of the body, the limbs assume positions which gradually become permanent; that the so-called tonic retraction does not occur, and that the shortening of the muscles is due not to contraction, but to growth of the limb, the foot remaining in its deformed position. A form of paralysis usually designated as spastic or active; spastic paralysis (Erb) ; paralysis with rigid mus- cles (Adams) ; and tetanoid paraplegia (Seguin), is also productive of club-foot. In this class of cases a more general dispensation of the consequences of the lesion seems to be inflicted. The patients have a silly or semi- idiotic look, although their intelligence seems rather to be retarded than obliterated. They frequently squint, and their progression is peculiar and quite characteristic. They walk on their toes with their knees pressed together, and, in order to maintain their equilibrium, throw one limb over the other, walking as it were cross-legged. There is general rigidity and spasm of the muscles, all the reflexes being greatly exaggerated. The form of club-foot in these cases is usually an equinus, and the contractions can, for the time being, be rectified by con- tinuous pressure, but upon its cessation the feet instantly assume their old positions. Its pathology would seem to indicate, in some cases, a lack of development, in others a lesion of some portion of the motor tract of the brain, followed by secondary changes in the lateral columns of the cord. Rupprecht, of Dresden, has studied the nature and treatment of this condition very thoroughly, and has shown that tenotomy in this class of cases is not only often followed by improvement in the position of the feet, but that in some cases there was an accompanying improvement in the mental status of the patient. For further information on this very important class of cases, the reader' is re- ferred to his very valuable remarks in Volkmann's series of clinical lectures. Many authors believe that this, or a similar condition, is an accompaniment of various spinal diseases, acute compression, syphilis, tumors, and caries. Among other conditions due to disturbance of the nervous system, pseudo-hypertrophic paralysis, post- hemiplegic contractions, and neuromimesis are produc- tive of club-foot. While the two former classses are rare as causes of acquired talipes, the latter or neuromimetic are more frequent, and have of late years attracted con- siderable attention. Examples of these very interesting cases have been cited by Paget, Little, Skey, Shaffer, Weir Mitchell, Haward, and others. They undoubtedly depend upon the neurotic diathesis, and may, by their similarity to the real condition, be very deceptive. Shaffer has devoted considerable space to this class of cases in his work on "The Hysterical Element in Orthopaedic Surgery," a perusal of which will greatly aid the student in the diag- nosis and treatment. Cases due to reflex paralysis have been reported by Sayre and others, who claim that a functional disturb- ance of the nervous system can cause spasm of certain muscles, which continuing for a time, while healthy growth is going on in their opponents, so disturbs the balance of power as to produce a permanent deformity. This mode of the production of club-foot has recently been the subject of much discussion, many authorities al- together disbelieving the origin of the deformity by this means. The paraplegia accompanying Potts' disease of the spine is also a cause of acquired club-foot. It generally occurs as an equinus, and is very similar to the spastic cases previously mentioned. It disappears as the para- plegia improves. One of the most frequent causes of acquired talipes is joint-disease of the lower extremity. Here it may either occur symptomatically, or follow the disease of the ar- ticulation. Especially is this true of the ankle-joint, where, at different periods of the inflammatory trouble, the foot assumes an equinus, varus, or valgus position. A very interesting class of cases are those due to occu- pation. In these cases, occurring principally in bakers, blacksmiths, printers, and other trades, the principal fac- tors are the weight of the body and long-continued posi- tion, and it is in this class that we often see the inflam- matory forms of club-foot. A similar class of cases are those observed in growing boys and girls, and usually occurring at about the time of puberty. Here the de- formity, which is a valgus, is probably due to increased weight and rapid growth of the body, without a corre- sponding growth of the muscles and ligaments of the feet. Long-continued decubitus, as in the continued fevers, has been productive of club-foot, generally an equinus. Volkmann mentions one case in which, after severe ty- phoid fever, an equinus resulted, and in which a year was occupied in restoring the feet to their normal position by active orthopaedic treatment. Traumatisms, resulting in deep cicatrices and burns in the neighborhood of the ankle-joint, are also causes of ac- quired club-foot. History and Literature.-In studying the history of club-foot, it has been thought best to divide the subject into three periods : a Pre-continental period, including the years from 460 to 370 b.c. ; a second, the Continental and Early English, including the seventeenth and eighteenth centuries ; and a third, or Continental and English, which embraces the nineteenth century and brings us down to the present day. To render the study more complete, separate notice is given of American contributions, espe- cially valuable for their originality in the mechanical im- provements devised for the relief of this deformity. I. Pre-Continental Period-B. C. 460-370.-The earliest author on the subject of club-foot, whose writings are pre- served or accessible, is Hippocrates. He mentions very clearly deformities of the articulations, and in all his works on ancient surgery, says his translator, there is not a more wonderful chapter than that relating to club-foot, on which he gives most valuable information. He says : " There is more than one variety of club-foot, the most of them not being complete dislocations, but impairments connected with the habitual maintenance of the limb in a certain posi- tion." He says further: " Most cases of congenital club- foot are remedial, unless the declination be very great, or when the affection occurs at an advanced period of youth." For early treatment he relied on bandages, for the application of which he gave very particular instruc- tions. He says : " After the application of the bandages, a small shoe made of lead is to be bound on externally, having the same shape as the Chian slippers. This is the mode of cure, and it neither requires cutting, burning, or any other complex means." This might imply that he had seen or heard of other means of curing club-foot, but of them, if they existed, we have no record. For a period of two thousand years or more, the sub- ject of club-foot was apparently completely ignored, and nothing was added to the knowledge collected by Hippo- crates, and handed down to us by Polybius. It was re- garded by all as a subject of ill-omen, and those unfortu- nately afflicted by the deformity as being especially the objects of divine wrath. Superstition forbade men from even mentioning it, much less of devising means for its cure. Celsus, whose writings cover so large a field, does not even mention it-a fit criterion of the condition of the times. II. Continental and Early English Period-Seventeenth and Eighteenth Centuries.-It was not until the middle of the seventeenth century that the question of club-foot again came into notice. In 1641 Ambroise Pare, "Les (Euvres" (Lyons), as- cribed club-foot to the circumstance that the mother, dur- ing her pregnancy, had been sitting too much with her legs crossed. He also gives a model of a boot for the treatment of the deformity. He was followed in 1643 by Severinus, who wrote of the subject. ("De recondita abscessum natura " ; Francof. 1643). In 1658, Arcseus, " De recta curandorum valuerum ra- tionale''(Amstel.), describes a process for the removal of the distortion, and figures an apparatus, and a boot, by which he treated deformities. Fabricius, in 1723, " Opera Chirurgica " (Batavia), proposes an iron boot for treating deformities of the feet. In 1741, Andry first used the term orthopaedy, and pub- lished a work on the subject in two volumes, entitled " L'Orthopedie " (Paris). It is evident from his remarks that he does not limit the use of the term to club-foot, as 199 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. some authors erroneously suppose, but under the deriva- tion opdbs, straight, and irai86s, genitive of irais, child, the whole subject of the rectification of deformities is included. Du Verney, in his " Traite des Maladies des Os" (Paris, 1751), contributed a very important chapter to the subject of club-foot. He recognized the muscular con- traction as a cause, and described the distortion as due to the influence of the muscles and ligaments. He writes of Varus and Valgus, and ascribes these distortions en- tirely to the unequal tension of the muscles and ligaments. He concluded that those muscles which are extremely tense draw the parts toward them, while their antago- nists yield, being relaxed. The year 1784 brings us to the most important era in the history of club-foot which we have yet to record, and from this date a marked impetus was given to the proper study and treatment of the subject. Thilenius, a phy- sician of Frankfort, proposed in this year a section of the tendo Achillis for a case of talipes equinus, and the operation, an open one, was performed by the surgeon Lorenz. It was completely successful, and the same opera- tion was subsequently performed by Sartorius. Thilenius has written under the title, " Medicinische und Chirur- gische Bemerkungen " (Frankfort). At about the same time Venel, called by some the "Father of Orthopae- dics," settled in Orbe, Switzerland, and founded an or- thopaedic institution. His success was such that Wanzel, then eleven years of age, was placed under his treatment with double club-foot. By means of his shoe he suc- ceeded in curing him in twenty-two months. This in- duced Bruckner, of Gotha, "Ueber Natur, Verfahren und Behandlung der einwarts gekrummten Fiisse (Gotha, 1796), and Naumburg, of Erfurt, " Abhandlung ueber die Beeinkrummung (Leipsic, 1796), to use and perfect Venel's method. Wanzel studied medicine later, and in his inaugural thesis, " Dissertatio Inauguralis medica de Talipedibus Varis" (Tubingen, 1798), described the pro- cedure used by Venel. Besides the authors already quoted, Ehrmann, of Germany ; Tiphaisue and Verdier, of France ; and Jackson, Sheldrake, and Mark Anthony Petit, of England, contributed to the literature and treat- ment of club-foot. Of these the most important are the writings of Thomas Sheldrake, of London (1798), who considered the contrac- tion of the ligaments as the essential cause of club-foot. He aimed his treatment essentially at these tissues. His own words are as follows: "The essential operation to be performed in curing a club-foot is to produce such an extension of some of the ligaments as, if it happened by accident, would constitute a sprain. It certainly is the duty of the operator so to conduct this operation that none of the consequences which would have taken place from an accidental operation shall ensue." Mark An- .thony Petit, of England (1799), is claimed to have had the first example of tenotomy on record, and to have been the first surgeon to perform it. This closes the second period in the history of club- foot, and while we can see the gradual progression from a purely empirical idea, both of the nature and treatment of the deformity, to a broader and more comprehensive conception of the subject, it will be admitted that as yet no decided scientific departures had been made. The nearest approach was the operation of Thilenius, which foreshadowed, as it were, the researches which were to follow, and which have proved of such invaluable worth to the sufferers from club-foot. III. Continental and English Period.-Nineteenth Cen- tury.-More general attention seems to have been di- rected toward the study and treatment of deformities at the beginning of this century, and many master-minds in different countries labored to bring the subject from out of the half mystical, half empirical atmosphere in which it was enshrouded at the close of the last century. This period was opened auspiciously by the writings of Ortlepp in Germany, whose work, " De Talipedibus, etc." (Jenae, 1800), contains many excellent suggestions, and of Bailly, in France, who wrote under the title " Du traitement et de la curabilite du pied-bot invetere " (Lyons, 1802). They were followed in 1803 by Scarpa, of Pavia, who in his work on club-foot, " Memoria chirurgica sui piedi torti congeniti dei fanciulli, e sulla maniera di corregere questa deformita " (Pavia, 1803), maintained the opinion entertained by Hippocrates, that the tarsal bones are not dislocated, but twisted on their axes, and only partially separated from their mutual contact. He contended that the primary disturbance is in the osseous system, and that, consequent on this displacement, the muscles are elongated or retracted, according to their position. He proved by dissection the inaccuracy of the supposed cause of club-foot residing in arrest of development or malformation. He designed an apparatus, universally known as " Scarpa's shoe," for the mechanical treatment of club-foot, the essential principles of which are retained to the present day, and on which most of the apparatus used at present are constructed. Jorg, of Leipzig, wrote on club-foot under the title, " Ueber Klumpfiisse und cine leichte und zweckmassige Heilart" (1803). On the 10th of May, 1806, Sartorius repeated the op- eration of Thilenius. The operation by open wound and " brisement force" combined, ended in anchylosis. In 1809 Michaelis, of Marburg, wrote a treatise " Ueber die Schwachung der Sehnen, etc." He contended that in al- most every case of club-foot the tendo Achillis is too short. He operated upon several cases of talipes equinus by partial division and rupture of the tendo Achillis. He reports that after the operation he at once brought the feet in their natural position. He seems to have operated very frequently. In less than one year he had performed eight operations of tenotomy : three for equinus ; one for varus ; three for contracted knees, and one for contracted fingers. Artopoeus, in 1810, " Sur la torsion congenitale des pieds des enfans," and Goepel, in 1811, " De Talipedibus varis ac valgis, corumque cura, " were also important con- tributors. In 1816 Delpech, of Montpelier, executed the fourth operation of tenotomy on record. He virtually did a sub- cutaneous operation, inasmuch as he made a small open- ing through the skin, and remote from the tendon. He laid down the following important rules for the perform- ance of the operation : 1. The tendon was not to be exposed. The knife was to be entered at a distance from the tendon, and not through an incision in the skin parallel to it. 2. After section the divided ends of the tendon were to be brought together, until reunion. 3. Gradual and careful extension was to be made be- fore complete union. 4. Complete extension being made, the limb was to be fixed in this position, and kept there until union was per- fect. From Delpech's works, " Chirurgie Clinique de Mont- pelier" (Paris, 1816), and "De 1'Orthomorphie" (1828), it does not appear that he again performed tenotomy. In 1817 D'lvernois wrote an essay on club-foot entitled " Essai sur la torsion des pieds et sur le meilleur moyen de les guerir." He was followed in 1820 by Palletta, who attempted to prove that the primary cause of the deformity consisted in a deficiency, complete or partial, of the internal mal- leolus (" Exercitationes pathological."; Paris, 1820). In 1823 Rudolphi, in his " Grundriss der Physiologie," added much valuable information to the pathological an- atomy of club-foot. He believed that club-hand and foot did not depend on extrinsic causes, but frequently occurred in young children from irritation and spasmodic action. He also first called attention to the fact that dis- tortions occur in the embryo as early as the third and fourth month of foetal life. From 1823 to 1831, many important contributions to the study of club-foot were made. Of these the most notice- able were those of Mellet, " Considerations generales sur les deviations des pieds James Kennedy, of Glasgow, "On the Management of Children in Health and Dis- ease" (1825) ; Stolz, in 1826, " Memoire sur une variete particuliere du pied-bot; " Bruns, " Dissertat. inaug. de Talipede varo " (1827); Pech, "De Talipedis vari et 200 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Club-Foot. regard to tenotomy, Little says : " The most favorable time for division of tendons is' a few months before the child may be expected to walk-about the age of six or eight months, until which time mechanical apparatus should be used." Little wrote his " Treatise on the Nat- ure of Club-foot" in 1839, and "On the Nature and Treatment of the Deformities of the Human Frame " in 1853, both being standard works on the subject to this day. Kennedy, of Dublin, "Observations on Cerebral and Spinal Apoplexy, Paralysis, and Convulsions of New- born Children," and Martin, "Premier Memoire sur le Pied-bot," were also among the most prominent publica- tions of this year; the latter ascribing congenital club- foot to deficiency of the liquor amnii. In 1837 Sewald (Berlin) wrote his celebrated thesis, "Diss, inaug. de Talipedibus," as also Lode, " Diss, inaug. de Talipedibus varis et curvatura Manus," etc. In the same year Pivain wrote his essay entitled, "Sur la Section du Tendon d'Achille," etc. Attention was also called to the subject of flat-foot, by Nevermann, in an article entitled " Ueber den Platfuss und seine Heilung." In 1838 Kness studied the subject carefully, and embodied , his researches in an article, "De Talipede Varis," and Wigel, in the same year, gave a resume of the operative treatment under the title " De operatione Vari." In 1839 Velpeau, of Paris, gave much attention to the subject of club-foot, and wrote on the subject in his " Nouveaux Elements de Medecine Operatoire." Head- vised, after division of the tendons, the reduction of the foot, by a powerful instrument, to its normal position, and also its immediate fixation. He called attention to the importance of the posterior tibial tendon, and de- scribes the operation for its division, its dangers, and ad- vantages. In the same year Krauss wrote on " The Cure of Club- foot, Bent Knee, Long Neck, Spinal and other Deformi- ties, with Cases." He was an ardent advocate of tenotomy, although he says "in congenital club-foot, if advice be early sought, a cure may be attempted by mechanical means alone, but nevertheless, in children one and two years old tenotomy is better." Hauser "on Talipes Varus" (Tunice), and De Russdorff "De Talipedibus," were also important contributors in this year. Between the years 1834 and 1840 we find tenotomy practised, and its effects upon the tendons very carefully studied, by such men as Bouvier, of Paris, Pauli, Von Ammon, Phillips, Held, Scoutetten, of Strasbourg, Bonnet, of Lyons, Jules Guerin, of Paris, Dieffenbach, of Berlin, and Pirogoff. The researches of Bonnet are described in his "Memoire sur la section du tendon d'Achille dans le traite- ment des Pieds-bots;" Pauli's in his essay "Ueber den Klumpfuss und dessen Heilung." The other contributors are : Von Ammon, who studied the effect of tenotomy very carefully in his "De Physiologia Tenotomiae;" Phillips, " Subcutaneous Tenotomy in Club-foot; " Held, " Sur le Pied-bot ;" Scoutetten (Strasbourg), "Memoir on the Radical Cure of Club-foot; ''Bonnet (Lyons), " Traite des Sections Tendineuses, etc. ; " Jules Guerin (Paris), ' ' Memoir upon the Etiology of Congenital Club- foot;" Dieffenbach (Berlin), "Ueber die Durchschneid- ung;" and Pirogoff, "Ueber cjie Durchschneidung der Achilles." From the experiments of Bonnet, he was led to regard the cause of congenital club-foot as residing in the tibial nerve. Pirogoff described two modes of performing tenotomy. 1. Introducing the knife between the skin and tendon and cutting inwardly. 2. Introducing the knife between the bone and tendon and cutting outwardly. The latter operation was always followed by effusion of blood into the sheath of the tendon. Jules Guerin believed tenotomy was not necessary for very young children, and that bandages were alone suf- ficient for the reduction of varus. He is among the first to have used plaster of Paris in the treatment of club-foot. Scoutetten's mode of treatment was by tenotomy and an apparatus combining fixation with flexion and exten- sion. In 1840 Coates published his " Practical Observations valgi causa" (1828); Cruveilhier, " Anatomie Patholo- gique " (Paris, 1829), who entertained erroneous ideas of club-foot and hand, thinking that a cramped position in utero was the sole cause of these congenital distortions ; Tortuae, in 1829, "Praktische Beitrage zur Therapie der Kinder-Krankheiten " (Munster) ; Buchetmann, 1830, "Diss, inaug. Abhandlung ueber die Plattfuss " (Er- langen) ; and Loeb Davides (1830). From the time of Delpech until 1831 it does not seem, judging from the writers just quoted, that the operation of tenotomy had been placed on such a basis that its per- formance had been often repeated, or its merits further investigated. In 1831 Stromeyer not only resuscitated, but established the operation on a permanent and scien- tific basis. By his discoveries he not only made the op- eration popular, but showing the impunity with which muscles and tendons might be divided, opened the field for the relief of deformities which before had baffled the surgeon, and which had condemned the sufferer to a life- long incapacity. Like all new departures, however, his disciples undoubtedly overdid the operation, and its ap- plicability was oftentimes lost in the desire to perform it. Thus its proper application, and the counter-indications for its performance, have only been the result of experi- ence ; but to Stromeyer and his influence is undoubtedly due the success attained by surgeons at the present day in the operative treatment of club-foot. He wrote under the title " Beitrage zur operativen Orthopadik " (Hano- ver, 1838). In 1833 Stork wrote very learnedly on " De Talipedibus varis." He was followed in 1835 by Vin- cent Duval, whose writings, "Traite pratique du Pied," and " Des Vices Congenitaux de Conformation des Artic- ulations," contain many useful observations. He made many important statistical deductions, and also proposed a classification and nomenclature, which, however, have not come into general use. He is also said to have been the first operator upon the tendo Achillis in France. In the same year Blance wrote his ' ' Diss, inaug. de novo ad Tali- pedem varum." Ryan, of London, in his "Practical Treatment of Club-foot " (1835), criticises the three di- visions of club-foot into Equinus, Varus, and Valgus, as having the merit of being short, but the want of being exact. Thus, he says, it is necessary that the form of club-foot called equinus should be carried to the greatest degree of development to give to the patient's foot the ap- pearance of a horse-foot, and an examination of thirty cases seemed to justify this criticism. In regard to the etiology, he considered general or partial paralysis due to cerebro-spinal disease, and the bad position of the child in utero as the two great causes; other less important ones he found in direct injuries, contusions, inflammation of the knee or tibio-tarsal joint, and nerve lesions. He did not think tenotomy a justifiable operation, unless all other means failed. In 1836 W. J. Little, of London, who was a sufferer from acquired club-foot, and who vainly attempted to have an operation performed in England, proceeded to Hanover, where he was operated on by Stromeyer for an equino-varus. In July of the same year, he himself per- formed the operation in Hanover. He then went to Ber- lin, and with Dieffenbach treated numerous cases of dis- tortion. On February 20, 1837, Little is said to have divided the tendo Achillis for the first time in England, although the honor was claimed by two men before him, by M. A. Petit, in 1799, and by Whipple, of Plymouth, in May, 1836, who states that when he performed the oper- ation he was not aware that it had been performed on the Continent, and that Brodie, to whom he wrote on the sub- ject, discountenanced it; but that Liston sanctioned the operation. To Little, however, is undoubtedly due the credit of popularizing the operation in England, and to his influence the advancement of orthopaedic surgery is largely owing. He is said to have been the first to use the term "Talipes" {Talus, an ankle, andjues, afoot) in its generic signification, although the term had previously been used by writers in a more limited sense. He saw and described talipes calcaneus, and made extensive re- searches into the pathological anatomy of club-foot, con- sidering the muscles as the parts primarily attacked. In 201 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. on the Nature and Treatment of Talipes or Club-foot, etc." (London), and Heine, of Stuttgart, his " Beobach- tungen ueber Lahmungszustande der Extremitaten und deren Behandlung," a very scientific work on the pro- duction of the deformities. In 1841 Vallin, in his "Abridged Treatise on Club- foot " (Nantes), gave it as his opinion that muscular con- traction played the most important part in the production of club-foot. He says : ' ' The circumstance which has the most influence upon the efficacy of the treatment of club- foot by apparatus, is the possibility of acting directly upon the displaced bones, and upon the causes which produced their displacements." In the same year Kennedy, of Dublin, wrote his " Ob- servations on Paralytic Affections met with in Children," which contains many important notes on club-foot. In 1842 Dunbar writes of the subject in his " Notes on the Surgery of Deformities, Club-foot." In this year, Lizars (Edinburgh), " Operation for Cure of Club-foot," says that "the child must be old enough to walk before the operation of tenotomy is performed. Two or three years of age is the earliest time at which tenotomy should be practised." After tenotomy, he advised a bandage from the instep to the toes, and over this a pasteboard splint. In 1843 Rilliet and Barthez write learnedly on the sub- ject in their " Traite clinique et pratique des Maladies des Enfants," and Petit jean wrote his work " Du Pied- bot." In 1845 Chelius, in his "System of Surgery" (London), devotes some space to the subject. In 1846 the most important work was that of Tamplin, whose " Lectures on the Nature and Treatment of Deformities" (London) was long one of the standard works on the subject, and may be advantageously consulted by the student at the present day. He devised many new modes of treatment, and his statistics as to relative frequency are very valuable. Meyer, " De Talipede varis, etc.," and Muller, " De Valgi pedis aetiologia quaedam," also wrote in the same year. Morrisson, in 1847, " Sur les Pieds- bots," and Berstedt, " De pedum deformitatibus " (1848), are valuable contributions. In 1849 Lonsdale wrote his celebrated work ' ' On Some of the More Practical Points Connected with the Treatment of Deformities " (London). In 1850 Degaille wrote on the etiology and treatment under the title " De 1'Etiologie et du Traitement du Pied- bot." He was followed, in 1852, by Bishop, of London, whose work, ' ' Researches into the Pathology and Treat- ment of Deformities in the Human Body," is a careful summary of the subject. At about this time, much at- tention was given to the repair of tendons after tenotomy, and although investigations concerning this process had been made by Von Ammon, Guerin, Pirogoff, Koerner, and others, it was left for Gerstaecker (1851), "Diss. Histol. de regeneratione tendinum ; " Thierfelder (1852), "Trans. Path. Society" (London, vol. vi., 1855); J. H. Boner (1854), "Die Regeneration der Sehnen, etc.," who performed many experiments on rabbits, but especially Paget, "Lectures on Surgical Pathology" (London, 1853), who has detailed minutely the microscopic changes through all the stages of the reparative process, and to whom we are largely indebted for our knowledge of the subject, to show the exact mode in which the required elongation of muscles is obtained in order to cure the de- formities for which the operation is performed. Adams, in 1855, also performed experiments upon rabbits in which the tendo Achillis had been divided subcutane- ously, and has written "On the Nature and Treatment of Club-foot" (London, 1856), and a "Treatise on the Reparative Process in Human Tendons" (London, 1860), in which he gives u resume of the published descriptions of experiments on animals, as well as post-mortem ex- aminations in the human subject. His work " On Club- foot : its Causes, Pathology, and Treatment," is the most exhaustive on the subject, and received the Jacksonian prize for 1864. It has passed through several editions. Brodhurst, of London, has contributed largely to the subject of club-foot, the most important of his writings being "On the Nature and Treatment of Club-foot" (London, 1856), and his work "Orthopaedic Surgery." He was a decided advocate of tenotomy, and employed it to the exclusion of all other means of treatment, consider- ing it better, even in the most simple cases, to divide the tendons. He made numerous experiments upon the re- parative process following the section of tendons, the re- sults of which were embodied in a communication to the Royal Society (November, 1859), entitled " On the Repair of Tendons after their Subcutaneous Division." From 1853 to 1863 many valuable papers upon the subject of club-foot appeared. Among the most noteworthy were those of Todd, " Clinical Lecture on Paralysis " (London, 1854); Bouchut, " A Practical Treatise on the Diseases of Children" (1855); Beckel, "De Pede Varo " (1856) ; Vetter, " De cyllopodia cum descript, casus pedi vari"; Esau, " Beitrage zur Lehre von Plattfuss"; Quicken, "De Talipedibus" (1859); Ebner, "Die Contracturen der Fusswurzel und ihre Behandlung " (1860). In 1863 Barwell, " Cure of Club-foot without Cutting Tendons," rendered himself famous by offering objections to, and strongly opposing, the practice of tenotomy, which after nearly a century of use, had of course become very popu- lar, and was supported by all the great surgeons. His treatment was directed to the restoration of the lost equi- librium in the opposing sets of muscles ; to substituting a force for the paralyzed muscles to be applied as nearly as possible in the direction and position of the paralyzed muscles ; to treating the foot, not as a whole, but as a com- pound of many bones ; and to allowing the weakened mus- cles to regain their power by what might be called passive motion. This he endeavored to accomplish by the use of india-rubber bands, also called "artificial muscles." In his objections to tenotomy he argues that the contraction is the result of paralysis in the opposing muscles. When the tendon is cut, all opposition to such contraction is annihilated, and the muscle itself contracts and the calf shortens. Tonic contraction of the muscle, however, still continues, and the cicatricial contraction will reproduce the same deformity, when the apparatus is removed. Non-union occasionally takes place. Weber, " Ueber die Anwendung permanenter Extension durch elastische Strange bei pes valgus " (1863), also advocated elastic force. Adams, in 1866, writes that Heather Bigg had used the same plan several years prior to Barwell. Many works appeared during the latter end of this period, and the literature of club-foot is now very voluminous. Stoess, in 1866, wrote on " Du Traitement du Varus" ; Richter, in 1867, on "De Talipedibus Varis" ; Mezger, in 1868, " De Behandlung van di Stortistic Pedis mit Eric- ties" ; Hirschfield, in 1869, " Ueber die Behandlung der Klumpfiisse" ; Francellon, in the same year, " De 1'Etio- logie du Pied-bot Congenital." In 1870 Nieden, " Ueber die Entstehungsweise und Ursache des angeborenen Klumpfusses" ; Volkmann, " Ueber Kinderlahmung und paralytische Contracturen" (Klinische Vortrage, No. 1), and Marx, " Ueber Pes Varus." In 1871 James Hardie, " On the Pathology of Club-foot and other Allied Affec- tions " (London) ; A. Luecke, "Ueber den angeborenen Klumpfuss" (Volkmann's Klinische Vortrage), and Brod- hurst, " Deformities of the Human Body" (London). In 1872 Reverchon, "Sur le Pied-bot," and "Du Traite- ment des Pieds-bots par le Massage force." In 1877 Chalot, "Du Pied Plat et du Pied Creu Valgus Acci- dentels." In 1878 Kocher, "Zur Etiologie und The- rapie des Pes Varus Congenitus " (Deutz. Zeit. fur Chir., Bd. ix.), and Bornemann, "Zur Therapie des Pes Varus Congenitus." In 1880 Van Hees, " Ueber Pes Equino- varus." In 1881 Ruprecht, " Angeborene spastische Gliederstarre und spastische Contracturen " (Klinische Vortrage); Dieffenbach, "Ueber Pes Varus und seine Behandlung;" Routier, "Du Pied-bot Accidentel," and Ulcoq, " Du Pied-bot Consecutif a la Paralysie Infantile et de son Traitement." In 1882 Pascaud, "Of Certain Orthopaedic Apparatus employed in the Treatment of Club-foot; Noble Smith, " Surgery of Deformities." In 1883 Schwartz, " Des Differentes Especes de Pied-bot, et de leur Traitement." In 1884 Parker and Shattock, " The Pathology and Etiology of Congenital Club-foot." In 1885 Reeves, "Practical Orthopaedics" (Section, Talipes or Club-foot). This brings us to the close of the third period, and 202 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Club-Foot. down to the present day. We have endeavored to give the more important works which mark the history of the subject, and to note those particularly whose views char- acterized the development of new theories as to etiology and treatment. American Contributors-Nineteenth Century.-In 1835, four years after Stromeyer performed his first operation, Dr. James H. Dickson, of North Carolina, is reported to have performed the operation of subcutaneous tenotomy for the first time in America. In 1839 Mutter, of Philadelphia, delivered "A Lecture on Club-foot," in which he advocated well-regulated and continued extension, which he believed was the only thing necessary, especially for the young and feeble. In other cases he advised tenotomy, and the proper fixation and retention of the foot, followed by apparatus. He be- lieved the immediate or proximate cause of congenital club-foot was a contraction of the tendo Achillis. Acci- dental causes of acquired club-foot he ascribed to contu- sions, sprains and luxations, fractures, preternatural lax- ity of the ligaments, and partial paralysis of the lower extremities. In 1840 Detmold, of New York, in his " Essay on Club- foot," states that the only remedy to be relied upon in the cure of club-foot consisted in the extension of the con- tracted muscles, gradually increased and continued until one set of muscles lose the inclination to spasmodic con- traction, and their antagonists regain their activity. In regard to the causes of club-foot, he believed the first and most frequent cause to be "irregular muscular action," the stronger muscles contracting, and the weaker ones yielding ; second cause, paralysis; third cause, a local stimulus or irritation, setting up contraction. He thought that in cases due to the first cause, the prognosis was gravest, and most favorable when the condition was due to prolonged contraction from a local stimulus. A pupil of Stromeyer, and having had the opportu- nity of seeing him operate, he was an ardent advocate of tenotomy, and to him and Mutter is due the credit of making the operation of subcutaneous tenotomy pop- ular in this country. Although many articles in dif- ferent journals appeared upon the subject of club-foot, and many plans of treatment showing much original- ity were devised, it was not until 1866 that a me- thodical account of the subject was given by Prince, in his " Orthopaedics " (Philadelphia), lie also gives a very ingenious plan for holding the foot, for the purpose of affixing apparatus for the removal of the deformity. He was followed in 1867 by Davis, who was the originator and promulgator of the "extension" theory, and to whom much credit is due for his original work in the treatment of deformities. In his work, "Conservative Surgery," he claims that he had practised Barwell's plan many years before Barwell adopted it. In 1868 Bauer's "Orthopaedic Surgery" was published. It is undoubtedly the most complete and scientific work upon the subject up to /his date, and its chapter on Talipes is a very comprehensive and exhaustive one. In 1875 Sayre, in "A Practical Manual of the Treatment of Club-foot," shows himself a decided advocate of " Barwell's arti- ficial muscles," although he doesnot believe in this method to the exclusion of other means of mechanical treatment and tenotomy. In this work he gives many excellent prac- tical suggestions for the treatment of the deformity, and in this, as well as other departments of orthopaedic sur- gery, he has done much for the advancement of the sub- ject. Shaffer, of New York, has devised many important im- provements in mechanical appliances for the cure of club-foot, and has contributed valuable articles to the literature of the subject. The most important of these are: "Traction in the treatment of Club-foot" (1878); "Hysterical Joint-Affections" (1880), in which he re- ports very interesting cases of "hysterical club-foot" and "Non-deforming Club-foot" (1885), originating in this last contribution a new class of cases, previously little observed or studied. Phelps, of Chateauguay, advocated and practised di- vision of the tendo Achillis, and then of all structures down to the bones opposite Chopart's joint. He read a paper on the subject before the International Medical Congress at Copenhagen, entitled " The Treatment of Equino-varus by Open Incision." Kingston, of Montreal, " On certain forms of Club- foot" (1884), reports four cases of severe equino-varus treated by open incision. Berg, of New York, has written a very original and valuable article on ' ' The Etiology of Congenital Talipes Equino-varus " (1882), the studies of the author throwing much light upon this very vexed question and antedating the researches of Parker and Shattock, of London, by several years. Many other names might be added to the foregoing ones, most conspicu- ously those of Pancoast, of Philadelphia; Hutchison, of Brooklyn , Yale, of New York ; Bradford, of Boston ; all of whom have added either to the treatment or the literature of club-foot. Varieties Especially Con- sidered.-Under this heading will be included a short account of the different forms of club- foot and their treatment, as well as some considerations concern- ing their morbid anatomy, path- ology, diagnosis, and prognosis. The purely primitive types of club-foot are so rare, either as congenital or acquired deformi- ties, that authors have, under the titles Varus, Valgus, Equi- nus, and Calcaneus, usually in- cluded the compound forms, and nearly all works upon the subject have described the changes found in them when re- ferring to the bones, ligaments, muscles, etc., involved in the malformation. This has led to much confusion in both nomen- clature and statistics. It wTas thought necessary to call atten- tion to this fact before proceed- ing to a description of the primi- tive types. Talipes Varus.- Synonyms : Ger., Klumpfuss; Fr., Pied-bot varus. The simple form is un- doubtedly one of the rarest of either congenital or ac- quired deformities, it being generally associ- ated with equinus, and almost all au- thors when writing of varus describe the compound form, Talipes Equino - varus. In the mildest form there is a slight inversion of the anterior part of the foot, the heel not being elevated. In a true case of varus, therefore, the deformity would take place at the transverse tarsal joint, the deformity. being on a lateral plane. The changes, bony, muscular, and ligamentous, as well as the treatment of the simple form, will be best described under the head of Talipes Equino-varus. Talipes Valgus. Splay-foot, Flat-foot. - Synonyms : Ger., Plattfuss ; Fr., Pied-bot valgus. This deformity may be congenital or acquired, the latter form being very frequent, the congenital rare. In the congenital form there is eversion and elevation of the outer border of the foot, the weight of the body being sustained upon its inner side. With this we find a sinking of the normal Fig. 689.-Acquired Talipes Valgus. 203 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. convexity of the arch. Here, as in varus, in the primitive type, the deformity takes place on a lateral plane, and oc- curs at the transverse tarsal joint. The bones are, as a rule, not very much displaced, the principal changes taking place in the astragalus and scaphoid bones, the os calcis only being implicated when there is a co-existing equinus. The astragalus is generally pushed downward and forward, and is seen as a promi- nence upon the inner side of the foot, with the rotated sca- phoid bone, which is also prominent. The cuboid bone is involved, being slightly ro- tated outward, and the malleoli have a lower plane than nor- mal. The ligaments implicated are those upon the plantar sur- face and inner side, the calca- neo-scaphoid ligament being relaxed. The muscles principally in- volved are the peronei, and the extensor longus digitorum, the tendo Achillis only participat- ing when there is an equino- valgus. Pes Valgus Acquisitus (see Fig. 689.)-The acquired form, generally known as splay-foot, or flat-foot, occurs very fre- quently, and if all the cases were grouped under the com- mon title of Talipes Valgus, would undoubtedly constitute the most frequent form of club- foot. A reference to the sec- tion on the Etiology of Acquired Forms shows the dif- ferent causes of this deformity. The principal ones are paralysis, rachitis, ankle-joint disease, rheumatism, and it is common in growing boys and girls as well as in cer- tain occupations, requiring long standing in one position. It also occurs secondarily in knock-knee and trauma- tism. In talipes valgus pain is a very prominent symp- tom, and many cases have been justly described as "in- flammatory flat-foot." The general changes found in the acquired forms consist essentially of a flattening of the arch of the foot, the weight of the body falling mostly upon its inner side. This brings the scaphoid and internal cunei- form bones closer to the ground, and it is at these points that the patients com- plain greatly of pain. The astragalus may also be displaced in the same direction. In some cases there are muscular con- tractions, the con- traction taking place in the abductors, the adductors being in a condition of paresis. Where the cases oc- cur as a result of in- fantile paralysis, the tibialis anticus is usually affected, more rarely the tibi- alis posticus, and in these cases in which the paralysis is of long standing or extensive, the prognosis is unfavor- able. The cases are always tedious, necessitating a long time for their cure, but otherwise, as a class, Talipes Val- gus of the acquired form is usually relieved by treatment. Talipes Equinus (See Fig. 690).-Synonyms : Ger., Pfer- defuss, Spitzfuss ; Fr., Pied-bot equin. This may be a con- genital or acquired deformity, but congenitally it occurs very rarely, Little and Broadhurst stating that they had seen but two cases, and Tamplin, according to Adams, discredits it entirely as a congenital deformity. In a typical case the foot should be extended, the patient walking on the ball of the toes. The acquired form of Talipes equinus is, on the contrary, a very frequent deformity ; especially is this true of the paralytic form. The most fre- quent cause of the deformity is found in infantile spinal paralysis. Its influ- ence in the produc- tion of the different forms of Talipes, and the explana- tions * have been mentioned under the section on Etiol- ogy. Other causes are found in spas- tic paralysis, neu- ro - mimesis, post- hemiplegic c o n - tractions, wounds, cicatrices,and long- continued decubi- tus. In this form of Talipes the os cal- cis is raised, and may even be in direct contact with the tibia. The astragalus is displaced downward, showing as a prominence on the dorsum of the foot. Where the deformity has advanced there occurs a de- cided bend at the transverse tarsal articulation, and the scaphoid is brought in contact with the os calcis. In the severer forms there is also a marked contraction of the plantar arch, these cases constituting the Pes cavus of some authors. Where the patient has extended the toes in walking, the proximal phalanges form articulations with the superior surfaces of the me- tatarsal bones. In some old cases where the deformity was allowed to exist without inteference, the bones after death have been found very light and cancellous. The ligaments are contracted upon the plantar surface, and elongated upon the dorsum of the foot. Adams found the astragalo-scaphoid ligament much lengthened, as also the interos- seous and cal- caneo-astraga- loid ligaments. The muscles involved are the posterior ones, the gas- trocnemius, plantaris, and soleus acting through the tendo Ach- illis. Pancoast asserts that the soleus is chiefly at fault, and has oper- ated upon this muscle ; but extension and flex- ion at the knee-joint so affect this deformity, increasing or lessening it, as to show the marked influence of those muscles attached to the condyles of the femur. The prognosis in Talipes Equinus is very favorable, patients having been relieved of the deformity at all ages. The diagnosis is easily made, the only difficulty being at times the discovery of the cause. The history of the case will generally decide this. Its appearance is diag- Fig. 692. -Severe Talipes Equinus. Fig. 690.-Talipes Equinus. Fig. 691.-Severe Talipes Equinus. Fig. 693.-Talipes Calcaneus. 204 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Club-Foot. nostic, and by simply raising the leg with the patient in a sitting position, the knee being depressed, the amount and character of the deformity will be easily ascertained. Care should be taken not to allow flexion at the knee- joint, for if this be permitted, the posterior muscles will allow more flexion at the ankle-joint, so that if the deformity be slight it will disappear, thus showing that false conclusions as to the amount of the deformity have been reached. Talipes Calcaneus. - Synonyms : Ger., Ilackenfuss ; Fr., Pied-bot talus. As a primitive deformity it is the rarest of all varieties. In this condition we have the di- rect opposite of the equinus form. The foot is flexed upon the leg, its dorsum approaching the tibia ; while the heel is lowered, and the sole of the foot elevated (Fig. 693). Here the displacement occurs at the tibio-astraga- loid articulation, and, as in equinus, upon an antero-pos- terior plane. In the congenital form the bones are not much altered. The astragalus seems to be drawn backward, and its neck more in contact with the tibio-fibular surfaces, while the anterior part, superiorly, is posterior to the tibia. The os calcis follows the oblique direction of the astragalus, and becomes vertical in its position. The acquired form is also very rare, and is usually the result of infantile spinal paralysis, affecting the posterior calf muscles (Fig. 694). Other causes are injuries, too rapid stretching of the tendo Achillis after tenotomy, and disease in the neighborhood of the ankle-joint. In addition to the bony changes described under the congenital forms, there is an exaggeration of all the displacements there mentioned. The ligaments posterior to the ankle are lengthened, and contracted upon the front and upon the plantar surface, the plantar fascia being contracted. The muscles in- volved are the extensor proprius pol- ilcis and longus digitorum, as also the tibialis anticus. The peroneus tertius may also be involved. The deformity is easily diagnosticated, and the prognosis is favorable in congenital cases, and while this is not so true of the ac- quired variety, great relief may be obtained by suitable ortho- pajdic appliances. It will be unnecessary to give in this article elaborate accounts of pes cavus or pes planus. In the former, pes cavus, there is simply an increased concavity of the plantar arch, while the dorsal convexity is abnor- mally prominent. It may be a congenital or acquired variety, the latter being much more frequent. Pain is a very prominent symptom in this class of cases, and the pressure coming upon the heads of the metatarsal bones and the heel, callosities and corns form which are very painful. Walking in many cases is ac- complished with the greatest difficulty, owing to the pain, and the gait is characteristic. Pes planus is considered by many authors as simply a spurious valgus. Here the depression is localized on the inner side of the plantar arch, but without the eversion of the sole. It is very common in certain races, and the negro is peculiarly liable to this deformity. Infants, as a rule, have flat feet, but the arch is developed when they begin to walk. None of the anatomical changes noted in typical valgus occur in this condition, excepting, perhaps, those cases in which the deformity has existed for a long time, when a true valgus may ensue. The symptoms are very similar to those of valgus, and pain is in many cases present. In this condition we do not have the eversion of the sole, nor is there the abnormal condition of the astragalo- scaphoid articulation, such as we see in the true valgus. Compound Forms of Club-foot.-In these forms of club- foot we may have an association of all the primitive types of the deformity. When, therefore, we speak of a com- pound club-fodt, we refer to a deformity having the char- acteristic qualities of two or more of the primitive types. Thus most frequently we meet Talipes equino-tarus (Fig. 695), in which we find extension and adduction combined, the deform- ity taking place both on an antero- posterior and on a, lateral plane. As a congenital deformity this com- pound form is the most frequent of all the varieties of club-foot, and is met with in every degree of severity. Authors have attempted to divide these degrees, but, like the stages of morbus coxarius, they are more arbitrary than real, and have no practical importance. The morbid anatomy shows the os calcis drawn upward, from the horizontal to a more ver- tical position. It is also ro- tated on its vertical axis and its anterior extremity directed inward, its posterior extrem- ity pointing outward and to- ward the fibula. The cuboid maintaining its rela- tion to the os calcis, follows the inward direction of its ante- rior part. The astra- galus follows the os calcis forward, so that the posterior portion of its superior articular surface is in contact with the in- ferior articular surface of the tibia, the anterior part of its articular facet projecting at the dorsum of the foot. The shape of the astragalus may be so much altered by these changes that the anterior articular surface looks in- ward instead of forward. The scaphoid bone is drawn inward, upward, and backward, carrying with it the cu- neiform bones, the metatarsal bones retaining their rela- Fig. 695.-Paralytic Talipes Equino-varus. Fig. 694.-Paralytic Tali- pes Calcaneus. tion to the tarsi, being displaced inward. Many authors have written upon the deficiency of the inner malleolus, considering it as one of the causes of the deformity. Neither Little nor Adams has found this in his dissections. Fig. 696.-Double Congenital Equino-varus. 205 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The question of these changes being primary or secondary has already been discussed in speaking of the etiology. The ligaments at birth show very little alteration in structure, but in more advanced cases the plantar liga- ments are contracted, as also the internal lateral and pos- terior ligaments. These may offer great resistance to eversion of the foot, and Adams has shown that the an- terior portion of the internal lateral ligament, passing from the malleolus to the scaphoid bone, may render this particularly difficult. The muscles at birth show no particular changes, and although the limb on the affected side is generally smaller than its fellow, the muscles themselves are normal, but undeveloped. It is important to remember that in con- sequence of the altered relations of the bones, the tendons may be much displaced. Thus the tendo Achillis is more external, being nearer the fibula, the tibialis posticus more forward and inward, and further separated from the tendo Achillis. Little has given the position of the tibialis posticus as being "exactly midway between the anterior and poste- rior borders of the leg on its inner aspect. " The tendons running in front of the ankle-joint pass near to the inner side, that of the tibialis anticus passing over the inner malleolus. The vessels and nerves follow the deformity, but retain their relations to the tendons. In this class of cases the prognosis is generally favor- able, although the varus is much more amenable to treatment than the equinus. The acquired form of the com- pound deformity is also very fre- quent, being most commonly due to infantile spinal paralysis. Other causes may be found in those already given in the description of talipes equinus. The morbid changes fol- low closely the description given above of the congenital form. The prognosis, especi- ally when the cause is a cen- tral one, is much more unfavor- able, this being readily appreci- ated when we consider the de- struction of the cells in the cord. We have written of this compound deformity at some length, because it is undoubtedly the most frequent of all the forms of club-foot, and also is the most difficult of treatment. Equino-valgus simply consists of the combination of the two primitive forms equinus and valgus, and for the morbid changes the reader is referred to the description of these two varieties. Calcaneo-varus and valgus are such rare forms of talipes that little is necessary for their description. A study of the component simple forms entering into their formation is all that is necessary for their diagnosis, morbid changes, and treatment. Non-deforming Club-foot.-For a full description of the very interesting form of cases designated by Dr. Shaffer, of New York, as " Non-deforming Club-foot," the reader is referred to the New York Medical Record for May 23, 1885, where an account of their characteristics and path- ology, with some remarks on treatment is given. Dr. Shaffer has undoubtedly described a new class of cases, practically unknown or unrecognized by other observers (Fig. 698). Here we shall only allude to the condition briefly. Dr. Shaffer says, "In non-defonning club-foot all the conditions found in certain forms of talipes exist with the exception of the exaggerated deformity. That is, there is a loss of normal relation between the articulation at the ankle and the muscles which act upon it, involving also in many instances the tarsus, producing a condition which prevents normal flexion at the ankle-joint, and modified mobility, with slight deformity at the tarsal, metatarsal, and phalangeal articulations. With this state of affairs, we find, as a result, varying with the conditions present, actual disability, pain, sometimes very severe, in various parts of the foot, ankle, leg, and even reflected to the lumbar region, and tender and inflamed articular sur- faces, especially at the junction of the first metatarsal bone with its phalanx. If these effects be wanting, we have only an awkward or peculiar gait associated with painful callosities and corns at various points upon the foot." Furthermore, he says, " Non-deforming club-foot may occur at any age. I have seen it in infancy, when doubtless its etiology is the same as that of congenital club-foot. It occurs rarely as an acquired condition in children, though often the 'good result' of many sur- geons after tenotomy and treatment leaves behind it a condition like that I have attempted to describe. It is seen very frequently during the period of second growth -the adolescent period-in both sexes, when at that par- ticular age there are not apt to be many important seque- lae. It usually does not reach its full development until adult life and full growth is at- tained. It occurs more frequent- ly in the female sex, and when looked for, is found sometimes in rapidly growing girls, and especi- ally in those whose growth has been apparently arrested before the average height is reached. And what is very important, and to a certain extent remarkable is this : it is found very often associ- ated with true rotary lateral curva- ture of the spine. We may have a condition of non-deforming club- foot from five different causes: 1, Non-deforming club-foot seen after polio-myelitis anterior; 2, non-deforming club-foot which follows simple and uncomplicated malposition, habit, etc. ; 3, non- deforming club-foot produced by traumatism, sprains, etc.; 4, non- deforming club-foot found after the infectious diseases of child- hood, especially diphtheria and scarlet fever ; 5, the non-deform- ing club-foot due, as I believe, to some remote trophic distur- bance, and seen quite frequently co-existing with true lateral cur- vature." All the forms which have been described may be simulated by the so-called "neuromimetic" or hysteri- cal club-foot. Their diagnosis is always surrounded with difficulty, and the differentiation of the symptoms demands great caution. The treatment, once the diagnosis is clear, should be addressed mainly to the neural symptoms and the general "morale" of the patient. It may become necessary, all other means having failed, to divide con- tracted tendons, as instanced in a case in which we divided the tendo Achillis. This case is related by S. Weir Mitch- ell in his " Lectures on Diseases of the Nervous Sys- tem " (Philadelphia, 1885, p. 129). Treatment.-In beginning the treatment of a case of club-foot, the surgeon should have in view two principal objects ; first, the removal of the deformity ; second, the restoration of the functions of the foot. . To accomplish this, many and various devices have been resorted to, and a history of these would furnish an interesting chap- ter to the subject. It will be impossible in a limited space to describe all the methods which have been used by surgeons in the treatment of club-foot, and it will be necessary to discuss only such as are in common use at Fig. 697.-Severe Congenital Equino-varus. Fig. 698.-Non-deforming Club-foot. 206 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Clmb-Foot. Club-Foot. duces the probe-pointed tenotome flatwise, as close to the tendon as possible, and beneath jt, and, its cutting edge being then turned toward the tendon, a sawing motion is imparted to the tenotome, and the tendon carefully di- vided. An assistant should firmly tighten the tendon dur- ing the operation, and as the section approaches comple- tion relax his hold on the part gradually. As tendons differ very much in their resistance, this precaution is very necessary, as otherwise, if not observed, the teno- tome would be very likely to cut through the skin. After the division of the tendon the knife is with- drawn and slight pressure made over the wound. A pad of lint fixed with adhesive plaster is placed over it, and the foot and leg bandaged. The immediate care of the foot after tenotomy is a source of much difference of opinion. Many surgeons believe in the immediate res- toration of the foot to its normal position. Others ban- dage it to a splint in the deformed or slightly less de- formed position, and gradually restore the limb during the process of cicatrization. In our opinion the applica- tion of such apparatus as will give the surgeon complete control of the parts, and at the same time allow extension, according to the activity in the reparative process is most desirable. Several accidents may happen in the performance of tenotomy. Among these are, division of the skin, making an open wound ; wounding of the posterior tibial or inter- nal plantar artery ; false aneurism and inflammation in the sheath of the tendon, or imperfect union of the tendon. These are to be treated according to ordinary surgical principles. present, and embody the most scientific principles for the removal of the deformity. The remarks of Adams are here very appropriate. ' ' The scientific treatment of tali- pes varus, when severe, as of several other deformities of the limbs, can only be accomplished by a judicious com- bination of the operative, mechanical, and physiological means, while many of the failures still witnessed in the practice of those who have not devoted much attention to the subject, are due to the want of this combination of principles, too frequently considered as antagonistic to one another, but which modern science teaches us are only reliable, in so far as their mutual dependence is recog- nized and applied by the scientific insight of the surgeon." The general treatment of club-foot is best divided into : I. The Mechanical. II. The Operative. Under the head of mechanical means are included: 1. Manipulations ; their object being to stretch the foot to its normal position. These may consist of passive motions, shampooing, and the "kneading" of the part. The importance of the hand as an instrument for the cor- rection of the deformity cannot be too strongly insisted upon, and the best apparatus is that which closely fol- lows its action. " The hand," says Bouvier, "is the ideal of mechanical means for reducing the deformity." 2. Massage and electricity. These are, strictly speak- ing, physiological means, but as their application is mechanical, we have placed them under that heading. These agents, as applied especially to the paralytic forms, will be found referred to in another portion of this work (see article Infantile Paralysis). 3. Splints. The use of splints embod- ies the application of such mechanical principles as will serve to correct the dis- turbed form of the foot. They may be used as permanent unyielding dressings, i.e., plaster-of-Paris or silicate of soda; or they may utilize elastic force, as in the apparatus of Barwell and Sayre; or, finally, they may combine extension with fixation, as seen in the various modifica- tions and improvements on Scarpa's shoe. The operative treatment of club-foot consists of : 1. Tenotomy, or division of contracted tendons. The proper time for the per- formance of tenotomy has been the cause of much difference of opinion, some ad- vocating its immediate performance, and others deferring it until such time as the patient is able to walk. In the majority of cases the early operation, if the case be of such a na- ture as to preclude the possibility of cure by simple mechanical means, is to be preferred. Experience alone can give the best indications for the operation, the pres- ence of rigidity, reflex spasm (Sayre), or an excessive amount of deformity not being in themselves sufficient reasons. The patient application of mild means should always be attempted, before the performance of an op- eration, however slight it may seem to the surgeon. Modes of Operating.-Tendons and fasciae are most con- veniently divided from below toward the skin, but some surgeons prefer to insert the knife between the tendon and the skin and cut inward. The latter method, where the relation of the vessels and nerves is much disturbed, is attended with considerable danger. The form of teno- tome used is largely a matter of choice ; as a rule only two are necessary. The best tenotomes for ordinary use should be one with a straight blade and sharp point for making the skin puncture, and another with a probe- point for completing the section of the tendon. The handles should be round, flattened upon the surface cor- responding to the dorsum of the blade. The patient, having been anaesthetized, is placed upon the table in a convenient position, and in a good light, and one assist- ant grasping the part to be operated firmly, the other places the limb not to be operated upon out of the way (see Fig. 699). The preparatory puncture having been made with the sharp-pointed knife, the operator intro- Fig. 699.-Position for Performance of Tenotomy. (From Sayre.) Adams has given a resume of the different accounts of the reparative process in the tendons, such as were found by Hunter, Mayo, Von Ammon, Guerin, Pirogoff, Koerner, Paget, and others. These observations show that the space between the divided ends of the tendon soon becomes filled up by plastic matter and serum; that in this new matter blood-vessels multiply rapidly, the new tissue surrounding the divided ends as callus unites the ends of fractures. This becomes changed into copnective-tissue and firm, and combining with the inter- mediate substance contracts gradually, assuming as it does the character of new tendon. 2. Myotomy. Little need be said of this procedure. It is scarcely ever done. Professor Joseph Pancoast, of Philadelphia, believed in the sole action of the soleus muscle in the production of equinus, and divided the muscle for the relief of this deformity, but the operation has never come into general use. •3. Tarsotomy and Tarsectomy. The first mentioned procedure is the division of such bony structures as are involved in the deformity by means of the osteotome, the second consisting of the removal of a wedge-shaped piece of the bones. When we consider how seldom these op- erations seem to be necessary, it is somewhat surprising that, as was recently shown by Lorenz, fourteen opera- tions have been devised, exclusive of tenotomy, for the cor- rection of talipes. They are : 1, Linear osteotomy of the scaphoid practised on the plantar surface (Hahn); 2, 207 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. support may be obtained by the insertion of a tempered steel sole into the shoe, so moulded that its convexity has a direct bearing upon the weakened plantar arch (see Fig. 700). In this condition Drs. Barwell and Sayre ad- vocate the use of elastic bands, to supply the action of the weakened tibialis anticus mus- cle. In addition, where the means above referred to cannot be pro- cured, good results may be obtained by the use of plaster-of-Paris or sili- cate of soda splints, moulded to the foot in a position of varus and al- lowed to set, care being taken to re- move them from time to time, when the parts should be carefully in- spected, and the splint readjusted to the corrected deformity. In this connection, as the treatment for the two conditions is the same, talipes planus or spurious valgus may be considered. Here there being a sim- ple giving way of the arch, due to relaxation of the ligaments and plantar fascia, it is only necessary to supply this deficiency by a tem- pered steel sole inserted in the shoe. In more pronounced forms, ap- proaching in character true valgus, the same treatment as was advo- cated in speaking of talipes valgus will be necessary. Talipes Equinus.-This form of club-foot occurring so infrequently as a congenital deformity, it will not be necessary to describe any special treatment for its relief. We will, therefore, proceed at once to a consideration of the acquired form. The most frequent cause of acquired equinus being infan- tile spinal paralysis, we should endeavor to improve the condition of the affected muscles by electricity, massage, etc. The paralysis occurring in the flexor muscles, we must be prepared to counterbalance the antagonism of the extensor muscles by suitable apparatus. The best method of doing this is accomplished by those instruments which combine the principles of extension with fixation. Of these there are many, most of them being improvements on the original Scarpa's shoe, and we will revert to these more fully when de- scribing the treatment of talipes equino- varus. Talipes Calcaneus.-Here, as in most of the typical simple forms, little need be said of the congenital variety. When there are no contractions of the anterior tibial muscles, simple manipulation and passive motion will easily overcome the deformity. When the deformity is more severe, an ankle support, having a stop- joint, preventing motion of extreme flex- ion, may be used, or a similar support, to which an artificial posterior muscle is attached, similar in character to that shown in Fig. 701. In the large majority of instances the treatment just described will be all that is necessary ; but in some cases it is expedient, gt times, to resort to tenotomy of the tibialis anticus, exten- sor proprius pollicis, longus digitorum, together with the peroneus ter- tius. All of these tendons may be reached through a single puncture made in front of the ankle-joint, close to the inner border of the tendon of the ex- tensor longus digitorum, care being taken to avoid the ante- rior tibial artery. Mechanical support, such as has been already described, may be used after the operation. linear osteotomy of the tibia above the malleolus (Hahn); 3, enucleation of the cuboid (Solly); 4, enucleation of the astragalus alone (Lund, Maron); 5, the same with the re- section of the tip of the external malleolus (Maron, Reid) ; 6, excavation of the spongy portion of the astragalus, leaving the articular surfaces (Verebely) ; 7, enucleation of the astragalus, and excision of a wedge-shaped piece from the anterior portion of the os calcis (Hahn); 8 enu- cleation of the astragalus and cuboid (Albert and Hahn), or of the astragalus and scaphoid (West); 9, enucleation of the astragalus, cuboid, and scaphoid (West) ; 10, enucleation of the scaphoid and cuboid (Bernet); 11, resection of the head of the astragalus (Lucke, Albert); 12, excision of a wedge from the outer half of the neck of the astragalus (Hueter); 13, excision of two wedges, perpendicular to each other, with bases at Chopart's artic- ulation, and the astragalo-calcanean joint (Rydygier); 14, excision of a wedge without regard to any individual bones (O. Weber, Davies-Colley, R. Davy). In the ex- perience of the authors these operations are rarely neces- sary, and, perhaps, only applicable in adult cases which have resisted all other forms of treatment, or in relapsed cases in which the inflammatory products have so aggluti- nated the different structures as to render other measures impossible. For a full description of these different surgical procedures, the reader can consult the special treatises, and also the article of Davies-Colley (Trans. Medico-Chirurg. Society, vol. lx., p. 11). 4. Brisement force. Under this procedure are classed all operations which have for their object the immediate restoration of the form of the foot, either by the hand or by powerful instruments. 5. Multiple tenotomy and open incision. The division of all the contracted tendons at one sitting has been per- formed, but has not met with general approbation, owing to the fact that no appropriate point of resistance is left afterward that can be utilized for mechanical treatment. Indeed, although it is the practice of English surgeons to divide many tendons, the tenotomy in this country is usu- ally limited to the tendo-Achillis, plantar fascia, and tibi- alis anticus and posticus. Open incision has recently been commended by Drs. Phelps and Hingston. A more extensive experience in this procedure, will best decide its relative merits. 6. Amputation. As a " dernier ressort" in severe para- lytic cases, in which the patient prefers an artificial foot, and where all ordinary means have been exhausted, am- putation has occasionally been performed. Treatment of Special Varieties.-Having finished the general remarks on the treatment of club-foot, we will now proceed to give an account of the special varieties. Talipes Varus.-Pure varus, either as a congenital or acquired deformity, occurs so infrequently that a consid- eration of the principles involved in its treatment, and the means employed, had best be deferred until we arrive at the treatment of talipes equino-varus. Talipes Valgus.-Congenital cases, treated soon after birth, may be cured by manipulations alone, these hav- ing for their object the carrying of the foot to a more in- verted position. To retain the foot in a good position after these movements, adhesive plaster (Maw's) with a roller bandage may be employed. Where the deformity is rather more severe, external splints of a simple character, composed of tin, gutta-percha, or hatter's felt may be used. These are moulded to the part, and a gradual in- version of the foot accomplished. The application of massage and electricity to the weakened anterior tibial muscle may be resorted to with advantage, and rest should also be enjoined. In the more severe forms of congenital valgus tenotomy of the peronei and extensor longus digitorum occasionally becomes necessary. In acquired valgus the treatment also varies with the amount of the deformity and cause. In mild forms un- attended by contraction of tendons, the application of a simple ankle support, composed of two lateral uprights connected with a band to encircle the calf, and with an inner pad corresponding to the axis of the astragalo- scaphoid articulation, and attached to the bottom of a shoe may be used. In the majority of cases additional Fig. 700.-Ankle Support for Valgus. Fig. 701.-Apparatus for Tali- pes Calcaneus, with Arti- ficial Posterior Muscle. 208 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Club-Foot. In those cases which are due to infantile spinal paraly- sis, and in which a marked contraction of the plantar fascia produces a " cavus," it may be necessary to divide the contracted fascia, but this must be carefully consid- ered, as many cases obtain a certain amount of support from this very contraction. Where the deformity arises from excessive length of the tendo-Achillis, the muscles themselves being unimpaired, a radical procedure consists in excision of the elongated tendon and suture of the di- vided ends. The operation is performed as follows : An incision being made down to the tendon, the sheath is opened and raised by a blunt hook or spatula, and folded or pinched between the lingers, so that the amount neces- sary for excision may be accurately ascertained. A sil- ver-wire, silk, or gut suture is then passed through the tendon, about a fourth of an inch above and below the place of incision of the tendon. This will prevent the slipping of the ends into the sheath. The ends are then approximated, the sutures twisted and buried into the tendon. In the opinion of the authors this will seldom be found necessary, although several successful instances are upon record. Treatment of the Compound Forms.-In the treat- ment of the compound forms of the deformity, the va- rious elements entering into their formation will have to be dealt with. Thus, taking for example equino-varus, we have to deal with a deformity taking place on two distinct planes, the equinus being on an antero-posterior one, and corresponding only with the tibio-astragaloid ar- ticulation, and the varus on a transverse plane, corre- sponding to the transverse tarsal joint. It is plain, there- fore, that all appliances intended for the relief of the compound forms of club-foot, and which have for their object the rectification of both elements simultaneously, are essentially false. That the elements entering into the formation of the compound forms should receive sepa- rate treatment has been especially emphasized by Dr. Little and Mr. Adams, of London. Little has stated that the varus or valgus should be thoroughly corrected before entering upon the treatment of the antero-posterior de- formity, and Adams has pointed out the advantage and advisability of using the os calcis and contracted tendo- Achillis as a fixed point upon which the tarsus may be extended, thus obtaining by these means a gradual un- folding of the deformed foot. Talipes Equino-varus.-By far the largest number of cases, both congenital and acquired, coming under the care of the orthopaedic surgeon, are cases of talipes equino- varus, and we shall endeavor to give somewhat in detail the various methods in use for the treatment of this de- formity. We have already pointed out the advisability of dividing the treatment of compound forms into two distinct periods. Thus in equino-varus our attention will be first directed to the inversion, or to the deformity oc- curring on a lateral plane. Of the various methods in vogue, the following will be considered : 1. Manipulation, massage, and electricity. 2. Retentive dressings. 3. Extension and fixation. 4. Elastic extension. 5. Tenotomy, combined with extension and fixation. 6. Brisement force. 7. Tarsotomy or tarsectomy. Manipulations and massage may with advantage be used in the slighter cases of varus, but these agents are useful in all cases of whatever severity, and the nurse is to be especially informed of the value of these agents. It is undoubtedly a fact that much can be done with the hand alone, and many cases of varus have been cured by these simple processes. The attendant should be in- structed as follows : The foot being firmly grasped, and the os calcis being fixed, the anterior part of the foot is to be gradually brought into a valgoid position. This motion should be repeated several times at short intervals ; the foot is then shampooed and may be placed in a light retention dressing. The manipulations should be used morning and night, and the splint modified as the amount of varus is corrected. It may be well in this connection to say a few words concerning massage. This is not, as is popularly supposed, a simple rubbing of the parts, but consists in a systematic "kneading" of the skin and deeper structures. These movements should consist of alternate friction and manipulation, the circulation of the skin being increased by pinching, while the subcutane- ous cellular tissue and muscles may be more deeply grasped. Light percussion of the parts will also be bene- ficial. (For further reference see article "Massage.") The use of electricity in the weakened condition of the muscles, but more especially in the paralytic forms of club-foot, is a most important adjuvant to the treatment. It will be impossible to do more than call the attention of the reader to its importance as a means of treatment, and for its technical application the reader is referred to the article upon Electricity. Retentive dressings may consist of simple adhesive plas- ter attached around the foot and secured on the external aspect of the leg ; it should be gradually tightened as the foot is everted, the dressing being kept in place by a roller bandage. This is the simplest form of retentive dressing. Moulded splints of gutta-percha, hatter's felt, sole-leather, or raw hide may also be used in simple cases of varus. These articles being cut to fit the parts, are Fig. 702.-Varua Brace Applied; A, before, B, after the deformity has been corrected. placed in hot water and softened, the foot being held in the position the operator wishes to secure. The sub- stance used is then moulded to the parts, and secured by a roller bandage. The dressings may be changed from time to time, according to the improved position. Splints of plaster-of-Paris or silicate of soda may be applied in the same manner. As dressings they have the disadvantage, when applied as fixed splints, of not allowing a careful daily inspection of the parts, ex- coriations and sloughs being especially liable to ensue. When they are employed it would seem advantageous to cut them, as they would then still retain their retentive properties, and allow manipulation, massage, etc. Extension and fixation may be most effectually used in overcoming the lateral deviation by the use of Shaffer's modification of Taylor's ankle support (see Fig. 702, A and B ; Figs. 703 and 704). This consists of a steel trough fitted to the internal aspect of the leg, extending from the internal malleolus to the upper third of the tibia. Hinged to this is the continuation of the trough, terminating in a joint which articulates with the foot- 209 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plate, allowing antero-posterior motion at this point. This joint has been added to Shaffer's original " lateral shoe," and by it we can adjust it to a co-existing equinus. A worm or endless screw operated by a key, and seen at A, Fig. 702, acting upon the sole-plate at right angles to the direction of the hinge, enables the surgeon to apply the apparatus accurately to the extremes of varus (or valgus), and by means of a key to bring the foot in the desired position. The splint should always be applied to the foot in its deformed po- sition, and maintained there by a roller band- age, as seen in Fig. 702, A. Then by the use of the endless screw ope- rated by the key, the foot can be brought into the corrected position as seen in Figs. 702, B, and 704. This simple appa- ratus, ■which, with a little instruction, can easily be applied and adjusted by the nurse or parent, al- lows of daily inspection, manipulation, and mas- sage. In the severer forms of equino-varus, in which the lateral element is in excess owing to the marked tarsal deviation and plantar contraction, the simple lateral brace above described has been found insufficient, and Shaffer has for these cases devised a more powerful apparatus, which can best be described in the following personal communication : " The success which has attended the use of the exten- sion or traction shoe * in the treatment of the antero- posterior deformities of club-foot, led me to seek some method by which traction could be applied to the lateral deformities of the tarsus-and especially those found in confirmed cases of equino-varus. The conventional club- foot shoe with the ball or socket, or hinged joint in the foot-plate, at a point corresponding with the medio-tarsal joint, had proved very unsatisfactory, especially in cases where there was much tarsal deformity or any consid- erable plantar contraction. The lim- ited success attending the use of the lateral shoe f led me to use this splint as a starting-point for further experi- ment. After various efforts I have perfected an apparatus which may be described as follows: To this simple lateral shoe, with its hinged lever and screw which imparted a lateral force principally to the os calcis, I added the antero-posterior worm and screw of the extension shoe, which latter gave an antero-posterioi pressure. I then dividec the foot-plate (with its retaining side curve) at a point opposite the me- dio-tarsal joint, and instead of the ball and socket, or hinge, I added an extension or traction bar to the concave or (in varus) the inner side of the tarsal deformity, with the centre of motion at the convex or (in varus) the outer side of the foot. The apparatus is placed upon the inner side of the foot (in varus), and the heel being re- tained in the heel-cup by the conventional strap or pad, the hinged bar and screw are first used to make pressure laterally against the os calcis. The key controlling the worm and screw is then used to flex the foot sufficiently to ex- ert a slight degree of force upon the gastrocnemius muscle, and when this position is gained the tar- sal traction is applied by using the extension or traction rod, which, acting upon the hinged centre of motion at the outer bor- der of the foot, carries the ante- rior part of the foot forward, and direct traction is exerted upon the resisting tarsal tissue. In many severe cases of talipes equino-varus, the tarsal traction shoe has overcome the deformity without the aid of tenot- omy." Elastic Exten- sion. - To Mr. Richard Barwell, of Lon- don, is due the credit of first employing elastic trac- tion in the treatment of club-foot, and Dr. Sayre has popularized it in this country. For the princi- ples embodied in Barwell's method the reader is re- ferred to the section on History and Literature. The application of Bar- well's dressing has been so lucidly explained by Professor Sayre that we quote his remarks in full: " This consists in cutting from stout ad- hesive plaster, spread on canton flannel, or the * mole-skin plaster,' a fan-shaped piece. In this are cut several slips converg- ingtowardthe apex of the piece, for its better adaptation to the part (see Fig. 705). The apex of the triangle is passed through a wire loop with a ring in the top (Fig. 705), brought back upon itself, and secured by sew- ing. The plaster is firmly se- cured to the foot in such a man- ner that the wire eye shall be at a point where we wish to imitate the insertion of the muscle, and that it shall draw evenly on all parts of the foot when the trac- tion is applied. Secure this by other adhesive straps and a smoothly adjusted roller. " The artificial origin of the muscle is made as follows : Cut a strip of tin or zinc plate, in length about two- thirds that of the tibia, and in width one-fourth the cir- cumference of the limb (see Fig. 707). This is shaped to fit the limb as well as can be done conveniently. About an inch from the upper end fasten an eye of wire. Care should be taken Fig. 705. Fig. 706. Fig. 703.-Lateral View of Varus Brace, applied to Deformity. Fig. 707. Fig. 704.-Lateral View of Varus Brace, showing deformity corrected. Fig. 708. * Vide New York Medical Record, November 23, 1878. t Op. cit. 210 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Club-Foot. not to have this too large, as it would not confine the rubber to a fixed point. The tin is secured upon the limb in the following manner: From the stout plaster above mentioned cut two strips long enough to encircle the limb, and in the middle of each make two slits just large enough to admit the tin, which will prevent any lateral motion ; then cut a strip of plaster, rather more than twice as long as the tin, and a little wider; apply this smoothly to the side of the leg on which traction is to be made, beginning as high up as the tuberosity of the tibia. Lay upon it the tin, placing the upper end level with that of the plaster (see Fig. 708). Secure this by passing the two strips above mentioned around the limb (Fig. 709), then turn the vertical strip of plaster upward upon the tin. A slit should be made in the plaster where it passes over the eye, in order that the latter may pro- trude. The roller should then be con- tinued smoothly up the limb to the top of the tin. The plas- ter is again reversed, and brought down over the bandage, another slit being made for the eye, and the whole secured by a few turns of the roller. A small chain, a few inches in length, containing a dozen or twenty links for graduat- ing the adjustment, is then secured to the eye in the tin. " Into either end of a piece of ordinary india-rubber tubing, about one-fourth of an inch in diameter, and two to six inches in length, hooks of the pattern here ex- hibited (see Fig. 706) are fastened by a wire or other strong ligature. One hook is fastened to the wire loop on the plaster on the foot, and the other to the chain above mentioned, the vari- ous links making the necessary changes in the adjustment." The dressing when complete is shown in Figs. 708 and 709. The arrangement of Barwell's dress- ing may be changed to suit the special deformity which it is de- signed to treat. Sayre states that the only objection which may be urged against this plan of treatment is that the adhesive plaster some- times slides and changes its position, soon becomes worn out, and requires frequent readjustment, and will often excoriate. To overcome this defect he has devised a club-foot shoe, upon the general plan of Scarpa's shoe, in which the mo- tive power consists of elastic bands, and which can be re- sorted to when the child is old enough to walk. It is ap- plicable to varus and valgus, and is thus described: In the sole, opposite the medio-tarsal articulation, is placed a ball and socket, or universal joint. "This sole and part embracing the heel consists of strong sheet-steel, covered with leather on both sides. Two lateral upright bars, B (Fig. 710), jointed at the ankle, are fastened near the heel and to the collar-band ; G, H, and J are points for the attachments of artificial muscles made of rubber tubing, with hooks and chains at their ends. To the in- side walls of the shoe, near A, two flaps of chamois leather are attached to lace together, which, passing over the front of the ankle-joint, keep the heel firmly in the back part of the shoe " (Sayre). Tenotomy Combined with Extension and Fixation.-In some cases it may be necessary, where they have resisted the means described above, to resort to tenotomy. This is best divided into two distinct stages, as follows : 1. Tenotomy of the tendon of the anterior tibial muscle, and the anterior portion of the internal lateral ligament (Adams), combined with the application of a lateral varus splint. 2. Division of the plantar fascia, and subsequent me- chanical extension of the deep plantar ligaments (Noble Smith), the extension being well accomplished by the above-described modification of Shaffer's varus splint. Here it may be urged, it is of the utmost importance that the strictest care be exercised after the performance of tenotomy. It is to the want of careful after-treatment that the majority of the bad results and relapses may be traced, and tenotomy should never be performed where this necessary after-care cannot be given. Brisement force, a procedure which has been attended with considerable success, and where the time at the dis- posal of the surgeon has been limited, has been performed in several ways. Of these the two most frequent are that in which manual force is employed, the patient being Fig. 709. Fig. 711. under an anaesthetic, and that in which the force is ap- plied by means of a powerful instrument. Bradford, of Boston, has devised such an instrument, which is de- scribed in the Boston Med. and Surg. Journal for March 20, 1884, and is shown in Fig. 711. Tarsotomy and tarsectomy, and their application, have already been alluded to in the remarks on the general treatment of club-foot. Having considered in detail the various methods for overcoming the varus element in talipes equino-varus, and before proceeding to a discussion of the means em- ployed in the correction of antero-posterior deformities, we may very properly give some consideration to the nor- mal amount of flexion and extension at the ankle-joint. This has been summarized by Shaffer as follows: "Its function, except in extreme extension, is that of a plain hinge-joint. In the conditions we have to deal with, flexion and extension are the only movements to be con- sidered. Extension of the foot, in the adult, is limited at about 135°, or 45° more than a right angle, using the long axis of the tibia as the plane of measurement. Flex- ion stops at about 70°, or 20° less than a right angle (see Fig. 712). The position of the foot in standing upon an Fig. 710. 211 Club-Foot. Club-Foot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. even surface, with the knee in full extension, is about 90°. The amount of liexion and extension varies in dif- ferent individuals, but these figures, based upon actual experiment and measurement, represent, I think, the average of normal movement in the living adult sub- ject." Upon this must be based our efforts in the reduction of these deformities, and we should endeavor to obtain a resultant position of the foot as near normal as possible : thus, in talipes equinus, the aim should be to make it possible for the foot to describe an arc, which will end in the position shown in the figure as 70°, and in calcaneus extension should be possible until the normal position marked 135° is attained. The means at our disposal for the accomplishment of this, are : 1. Manipulation, Massage, and Electricity. These have the same function in the antero-posterior deformity as was described in speaking of the varus element. It is only in the application of these forces that the difference exists. Here manipulations, etc., should be directed to those muscles and tendons producing the equinus, the ap- plication of the forces mentioned having for their object the conversion of the equinus into a calcaneus position. 2. Retentive dressings have been so thoroughly described when speaking of varus, that it is not necessary to repeat the description here. All the articles there men- tioned for the construction of sim- ple splint may be used with ad- vantage in equinus, both before and after tenotomy. 3. Extension and Fixation. The ordinary forms of apparatus used to accomplish extension and fix- ation consist essentially of two into the heel-cup, and attempt to flex the foot in very much the same manner we would shut the half-opened blade of a knife-the heel, unless restrained, slips for- ward. The attempt is made to control this movement by tying the heel down to the foot-plate and in the heel-cup, with the heel-strap. If, after this heel-strap (the ana- logue of the anterior annular ligament) is tied, a consid- erable pressure be applied in the direction of flexion (even in many cases after tenotomy), the further tendency of the heel (being restrained in front by the heel-strap) is to slip upward and backward away from this artificial an- nular ligament, ultimately, in many cases, resting on the top of the heel-plate, which forms the cup. When this occurs, all control over the foot is lost, as it turns toward that side upon which the contractions exist. One of the direct effects of mechanical flexion, as applied in the cus- tomary forms of apparatus, to overcome either a post- tibial or a plantar contraction, is to crowd the tarsal bones together. " " The foot plate rotates around an axis, the centre of which is the ' ankle-joint ' of the apparatus. The point at which the retaining force and counter-pressure (under the heel-strap), which holds the foot in the apparatus, is made, must also rotate around the pivotal point. Upon this heel-strap we must rely principally for the means of retaining the foot in the apparatus, and it supplies the only im- portant means for regu- lating the relation of the anatomical to the arti- ficial centre. If the foot, as a whole, could be se- cured perfectly in the ap- paratus, and be made, as we apply a gradually in- creasing force, to me- chanically follow the di- rection imparted to it by the artificial mechanism, the trouble would be re- duced to the minimum. Our artificial would then correspond to the human mechanism. But, princi- pally through the causes referred to, the centre of rotation in the foot and in the apparatus become changed in their relations to each other, and all the pressure ex- erted under these circumstances i s productive of in- jury. As pointed out, the tarsal bones become crowded together, the heel slips beyond the control of the apparatus, exposed points are apt to become excoriated, and the result, while sufficient force has been employed, though misapplied, is very discouraging in very many instances." In view of the justice of these criticisms, and to over- come these faults, Shaffer has devised an improved ex- tension club-foot shoe, a modification of Scarpa's shoe, which presents nothing novel with the exception of an extension-bar acting upon the sole of the brace. The club-foot extension apparatus (Fig. 713) consists of the ordinary uprights fastened to the heel-piece by a plain joint on one side, and an endless screw', A, on the other. This screw allows us, by using a key, to place the foot-piece of the apparatus, as a whole, in any antero- posterior position wre choose, and to alter it at will, cither before or after application to the foot. That part of the foot-piece which corresponds with the tarsus and meta- tarsus is joined by a common extension-rod, C, to the por- tion w hich lies under the os calcis. With a key we are uprights running parallel, and placed on either side of the leg, connected by a band to surround the calf ; a joint corresponding to the ankle ; a heel-cup with a strap and pad to secure the os calcis ; and a sole-plate, with or without a hinge, to corre- spond with the medio-tarsal joint. This, which is the usual modification of Scar- pa's shoe, is made the means for the application of force, intended to act in place of the anterior and lateral muscles. The objections to the ordinary forms of ap- paratus used for the correction of antero-posterior de- formities has led Newton M. Shaffer, of New York, to criticise them as follows: "It seems very easy to con- struct an apparatus with a joint to correspond with the tibio-astragaloid articulation, and to make this joint the centre of an artificial movement imparted to the anterior part of the foot through the medium of the foot-plate. But let us see what happens when we attempt to do this with the ordinary forms of apparatus. The centre of motion, so far as the equinus position is concerned, is at the tibio-astragaloid articulation. The resistance lies in the post-tibial muscles, and the power is applied in front to the tarsus and metatarsus-the object being simply to ilex the foot and bring down the heel. As the anterior part of the foot rotates upon its artificial ankle-joint cen- tre, or, to put it in other words, as we crowd the os calcis Fig. 712.-Various Degrees of Nor- mal Flexion and Extension at the Ankle-joint. (Shaffer's modi- fication of Noble Smith's scheme.) Fig. 713.-Extension Equinus Brace, adjusted to Deformity. 212 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fqub-Foot. Citi b-Foot. enabled to extend the anterior part of the foot-piece at pleasure. To apply this instrument, we first, by means of the key, place the foot-piece in a position that will exactly correspond with the antero-posterior position of the foot (whether tenotomy has been performed or not). We then secure the heel by tying the heel-strap, D, and by means of another webbing-strap, E, pass- ing over the tendo- Achillis, immediately above its insertion into the os calcis, secure it to the anterior or exten- sion portion of the foot- piece by buckles on either side, as shown in the figure. The key, at B, is now used to flex the foot, in over- coming to the desired extent the tendo-Achil- lis resistance. ' ' When this shall have been ac- complished it will be found, as in all similar apparatus where the artificial flexion alone is depended on to over- come the post-tibial re- sistance, that the poste- rior aspect of the heel is pressing against the heel-plate " (see Fig. 714). In varus the cu- boid, in valgus the sca- phoid bone, becomes uselessly crowded, and in a direction which does little or no good. All the tarsal bones are also crowded together by the force which is act- ing in the arc of a circle, the centre of which is the ankle- joint. But now, a turn or two of the key, at C, brings the foot under control, and the centre of motion being thus transferred, the heel must ne- cessarily describe an arc, w'hose cen- tre is at the point of resistance, D, and is thus brought firmly into the heel-cup, and, if the extension force be further applied, will rest squarely upon the extension-bar, thereby se- curing flexion at the ankle corre- sponding to the degree of flexion of the foot-piece of the brace, as shown in Fig. 715. If the tarsal deformity be only slight, the pressure at the cuboid or scaphoid is modified ; the compression of the tarsus is relieved ; the plantar fascia, the plantar mus- cles, and the tarsal ligaments are ac- tually stretched; besides which, the os calcis is placed under restraint; in this way the trac- tion force pass- es through the tar- sus directly to the t e n d o - Achillis. The mechani- cal counter-ex- tension, of course, is at the heel- strap, D. It sim- ply retains the foot in a position that allows a cer- tain amount of force to be expended on the contracted tissues. The greater pressure under the heel-strap, however, is exerted by flexing the foot with key B, rather than by using the extension at C. Particular pains, however, should be taken not to make these combined forces too great. " As a matter of precaution I always place several thicknesses of sheet-lint, or a thick layer of absorbent cotton (this latter makes an excellent elastic pad) under the heel-strap and at the sides of the heel-cup. If a very considerable ex- tension is necessary, I pass an additional padded strap over the lower end of the tibia, passing the tapes at- tached back of the two uprights, securing them in front over the pad. It is a matter of surprise to me how well, with a little care, pressure is tolerated at this exposed point under the heel-strap, and, also, how little traction, applied in the manner indicated, through the tarsus, is necessary to accomplish the object." In order to inspect the part exposed to pressure without removing the ap- paratus, it is only necessary to loosen the heel-strap and turn key C until the extension-rod drops from the cylin- der, when the entire posterior part of the apparatus may be easily removed. " The part under the heel-pad should be inspected once a day. An important point may be mentioned here : it is always well to overcome almost wholly the lateral malposition of the tarsus before apply- ing direct traction. Time will be saved, and some annoyance also, if this rule be uniformly followed." The force which may be exerted by the above apparatus should not be applied continuously, as is popularly supposed. On the con- trary, it should be used as an in- termittent force, and at stated in- tervals. In order to maintain the position gained by the extension as used above, it is well to place the foot in a re- tention shoe, whilst the patient sleeps. The same apparatus may be used when the foot has been brought to a right angle, where it can be secured by means of a stop-joint (see Fig. 716). Should the above extension and fixation apparatus be unobtainable, good results are often secured by the use of the means described un- der the head of Retentive Dress- ings. 4. Elastic exten- sion has already been spoken of in detail when dis- cussing the treatment of the lateral deformity. The meth- ods of Barwell and Sayre, so adapted as to meet the an- tero-posterior deformity, as shown in Figs. 708, 709 and 710, describe the apparatus used by them. 5. Tenotomy, combined with extension and fixation, will comprise the division of the tendo-Achillis with the nec- essary after-treatment, this completing the third stage in the treatment of the compound form, talipes equino-varus. No especial description is required for the division of the tendo-Achillis, and the after-treatment has been discussed under the general consideration of tenotomy. Two conditions may be alluded to before closing this section. First; Symptomatic or compensatory equinus, a con- dition found after shortening of the leg from whatever cause, the patient attempting to equalize the length of the extremity affected by standing upon the ball of the foot. This is easily corrected by the addition of a high sole or patten. Second; A condition of "residual" varus. Often, even after the foot has been brought into excellent posi- tion, a slight inversion of the anterior part of the foot remains. This is often due to a relaxed condition of the Fig. 714.-Extension Equinus Brace; first stage of correction. Fig. 716.-Retention Equinus Shoe. Fig. 715.-Extension Equinus Brace; complete correction. 213 Club-Foot. Coal Cras. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hip- and knee-joints, allowing of abnormal inward rota- tion of the foot. To correct this, many forms of appara- tus have been devised. Those of Gregory Doyle, or Stillman's modification (see Fig. 717), as also those of Dr. Sayre and Dr. Sted- man, afford the best means at our disposal for overcoming this condition. Talipes Equino-val- gus.-The principles of the treatment of club-foot having been fully discussed under the caption Talipes Equino-varus, it is only necessary here to speak of the modi- fication of methods caused by the difference in the direction of the de- formity, and the tissues involved. Owing to its extreme rarity the sur- geon is seldom called upon to treat cases of this kind ; but here, as in talipes equino-varus, it is necessary to overcome the element of valgus first, which may be accomplished by means similar to those mentioned when speaking of equino-varus, the extension force, however, being ap- plied to the contracted peronei group ; after the reduction of the lateral de- formity, the equinus is overcome by the same means as serve to correct the same deformity co-existing with varus. Massage, electricity, and the other adjuvants heretofore mentioned should all be used in the manner al- ready described. Similar methods will apply to Tali- pes Calcaneo-varus and Valgus. When speaking of Talipes Calcaneus, the means for the correction of the deformity were fully dis- cussed, and attention was called to the application of rubber muscles posteriorly, and to excision and suture of a portion of the tendo-Achillis ; reference to this portion of the article will furnish details of these methods ; the lateral deformity, will of course, require the same meth- ods of treatment as are called for by similar lateral deviations occurring in the compound forms already de- scribed. For the works which have been consulted in the prep- aration of this article the reader is referred to the section on History and Literature. A. Sydney Roberts and Samuel Ketch. COAL GAS {Illuminating Gas, House Gas). These names are applied to a rather complex mixture of several gases, made by the destructive distillation of bituminous coal, wood, oils, resin, petroleum, etc. The complete apparatus for its preparation consists of: 1. A set of semi- cylindrical iron or clay retorts, set horizontally in a fur- nace. 2. A series of horizontal and upright iron pipes act- ing as condensers, in which the liquid products of the distillation are condensed and separated from each other, and from the gases. 3. One or more purifiers, which consist of uprightstacks, containing moistened coke, freshlyslaked lime, ferric hydrate, or mixtures of these with sawdust. The object of these purifiers is to absorb the most of the carbon dioxide, sulphuretted hydrogen, etc., before the gas is stored for use. 4. A gasometer or gas-holder, which consists of an inverted iron tub of large size, floated in a well of water. The gas is conducted into this gas- ometer by a pipe leading from below and terminating above the water, where it is stored ready for use. The coal is heated in the retorts to a cherry-red heat, or about 1,500° F. This temperature breaks it up into coke (which remains in the retort), liquid and volatile pro- ducts, and gases. Ordinary bituminous coals yield about ten thousand cubic feet of rather poor gas per ton. It is a common practice to mix with these coals about five to ten per cent, of a rich boghead or cannel coal, to improve the illuminating power of the gas produced. Composition.-The gas ordinarily used is a mechani- cal mixture of various gases, some of which are illumin- ating agents, while others have no value in this respect, but are combustibles furnishing considerable heat, while there are usually some present which are inert either as combustibles or illuminants. Besides the true gases, there are present vapors of certain liquids, which are of value as illuminating agents. The chemical composition of the gas varies with the coal used, and the temperature to which it is subjected. The chief constituents of coal gas, with the quantities of each, are given in the following table from Letheby: Fig. 717. - Stillman's modification of Greg- ory Doyle's Spiral Spring Apparatus for residual varus. Volume per cent. 1. Hydrogen 25 to 50 2. Marsh gas 35 to 52 3. Condensible hydrocarbons: Olefiant gas (C2H4), Propy- lene (C3H6), Butylene (C4H8) 3. to 20. 4. Benzol and its series ? 5. Acytelene (C2H2) ? 6. Naphthalene (CI0H8) ? 7. Carbon dioxide (CO2) 0. to 2. 8. Carbon monoxide (CO) 5. to 9. 9. Cyanogen (CNCN) traces 10. Ammonia (NH3) 0. to 0.06 11. Bisulphide of carbon (CS2) 0.004 to 0.04 12. Aqueous vapor (H2O) 0.6 to 2.5 13. Oxygen 0. to .10 14. Nitrogen 0. to 8. 15. Sulphocyanogen traces It will be seen that this table presents wide variations as to the percentage of the various gases. The illumi- nating power of the gas varies with the proportion of the heavier hydrocarbons, and the heating value with the hydrogen, marsh gas, and carbon monoxide present. The specific gravity of coal gas is about from 0.400 to 0.650, air being taken as 1.000. The illuminating power of gas is measured by compari- son with a standard spermaceti candle of six to the pound, and consuming, as near as may be, one hundred and twenty grains of spermaceti per hour. It is assumed that the light given off is in direct proportion to the sperm consumed. The gas to be tested is to be burned at the r;Ue of five feet per hour. Such a burner should give as much light as sixteen or eighteen standard candles. It may reach as high as twenty five or thirty candle-power. Water gas may be referred to here, as a gas manufac- tured and sold for the same purposes as coal gas. Its manufacture is conducted on a large scale in most cit- ies, and to a large extent it has taken the place of coal gas. This gas is manufactured as follows : Steam from a boiler is forced through a bed of glowing anthracite coals, previously heated to a very high temperature. The steam from the boiler is passed through pipes or flues over the fire-box, so as to superheat it to a temperature of 800 to CLYSMIC SPRINGS. Location and Post-Office, Wau- kesha, Waukesha County, Wis. Access.-See Bethesda. Analysis (R. Ogden Doremus, M.D., LL.D.) Grains. Chloride of sodium 0.548 Sulphate of potassa 0.205 Sulphate of Soda 1.076 Bicarbonate of lime 15.896 Bicarbonate of magnesia 8.540 Bicarbonate of soda 0.803 Bicarbonate of iron 0.685 Phosphate of soda 0.453 Silica 0.810 Alumina a trace Organic matter a trace 29.016 Therapeutic Properties.-This water, like the " Bethes- da," its neighbor, is remarkable for its purity and spar- kling appearance. It belongs to the alkaline-calcic class, and is diuretic. It has become popular as a table water, pure, or as a diluent for wines. There are two springs in this group, yielding about forty thousand gallons per day. G. B. F. 214 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Club-Foot. Coal Gas. In the first condition the person rapidly becomes uncon- scious, and recovers rapidly when removed into fresh air. When the gas is admitted to the air of a room slowly, the headache, dizziness, nausea, and muscular weakness are the prominent symptoms, and they are re- markably persistent. The condition of the patient often seems to remain constant for days after the accident; and when entire unconsciousness has occurred, recovery is very unusual. In truth, while the one is a suffocation by coal gas, the other is a true poisoning or toxaemia. The first is produced by a rapid displacement of the air of the room with the gas, while the other is a slower and very gradual admixture of gas with the air. Fresh air and stimulation will usually suffice to restore the patient in the first case, but in the second, while these measures should not be neglected, they are much less use- ful, and where the time of exposure has been consider- able, of slight benefit. It may be well to name here some of the sources of coal-gas poisoning, other than leakages directly from fixtures in the room. The odor of the gas is so characteristic that this will in most cases give its warning. Repeated instances, however, prove that people may be killed by this gas without detecting the odor. Cases of poisoning have occurred where the leak in the pipes occurred in an adjoining room, or in a cellar or other room underneath. Most of such accidents occur in the night, while the victims are asleep, even though they were exposed to the same influences during the pre- ceding day. It should be known that these poisonous gases may diffuse themselves through walls, soil, and partitions. It should also be remembered that the odorous vapors may be almost entirely removed by diffusion through a thick wall or several feet of soil. The gas deprived of its odor may thus pervade the air of a sleeping or sitting-room, and give no warning of its presence. In winter, when the ground is frozen, and the upper lay- ers are impervious to the gas, this may diffuse itself several feet laterally from a broken street-main, reach the cellar, pass thence to the rooms above, and so do its deadly work unperceived. That this accident has frequently occurred is shown by abundant evidence taken from the statistics of any large city. Aside from the fatal cases of poisoning from this source, we can easily see that there must be a much larger number of cases in which headache, dizziness, loss of appetite, general debility, anaemia, etc., maybe dependent upon a smaller amount of the same gas con- tinually finding its way into the air of houses. It is evident, from the above, that cases of poisoning may occur in houses where gas is not used, and where the pipes do not even enter the house. There has been, at various times, not a little discussion as to the relative poisonous effects of coal gas and water gas. This question has been made the subject of a great number of investigations. We may note that of Com- missioner Raymond, of Brooklyn, N. Y., Health Dept.,- 1883, and that of the Committee on Manufactures of the Massachusetts Legislature of 1884. Experts, chemists, and physicians of reputation and note were found to give opinions upon both sides of this question. When we turn to the experimental evidence, there seems to be some variation and lack of uniformity of re- sults. The weight of experimental evidence, however, goes to show that water gas is decidedly more dangerous than coal gas. With a given amount of gas, the danger-line is reached sooner with water gas ; and, indeed, in many rooms it is not easy to get a fatal mixture of coal gas and air with the escape from a single burner-jet, owing to natural ventilation through walls, floors, windows, etc. That is, dogs, cats, rabbits, and pigeons will endure almost in- definitely an atmosphere containing one per cent, of coal gas, while the same animals die in from five to eight hours, when exposed to an atmosphere containing one per cent, of water gas. The post-mortem appearances, in cases of poisoning by 900° F. In passing this hot steam through the coals the water is decomposed, the oxygen combines with the car- bon of the coal to form carbon dioxide, which is reduced, by the heated coal above, to the monoxide. C 4- 2H2O = CO2 + 2Ha. (CO2 + C = 2CO). The hydrogen of the steam remains in a free state. After the steam has passed through the coal for a short time, the latter cools off and the process stops. The air-blast is now turned on until the coal is again heated to the required degree, when the steam is again passed into it. It is, therefore, an alter- nating process. The gas thus produced has very little illuminating power, but answers well for heating pur- poses. To give illuminating power it must be charged with hydrocarbons. This is accomplished as follows : Naphtha, or light benzine, is placed upon shelves in a carburetter, and the gas passed through the apparatus. A small quantity of the vapor of the naphtha is taken up by the gas. This mixture is now passed through retorts heated to bright redness, by which process the vapors are decomposed and converted into permanent gases instead of condensible vapors. This is the Tessie-du-Motay pro- cess. Water gas is cheaper and usually of higher illu- minating power than coal gas, and is consequently super- seding the latter. The principal differences in the chemical composition of coal gas and water gas are, that the latter, as usually manufactured, contains a larger percentage of illuminat- ing agents and of carbon monoxide than the former. The following analyses of the two gases, by Professor Remsen and Dr. Love, will serve to illustrate these dif- ferences : Remsen. Love. Constituents. Coal Water Water gas. gas. gas. Carbon dioxide 0.0 0.3 0.0 Illuminants (ethylene, propylene, butylene, ethane, profane, butane) 4.3 12.85 15.75 Carbon monoxide 7.9 28.25 21.51 Hydrogen 50.2 30.30 46.49 Marsh gas (methane) 29.8 21.45 11.75 Nitrogen 7.8 6.85 4.30 Oxygen 0.20 Action on the Economy.-All forms of illuminating gas are irrespirable, and more or less poisonous. They are irrespirable because they do not furnish oxy- gen. The chief poisonous agents are carbon monoxide and the heavier hydrocarbons mentioned above under the name of illuminants. The physiological action of carbon monoxide has al- ready been discussed in the article upon that subject, which see. The heavy hydrocarbons are more or less poisonous when mixed with air. The symptoms produced are diz- ziness, headache, nausea, and prostration. These com- pounds are more deleterious than the lighter marsh gas, but their exact physiological action is not well understood. The physiological effects of illuminating gas are not alone due to the carbon monoxide, as some have supposed, but to the combined effect of this gas and the heavier hydro- carbons, togethei' with the loss of oxygen due to the dis- placement of air by the gas. Symptoms.-The symptoms of poisoning by coal gas are : headache, dizziness, nausea, a staggering gait, great muscular weakness, prostration, loss of memory, and finally unconsciousness and complete asphyxia. Convul- sions frequently end the scene. There is usually little difficulty in making the diagnosis, as the circumstances under which the patient is found, the odor of the gas, etc., will prevent deception. The only diseases likely to be confounded with this form of poisoning are, cerebral apoplexy and uraemic coma. Should the physician not see the patient before the odor of the gas has escaped, such difficulty might arise. In both of these diseases the symptoms are pretty constant, while in coal-gas or water- gas poisoning they are apt to fluctuate ; the patient will frequently rouse up for a time, and answer questions in- telligently, and then lapse into unconsciousness, or be seized with convulsions. A marked difference in the symptoms will be noted when the gas is admitted into the air rapidly or slowly. 215 Coal Gas. Coca. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. illuminating gas, are somewhat similar to those found after poisoning with carbon monoxide. There is generally an odor of the gas about the body, especially on compressing the chest, so as to expel the residual gas from the lungs. The countenance may be pallid, pink, or purple, vary- ing in different cases. Frequently more or less froth will be found issuing from the mouth, due probably to the nausea which precedes death, and which is one of the marked symptoms. Occasionally, rose-colored patches will be found on the thighs or other parts of the body. On opening the body the blood will generally be found everywhere in a fluid condition, and uniformly of a light red color on both sides of the heart. It shows the spec- troscopic bands of carbon monoxide haemoglobin. (See Vol. I., Fig. 559, p. 760.) The lungs will usually have a brilliant red hue, while the bronchial tubes wfill be filled with a frothy mucus. The venous sinuses of the brain and the vertebral nervous system will be found en- gorged with blood. The above appearances are not always found, how'ever, for there is great variation in this form of poisoning, both as to the symptoms and as to the post-mortem appear- ances. These variations are probably explained by the fact that in some instances the cause of death is a true suffocation, while in others it is poisoning. In the for- mer we may expect a livid hue of skin, dark, clotted blood, and engorgement of the venous sinuses ; while in the latter we may expect the light, fluid blood, the rose- colored spots upon the skin, a lingering death, etc. More careful observation is needed upon these points. Treatment.-We have incidentally mentioned nearly all that can be said of the treatment of coal-gas poisoning. If the case is one of suffocation, and the time of exposure has not been too long, fresh air, stimulants, and rest will usually suffice to restore the patient to consciousness. No antidote for poisoning by the gas is known. Trans- fusion of blood has been tried with apparent success. In experiments upon the lower animals the introduction of salt-water into the veins has occasionally been success- ful in saving life. Inhalations of oxygen have often been tried, with temporary benefit, but it does not seem to expel the car- bon monoxide from the blood. If persisted in, it may save life where the blood is not too nearly saturated with the gas. E. H. Bartley. shaped ring of confluent filaments, free above ; anthers erect, two-celled. Ovary free, containing one fertile one- ovuled cell, and two (by abortion) sterile ones. Styles three, partly united below, stigmas capitate or club-shaped. The fruit is an ovoid-oblong, slightly asymmetrical drupe. Leaves alternate, smooth, entire, bright green above, pale green and glaucous beneath, thin and fragile when young, somewhat coriaceous when old ; they arise from very short petioles and are provided with small stipules, which are united along their inner margins in front of the petioles, and remain, after the leaves have fallen, as stiff, triangular, almost spinous scales. The size, shape, and other details of the leaves will be given below in the description of the drug. Coca is a native of South America, but the exact local- ities in which it is indigenous, or its truly wild form, arc as yet matters of doubt. Most observ- ers only report having seen it culti- vated in the " Cocals," or plantations which are to be found in nearly all the tropical countries of the continent- Bolivia, Peru, Columbia, Brazil, and the Argentine Republic-but especially in the two first. It flourishes best in the warm, moist climate of the moun- tain sides and valleys, from two to five thousand feet above the sea. The prov- ince of La Paz, in Bolivia, is noted for the extent and number of these plantations. The present call for it, all over the world, will probably lead to its transplantation to other countries, where its cultivation may be as successful as that of Cinchona in India has been. It has been raised by the natives of South America for centuries-in fact longer than our knowledge of them extends-and has been frequently mentioned and described by travellers and European residents there ; but, excepting as a curiosity or rarity, did not find its way into Europe or this country until about fifteen years ago, when it was offered in small quantity, with the interesting stories of its marvellous sustaining power. Since then it has been kept in very moderate but increasing use as a nervous stimulant and tonic, and gained admission into the United States Phar- macopoeia of 1882 on this account. But it was not until the brilliant discovery of Koller, last year, that it attained any great importance among medi- cines. It is just entered in the new British Pharmacopoeia of 1885. When the leaves are fully growm, they are carefully plucked one by one, so as not to break them, and also in order not to injure the buds and so damage the succeeding har- vest. They are then dried in the sun and packed in bags or bales for transportation. Two or three crops are gathered in the course of the year. The quality of Coca is very sensitive and easily injured by too quick or too slow drying, packing while damp, collecting at an im- proper age, etc., and a good deal of that which reaches us is in an infe- rior condition from one or other of the above causes, being deficient in color, odor, taste, or alkaloidal strength. Still, apparently poor Coca may have a fair alkaloid strength, since, like tea and coffee, its market value has not depended upon assay, but rather upon its fra- grance and fine appearance. Most of our Coca is exported by way of Lima. The total amount produced is said to be more than forty million pounds. Fig. 719.- Bud of the same, en- larged. Fig. 720.-Flower of Coca Plant, enlarged. Fio. 721. - Coca Fruit, enlarged. COCA, Br. Ph. ; Erythroxylon, U. S. Ph. ; Cuca, Co- chuco, etc. The leaves of Erythroxylon Coca, Lamarck ; Order, Linacem, Erythroxylea. This is a small, bushy shrub, from two to four or live feet high, with a purplish- brown, wrinkled bark, and smooth tw'igs and leaves. The flowers are small (five or six milli- metres in diameter, £ inch), and borne either singly, or usually in clusters of three or four, upon short, slender, re- curved, bractcd stems arising from the axils either of the leaves themselves, or of their persistent stipules, which remain after these have fallen away. They are regular and perfect. The calyx is smooth, cup-shaped, and consists of five triangular-ovate, point- ed, nearly separate se- pals. Corolla yellow- ish-white, of five petals, each composed of a short, broad, ascending claw, and a rounded, concave, spreading limb. From the upper part of the claw arises a blunt bifid erect scale (ligula) about as long as the claw itself. Stamens ten, arising from a short, thick, cup- Fig. 722. -Coca Leaf, showing the venation and the characteristic longitudinal creases. Natural size. (Baillon.) Fig. 718.-Coca Plant, Flowering Branch. One-third natural size. (Baillon.) 216 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coal Gas. Coea. The dried leaves are rather stiff and brittle, usually con- siderably broken by the pressure and manipulation of dry- ing and transportation. They have a pleasant tea-like odor and an aromatic bitter taste, which leaves the tongue slight- ly anaesthetic. They are from three to five centimetres (one to two inches) long, oval or broadly oblanceolate, with a tapering base and a rather blunt emarginate apex ; border entire, surfaces smooth. The midrib is straight and promi- nent ; the veins arising from it are small and inconspicu- ous and freely reticulated. Upon each side of the midrib, on the lower surface of the leaf, a fine line extends in a curved direction from the base to the apex, giv- ing it a three-nerved appearance. It is not a nerve or vein, however, but only a crease indicating where the leaf was folded in the bud. It is the most distinctive feature of the leaf, and relied upon as a test of genuine- ness-in many specimens it is very faint, however, and sometimes quite invisible. In color the dried leaves vary, the best are light olive-green above, and whitish-green below ; from this they range to dirty-green, brownish- green, and greenish-brown. A fair proportion of alkaloid is sometimes found in unpromising-looking lots. Composition. - The principal active constituent of Coca was discovered by A. Niemann in 1859 or 1860, and named by him cocaine. Gadcke had already come very near recognizing it some time before, but had considered the substance which he obtained to be caffeine. W. Lossen afterward (1862) separated a second base from the drug, to which he gave the name hygrine. Besides these it contains a peculiar tannin, coca-tannic acid, a brownish-red mass, giving a brownish-green color with the iron chloride, a peculiar wax, and other unimportant substances. Its odorous principle does not appear to have been examined. Cocaine.-This base, which has just attained to such intense interest, "crystallizes in large four- to six-sided prisms of the clinorhombic system. Its taste is bitter- ish, soon benumbing the nerves of the tongue and depriv- ing it of feeling and taste. Reaction strongly alkaline. It melts at 98° C. (208° F.), crystallizing again as it hardens ; by a higher temperature it is mostly decomposed, but a small portion appears to be vaporized unchanged. It dissolves in 704 parts of water at 12° C. (53° F.), in nearly all parts of alcohol, and still more freely in ether " (Nie- mann).* The ' ' Cocain pur " of Merck, which has been in the market for a number of years, is in soft lumpy, crystal- line masses, consisting of fine, brilliant, but short and broken prisms and scales-its color is pale lemon-white. Cocaine dissolves with great facility in acidulated solu- tions, forming definite and generally crystalline salts (see Administration). These salts are easily soluble in water and alcohol, but not in ether; in taste and action they resemble the alkaloid itself. The proportion of co- caine in Coca is very variable. It is never large, seldom exceeding one-fifth per cent.,f and often is much smaller ; in some specimens, the merest trace only, or even none at all, can be found. A good deal of loss unquestionably takes place in improper drying or collecting of the leaves, some in transportation, and some also by imperfect meth- ods of extraction and consequent decomposition of the cocaine into benzoic acid, methyl-alcohol, ceqonine, and other useless products. There are several methods for separating it. Niemann's was to exhaust the leaves with acidulated alcohol, neu- tralize the solution with milk of lime, filter, and evaporate to syrup. This was treated with water to separate the resins, etc., and precipitated with sodium carbonate. The precipitate, dissolved in ether and evaporated, was crude cocaine, etc. M. Lossen made a watery extract, purified it with subacetate of lead, separated the lead by sulphate of sodium, alkalized the filtrate with soda, and washed out the cocaine with ether. Dr. Squibb has pub- lished his manufacturing process,1 which is somewhat like Niemann's. It consists in exhausting the leaves by means of acidulated alcohol, distilling off this solvent, and mixing the residue with water ; this separates into a dark opaque chlorophyl- and- resin-, etc., containing layer, and a watery one holding the alkaloids. This latter is siphoned out, filtered, neutralized with sodium carbon- ate, and washed out with ether which takes the alkaloids. The ether is next treated with acidulated water, which re- moves the alkaloids from the ether as salts. Sodium car- bonate and ether are again used, and the bases, in a purer condition, transferred to ether again, from which they are finally separated by evaporation in a brownish granulated mass, which is further cleaned by means of purified bone black and more washing with ether and water. Squibb's Cocaine is "in light, white, spongy fragments, or in light amorphous powder, very much like magnesia, not perfectly white, but nearly so ; nearly soluble in wa- ter, very soluble in acids, giving solutions that are not quite colorless." Taste, etc., as described above. A num- ber of other American makers produce now excellent co- caine salts. Hygrine, the second alkaloid, is a thick, oily liquid of strongly alkaline reaction, biting taste, and strong tri- methylamine-like odor. It has no recognized value. Action and Use.-The early interest in Coca was based upon the repeated and marvellous accounts of travellers, of its enormous consumption by the aborigines of South America, and the labors which they performed by means of its assistance, such as passing whole days at work in the mines, or travelling from morning to night through the forests without food or the desire for it; ascending mountains without inconvenience from the rarefied air; carrying a hundred pounds thirty miles in a day, and do- ing other similarly incredible feats of strength and endur- ance. These stories are probably exaggerated, but they all bear testimony to its value in the same direction, that it does exert a sustaining power upon those en- gaged in prolonged labor, and does postpone the sensa- tions both of fatigue and hunger. The native method of taking coca is substantially as follows : The Indian al- ways has the leaves by him as the tobacco-user here has his pouch and pipe, and carries them in a bag or wallet at- tached to his belt. He also carries a small gourd filled with powdered lime, or with the ashes of some favorite plant, to use with the coca. Several times a day, if practicable, he rests from work for about fifteen minutes, takes some of the leaves and chews them into a pulpy ball, and then, dipping a stick into the lime or ashes, puts some of it upon the half-masticated coca; then he continues the chewing until the mass is exhausted, generally swallowing the saliva. But if his work is particularly arduous he may chew the leaves almost constantly while employed. So necessary is this substance deemed by him that he cannot be induced to do without it, and contractors for labor in mines and forests, and the builders of the new mountain railroads, are obliged to furnish daily rations of coca as a part of his food supplies. This article has naturally for many years been re- garded with especial interest by investigators both in Europe and here (although its actual employment in medicine has been very limited until within a year), and a number of observations have been made of its effects by mountain climbers, troops under exercise, sportsmen, pedestrians, students, and others, with, in general, cor- roborative testimony as to its value as a nervous stimu- lant, and its general resemblance, in this respect, to tea and coffee. At one time its active principle was sup- posed to be identical with that of those beverages. In some cases, however, of experiment, and often in prac- tice, it appeared wholly to fail in producing the desired effect; a result perhaps due to the uncertain quality of the coca at first imported. One of the most graphic accounts of the action of medium and full physiological doses of cocaine upon warm-blooded animals is that of the experiments of Anrep and Rossbach, given in " Nothnagel and Ross- bach's Therapeutics." After injecting a moderate dose (0.01 Gm. per kilo) into a quiet and tractable dog his manner became almost immediately changed. He did not remain quiet a moment, but danced in a circle about * Translated from Huseman's Pflanzenstoffe. + Squibb gives 0.34 per cent, and 0.27 per cent, of cocaine salt, the former equalling about 0.3 per cent, of cocaine. 217 Coca, Coca. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. his master upon his hind legs, with his body erect and the fore-legs stretched out. All his muscles were in constant motion, the tail wagging, the chest and abdomen trembling, not with convulsion, but exactly as if he were under the influence of sudden and most intense joy by the return, say, of his master after a long absence. His expression and actions were only those of pleasure. There was not the slightest appearance of distress. This con- dition lasted for hours, during which he was not quiet one second while he was left free. If the hand was laid upon his head or back he was able voluntarily to keep quiet, and only his hurried respiration betrayed his ex- citement. After from one to three hours he gradually became quiet, without any appearance of exhaustion, and continued fresh and lively. If the dose were increased to one and a half centigram per kilo (0.015 per 1000), the excitement was intensified and distressing. He did not recognize his master, his ex- pression was altered, he whined, barked, and trembled. He was frightened at every noise, carried the tail between the legs, wagged his head like a pendulum, and stood for fifteen minutes keeping up this rhythmical oscillation, with hurried breathing, dilated pupils, and dry mouth. This state was suddenly succeeded by another of intense and reckless joyousness, lasting another quarter of an hour. Then he jumped unceasingly about one of the ex- perimenters in a circle as if bewitched ; it was very dif- ficult to call him away, not because he could not hear his master's voice, or did not wish to obey him, but because he could not resist the impulse which restrained him where he was. At last, after persistent calling, the dog appeared to throw off this spell, and rushed with great joyousness to his master, only to begin again his antics around him as he had previously done around the first observer. After three or four hours he became, as in the first instance, gradually quieter, slept, and recovered. After a dose of two centigrams per kilo (0.02 per 1000) there was tremendous excitement of the musculatory ap- paratus and the cerebrum, but soon followed by great weakness ; he could not stand, but lay on the side, with the limbs drawn up, and had difficulty of breathing. Consciousness was still present; when called he raised his head and looked entreatingly at the speaker. After twenty minutes clonic convulsions occurred, with swim- ming movements of the hind feet; occasionally opistho- tonos. These manifestations became more severe in char- acter ; consciousness was lost, the head was constantly beaten upon the ground ; and during an hour he was not quiet for a minute. Then spells of quiet appeared, which became longer and longer, and were followed by sleepi- ness, loss of appetite, and recovery.* The principal action of cocaine thus appears to be upon the central nervous system, to which it is a most ener- getic stimulant; in moderate quantity giving the com- fortable feeling of mental activity and other psychical phenomena noticed also after a dose of tea or coffee ; a willingness to take bodily or mental exercise, wakeful- ness, " nervousness," etc. This effect is, too, undoubt- edly produced not by disturbance of the circulation but by direct action upon the cortical cerebral nerve-cells themselves. When the dose is increased all the nerve- centres partake visibly in the excitement, and cause the dancing, circular antics, staggering, rhythmic movements, convulsions, and, finally, coma, noted in the above inter- esting experiments. The pupils are dilated, both by internal administration and local application, but to a less degree than they are by atropine. Accommodation is also impaired to a vari- able extent. The circulation is not especially affected by small doses ; by moderate ones the rapidity of the heart-beats is in- creased, by large ones it is retarded. The peripheral arteries are contracted. Respiration is hurried. The sur- face temperature (in animals) is raised, and secretions are diminished. Death is said to take place by the final failure of respiration, the heart beating after this has ceased. Although coca postpones the feeling of hunger, it does not postpone death from starvation, as Anrep showed the final result to take place at about the same time with and without this remarkable substance. Locally, cocaine benumbs the nerve-extremities, and if sufficiently concentrated renders them completely anaes- thetic. Applied to mucous surfaces, or injected into the tissues, the effect is the same-insensibility : upon the tongue, it causes a suspension of taste ; upon the larynx, its effect is such that the vocal chords may be touched without pain ; upon the eye, it produces such a degree of anaesthesia that the conjunctiva may be rubbed or cut without the patient's knowledge, etc. This quality was noticed as long ago as 1862, by Professor Schroff, and in 1868 by Moreno. Van Anrep, in 1880, pursued the study still further, and even hinted that this property of cocaine might some day be utilized, but no practical application of the discovery was made until Dr. Carl Koller, of Vienna, logically concluded, from what was already known about it, that its anaesthetic power could be made useful in examinations of and operations upon the eye, and made the series of experiments upon guinea-pigs, rabbits, and dogs which established its efficiency, and completed one of the most brilliant discoveries in ophthalmic sur- gery of recent times. The result of Koller's experiments was reported to the Convention of German Oculists, at Heidelberg, in September, 1884, by his friend, Dr. Bret- tauer, of Trieste, and again by himself before the Vienna Royal Imperial Society of Physicians, a little later.2 The experiments and cases were so definite and convincing, that the news of them spread with great rapidity, and within a few weeks the medicine was used in its new sphere all over the world. Dr. Noyes, of New York, then abroad at Kreuznach, sent the news to this country in two letters, one to the Medical liecord,3 and the other to Dr. Squibb, both bearing the date September 19, 1884. In the latter he asked to have two friends, one in Brooklyn and an- other in New York, notified of the discovery. Dr. Squibb immediately sent each of them some cocaine so- lution. Dr. Bull, of New York, one of the gentlemen mentioned, tried it on October 8th, probably for the first time in this country.4 The efficiency of the new agent was so evident, and its application so general, that its use spread immediately to ail parts of the world, as far as the limited amount of the alkaloid to be had permitted. For months after nearly every number of the various medical and pharmaceutical journals of this country and of Europe, contained some notice of, or contribution concerning it,* corroborating in various departments of medicine the main facts of Kol- ler's paper. The use of the new anaesthetic rapidly ex- tended to other branches of surgery. It had for some time been used, like bromide of potassium, applied by brush or spray, to make the pharynx tolerant of the la- ryngoscopic mirror. Now it was found useful in laryn- geal operations as well, and in operations within the nose it was found not only to produce insensibility, but to greatly decrease the turgescence of the mucous mem- brane and so facilitate examinations. Then the aurists found it useful in earache, injected through the Eusta- chian tube, or even applied exteriorly to the drum. At about the same time felons were injected with it and opened with diminished pain, and small tumors were re- moved painlessly after an injection of cocaine at their sides. The cocaine anaesthesia appears to be complete so far as the drug can find actual contact with soft and living tis- sue. Of all the surfaces which can be thus reached the conjunctiva is the one where the epithelial covering is thinnest, and absorption most quick and free. Here, theoretically, it would act the most perfectly, and, in practice, it is here the most successful. In the nose the great vascularity of the mucous membrane facilitates its ready absorption, and the superficial anaesthesia is also * Many of these may be found in the Therapeutic Gazette for the year following Koller's publication, as well as in several monographs and pam- phlets, e.g., Knapp's Cocaine and its Use, etc.; Turnbull, The New Lo- cal Aniesthetic, and others. ♦ The above is a free translation from the work referred to. 218 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coca. Coca. quick and complete. The mouth, pharynx, and larynx respond easily, although, perhaps, not quite so satisfac- torily, to its influence. In the uterus, vagina, and urethra stronger applications are necessary to produce the same results, and upon the skin it is so little absorbed that it is very inefficient. In all these places its action is super- ficial, unless it is maintained by repeated applications, or by admission into the deeper tissues either by subcutane- ous injection, or by flooding the cut with it in the course of an operation. A cocaine subcutaneous injection ap- pears to produce insensibility of a surface of skin extend- ing two or three inches in each direction from the point of puncture. Among the numerous other uses to which it has been logically and successfully put, are the treatment of tooth- ache and exposed nerves, of burns, which, if the cuticle is removed, it relieves like magic, inflamed nipples, photo- phobia from keratitis, etc. It has also proved useful in the vomiting of pregnancy and in sea-sickness, an effect probably due, like part of the relief of hunger, to its an- aesthetic effect upon the stomach. The dysphagia of phthisis, vaginismus, tenesmus of the sphincter ani, and neuralgia have all been benefited in the limited number of cases reported. In genito-urinary surgery, although not wholly satisfactory, still it does overcome a part of the pain. For its general stimulant effect it is given for de- bility of the nervous system, the opium habit, as an ad- juvant to tonics, etc. Finally, it should be remembered that injections of cocaine for local purposes may be fol- lowed by unpleasant general effects ; excitement, hallu- cinations, etc. Administration.-Coca leaves may be chewed and swallowed, to obtain their physiological effect upon the stomach and system in general. This is the original method, and has some advantages; the slow ingestion and prolonged local effect upon the mouth, pharynx, and stom- ach, and probably the quieting influence of mastication, have something to do with the relief it gives to the gnawing of hunger, the nervous nausea, and other disagreeable sen- sations in the epigastrium, and may sometimes be util- ized. The taste is not at all disagreeable ; it is even pleas- ant after a little use. From two to eight grams (2 to 8 Gm. = 3 ss. ad 3 ij.) is the usual dose, but until the sup- ply is of more uniform quality it is only a tentative one, to be varied according to the effects produced. A Fluid Extract (Extractum Erythroxyli Fluidum, U. S. Ph., Ex- tractum Coca Liquidum, Br. Ph.) made in the usual way with diluted alcohol, strength f, is officinal and theoreti- cally represents the leaves. Much of that heretofore ob- tainable has been inert, probably on account of the poor quality of the drug used. When good it is an excellent preparation. The cheapening of the alkaloid now per- mits its salts to be used internally. Cocaine itself is not employed for administration on account of its insolubility, but its salts dissolve in water readily, and several are in use. The most generally em- ployed, and on account of its large proportion of pure alkaloid (nine-tenths), its permanence, its ready solubility, and unirritating character, the best, is the Hydrochlorate {Cocaines Hydrochlor as, Br. Ph.). It is soluble in nearly all proportions of water and alcohol, and is thus described in the new British Pharmacopoeia: "In almost colorless acicular crystals, or crystalline powder, readily soluble in water, alcohol, and ether. Its solution in water has a bitter taste; gives a yellow precipitate with chloride of gold ; and a white precipitate with carbonate of ammo- nium, soluble in excess of the reagent. Its solution pro- duces on the tongue a tingling sensation followed by numbness. The aqueous solution dilates the pupil of the eye. It dissolves without color in cold, concentrated acids, but chars with hot sulphuric acid. The solution yields little or no cloudiness with chloride of barium or oxalate of ammonium. Ignited in the air it burns with- out residue. Dose, | to 1 grain" (=0.01 to 0.06 Gm.). For external use ; for instillation into the eye, ear, nose, and other mucous cavities ; for subcutaneous injections, atomization, and the numerous modes of producing local insensibility, an aqueous solution of the cocaine salt is the only suitable form. No acid is needed to dissolve it, and if added only makes the mixture more irritating; the same objections hold good against alcohol, and glycerine reduces its power if anything. In ointments, cocaine is not very active, and it has to be used in extravagant quan- tities to influence the sensitiveness of the skin. The oleate even has proved rather disappointing. For oph- thalmic use small gelatine discs of cocaine, similar to those made of eserine (physostigmine), are officinal in Great Britain, and convenient. (Lamella Cocaina, Br. Ph.). Each contains jAo grain of the hydrochlorate. Cocaine may be combined with physostigmine if desired. For general purposes a four per cent, solution suffices. Two or three applications of this within fifteen minutes will perfectly benumb the conjunctiva, and partially deprive the surfaces of the urethra, uterus, and membrana tym- pani of feeling. It is also concentrated enough for sub- cutaneons use, as a few drops of it will suspend the sensi- bility in an area of several square inches of subcutaneous tissue. For granulating surfaces like ulcers, ingrowing toe-nails, etc., a stronger solution, ten or twenty per cent., or more prolonged use is necessary. Feeling is seldom entirely absent in these cases without subcutaneous injec- tions. For freshly abraded and painful surfaces, such as scrapes of the skin, and recent burns with blistered or raw surfaces, painting with a two per cent, solution may give complete rest from pain. By all methods anaesthetic ef- fect of cocaine is very transient, beginning in three or four minutes from the first application, and disappearing in less than half an hour from the last. Solutions of cocaine, like those of other alkaloids, are slowly decomposed and weakened by the growth of mi- croscopic fungi. This may be prevented by several additions ; that which the author prefers is to add from two to four parts per mille of pure carbolic acid. The odor and taste of so dilute a solution of the acid are not very perceptible, and it is not in the least irritating. An- other method is to use thymol water (nAns). which is much more pronounced in taste and odor. Boric and sali- cylic acids, and other antiseptics will readily suggest themselves, but none are better than the first one named. Allied Plants. - The genus Erythroxylon is the second largest in the order, and contains about fifty species, all tropical shrubs or small trees. Most of these are South American, but a number are inhabitants of Africa, and one or two each of India and Australia. Several of the American species are in local repute as tonics, purgatives, astringents, etc., but none have as yet been shown to have the qualities or composition or Coca. The field is worth investigating. The only other genus of great importance in the order is Linum (flax, linseed), which, besides the indispensable L. usitatissimum, num- bers several pretty garden flowers among its species. It is needless to say that Linum and Erythroxylon are by no means as nearly related as plants in the same order generally are, either in habit, appearance, or qualities. Allied Drugs.-When internally administered, the nearest related drugs to cocaine are caffeine and its allies, which are every day given for the same class of cases in which cocaine is indicated. The local action of cocaine is simulated by several agencies, although none of them are capable of producing complete insensibility without disastrous after-effects. Cold, by contracting the vessels and so diminishing the blood-supply, acts to a degree very much like cocaine, and is in frequent use for the same purpose ; in this connection may be mentioned the rigoline and ether sprays for "freezing," ice to painful swellings, etc. Carbolic acid also benumbs the tissues. If sufficiently concentrated, aconite has a marked property in this direction, and there are also others ; but with none of these can an equal amount of anaesthesia be obtained compatible with safety. With ether, chloroform, opium, and the other central pain-destroying agents, it has little in common, theoretically. It may be noted that there are two other entirely dif- ferent products with names easily confounded with Coca. First, Cocao, Cacoa seeds, Cocoa butter, Chocolate, from Theabrama Cacao, which contains the alkaloid theobro- mine resembling Caffeine, and a very permanent solid fat; and secondly, the Coco Nut from Cocos nucifera, which 219 Coca. Cod-Liver Oil. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. contains sugar and a soft, solid, lard-like fat. The re- semblance in names is a mere coincidence. IF. P. Bolles. 1 Ephemeris. January, 1885. 2 Lancet, December 6. 1884. 3 Medical Record, October 11, 1884. 4 Ephemeris, vol. ii., Nov. 6,1884. Coccus Cacti Linn.; Order, Hemiptera. The males are about half a centimetre long, or less (one-sixth inch), ex- clusive of antennae and of the two long bristles pro- jecting from the posterior segments of the abdomen, with slender bodies, and, when fully grown, large, ef- ficient, horizontally held wings. The antennae are shorter than the body, but the two posterior bristles are sev- eral times as long. They are never collected for the market. The females are much larger (because thicker) and a little longer than the males, rounded, convex above, flat below, wingless, transversely wrinkled; an- tennae and posterior bristles both very short. When big with young they are about as round as ticks. Both sexes are deep red or reddish-brown. The females are said to be more numerous than the males in the propor- tion of two hundred to one, a not uncommon condition of things among insects. The Cochineal insect is a native of Mexico and Central America, where it abounds as a parasite upon several genera of Cacti, especially the Opuntias. It is also found, probably wild, in the West Indies. For commercial pur- poses, however, it has long been bred and raised upon Opuntia Cochinillifera, and probably other species of this genus which are cultivated in plantations for the pur- pose. The pregnant females, placed upon them, deposit their Numerous progeny, which feed and live upon the plants. These, when fully grown (and pregnant) are collected, killed by heat, and dried. This insect, to- gether with its foster-plants, have been introduced into the West Indies, East Indies, Java, Southern Europe, and Africa. Description.-The dried cochineal is described as fol- lows : "About one-fifth of an inch (5 millimetres) long; of a purplish-gray or purplish-black color; nearly hemi- spherical ; somewhat oblong and angular in outline; flat or concave beneath ; convex above; transversely wrinkled ; easily pulverizable, yielding a dark-red powder. Odor, faint; taste, slightly bitterish. It contains a red coloring matter, soluble in water, alcohol, or water of ammonia; slightly soluble in ether, insoluble in fixed and volatile oils. On macerating Cochineal in water the insect swells up, but no insoluble powder should be separated." Composition.-Good Honduras Cochineal contains, according to Hager, six per cent, of moisture, from fif- teen to eighteen of fat, from forty to forty-five of car- minic acid, from three and a half to five of ash, and from seven to eleven of insoluble residue. Of these the only one of use is the carminic acid or coloring matter, a brilliant red powder, soluble in water and alcohol, but insoluble in diluted acids. It is the basis of carmine, and. the different pink, purple, and other beautiful lakes used in painting and dyeing. Cochineal being an expensive article, is subject to much adulteration ; crude foreigrf substances, like stones, starch, tapioca, etc., and insoluble and heavy earths added to increase its weight, are easily detected. The most difficult to recognize is the substitution of partially exhausted for fresh insects ; this can only be detected by a sort of assay for the coloring power left in them. Like nearly everything else that can be in any way swallowed, this too has been used in medicine, as "anodyne, tonic, astringent." It has no medical value whatever, and is wholly consumed at present in the manufacture of dyes and paints. In pharmacy and confectionery it is fre- quently used for its color. Allied Insects, etc.-The wild Cocci are collected in Mexico and elsewhere to supply an inferior grade of Cochineal. Besides, Coccus Ilicis Fabricius, Kermes is a larger species, living upon a species of oak (Quercus cocci- fera Linn.). It is collected and dried in Southeastern Eu- rope, and has constituents similar to those of C. Cacti, but the color is inferior and less in quantity. For other coloring matters used in pharmacy, see Saffron. W. P. Bolles. COCCYGODYNIA. For this term medical nomencla- ture is indebted to Sir James Y. Simpson, who gave the name to a painful affection of the coccyx, or of the parts in intimate relation with that bone-claiming for the name the negative merit, that it conveyed no erroneous impression concerning the pathology of the disorder. It is probable that the term embraces several distinct diseases, some of which may be simply neuralgic ; some, possibly, rheumatic ; some only sympathetic; while others are certainly due to organic degeneration of the bony structure itself. As the name implies, it matters not what may be the morbid condition which gives rise to it, pain in the region of the coccyx is the symptom that calls into exercise the resources of the medical art. The affection is more common in women than in men, and is most frequently encountered in women who have borne children, though by no means confined to them. It may continue indefinitely, if left to itself, and the pain is sometimes very severe. The pain is excited by pressure, or by any movement of the bone. Sitting, walking, defecation, and even mic- turition, in some cases, occasion paroxysms of intense suffering. The principal causes of coccygodyniaare direct violence to the coccyx, injuries inflicted during parturition, the influence of cold, and uterine, ovarian, or rectal disease. The diagnosis is not attended with difficulty. A thor- ough physical examination will always remove any ob- scurity and enable the surgeon to distinguish between this affection and painful haemorrhoids, anal fissure, foreign bodies within the rectum, or any other local dis- order to which the symptoms may point. A favorable prognosis may always be given, unless the pain be dependent upon some incurable disease elsewhere ; otherwise, with proper treatment, complete and prompt relief can be promised. The treatment must, of course, vary to meet the con- ditions that may be present. If, upon investigation, the affection is found to result from uterine, ovarian, or rec- tal disease, curative measures should be addressed to the primary disorder. In the absence of any such exciting cause, or of any displacement or appreciable disease of the bone, the remedies appropriate in the several forms of neuralgia may be resorted to with a fair prospect of success. Among the most potent of these are opium, quinine, blisters, and electricity, and such general medi- cation and such management as the condition of the pa- tient may demand. In the event of failure after a faithful trial of this plan, surgical interference should be confidently advised. Two procedures are available. One consists in the isolation of the coccygeal bones from the surrounding tissues, by means of a tenotomy knife ; the other, first practised by Dr. J. C. Nott, of Mo- bile, in the removal of the coccyx entire, or of the lower part of the bone. A modification of the operation proposed by Dr. Nott has been recently suggested by Dr. Garretson. He exposes the bone by an incision through the skin, and by means of a " bur" attached to a dental engine, the bone is ground away to any desired extent, leaving the periosteum upon the anterior surface, with all of its attachments, intact. In the great majority of cases, the complete division of the muscular and tendinous structures surrounding the coccyx will suffice, though occasionally the extirpation or the enucleation of the bone, or a portion of it, ■will be found to be necessary to effect a permanent cure. James B. Baird. COCOA-NUT, OIL OF (Oleum Cocos, Ph. G.). The fat obtained from the albumen of the seed of Cocos nucifera Linn.; Order, Palmce. This magnificent Palm, a native, perhaps, of tropical Asia and many islands of the Pacific COCHINEAL (Coccus, U. S. Ph., Br. Ph.; Cochenille, Codex Med.}. This is the entire body of the female cochineal insect, 220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coca. Cod-r<iver Oil. and Indian Oceans, is cultivated in all warm countries for its edible seeds and numerous useful products. Its well-known fruit and seed are among the largest in the world, and the fleshy "albumen" of the latter is the source of the oil under consideration. Several methods are employed in separating the oil, and give rise to some diversity of appearance in the product. That obtained by cold expression is softer, and melts easier than those obtained by heat. These also vary according to the degree of heat and method used. Sometimes the pulp is simply warmed and then expressed as above, at other times the oil is boiled out as lard is in the country. The yield is about fifty per cent. The oil varies in consistency from that of hard lard or butter, to that of petroleum in the summer, and melts between 60° and 80° F. It is greenish-white or creamy-white in color, and has a lard-like odor, with, in most specimens, a certain degree of rancidity. Taste, when fresh, not disagreeable. It is a rather complicated substance, and contains free and combined fatty acids, both fixed and volatile. Among the principal glycerides are those of palmitic, caprylic, myristic, and lauric acids, also those of stearic, caprinic, and others. In the countries where it is produced, Cocoa-nut oil is used for all the every-day uses of such fats-food, fuel, soap, etc. In temperate climates it is not likely to dis- place the olive, cotton-seed, almond, and many other oils like them, with which those countries abound. It is, however, abundant and cheap, and when good, not dis- agreeable-and well adapted to fill the place of lard and other animal fats, in the preparation of ointments and cerates. It has been given as a substitute for cod-liver oil, but with no particular advantage. It is considerably used in soaps. Allied Plants.-There are some thirty species of Cocos, of which this is the most valuable. The nearly related Elms guineensis Jacq., of Africa, and one or two other species, furnish from their seeds, which are about as large as butternuts, an abundance of fat, the Palm Oil of African commerce. This palm is also cultivated. The oil, which is obtained by expression, is about as thick as butter, of a brownish-orange color, a sweetish taste, and, when fresh, an agreeable, fiower-like odor. Like the above, it is rather prone to become rancid-and whitish or grayish in color. It melts between 80° and 100° F., and consists of olein, palmitin, and free fatty acids. It is very extensively used in the manufacture of soaps, and very little used as an ointment, or for inunction, over stif- fened joints, etc. It has no special advantage over others of its class. For the order, see Areca Nut. Allied Drugs.-See Olive Oil. IF. P. Bolles. are thrown, as the fish are cleaned, into barrels, where they lie until putrefaction begins, and the oil escaping from the decomposing cells rises to the top this is then drawn off. Upon returning to the shore, the remaining pulp is boiled and the rest of the oil strained out. Such products are dark in color and offensive-smelling; they are unfit for medicine. The pale, sweet oils are made by fishermen who catch near shore, and every day or two land with their fish ; they separate the oil at once from the fresh and clean livers. The common way is to simply scald them in water until the tissues become disintegrated, when the mass is strained through cloths' the water and oil finally separat- ing from each other upon standing. The best method is to heat the livers in a vat or barrel by means of injected steam until they become softened, and then strain them and allow the oil to separate as above. Most of the fine oil used in this country is prepared in this way during the winter months, and then has also a portion of its stearin, etc., removed by freezing and expression. Most of our fine oil is manufactured on the New England coast; that of Europe, in Norway, Scotland, and England. The bet- ter grades of Norwegian oil are imported for medicinal use here, but not very extensively. Cod-liver oil has had some reputation as a medicine for a century or more, but its extensive and most important use in phthisis is less than half as old. The quality of oil suitable for dispensing is a pale yel- low liquid of faint fishy odor, and a peculiar, at first not very marked, but finally disagreeable, slightly acrid taste. It does not dissolve in alcohol, but, like all fats, is readily soluble in ether. Its specific gravity is about .922. " On the addition of sulphuric acid the Oil acquires a violet color, soon changing to brownish-red ; and if one drop of the oil be dissolved in twenty drops of di- sulphide of carbon, and the solution shaken with one drop of sulphuric acid, it will acquire a violet-blue tint, rapidly changing to rose-red and brownish-yellow. With nitric acid the Oil yields a purple color, changing to brown " (U. S. Ph). In addition to the above tests a cultivated taste and smell are necessary to judge of the quality, or even genuineness of the drug. Composition.-Although a complex mixture, it is not known how far its value depends upon its complexity; certain it is that the modern clear and comparatively agreeable oils contain less of the unusual ingredients than the older ones, and that some of these ingredients, at least, were products of decomposition of the livers, or empy- reumatic decompositions brought about by the method of manufacture. It is not fully proved that these clear and light oils are more efficient as medicines, but they cer- tainly are less disgusting, and can be taken by numerous persons who could not endure the others. The principal bulk of the Oil is olein, of which it con- tains seventy per cent, or more, and most of the rest is palmitin ; these with a little stearin constitute ninety-five or more per cent, of the whole, and are common to most oils, both animal and vegetable. There are further free acids, acetic, butyric, gadic, and others, several biliary substances, and finally iodine, bromine, chlorine, sul- phur, and phosphorus in composition, besides trimethyl- amin. It has been held that the peculiar value of this oil was due to the iodine and other haloids contained in it, but their exceedingly small quantity does not give much support to the view. The proportion of iodine is from 0.025 to 0.035 per cent. ;1 of the others still less. The biliary ingredients have also been suggested in this connection, with some plausibility ; but with our present knowledge we must confess that we do not know how truly, and that the estimation in which the medicine is held is based upon clinical evidence only. Action and Use.-This is the most readily absorbed and assimilated of oils. A loop of intestine containing it, compared with another containing another oil, is said to show an appreciable gain over the other in absorption. It is natural, therefore, that, added to other food, it should increase nutrition and the accumulation of fat. This quality is sufficient to explain its usefulness in the treat- ment of cases of simple emaciation, from bad nutrition. COD-LIVER OIL {Oleum Morrhuce, U. S. Ph., Br. Ph. ; Oleum Jecoris Aselli, Ph. G. ; Huile de Foie de Morue, Codex Med.). A liquid fixed oil, obtained from the fresh livers of the common codfish, Gadus Morrhua Einn., and two or three other closely related fish of the family Gadida. The foreign Pharmacopoeias recognize only that from the cod, while ours admits also that of the livers of the pollock, hake, and haddock, all species of Gadus, whose oils are hardly distinguishable from that of the cod, and, so far as known, equally good. The English and German Pharmacopoeias unite in requiring the oil to be expressed without much heat from fresh and sweet livers. The United States' does not limit the heat, but the requirements of the market here effectually exclude oils in any way injured in extraction. The French Codex recognizes also those obtained by allowing a preliminary decomposition of the livers before ex- pression, the brown oils, but advises against them. They are never used in this country for medicine, as their taste and smell are more disagreeable. The codfish is too well known to require description. It is very widely distributed and abundant, inhabiting the temperate and colder parts of both the Atlantic and Pacific Oceans. Cod-liver Oil is prepared in several ways, according to the character of the fisheries and the use to which it is put. If they are far from shore, as on the Banks, where the boats remain out perhaps for several weeks, the livers 221 Cod-Diver Oil. Coffee. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in chronic and wasting diseases, at the end of fevers, etc. So far, it can hardly be considered a medicine, but only a particularly fortunate form of non-nitrogenous food. It is emulsified and absorbed exactly as other oils are, and undoubtedly becomes, in the same way, a part of the bodily tissues. In this view, other oils should have the same effect according to their assimilability, and suitable doses of olive, linseed, and lard oils should be equally as good, and cream, from its state of emulsion, even better. Experience has not, however, confirmed their equality. The most important uses of Cod-liver Oil, moreover, are observed in a series of cases wdiose pathology is as obscure as the action of the remedy-such as the ' ' scrofulous " dis- eases whether glandular or ulcerative, lung-degeneration, chronic rheumatism, etc. It must in these cases act in some gentle and peculiar way upon the pathological pro- cesses, tending to return them to normal physiological ones, and in this respect is to be classed in the hetero- geneous number of medicines called alteratives. Attrib- uting this power to the iodine or biliary compounds discovered in the oil, as has been noticed above, is a mat- ter of pure theory, scarcely tenable. Its uses have been mostly noticed in the preceding sentence but may be re- capitulated a little more in detail. It is given, more than in any other disease, in phthisis pulmonalis. The long, wasting course of this complaint calls very distinctly for remedies that will prevent waste, on the one hand, and promote nutrition on the other. Alcohol and Cod-liver Oil may be regarded as types of these two therapeutic agents, and experience has long ago shown them to be two of the most generally useful things that can be given. Neither is a specific, neither appears in the slightest de- gree to change the character of the poison lying at the root of the complaint, but both retard the loss of flesh and strength, each in its peculiar way. The oil is often given alone in the early stages of the disease, and generally with advantage, as alcohol, in small doses, more readily loses its effect. It is also frequently combined with malt extracts, the hypophosphites, iron, iodine, arid other al- teratives or aids to nutrition. Besides the general action, the oil has an undoubted favorable effect upon the chronic bronchitis and catarrhal pneumonia present, and it is there- fore of value in the cough of consumption. It is also of great service in subacute and chronic idiopathic bronchitis (" colds in the chest "). In the persisting colds of infants and the aged, with a good deal of weakness, it has no equal. In chronic catarrh of various mucous membranes, ear, nose, vagina, urethra, etc., especially if attended with, or depending upon, debility, it is sometimes useful. In hip-disease, and similar degenerations of other joints ; in glandular abscesses, in chronic ulcers ; in short, wherever there is waste, emaciation, and thinness of blood, it is to be tried. The great obstacles to the fullest use of Cod- liver Oil are its taste, which is so repugnant to many that they can scarcely take it, and its liability to disagree with the stomach, and either to produce nausea and vomiting, or, what is equally disastrous, to impair the appetite and so to more than undo all its possible benefit. The different methods of administration mentioned below sometimes overcome this. Administration.-The dose of the Oil is from twelve to thirty cubic centimetres (12 to 30 c.c. = 3 iij. ad § j.) two or three times a day. If it can be taken clear it may be so given ; the taste, even of the best, is somewhat repul- sive, and becomes more so toward the last of the bottle in summer, as it rather easily becomes rancid. It is best, therefore, to purchase only a small quantity at a time, and to keep it as cool as possible. The taste may be disguised by means similar to those used with other oils (e.g., Cas- tor Oil, q.v) : rinsing the mouth thoroughly with whiskey, spirit of lemon, peppermint, or some such pun- gent vehicle, swallowing the oil at once, and again rinsing the mouth, is as good as any of the extemporaneous means used for this purpose. The liquor, if desirable, may be spit out. Large elastic capsules containing six or eight grammes ( 3 j. ad 3 ij.) are made, but not much used, on account of their expensiveness. The following combi- nation, when liquor is to be given with it, is a well-known favorite : Cod-liver oil 50 parts. Whiskey 35 " Comp, tincture of lavender 15 " It must be thoroughly shaken for every dose, as the oil immediately begins to separate. The lavender is only added as a flavor, and may be omitted. All oils appear to be less offensive to children than to adults. Another method is to mix it with about an equal part of one of the syrupy malt extracts ; the mixture does not separate so readily as the above. Its taste is well borne by children. Then there are the numerous emulsions made and advertised everywhere. They come under one of the following classes : First, mucilage emulsions, of which the following is an example : Cod-liver oil 50 parts. Oil of wintergreen 2 " Mucilage of tragacanth 15 " Water of orange flowers, sufficient to make 100 " A little " knack " is required to make it well. The mu- cilage is the emulsifying agent, and the oil should be added to it very slowly, and most thoroughly stirred until it is divided into invisible particles, before the water is added. The oil of wintergreen is only a flavor, which may be varied to suit. This makes a good, permanent mixture of about the consistence and appearance of thick cream. Instead of tragacanth, mucilage of acacia, about twice the amount, or a decoction of Irish moss, may be used. Second, egg emulsions: These are made like salad dressings, by using the yolk of egg as the suspending ingredient. The following is a good one : Cod-liver oil 50 parts. Oil of sassafras 3 " Chloroform 2 " Glycerite of yolk of egg 10 " Rose-water, enough to make.... 100 " Here the oil and the egg must first be "emulsified," when the other ingredients may be added-the water last. This is a thinner liquid than the preceding. The pancreatic emulsions are nominally made by emul- sifying with pancreatin, and are theoretically the most perfect of all, but are practically attended with some difficulty ;-the ordinary "pancreatin" of the shops will not make a good result, and of those claimed to be so produced some are made by means of added alkalies, others by the fresh pancreas itself, and some do not even contain any Cod-liver Oil at all. An ounce or two of perfectly sweet pancreas, chopped fine and mixed thor- oughly with a gallon of oil, will, it is said, suffice, when the oil is filtered off and mixed with water, to emulsify it perfectly. Like the other emulsions, it can be flavored to taste. Iodine, iron, the hypophosphites, and other suit- able additions can be made to all of them, but alcohol and tinctures are incompatible with the mucilaginous ones. Cod-liver oil is sometimes given by inunction to mar- asmic babies, with apparent benefit. Allied Fishes.-Several of these, as far as they possess any interest in this connection, have been mentioned above. Numerous other fishes of this and other genera have been long utilized for their oils, which are largely used in currying leather, and otherwise in the arts. Allied Drugs.-For the oils in general, see Oilve Oil. Compare also Malt, Iron, Iodine, etc. W. P. Bolles. 1 Hager: Pharm. Prax., iii., 122. CCELOM. This term is now generally used, by embry- ologists and others, to denote the body cavity in its widest morphological sense. There appears very early in the development of the vertebrate embryo a large cavity lined by mesoderm on each side of the body. The two cavities are entirely distinct, and the surfaces of each are covered by a continuous layer of epithelium (mesothe- lium). Between these two spaces lies the intestine with the mesentery. Subsequently the mesentery on the ven- tral side of the intestine disappears, so that the two cavi- ties are fused and thenceforth correspond to the body cavity of anatomists. In the mammalia the anterior part 222 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cod-Liver Oil. Coffee. of each cavity becomes separated off, to make one of the pleural cavities. It is thought by some writers that the pericardial space is also a derivative of the primitive coelom, but further investigations are necessary to settle that point. Besides these parts there also arise from the coelom a series of paired hollow sacs of epithelium, which afterward separate entirely from the main cavity. These sacs, which make a regular row on each side of the dor- sal axis of the embryo, were thought by the early embry- ologists to be the beginnings of the vertebrae, and accord- ingly they gave them the name of proto-vertebrae, and, although it is now known that they have nothing to do with the origin of the vertebrae, they are still often called by their old name. In reality, they develop into the striped muscles of the body, and hence are better named the muscular segments or myotomes. The epithelium of the body cavity is converted, for the most part, into the peritoneum and pleura, but along cer- tain dorsal areas of the abdominal cavity it is transformed into essential portions of the urogenital apparatus. The morphologist then includes under derivatives of the coelom : 1, the pleuro-peritoneal spaces, and perhaps the pericardial cavity ; 2, the striped muscles of the body ; 3, the peritoneum and pleura ; 4, the sexual glands; 5, the urinary glands ; 6, the urogenital ducts. For details see under Fcetus. It is probable that the coelom is always a derivative of the embryonic digestive canal (entoderm), or, as it has been called, an enterocoele. It has been supposed that the body cavity in some ani- mals arose by the splitting of the mesoblast-so-called schizocale. The nature, origin, and metamorphoses of the coelom are treated under Foetus ; this article aims only at giving a definition. C. S. Minot. can coffees larger and greenish- or bluish-gray. Mocha has the richest flavor, Java is one of the most delicate, and the West India and Brazilian kinds are coarser and less fragrant. Age, before they are roasted, improves them all. The annual consumption of this seed is said to be twelve millions of pounds (Bentley and Trimen, i., 144). Coffee is raised in orchards, where the trees are set in rows; trimmed and tended, they are long-lived and bear for many years. Two crops are usually produced each year. The pulp of the fruits is separated, usually by mechanical means, and the papery endocarp, when dry and brittle, broken apd rubbed away. The testa of the seed is usually also absent in commercial coffee, except- ing on the face, where it enters the ventral fissure. Composition.-The most interesting ingredient, Caf- feine, is described elsewhere. It occurs in coffee in com- bination with caffeo-tannic acid, in varying proportions between one-half of one per cent, and two and three-tenths per cent. The quality of the coffee, as usually estimated, bears no relation to its amount of alkaloid. Of the caffeo-tannic acid the yield is from four to five per cent. It is of the series which give green salts with the persalts of iron. Besides these are fixed oils, from fourteen to twenty-two per cent., dextrin from fourteen to sixteen per cent., a large amount of albuminoid matter, and a very COFFEE {Cafe, Codex Med.). Coffee itself is not offi- cial in the present Pharmacopoeias of the United States, Great Britain, or Germany, having been replaced by its alkaloid (see Caffeine). The Coffee plant, Coffea Arabica Linn., Order Rubiacea, is a good-sized shrub or small tree, with opposite spread- ing or horizontal branches, and dark green glabrous, nearly evergreen leaves. These are stipulate and short- petioled, entire, ovate-acuminate, and opposite. The flowers grow in close clusters in the axils of the leaves ; they are white, and about one centimetre (one-third to one-half inch) in diameter, and convolute in the bud. Calyx small, its tqbe adherent, its limb nearly obsolete. Corolla funnel-shaped, with spreading five-lobed border, bearing the five stamens at its throat. Ovary two-celled, style single, stigmas and ovules two. The fruit is an oblong, rounded, scarlet or purple, slightly juicy berry, with a thin, fleshy mesocarp, and a papery endocarp, loosely enclosing the two seeds. It is about two centi- metres long (one-half to three-fourths of an inch). The seeds are the coffee of commerce; they vary in size from seventy-five to one hundred millimetres in length (one-fourth to one-half of an inch) ; they are ob- long-ovoid, rounded at the ends, convex upon the dorsal and flat upon the ventral surface, with a longitudinal fissure upon the latter, produced by an irregular infolding of the albumen itself. Embryo very small. The color of the prepared (decorticated) seeds varies between yel- lowish-gray and grayish-green, and, with the size, is noted in distinguishing the numerous varieties from, each other. This shrub is a native of tropical Africa, where it grows very extensively upon both coasts, and far into the in- terior. It is also cultivated in most of the warm parts of the earth, especially in Java and Brazil. The earliest knowledge of coffee came from Arabia, where it was introduced from Abyssinia at least four hundred years ago. Its use was introduced into Europe by way of Constantinople, reaching London and Paris about the middle of the seventeenth century. Its culti- vation was begun in Batavia at about the end of the same century, and in the beginning of the next it was being raised in India, Brazil, and the West Indies. The plants and the berries of these different countries present slight variations. Mocha coffee is small, plump, and dark yel- low ; Java larger and paler, and the Indian and Ameri- Fig. 723.-Branch of the Coffee Tree, Coffea Arabica, with Fruit. (Bailion.) minute amount of volatile oil. Roasting changes the character of coffee very materially, dissipating a little of its caffeine and most of its water, and forming some fragrant decomposition products not much understood. The seeds lose about fifteen or twenty per cent, in weight, and gain much more than that in volume. The sugar and dextrin are changed to caramel, and the soluble por- tions in general are diminished. Unground coffee is seldom adulterated, although it is said to have been mixed with castor-oil seeds (which have about the same size and shape, and are easily recognized by simple inspection) ; but ground coffees are apt to be adul- terated, the world over, by grains of various kinds. These and chicory roots are the most important admixtures. It is better to purchase the whole seed than to puzzle over the mixtures. Pure ground and burnt coffee shaken in water does not immediately discolor it, as most of the imi- tations do. Action and Use.-The effect of coffee is in the main the same as that of caffeine, a nervous and cardiac stim- ulant ; but it has, in addition, a pleasant, exhilarating effect upon the feelings, which is probably in part also due to aromatic ingredients contained in it, or developed by the roasting. It is occasionally given for sick- and neu- ralgic headaches, and to counteract the disagreeable after- effects occasionally produced by opium ; and in opium- 223 Coffee. Colcliicum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. poisoning, which it mildly antagonizes by its stimulating effects upon the brain and circulation. The universal use of coffee, however, greatly restricts its usefulness as a medicine. Its excessive use, or its use by those unfortu- nately sensitive to it, produces wakefulness, ' ' nervous- ness," confusion and incoherence of thought, palpitation, and irregular action of the heart and dyspeptic disorder. The dose of coffee for, say, headache, is from fifteen to twenty grams (§ ss.) in infusion, that is, a cupful made strong and '' black." A fluid extract is to be had if desired. Allied Plants.-There are twenty species of Coffea natives of tropical Asia and Africa, several of which con- tribute a part to the total yield. One of these, Coffea liberica, of western Africa, produces a larger seed, with a strong, full, but rather rank, flavor, known as Liberian coffee. Coffee leaves themselves contain caffeine, and are used as a beverage in the East. For the order, see Cinchona. Allied Drugs.-Tea, Kola Nuts, Paraguay Tea, Guarana, and more remotely Coca. See Caffeine. W. P. Bolles. The gases are nitrogen, carburetted hydrogen, carbonic acid, and oxygen. These are disengaged at regular in- tervals, bubbling up from the bottom of the spring. The waters of Coeze are taken internally in doses of from two to eight glasses, at intervals of fifteen minutes, in the morning, fasting. The duration of a course of treatment at the Saulce spring is from twenty to twenty-five days. The waters enjoy a great reputation in the treatment of goitre and cretinism, and are also recommended for anae- mia and chlorosis, scrofula with glandular hypertrophy, digestive troubles associated with enlargement of the liver and spleen, eczema, psoriasis, and other skin affec- tions. T. L. S. COLCHICUM {Colchici Radix, U. S. Ph. ; Colchici Cor- mus, Br. Ph. ; Colchici Semen, U. S. Ph. ; Colchici Sem- ina, Br. Ph. ; Semen Colchici, Ph. G. ; Colchique, Codex Med., bulb, flower, seed; Meadow Saffron). Colchicum autumnale Linn., Order, Liliacece Colchicece, is a bien- nial, or by lateral budding perennial, herb, with a very COHOSH, BLUE (Caulophyllum, U. S. Ph. ; Pappoose Root, Squaw Root). The rhizome and rootlets of Caulo- phyllum thalictroides Michx. (Leontice thalictroides Linn.); Order, Berberidece. This is a perennial herb, with an erect, smooth stem, about fifty or seventy-five centimetres (20 to 30 inches) high, bearing a thrice-ternate leaf above the middle, and a raceme of greenish-yellow flowers at the top. The rhizome is horizontal, thick, crooked, scarred above, and covered below wdth numerous roots. It is a native of rich, damp woods, over most of the United States, and grows also in Japan and Mantchuria. It was a favorite remedy in labor among some tribes of the North American Indians, as its vernacular names indicate. The dried rhizome is thus described in the Pharma- copoeia: "About four inches (10 centimetres) long, and about one-fourth to two-fifths of an inch (6 to 10 milli- metres) thick, bent; on the upper side with broad, con- cave stem-scars, and short, knotty branches ; externally, gray-brown; internally, whitish, tough, and woody. Rootlets numerous, matted, about four inches (10 centi- metres) long, and one twenty-fifth of an inch (1 milli- metre) thick, rather tough ; nearly inodorous ; taste sweetish, slightly bitter, and somewhat acrid." There is nothing in the composition, as far as known, of this substance that would indicate for it any special value. Besides albumen, gum, starch, resins, etc., it contains saponin, or something like it. It has, however, consider- able employment, chiefly among irregular practitioners, as an emmenagogue, diaphoretic, uterine stimulant (in labor), etc. Dose, three or four grams (3 j.) in decoction. Allied Plants.-See Barberry. Allied Drugs.-The power and value of Blue Cohosh are too doubtful for interesting comparison. A list of Emmenagogues, etc., will be found under Ergot. W. P. Bolles. COISE is h small town in the Department of Savoy, France, much frequented during the season by invalids coming to take the waters. The town, known also as Coeze, lies at an elevation of about seven hundred feet above the sea, and enjoys a rather mild climate. There is one spring at Coise, called the source de la Saulce, the composition of which, according to an analysis made by M. Morin, is as follows : Each litre contains- Gramme. Sodium bicarbonate 0.8138 Magnesium bicarbonate 0.0191 Ammonium bicarbonate 0.0151 Calcium bicarbonate 0.0113 Potassium bicarbonate 0.0045 Sodium chloride 0.0041 Magnesium chloride . 0.0034 Magnesium iodide 0.0077 Magnesium bromide 0.0015 Aluminium silicate 0.0162 Magnesium sulphate 0.0033 Ferric oxide 0.0020 Glairine 0.0122 Earthy phosphates traces Fig. 724.-Colchicum. Flowering plant, one-half natural size, and de- tails of structure. (Bailion.) short subterranean upright stem, arising from the apex of a corm, and having at its side another corm, either younger or older according to the season. It sends up, in the autumn, from one to three crocus-like flowers, and, in the following spring, the partly grown capsules of these flowers, enclosed in a scanty rosette of long, weak, strap-shaped leaves. These come to maturity and dry up by the middle of the summer. The flowers appear in September or October, after the vegetation of the previous generation has disappeared, springing from the bare ground, enclosed only by a spathe-like bract. The ovary is subterrannean, and does not come above the surface until the following spring. It consists of three partly united, many-sided, superior carpels, surmounted by three very long filiform styles, which reach to the top of the flower. The perianth con- sists of an elongated, slender, whitish tube, and six nar- Total solids 0.9142 224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coffee. Colchicum. rowly oval, reddish-lilac segments, in two series. Stamens six, arising from the throat of the perianth, with versatile anthers. The fruit ripens in June, when the nearly sep- arate follicles split along their ventral sutures and dis- charge the numerous small seeds. As these are officinal they will be described below. The corm of Colchicum, in the latter part of the sum- mer, when it is usually gathered, is principally composed of that portion which has just done service in ripening the fruit. It is about five centimetres long by four in width (2 x 1| inches), and enclosed in two brown papery coats. It is irregularly pear-shaped, rather pointed above, blunt and oblique at the base, and flattened and grooved on one side. At the apex is the scar or remains of the now decayed aerial vegetation. At the base, on the flat- tened side, is attached the new bud which is to produce the flower in the autumn, enclosed in the general cover- ings above mentioned. Later in the season the stem and sliced transversely and dried by the aid of gentle heat. Their quality is very sensitive to carelessness in drying. The seeds are simply collected when ripe. It has been known as a poison since the time of Dios- corides, but, as a medicine, only for the last two or three hundred years. Its first admission to the London Phar- macopoeia was in 1618, and, thirty-two years after, it was dropped, and did not reappear in it until 1788, since which time it has been in regular employment (Pharma- cographia). Description.-The slices into which the corm is cut are about three milliinetres (one-eighth inch) thick, and from one to three centimetres in diameter, according to their position. Their cut surfaces are white or grayish- white, their edges (surface of the corm) brownish-yellow. In shape they vary a little ; those cut from the upper part may be simply round, but those of the middle and lower portions are flattened or indented at one side, where the flower-buds lay, or they may even be typically kidney- shaped. The drug is occasionally sliced vertically, when the slices will be more or less ovate. Even the whole corms are sometimes met with. They are hard, brittle, and loaded with starch. Taste very bitter and acrid, odor simply earthy. Colchicum Root, which is very dark colored internally, or breaks with a horny fracture (show- ing too much heat used in drying), should be rejected. The seeds are of more modern use, having been intro- duced about sixty years ago. They are globular, about two and a half millimetres (one-tenth inch) in diameter, slightly pointed at the hilum ; surface brown, rather rough and dull ; odor none ; taste bitter and acrid ; text- ure very hard. Composition.-The corms, in drying, lose two-thirds of their weight, and, when about dry, consist largely of starch, in fine rounded, by mutual pressure, polyhedral, and sometimes compound grains. Sugar, gum, oil, tan- nin, etc., are other common substances contained in them. The seeds also contain sugar, oil, gallic acid, etc., as in- cidental constituents. Both contain, as their peculiar principle, the intensely active substance colchicin, in small quantity-in the " root" from 0.05 to 0.2 per cent., in the seeds about 0.2 per cent. It is also present in the leaves. Colchicin is a pale brownish-yellow, exceedingly bitter powder, of very doubtful alkaloidal properties. It is freely soluble in water, and occasionally used instead of the crude Colchicum. Action and Use.-Colchicum and colchicin (as well as the decomposition product colchicein, which is never used) act exactly alike in the system, varying only in de- gree. Colchicin will, therefore, be taken as the type. It is a very active poison, killing animals of every class, but it is especially obnoxious to the carnivora and man ; thus, according to Rossbackand Wehmer, five milligrams (0.005 Gm. = gr. are sufficient to kill a good-sized cat, and three centigrams (0.03 Gm. = gr. ss.) would be fatal to man; while guinea-pigs and frogs require, respectively, three and two centigrams (0.03 and 0.02 Gm. = gr. ss. et gr. |) to accomplish the same result. It is slow in its ac- tion, and this is not much accelerated by increasing the dose. Important effects are produced both upon the central nervous system and upon the alimentary canal. In frogs and other cold-blooded animals an early period of spinal stimulation, as shown by convulsions, is ob- served. But this is less marked, or wanting, in warm- blooded animals. Central paralysis-loss of motion, sen- sation, consciousness, etc., are common to all. But the most interesting feature, from a medical point of view, is the violent disturbance of the alimentary system that it occasions. Persistent vomiting, purging, pain, and fin- ally acute gastritis and enteritis, follow its absorption. The ejecta become bilious and bloody ; the copious dejecta at last consist of mucus, flakes of lymph, serum, and blood. Excessive prostration is a natural consequence, and death may occur several days after taking the poi- son, as a secondary result of the inflammation. The mucous membrane of the stomach and intestines is found, after death, to be thickened, softened, and intensely in- jected. Whether taken by the mouth or subcutaneously, the effect in this respect is the same. Locally, colchicin Fig. 725.-Colchicum. Plant in fruit, and enlarged seed. (Bailion.) flowers of the young bulbs form a column at the side of the old one, fitting into its flattened or grooved surface, and having the appearance of being simply a lateral bud of the older corm. During the following spring, how- ever, the elder tuber shrivels away, and the new one, as its fruit ripens, becomes large and plump, and, in its turn, develops a junior for the succeeding fall. An ex- actly similar mode of propagation is to be seen in the Aconite plant (vol. L), which is, however, in all other re- spects very different. Colchicum is a native of Middle, Southern, and Eastern Europe. It is frequent also in England, and occasionally cultivated, for its pretty but sombre flowers, in this coun- try. Our medical supply of the root comes principally from England and Germany. The corms are usually collected in, or shortly after, midsummer, when they are the plump- est and finest looking. From this time until fall they do not change much, and if gathered when in flower would be, probably, equally good. They are sometimes used abroad in the fresh state; sometimes also dried whole. Usually, however, and always for this market, they are 225 Colcliicuni. Cold. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is irritant; applied to the skin it produces redness, snuffed into the nose it is sternutatory. The effect of small doses is similar to that of large ones, excepting in its degree- some prostration and lowering of the pulse-rate, colicky pains, nausea, loss of appetite, and purging. Occasion- ally sweating, vertigo, headache, muscular weakness, etc., occur. These symptoms indicate the limit beyond which it should never be given in medicine. On the other hand, still smaller doses which do not occasion special discom- fort, are often more useful for continuous administration. According to Rossback, it does not exert any marked effect upon the heart. Its action upon the kidneys has been the subject of many discordant observations, most of them quite old. Judgment upon them must still be reserved. Unless connected with its asserted power of increasing the uric acid, etc., in the urine, the value of Colchicum in medicine must be acknowledged to be based upon em- piricism only. The doses in which it is believed to be most efficient are often small, and not productive of ap- preciable physiological disturbances. The one disease for which it is almost always given is gout. Indeed, it is generally spoken of as a specific for that distressing mal- ady, whether in full doses during the attack, or in lesser ones, long continued, as a preventive during the interval. Sometimes it is combined with salines like Epsom salts and magnesia, frequently with opiates; both of these methods have their advocates, and probably their advan- tages in different types of the disease. In chronic rheu- matism Colchicum is less useful, in acute and in subacute forms scarcely at all so. Quite naturally, the use of this medicine is far more restricted in this country than in England. It should never be used as a simple cathartic. Administration.-The powdered " Root" may be ad- ministered in substance. Dose, from one to five deci- grams (0.1 to 0.5 Gm. = gr. ij. ad viij.*). That of the pow- dered seed should be something less, but it is not often used. The preparations are unnecessarily confusing. There is a Fluid Extract of each (Extractum Cokhici Radicis Fluidum, U. S. Ph., and Extractum Cokhici Seminis Fluidum, U. S. Ph.) of the same pharmaceutical strength (}); but as the seeds are generally more active, their doses should be different, as stated above for the seed and " Root." There is also another unnecessary duplication in a wine of each (Vinum Cokhici Radicis, U. S. Ph. ; Vinum Cokhici Seminis, U. S. Ph.), the former made with forty, the latter with fifteen per cent, of the active ingredient. Doses theoretically based on the above dose of the crude article should be from twenty-five to one hundred and twenty centigrams (0.25 to 1.20 Gm. = v. ad xx.) of the former, and say, from fifty to two hundred of the latter (0.5 to 2 Gm. = viij. ad xxx.) ; but about three times as much as these doses is generally directed. Besides these, a solid Extract is also made of the root {Extractum Cokhici Radicis, U. 8. Ph.), "dose, one decigram," and a Tincture of tlie Seeds {Tinctura Cokhici, U. 8. Ph.) of the same strength as the Wine of the Seeds. Two of the above preparations would have been ample, and if the usual dose is a criterion, all of them must lose very much in strength from the standard of Colchicum itself. Colchicin is seldom given; one-half milligram is about a dose (0.0005 = gr. T|o). Allied Plants.-Several species of Colchicum were, at least in part, the source of similar corms, called Her- modactyls, and imported into Europe from Asia Minor and the East, but they are now obsolete. They have no value. For the order Liliacece, see Squill. Allied Drugs.-Colchicin resembles Veratrine very closely in many respects, also Tartar Emetic in some of its qualities, and the drastics in general. Iodide of Potash, Aconite, Arsenic, Lithium, Sulphur, Strychnia, etc., are a few of the miscellaneous remedies which are associated with it as remedies for gout. W. P. Bolles. COLD, EFFECTS OF. The sources of precise knowl- edge regarding the action of cold are the relations of voy- ages and military expeditions, the accounts of balloon and mountain ascents, the ■works of the experimental modern school, and the researches of forensic medicine. The sensation resulting from the absence, loss, or dim- inution of heat is too well known to require definition. As a rule, any temperature lower than the average human temperature causes this peculiar sensation. Cold has no absolute sense ; it is only diminished heat accompanied by relative sensations. The incongruity existing between heat and cold, as experienced by the human body, and the actual temperature as revealed by the thermometer, hav- ing been observed by travellers and experimenters, has given rise to the distinctions of thermometric cold and physiological cold. I have on several occasions observed these relative sensations in different latitudes. On a polar voyage to the Siberian Arctic, in the middle of July, I have seen the decks covered with snow and hail, that was accompanied by a bitter cold wind that penetrated one's winter clothing, and a fewr days afterward, when the ther- mometer registered but 45° F., the heat was quite uncom- fortable. Again, in the latter part of June, at St. Michael's, Alaska, the sun was found almost overpowering, although the thermometer registered but 60° F. In striking oppo- sition to this is the piercing cold that I have experienced on being exposed to a " Levanter " in the vicinity of the Mediterranean Straits, and to Texas northers, during the continuance of which the cold is felt more acutely than it would be in the Arctic regions. This phenomenon is also noticed among the Andes in Peru. A disagreeable sensation of cold, not indicated by the thermometer, is one of the experiences of travellers in that part of the world, the cold being keen and penetrating with the mer- cury standing at but 60° F. It is proposed to distinguish these phenomena as physical cold and physiological cold, the former indicating that revealed by the thermometer, the latter that not indicated by instruments. Arctic travellers have noticed this relative sensation of cold, as well as the impunity and even certain degree of comfort, with which they can expose themselves to a low temperature that would be attended by serious results in a more southern latitude. Ross relates that after support- ing cold of - 47° F. his companions experienced an agree- able sensation in a temperature of -29° to -24° F. Dr. Hayes relates that in Greenland he swam in a pool of water on the top of an iceberg, and the captain of a New Bedford whaler has often gone swimming off the coast of Arctic Siberia. On one of these physiologically warm days that sometimes occur in the high latitudes, I plunged into the icy waters of Kotzebue Sound, and after the momentary sideration to the nervous system that accom- panied the shock had passed away, there was no great discomfort. The swim was, moreover, followed by a pleasurable reaction. Not the least curious phenomenon of the regulative functions of the pyrogenetic mechanism is the influence that increases the resistance to cold, such, for instance, as the actual rise of temperature that follows upon strip- ping in a cold atmosphere, or upon first entering into a cold bath ; and a subject worthy of special mention, and by no means distantly related, is the busy activity of the metabolic tissues, and the metabolism of the food within the alimentary canal, which accounts for the heat of such homothermous animals as the whale, the seal, the walrus, and the pygopodous birds. There are still among the problems of science the physical and chemical law s that may explain this morphological process-this physiolog- ical action of the protoplasm resulting in the evolution of kinetic energy sufficient to supply the bodies of such ani- mals with iieat, and thus enable them by remarkable adaptability to withstand extreme Arctic cold. Whether the retia mirabilia of the whale and of the duck enable them to combine a greater quantity of oxygen with hae- moglobin, which thereby acts as a source of heat, or whether the function of the liver is the chief thermogenic source, is still a question requiring a solution. Equally so is the question as to what means the energy-yielding material becomes changed into actual energy. It may be * This dose, from the British Pharmacopoeia, probably refers to a fresher article than we ever have. Colchieum is a very variable drug, and must be tried tentatively at first. 226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colchicum. Cold. that the nervous system, acting as a liberating force, like the throttle-valve of a steam-engine, removes hinderances or impediments to the conversion of potential into kinetic energy ; or that all the internal work of the animal organ- ism, all the mechanical labor of the internal muscular mechanism, with their accompanying frictions, and the molecular labor of the nerves and the other tissues pro- duce a certain amount of animal heat, and thus account for the special function of calorification. The physiological action of cold upon the nervous sys- tem, although not studied with so great care as the effect of cold upon the circulatory apparatus, deserves a promi- nent place, since it is through the medium of the nervous system that results the instinctive comparison of two mesological conditions, or of two bodies unequally warmed, or, in other words, the sensation of cold result- ing from the subtraction of heat. This sensation, as before explained, is not always accompanied by loss of heat, and may be purely subjective. Common instances are seen in the cold stage of intermittent fever, which shows an elevation of temperature much above the nor- mal, not only during but preceding the appearance of the chill. The sensation of cold in other cases is not pro- duced, in spite of a real and progressive cooling of the body. This is noticeable in the algid attack of perni- cious fever; and it is stated that the mercury marks a de- gree of temperature inferior to the normal during the sensation of heat that accompanies the reactive stage of a cold bath. Sensibility to cold may be exaggerated, per- verted, or abolished in some diseases of the nervous sys- tem. In locomotor ataxy with greatly diminished general sensibility, patients have been known to be unable to wash in cold water without experiencing the keenest pain and subsequent discomfort. The sensation of cold is some- times replaced by a disagreeable burning sensation in myelitis, when a piece of ice is placed on the skin of the trunk. On the other hand, swimmers accustomed to passing hours in water become quite insensible to cold. The state of the mind also modifies the power of resist- ance to cold, the body becoming more or less insensible to the impression by the intervention of ecstatic thoughts, lively emotions, or mental derangements. Familiar in- stances occur in religious devotees ; in delicate women who, through vanity, forget their habitual sensibility to cold and expose the neck and shoulders to freezing tem- peratures ; and in the insane, who often go stark naked in winter without being affected by the cold. Very little is known of the causes of these differences in the sensation of cold. From a neurological point of view they have been studied by various observers, and among the most important conclusions touching the subject are those of Drs. Mitchell and Richardson. Everybody knows of the anaesthetic use of cold in surgery. Accord- ing to Horvath (Centralblatt, 1873, p. 209), alcohol at -5° F. leaves intact the sense of touch, while suppressing that of pain, a fact that leads him to believe that the senses of touch and of pain possess special apparatuses of reception and of transmission. He has utilized this prop- erty of cooled alcohol in causing the disappearance of pains from burns, and thinks that this means of pro- ducing local anaesthesia is to be preferred, since it has none of the inconveniences of ice or of the spray appa- ratus. The study of cold upon the nerves has been almost ex- clusively confined to its action upon their peripheral ex- tremity ; the effects of cold upon the nerve-centres is yet to be studied. While the energy of the nervous system is increased, and intellectual work is favored by moderate cold, the reverse effect is produced if the cold be exces- sive. The benumbing influence of cold upon the intelli- gence is one of the stock observations of writers who contrast the thick intelligence of northern people with the noisy and talkative southerner, and with the exalted irri- tability in love, vengeance, and the other passions of the Arabs, Bedouins, Abyssinians, and Moors of the burning deserts. These differences, even admitting them to exist, are not questions of heat or cold, but rather of race and of mesological condition, since Eskimos are more gay, lively, and talkative than the individuals of many races outside of the Arctic circle, and the heavy Hollanders during the prevalence of severe cold becoipe as lively and gay as the French. Moreover, it does not appear that the Montreal ice carnivals are less wanting in gayety than the Mardi-Gras festivals of New Orleans. Paralysis of the will-power has been noted by various persons while in the polar regions, the exposure being attended by slow- ness of the mental operations and many of the symptoms peculiar to drunkenness. I have several times experi- enced these symptoms, once immediately on entering a warmed apartment with another person, who was affected in the same way. .Temporary amnesia is one of the ef- fects of severe cold. An invincible tendency to sleep is a well-known phenomenon attending prolonged exposure to a low temperature. This, however, does not seem to occur when the body is immersed in water at a low tem- perature, as the experience of shipwrecks has proved. In studying the biological action of cold, it has been observed that everything that freezes does not necessarily die. Germs, grains, and insect eggs may support intense degrees of cold and yet preserve their vitality ; a frozen frog's heart when thawed will pulsate ; and stiff-frozen frogs and fish have been known to come to life and thaw visibly. In spite of the constant low temperature of the polar seas, the bottom swarms with submarine life ; pro- digious numbers of animated beings live in the free air at an average temperature of -50° F. ; and algae flourish in a constant temperature of -35° F. The famous lon- gevity scheme of John Hunter, which furnished a motive for a French novel, was founded on observing the resus- citation of frozen frogs. Hunter was, however, com- pletely disillusioned after a simple experiment, which convinced him, as it has done subsequent observers, that an animal cannot be completely frozen and live, doubtless for several reasons, the most prominent of which is the increase in volume of the liquid contents of the body in passing to the solid state, and the consequent rupture of the tissues, which give way in obedience to physical law. Certain animals and plants possibly resist freezing by virtue of what may be called anatomical determinism. A hibernating frog resists a degree of freezing from which it would promptly die when its body is gorged with wa- tery juices, as is the case in warm weather ; and it is in consequence of a similar anatomical disposition that dried grains preserve their germinative power after having been submitted to low temperatures, and that ligneous plants resist the cold better than herbaceous plants. The paralyzing action of intense cold leads to dimin- ished vitality of all the anatomical elements, and finally to their death. The motions of the leucocytes and of the vibratory cilia disappear under its influence, and the nerves gradually lose their function. It is without doubt the toxic effect of intense cold on the blood-globules that causes the weakness and somnolency, the disturbance of the sense-perception, of memory, and the comatose state that overwhelms belated travellers in the snowy wastes of the polar regions. Experiments show the first effect of cold to be contraction of the capillary vessels, then altera- tion of the globules, which become crenelated on their edges and dark in color. When the temperature of a rabbit placed in a freezing mixture has reached 50° F., the reflexes still persist, but with extreme slowness, and the electric reaction of the muscles becomes feeble, slow, and prolonged in the descent. The animal may be appar- ently dead for half an hour, and yet be recalled to exist- ence by warmth and artificial respiration (see Death, Signs of). Some animals, like plants, follow the oscillations of the exterior temperature. The same degree of cold al- ways leads to the same effects on marmots and on grape- vines ; but the superior animals may live in the most in- tense temperature. In the human species this force of resistance is measured by other conditions than cold. These conditions are internal and external. The state of the organism at the time of exposure and other individ- ual conditions may either exaggerate the action of cold or augment the force of resistance. The differences in the impression of cold during a wind and during a calm are too well known to require com- 227 Cold. Cold. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ment. The sensation is also keener under the influ- ence of dampness of the surface of the body, evapora- tion, rarefied atmosphere, a high altitude, and nocturnal radiation. Among the internal conditions that exagger- ate the susceptibility to cold is age; old marasmic peo- ple, in whom the heat-producing power is feeble, being particularly sensitive and liable to accidents from cold, and the new-born become more suddenly reduced from this cause than older persons. The same cause that makes young animals offer such a great resistance to as- phyxia doubtless accounts for the facility with which they succumb to cold. Alcohol, taken in toxic doses, re- duces the temperature and diminishes resistance to cold, and it is proved experimentally that analogous effects follow the administration of such substances as opium, cyanhydric acid, gelseminum, digitalis, belladonna, to- bacco, euphorbia, and camphor. Notwithstanding these experiments the experience of travellers in cold countries is that alcohol, taken in mod- eration under the form of beer, is one of the best antago- nists to cold. There is an absolute consensus of opinion, both among executive and medical officers of late Arctic expeditions, in regard to the moderate and judicious use of alcoholic beverages. The pronounced taste of the northern inhabitants for strong drink, and that indescribable northern craving for spirits even among persons that care nothing for them in lower latitudes, seem to warrant the assertion that, under no circumstances or conditions, are beer and claret more palatable or more valuable from a hygienic point of view than when taken at meals during an Arctic voyage. All asphyxiating or debilitating influences, hunger, fa- tigue, mental depressions, exaggerate the influence of frigorific effects on the organism. Vanquished and demoralized armies are particularly susceptible to the morbid effects of cold, and the history of the disastrous effects of cold in armies is so full of in- struction that the facts at once arrest attention. In the armies of Xenophon and Alexander a great number of men perished from cold. At the siege of Metz, in December, 1552, the army of Charles V. sustained great loss by deaths from cold. Ambroise Pare speaks of having treated soldiers who from extreme cold had lost their ears, the half of an arm, the toes, and even the virile member ; and Fabricius Hil- danus says that the German army dispersed in France in 1568 lost heavily from the effects of cold. In 1719 seven thousand Swedes, who had set out to besiege Drontheim, perished with cold in the mountains that divide Sweden and Norway. These accidents from cold are, however, almost trivial when compared with those attending the disastrous re- treat of the French from Moscow, and the siege of Sebas- topol (see Army Diseases). To state the morbific influence of cold, as related by some authors, would be almost to repeat the nosological table. As an exciting morbific cause its influence has been greatly exaggerated, and many morbid conditions are attributed to cold in which this agent in reality takes no part, or is only an accessory. Many old, and even some contemporary, authors rank under the head of maladies from cold such general diathetic diseases as gout and rheumatism. That cold may occasionally provoke an attack of either of these diseases may be admitted, but to speak of it as a pathogenic cause is just as absurd as to say that cold causes typhus and scurvy, or cirrhosis of the liver and chronic nephritis. Although we may eliminate many diseases, the origin of which is improp- erly attributed to the effects of cold upon the organism, or in which this agent is only an indirect or quite acces- sory fact, yet the importance of cold as a cause of dis- ease or of death brings us into the presence of a great number of affections that arise more or less directly from cold. The subtraction of heat from the human body may be the cause of local accidents (see Chilblain and Frost-bite), or of general accidents. Owing to the troubles of the peripheral circulation panaris is of fre- quent occurrence in cold regions, having been noticed particularly among the crews of ships off Iceland and Newfoundland, and among Arctic whalers. Cold may be the direct cause of sudden death by asphyxia. It may also hasten death in a state of drunkenness. After a pub- lic fete in St. Petersburg, during which an unlimited supply of spirituous drinks was placed at their disposal, eighteen hundred persons perished from cold in the streets and public squares. According to official docu- ments, it is estimated that in Russia about seven hundred deaths occur every winter from the direct and immediate effects of cold, to which number must be added the bodies discovered in spring after the lakes and rivers have thawed. Out of six hundred and thirty-five judicial au- topsies at Kasan, fifty-seven concerned frozen corpses, about nine per cent, of the total number. At Riga the proportion is about the same. A proportion of two per cent, is estimated for Western Europe. The reports of criminal justice of France show that between two hun- dred and three hundred persons succumb yearly to the combined influences of cold, hunger, and fatigue ; and of the four hundred or five hundred others whose acci- dental death is attributed to alcoholism, it is fair to pre- sume that cold also had its part of action. The accidental death of drunken individuals who stray off into lonely places and unfrequented streets and perish during the nights of winter is a common occurrence in all our large towns, and such circumstances may give rise to the most complex medico-legal questions. The action of cold on the organism is so variable that it is impossible to give the exact point to which temperature may be lowered be- fore death occurs. It may be lowered to 86° F. in a cold bath ; a woman drunk and frozen, with a vaginal temper- ature of 78° F., is known to have recovered; a drunken man exposed during the night at a temperature of 33° F. has been known to survive, although the rectal tempera- ture was down to 75° F. ; persons have been buried for days in snow and have recovered ; and hyperborean trav- ellers have resisted with impunity the prolonged action of temperatures that seem almost incredible to other persons, which goes to show that with good food, warm clothing, a shelter, and moral energy the organism may resist for a long time even the severest polar cold. On the other hand, a slight degree of cold may suffice to produce frost-bites and cause death. This has been observed more particularly in the disastrous retreats of armies, notably those of the French, not only in Northern Europe, but in Africa. One of the effects of cold, when not counterbalanced by hygienic means, is the pernicious anaemia of high lati- tudes. In this affection the red globules, whose normal figure is five millions to the cubic millimetre of blood, fall to one million, and this state is characterized by haemor- rhages, more particularly of the retina. Visceral congestions, resulting from the diminished calibre of the peripheric capillaries, are among the results of cold. The congested state of the central organs from this cause is translated into affections of the pulmonary organs, and produces that invincible tendency to sleep observed in persons benumbed by cold. In many dis- eases produced by cold the part acted on by this agent may have no direct relation with the one that becomes affected ; the inflamed organ being at a distance from the point acted upon by the cold. Peripheric lesions pro- duced by the impression of cold may ascend to the nerve- centres, as in chronic myelitis, and it is established that a considerable number of diseases of the nervous system may be produced by the action of cold on a distant part of the body. In connection with this phenomenon the influence of cold may also be studied in diseases of the circulatory apparatus, of the digestive and genito-urinary organs, and in connection with the trophoneuroses. Death from cold may occur from syncope, asphyxia, or coma. The necrotomic proofs are rather scanty. In fact, it may be said that there is nothing characteristic, and it is doubtful whether there be any corroborative evidence. Numerous and complex problems may arise in con- nection with accidental deaths from the alleged effects of cold, and it may be a delicate and difficult matter to de- cide in many cases whether the cold figured as an ac- 228 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cold. Cold. cessory or as a principal cause. Questions of this kind may arise on such ordinary occasions as the death of a tramp in a police station after a night of exceptional cold ; the death of drunkards during exposure to a winter night, or that of persons that have been beaten and left to die on a public way, as much from the effects of cold as from their wounds ; the death of children or sick people found in conveyances ; and in the exposure of infants or invalids for purposes of infanticide, or hastening the death from interested motives. Irving C. Bosse. been removed on one side, and on the corresponding side of the pia the application of ice had little or no effect upon the calibre of the vessels. A cold wet compress upon the abdomen or back produced, almost without exception, immediate and persistent dilatation of the arteries and veins, the pulsation of the vessels becom- ing slower, but more pronounced. After the termination of the experiment, the dilatation sometimes continued for a short time, and then was succeeded by a contraction which passed off quickly. Cold plunge baths have a more powerful effect on the vessels of the pia mater than wet compresses. When an animal was placed in a cold bath, the dilata- tion of the vessels of the pia mater kept increasing as the animal's body was by degrees dipped into the bath. At the same time the movements of the brain became slower, but greater. It is only after a long stay in the cold bath that contraction of the vessels and sinking in of the brain occurs, in consequence of the blood being much cooled down. After the animal is removed from the bath the vessels of the pia mater again contract, and frequently re- main so for half an hour. Rubbing the belly or back of the animal with a cold cloth is always followed by a more or less powerful contraction of the vessels of the pia mater. After the friction has ceased a considerable but very transient dilatation follows. Friction with a dry cloth has the same effect on the vessels of the pia mater, but to a less extent. Injections of cold water into the rectum always cause a moderate dilatation of the vessels of the pia mater. Local Action of Different Degrees of Temperature.-It has been shown by Esmarch that if cold is sufficiently long applied to a peripheral part, even the temperature of the bone will be reduced. The local application of cold has not much influence, except as regards the abdomen, in reducing the general temperature of the body. It requires at least one-fourth part of the body to be brought under the direct in- fluence of the cold before much reduction can be effected in the general temperature. It Tias been experimentally proved that the application of cold to an inflamed part makes the course of the inflammation slower and milder. The phenomena of the inflammation are restricted through the action of the cold ; in part through the slowing of the blood-current, and in part through the reduction of the temperature. The cold diminishes the emigra- tion of the leucocytes, and consequently retards suppura- tion. The pus in an inflammation treated by cold is thinner and poorer in cells. Another point that should be con- sidered in applying cold is the restricting influence it has over fermentation and decomposition, while warmth, on the contrary, hastens these. The sudden application of cold to one part of the body has an influence over a distant part. This is well illus- trated in the power the sudden application of cold water to the face has in checking haemorrhage from the mouth during operations on this part. This action of water is frequently and successfully made use of by surgeons in the operation for cleft palate when bleeding is trouble- some. In the same way bleeding from the nose may be arrested by applying cold water to the back of the neck. Not only can we influence superficial, but also deep parts in this way. It has been experimentally proved that ice applied to the lumbar region causes contraction of the arterioles of the kidneys, and consequent diminished blood supply to these organs. In all these examples the cold acts in a purely reflex manner. The impression or irritation is carried to a nervous centre and reflected back to the arterioles of the part or its neighborhood. When a hand is immersed in ice-cold water the temperature of the other hand also falls. Here there is a diffusion of the impression from the nervous centre to both upper extremities. Action of a General Cold Bath.-When a person enters a general cold bath, the temperature of the surface is im- mediately lowered. This is due to the accumulation of blood in the internal organs and the benumbing effects of the cold on the superficial nerves of the skin. The sob- COLD, THERAPEUTICS OF. Cold induces changes in the living animal body in three different ways : 1. Through its temperature. 2. Through its mechanical action. 3. Through its chemical action. 1. Through its Temperature.-Different degrees of temperature cause changes in all living structures, from the simplest form of protoplasm to the most highly developed organism. This can be demonstrated by watching the effect of a low temperature in arresting the amoeboid movements of some of the lowest forms of protoplasm. The immediate effect of the application of cold to the body is one of irritation. This irritation is the greater, the greater the difference in the temperature between the body and the medium applied. 2. The mechanical action of cold is well illustrated by the effects of the application of a few drops of cold water in rousing persons who have fainted, and in the effects of the cold douche in rousing people from a con- dition of coma to one of consciousness. 3. The chemical action of cold is demonstrated by the abolition of innervation, which is caused by the appli- cation of cold over a nerve. One of the most important actions of cold when applied to the skin is the influence that is effected on the circula- tion. An influence is brought about in a double way: First, we have the reflex influence which follows immedi- ately on its application. Second, the effect that is brought about in the circulation by the withdrawal of heat from the body. That the immediate action of the application of cold on the circulation is brought about reflexly, is demonstrated by its non-appearance when the vagi have been previously divided. The primary influence of cold on the circulation is ac- celeration, which is, however, of short duration, soon giving place to a slowing. Through the influence of cold on the skin we are not only able to influence the vessels to which the cold is di- rectly applied, but also those at a distance. By apply- ing cold to the surface, we cause contraction of the ves- sels at the point of application. But the quantity of blood is not the only thing to be taken into account, for the pressure of the blood in the vessels of any part is one of the most important factors in nutrition and functional activity. The amount of blood in the living body is con- stant and cannot be rapidly increased or rapidly dimin- ished, except under the influence of mechanical injury. We, however, can, by the application of cold, send a large quantity of blood to one part of the body, while the quantity in another part is greatly lessened. It is only recently that it has been demonstrated that contraction or dilatation induced in a large vascular area by the external application of cold, must evidence itself by contrary con- ditions in other vascular districts. It is to Schuller that we are indebted for this knowledge. He removed from rabbits pieces of each parietal bone, and observed the vessels of the pia mater. A careful study of the normal appearances enabled him to estimate exactly the altera- tions which appeared in these vessels under the action of various agents, when applied to different parts of the body. He found that when pieces of ice were laid on the dura mater, marked contraction of both arteries and veins took place, and which continued for thirty seconds after the removal of the ice, when it had been applied for ten seconds. In most of the animals experimented upon, the superior cervical ganglion of the sympathetic had 229 Cold. Colic. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bing respiration is due to the irritation of the peripheral nerves being carried to the respiratory centre. If the temperature of the bath be not too low, and if the person be fairly vigorous, the feeling of discomfort at first experienced soon gives place to the condition known as reaction. The coldness and depression are succeeded by warmth and a feeling of exhilaration. The pulse be- comes quick and the respiration easy. If, however, the immersion lasts for too long a period, the condition of reaction is supplanted by one of coldness and depression, the pulse is weak and frequent, and there is muscular debility. This result is largely due to the continuous abstrac- tion of heat, and to the accumulation of blood in the great venous trunks. The metamorphosis of tissue is inter- fered with. If a healthy reaction is established after a cold bath the effects are what we term tonic, the cir- culation is quickened, tissue-changes take place more rapidly, and as a result of increased tissue-changes we find more urea and urates in the urine, and, as a result of this increased tissue-change, the appetite and digestive power are improved and the body gains in weight. The Internal Action of Water.-The rapid drinking of a large quantity of cold water reduces the pulse-beats. A third of a litre, for instance, drank at a temperature of 18° C. (64.5° F.), has the power of reducing the pulse twenty beats in half a minute. In ten minutes it regains its for- mer frequency. The temperature also falls as a result of drinking large quantities of cold water, but only for a few minutes. The fall in the temperature is greater in the rectum than in the axilla. If cold water is injected into the rectum, the tempera- ture of the stomach falls over a degree. This shows that by the use of cold injections we are able to reduce the temperature of the stomach and neighboring abdominal organs considerably ; while by introducing cold water into the stomach, the greatest reduction takes place in the rectum and neighboring pelvic organs. In disease of these parts we are able by the use of cold water to influ- ence it. Water is absorbed from the stomach and intestinal canal into the blood through the veins and lymphatics. The celerity with which absorption takes place depends on the fulness of the veins, etc. The lower the tension in the blood-vessels, the quicker does it take place. After profuse serous diarrhoea, as in cholera, the ab- sorption of water is very rapid. Water deficient in saline matters is more quickly absorbed than one rich in those elements. The rapid absorption of water into the blood increases the arterial tension. An excess of fluid is retained but a short time in the blood, usually not longer than fifteen or twenty minutes. Half an hour after the absorption of a large quantity of water, the blood contains no more fluid than it would if no water had been taken for twenty-four hours. From this it follows, that if we are to increase the volume of blood and to heighten the tension in the arterial system, we must give water in small doses and at short intervals, at least every half hour. If, on the other hand, we desire to increase the resorptive powers, and thereby take water from the tissues, we order large quan- tities of water at long intervals. This makes the blood poorer in water. The tissues, in consequence, yield up their water, but it is not water alone that is taken up, but also solids. We are enabled by the administration of large quantities of water to promote the absorption of solid exudations. It has been shown by Bocker that the body weight is diminished by the drinking of large quan- tities of water. Large quantities of cold water act as a diuretic. There is not only an increased elimination of water through the kidneys, but also of solid ingredients, especially of urea. The power that water possesses of favoring tissue- changes is further evidenced by the fact of the increased excretion of carbonic acid, and the increased absorption of oxygen. The sulphates and phosphates are also in- creased. Too little use is made of this power of water in the treatment of disease. The drinking of cold water acts on other functions also. It increases the peristaltic movements of the intes- tines. It also promotes the absorption of substances by the portal system. The Different Methods of Using Cold Water, and the Indications for its Use.-1. The General Cold Bath.-This is by far the most powerful means we have of withdrawing heat from the body. To have the desired effect the temperature should not be above 20° C. (68° F.), and when possible it is generally advisable to have it a few degrees lower. It may be laid down as a rule, that a person in a high fever suffers no harm from the sudden cooling down of his body, provided the tempera- ture does not fall below the normal. The contra-indica- tions of the cold-bath treatment of fever arise from other factors, and not from the circumstance that there is any danger in either slowly or suddenly taking the temperature down from a high point to the normal. The intensity of the cold used, and the duration of the bath are not of so much importance as would at first sight appear. The point that should not be forgotten is, do not bring the tem- perature below the normal. As the cold bath is used generally in fevers, there is very little danger of this. As a rule the effects of the cold are less pronounced than we expect. The duration of a cold bath for the treatment of py- rexia should not, as a rule, exceed ten minutes. If the patient is feeble, the duration should not exceed five minutes. For such patients a bath gradually cooled down from 90° to 60° F. is preferable. After a febrile patient is removed from a cold bath, he should be kept perfectly quiet. It is better to leave him partially dried than to disturb him too much. With many practitioners it is the custom to administer a stim- ulant before and after the bath. This is a good practice. If the patient has a rigor while in the bath, he should be at once removed. The Uses of the General Cold Bath.-As an antipyretic in the various forms of fever, especially in typhoid, the cold bath is extensively employed. There is a great difference of opinion as to what degree of heat demands the cold-bath treatment. There is a general consensus of opinion that hyperpyrexia demands this form of treatment. Some contend that a temperature of 104° F., and upward, is sufficient evidence for the em- ployment of cold baths. Those who hold this view recom- mend a cold bath whenever the temperature reaches this point, and they repeat it even as often as from ten to twelve times in the twenty-four hours. Cold baths are used not only in typhus and typhoid, but also in the exanthem fevers. One hundred years ago Currie, of Liverpool, used cold baths for reducing the pyrexia of scarlet and other fevers with alleged great suc- cess, but this practice gradually fell into disuse because it was thought that "it drove the rash in." In the case of measles there was the additional alleged danger of the presence, always, of more or less bronchitis. The cold bath is the only means that we have of dealing with the hyperpyrexia of acute rheumatism. Here the danger is so immediate and so great that our medicinal antipyretics are of little value. When the temperature in acute rheu- matism reaches 107° F., and over, the case should at once be looked upon as extremely serious, and should be treated with the cold bath. Contra-indications to the Use of the General Cold Bath in Fevers.-Haemorrhage from the bowels in typhoid fever is a contra-indication to the employment of cold baths, because the cold produces fluxion to the internal organs, and therefore is likely to increase any haemorrhage if it is present. If haemorrhage is not present, it does not pre- dispose to it. This is the experience of Liebermeister and others, who have had an extensive experience with the cold-bath treatment of fevers. A very important contra-indication to the use of the cold bath is the exist- ence of a weak heart, no matter whether this weakness is due to a previous organic change or to a present degenera- tion of the muscular fibres from the continuous high temperature. When the circulation is so depressed that the peripheral parts are cold, while the body temperature 230 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cold. Colic. at the same time is high, there exists no hope that a further cooling of the surface can influence the internal temperature to any extent; on the contrary, the cooling will be the more apt to increase the paresis of the heart already present. In slight degrees of heart-weakness the bath gradually cooled down is the appropriate treat- ment. Some patients withstand the influence of cold baths very badly ; after every bath there is a coldness of the extremities. In these cases the bath should not be repeated. In either form of pneumonia-the croupous or the ca- tarrhal-and even in bronchial catarrh of a severe form, cold baths are not contra-indicated. In women during menstruation, if fever of a dangerous degree is present, cold baths are indicated if the temperature resists ordi- nary antipyretic means. Pregnancy and the puerperal period are not contra-in- dications if the fever present is very high. Although the general cold bath is the most powerful refrigerant, there are other ways of using cold water to bring out its antipyretic effects. One of these is the employment of cloths wrung out of ice-cold water, laid over the chest and abdomen. In private practice this is a much more convenient method than the bath, but, as might readily be expected, it is not nearly so efficient. Ringer speaks highly of the following method, which he has put into practice in numerous instances with suc- cess. He dips four small towels into iced water and wrings them nearly dry, so that they may not drip and wet the bed. He applies them one below the other, from the chest downward. As soon as all the cloths are placed he has the first redipped and again applied, then the second, then the third, and so on constantly. This continuous changing is kept up until such time as the temperature is reduced down to 101° F. or thereabouts. Supplementary napkins to the head, thighs, and arms will, of course, still more quickly lower the tempera- ture, and should be employed if the patient is big and stout, since large quantities of heat have to be withdrawn through the bad-conducting fatty layer beneath the skin. If the napkins are incessantly changed this method is most efficacious, and is often highly agreeable to the pa- tient, being in this respect superior to the general cold bath, which is usually very disagreeable. Another convenient way of abstracting heat by means of cold, is by placing bottles filled with ice-cold water along the sides, in the axillae, along the neck, etc. This method has the advantage over the last, that it is less troublesome to the patient. The water in the bottles should be frequently changed. The reapplication of cold, in any of the forms described, must be regulated by the subsequent course of the tem- perature. If it ascends to its original height the process must be repeated, and repeated as often as the rise takes place. In very severe cases of hyperpyrexia the patient is, of course, insensible-he is in a comatose state, and if the cold bath does not restore consciousness in ten or fif- teen minutes, then it is recommended by some physicians to pour cold water (at 45° F.) over the head, for about a minute at a time, every half hour during the time that the patient is in the unconscious state. As to the amount of fall of temperature generally brought about by keeping febrile patients in a cold bath at 65° F. for a period of ten minutes, it varies greatly. Sometimes we only find a fall of 2° F., but as a rule it is about 3° in adults, and 4° in children. Falls of 7°, and even 12°, have occurred from the use of a single bath. The writer has seen a fall of 9° occur in ten minutes in a case of puerperal septicaemia. Now as to the success of the cold-bath treatment of fevers. First, as to the success of this form of treating typhoid fever whenever the temperature exceeds 103° F. This method of treating typhus and typhoid fevers is very general in the German clinics, and as a result it has been clearly proved that it has abated the rate of mortal- ity in these diseases. Brand has treated one hundred and seventy cases of typhus, and Bartels thirty cases of ty- phoid, without a single death. Stohr reduced the mor- tality of his typhus and typhoid cases from thirty per cent, to six per cent., and Liebcrmeister lessened his from twenty-seven per cent, to eight per cent. Notwith- standing this favorable showing, the cold-bath treatment has not as yet found any favor in England nor on this side of the Atlantic, except in the exceptional cases in which hyperpyrexia is present. James Stewart. COLECTOMY. This is the operation of excision of the colon. It does not differ in detail from that employed in excision of the small intestine (Enterectomy). It has been performed eight times, in all cases for car- cinoma of the colon: The incision is made through the abdominal walls, the entire mass of diseased tissue is re- moved, and the ends of healthy colon remaining in the abdomen are united by sutures, preferably Lembert's. Out of 8 cases collected by Gross, 3 proved fatal as a re- sult of the operation, while the remaining 5 proved suc- cessful as operations, although 2 died of recurrent dis- ease a few months later. IE L. IE COLIC, INTESTINAL. Intestinal colic is pain in the intestines, with or without spasm, occurring mostly in seizures of variable duration and at varying intervals, and usually without inflammation, fever, or discoverable organic change. Enteralgia is a term sometimes applied to colic, but more often to a neuralgia of the intestines without spasm. The terms are frequently used inter- changeably, and no discussion of either could fail to in- clude, in some measure, both subjects. Etiology.-Colic attacks both sexes, is very rare after the middle period of life, but affects all ages up to that point, and is especially frequent in infancy. It is due to many causes, and arises under a great variety of circum- stances. Indigestion causes a majority of all the cases. Irritating, indigestible, and decomposing food in the in- testines causes pain directly, and often provokes spas- modic and painful peristaltic action, while gas is rapidly formed wherewith the bowel is distended to the extent of producing suffering. A diarrhoea may be set up ex- pelling the offending material, when the colic ceases. In some cases of mild intestinal indigestion there are frequent slight colicky pains without other symptoms. Constipation may induce colic in the large intestine. The colon becomes distended with hard, dry faeces, by which, after a variable period of tolerance, it is stimu- lated to severe spasmodic efforts to evacuate itself, with the result, usually, of sharp pains. Various foreign bodies in the intestines induce pain, as worms, irritating medicines, the indigestible portions of fruits and vege- tables, intestinal concretions, and unnatural objects swal- lowed by accident or caprice. Collections of gas, when large or imprisoned so as to resist peristaltic force, cause the severest colic, especially in infants. Even the move- ment of moderate quantities of gas through the intestine is sometimes painful. Cold drinks in large potations, ices and ice-cream, may cause colic, and cold catching and chilling of the surface may induce it by congestion of the abdominal organs and disturbance of the nervous system. Rheumatism and gout may attack the muscular and ner- vous tissues of the intestine and induce pain. Alcoholic excesses are sometimes followed by colic. Probably the alcohol simply induces indigestion, which, in turn, causes the colic. This view seems the more plausible, since in many of these cases there are, with the colic or preceding it, vomiting, abnormal thirst, hiccough, and constipation. Malarial poisoning occasionally produces regularly re- curring paroxysms of enteralgia, the periodicity corre- sponding with that of intermittent fever. Lead-poisoning is a prolific cause of colic in adults, and poisoning by copper induces it in a few cases. Dysentery and other inflammations of the colon and rectum are attended with colicky pains, more or less severe and frequent. Syphilis is said occasionally' to produce nocturnal en- teralgia. Invagination of the intestine, hernia, and peri- tonitis, local and general, may cause interrupted pains in the intestines. Colic is sometimes a true neurosis, and due to the ordinary causes of neuralgia and hysteria. De- pressing emotions may cause it, and debility from chronic 231 Colic. Colocynth. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. disease or other cause tends to the easy occurrence of in- testinal pains. Symptoms.-The symptoms of colic vary in degree and character. An attack, especially when due to digestive disturbances, may be preceded by such symptoms of so- called biliousness as anorexia, sense of oppression, or weight in the stomach, eructations, and, possibly, nausea and vomiting. All the forms of colic, and nearly all forms of intestinal pain, are characterized by more or less fluctuation and periodicity in the suffering. The pa- roxysms last from a few seconds to several minutes, and are followed by remission or complete cessation of pain lasting from a few minutes to many hours. Although colic may occur in any part of the intestinal canal, unless it is in the rectum, the patient usually refers the pain to the neighborhood of the umbilicus, whichever portion is involved. The pain may be felt in other regions of the abdomen, especially in the hypochondria if the disease is in the large intestine, but in some cases of colitis the pain is complained of at the umbilicus exclu- sively. In non-inflammatory cases pressure on the abdo- men frequently lessens the pain. Colic has all shades of variation in degree of pain. Sometimes so mild as to disturb the patient but little, so little as not to prevent his moving about and attend- ing to the duties of life, it may be so severe as to cause him to writhe and groan, bend his body forward, plunge his fists into the abdomen, or lean forward over the back of a chair, or roll about in an agony of torture hardly exceeded in human experience. Patients characterize the severer pains by a variety of terms, according to in- dividual fancy, as griping, twisting, cutting, and tearing. The abdomen may be variously distended with gas, or it may be quite fiat, so flat that, in a thin patient, the spinal column may be easily felt from the front. In colic due to indigestion much flatus may exist, distending the abdomen and giving evidence of its active movement during a paroxysm by frequent and loud borborygmi. In the absence of distention, the peristaltic movements and knotting of the intestine by the spasm thereof may usually be felt through the abdominal wall at the moment of suffering. During the paroxysm the intestine is ob- served to be in strong movement, or in hard masses or nodular tumors, but during an interval the abdomen is soft and without motion. In attacks of pain with inflam- mation, and sometimes without it, the abdominal muscles may be tense, and the cremaster may be contracted. Fre- quently with colic there is tenesmus. The temperature in an attack of ordinary colic is rarely elevated, fever is quite unusual, while the extremities and surface are often cold and clammy with perspiration. The pulse is not usually accelerated; frequently in a paroxysm it is abnormally slow, increasing its rate imme- diately afterward. In infants, who furnish a large majority of all cases of colic, the symptoms during an exacerbation are repeated or increased crying, refusal to nurse, entirely, or but for a moment at a time, flexing the legs and thighs, and bend- ing the body in multifarious contortions. A number of other symptoms may attend those of colic, varying with many circumstances and conditions ; thus there may be nausea and vomiting, dyspnoea and a sense of compression of the chest, faintness, tremor, and vertigo. In hysterical colic considerable cutaneous hyperaesthe- sia may be present, causing light pressure and palpation to be quite painful, while firm and deep pressure gives com- fort. Other evidences of plumbism nearly always attend lead colic. Among these are anaemia, cachexia, consti- pation, anorexia, a bad breath, the blue line of the gums about neglected teeth, and paralysis of the extensor mus- cles in the forearm. Pathology.-For the occurrence of intestinal colic there must exist either an irritation or hyperaesthesia of the intestine, or both. There is reason to think many cases of enteralgia-intestinal pain without spasm-are pure neuralgias of the sympathetic nerves of the abdo- men, otherwise neuroses. The constipation, scantiness of the urine, and retarded pulse, often observed in colic, particularly that from plum- bism, are evidences of nervous disturbance as veritable as is pain.1 The pneumogastric nerves are proven to have relations with the muscular fibres of the intestine, and may be presumed to play some part in their pathology. Electrization of the pneumogastrics causes contraction of the muscles of the intestine. Galvanization of the solar plexus induces contraction of the small intestine. Irri- tation of the fifth nerve at certain points, and of the me- dulla oblongata, causes muscular movement of the stom- ach and intestines. Colic is usually attended with more or less muscular con- traction or spasm of the intestines, a thing easily demon- strated in lean patients. The contractions are regularly peristaltic, as in colic of the large intestine from constipa- tion, or irregular, erratic, and ineffective toward moving the contents of the bowel forward, but rather preventing it. In severe cases of colic, with the most excruciating agony from muscular contractions, often no evacuation results until the system is brought fully under the influ- ence of opium to stop the pain, wrhen free dejections take place. In dysentery and other inflammatory states of the colon and small intestine, the colicky pains experienced are probably due in most cases-or chiefly due-to normal pe- ristalsis in a tender intestinal tube. But the inflamma- tion of the intestine probably sometimes induces spasm in other parts than at the seat of disease. In lead colic the ganglia and filaments of the sympa- thetic nerves of the abdomen have been found enlarged by thickening of their connective-tissue. The sheaths of some of the small vessels of the mucous membrane have likewise been found in this condition. Diagnosis.-Intestinal colic is to be discriminated from hepatic, renal, ovarian, and uterine colic ; from gastralgia, peritonitis, and other inflammations within the abdomen ; from intussusception, hernia, and other obstructions of the intestines; from spinal disease, aneurisms of the abdo- minal aorta, and from labor pains. From hepatic colic it is distinguished by the relatively long continuance of the former, by the location of the pain with tenderness at the epigastrium, by the relatively continuous character of the pain, and by the frequent oc- currence of icterus. In renal colic the pain is in the region of one ureter, and continues usually much longer than a paroxysm of intestinal colic ; pains shoot down into the groin and pubic region, which perhaps never occurs in intestinal colic; and there is a frequent desire to urinate, and bloody urine may be passed after a paroxysm, if not during its continu- ance. Gastralgia at times resembles intestinal colic, but the pain is usually higher in the abdomen than in the latter affection, and has such positive relations with the gastric functions as to make the diagnosis usually easy. Peritonitis rarely occurs without some fever and a rapid pulse, although it may exist without either. The patient is quiet, the abdomen is tender in some degree, and there is no moving about and pressing the abdomen for comfort as is seen in intestinal colic. But it is hardly safe to re- gard all cases of tenderness of the abdomen as inflamma- tory, since in lead colic-uniformly unattended with in- flammation-pressure may cause pain. On the other hand, in some cases of intestinal ulceration gentle and firm pressure gives a sense of relief. Strangulated hernia has been mistaken for colic, the pain being paroxysmal and referred to the umbilical region. In a case of colicky pains in the abdomen, about which there can be doubt as to its seat and character, careful examination for hernia, in the several regions of its possible occurrence, should never be omitted. Intus- susception and twisting of the gut have been more than once mistaken for flatulent colic. In these conditions there are usually complete intestinal obstruction, some vomiting, at first of a simple character, but later consist- ing of stercoraceous matter, with complete absence of evacuations from the bowels, except in some cases of in- tussusception in which there may be voided a few small and possibly bloody stools from the canal below the in- vagination. There is no certain way to diagnosticate the presence of 232 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colic. Colocyntli. worms as a cause of colic, except to see them. If they are suspected, the test of treatment may be made with some anthelmintic medicament. The pain of abdominal aneurism is less severe and paroxysmal than that of colic, there is no movement of gas in conjunction with the pain, nausea and vomiting are absent, as also is a tendency to diarrhoea. Ausculta- tion will readily determine the question of aneurism, and the application of this test should never be neglected in any case of persisting abdominal pain in an adult. Prognosis.-In the main the prognosis is favorable. Deaths have occurred from rupture of the intestine due to gaseous distention. An occasional death of an infant with convulsions following upon colic seems to be due to this event, but probably in most such cases the colic, the convulsions, and the death are results of some common cause. Severe colic may lead, in infants, to intussuscep- tion. Treatment.-The first indication in colic is to stop the pain and spasm-after that the cause is to be removed, if possible. In cases of moderate severity benefit may be expected from mild opiates and carminatives, warming agents for the stomach and bowels, like the compound tincture of cardamon, preparations of mint, anise, gaul- theria, aromatic spirit of ammonia, compound spirit of ether and chloric ether. Of the opiates the best for such cases is paregoric. For severe attacks quick relief is demanded, and a prompt-acting remedy should be chosen. Chloroform and ether by the stomach and by inhalation, and mor- phine hypodermically, fulfil the indication best. Chloro- form and ether by the stomach act more promptly than preparations of opium, but, because more sustained in their action, the latter are desirable remedies in severe cases. For prompt and certain action nothing takes the place of hypodermic injections of morphine. One moderate dose is usually sufficient, but it may be re- peated if necessary. In some intense cases the pain is slow to yield to even repeated doses, and caution is neces- sary to avoid the introduction of a quantity sufficient to bring on fatal narcotism-a thing that has been done more than once. The morphine should be supplemented by the internal administration of such remedies as chloro- form, ether, compound spirit of ether and chloric ether, and by inhalation of anaesthetics if necessary. In cases due to indigestion the irritating contents of the alimentary canal should be evacuated with laxatives. Next to quieting agents for the pain, mild cathartics are the most widely useful medicines in colic. Where there is a tendency to the extensive development of gas in the in- testines from indigestion, antifermentatives and aids to digestion should be used, as, for example, the sulphites and hyposulphites, the salicylates, carbolic acid and the carbolates, the preparations of pepsin and pancreatin, and the various stomachics and carminatives. In lead colic the first medicine is opium ; the system should feel the effect of it before catharsis is attempted to be produced. One of the best cathartics is croton oil in small doses, but other vegetable cathartics and the salines may be used with good effect. Enemas of mistura asafoetidae may relieve flatulence-an excellent measure for children-and a long catheter passed up the rectum as far as possible may give exit to volumes of gas. This latter result is more likely to ensue if the body can be to some extent inverted so that the pelvis is much higher than the shoulders, with the spine uppermost. If gaseous disten- tion is so extreme as to seriously threaten the integrity of the intestine, or to portend shock or death from interfer- ence with vital organs, it is justifiable to puncture the intestine through the walls of the abdomen with a trocar of small diameter, and evacuate some of the gas if possi- ble. This operation, not wholly devoid of difficulty and danger, may yet, in a perilous meteorism-a most rare occurrence-offer to the patient the lesser of two dangers to life. If the surfaces of the body and extremities are cold they must be kept warm by stimulating applications of mustard, capsicum, and similar agents, by clothing, a hot bath, ora liberal use of bottles of hot water or some other heated thing. Mustard sinapisms and hot turpen- tine stupes to the abdomen frequently somewhat relieve slight colicky pains ; they are of small cofasequence for severe pain. Stupes or dry flannels over a part need not be removed or changed for reheating ; they may be kept continuously hot by a succession of hot plates laid against them. Where inflammation exists, particularly if the peritoneum is involved, the incessant contact of a hot dressing constitutes one of the best measures of treat- ment. The colic of infants requires treatment on the same general principles as that in adults. The cause, which is usually some form of maldigestion, must be discovered and corrected if possible. Infants who are predisposed to attacks sometimes experience much benefit from a constant slight effect of belladonna or the bromides, or both. This treatment is harmless, and may be continued a long time if necessary. For the relief of an attack of colic a few drops of whiskey or brandy, or the compound spirit of ether well diluted with water, slightly sweetened, may be given, or these failing to give relief, the campho- rated or the deodorized tincture of opium may be resorted to with caution. At the same time the mixture of asafcet- ida may be injected into the rectum. Frequently no per- manent relief is experienced from these or any measures till the bowels are freely evacuated of their irritating con- tents. Norman Bridge. 1 J. W. Bigbie, Reynolds' Syst. Med., vol. iii., p. 133. COLLOID DEGENERATION OF THE SKIN. This rare affection is characterized by the appearance in the skin of numerous small tumors-rounded, fiat, or raised -the size of a pin's head to a split pea, of a pale or bright lemon color, shining and translucent. They look like ves- icles, but when pricked are found to be firm or to exude a little blood and a transparent gelatinous fluid. The pro- cess is a colloid degeneration of the connective-tissue of the corium. Arthur Van Harlingen. COLLONEMA. The name collonema (gelatinous tu- mor) was given by Johannes Muller to new formations which consist entirely of gelatinous substance. It is probable that he included with these new formations many cysts with gelatinous contents. Billroth has de- scribed under this heading a tumor as large as a hen's egg, which was removed from the inguinal region of a boy eight years old. It was composed of a material which had the consistency of gelatine in the fresh state, in which ran a few vessels with very thin walls, and contained in addition a few scattered cells. Virchow has included all such gelatinous tumors with the myxomas, and under this head we shall discuss them. W. T. Councilman. COLOCYNTH (Colocynthis, U. S. Ph.; Colocynthidis Pulpa, Br. Ph.; Fructus Colocynthidis, Ph. G.; Colo- quinte, Codex Med.), the Fruit. Citrullus Colocynthis Schrader (Cucumis Colocynthis Linn.), is a perennial herb with a large, branched, woody root, from which spread several long, slender, angular, branched stems. The leaves are long, petioled, alternate, triangular, heart-shaped, and deeply lobed, each accom- panied by a lateral (stipular) tendril. Flowers monoe- cious, solitary, axillary, yellow. The whole plant bears a general resemblance to the water- and citron-melons -near connections-but is smaller, slenderer, and besides rough-hairy, while the others are more nearly smooth. The fruit is globular, from two to four inches (ten to twenty centimetres) in diameter, with a thin, leathery, mottled-green pericarp, and a fleshy, very bitter pulp. The latter consists of the mesocarp and three thick parie- tal placentae which entirely till the cavity of the pericarp, and make a spuriously three- or six-celled, out of a nor- mally one-celled, ovary. The plant is widely distributed over waste and desert places in India, Arabia, Syria, the " Levant," the Medi- terranean islands, Northern and Western Africa, the Cape of Good Hope, Java, etc. It also grows in Spain and other portions of the extreme South of Europe, and has, in addition, been cultivated in several countries for 233 Colocy ntli. Colorado Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. many centuries. As was to be expected considering its locality, it was well known to the ancient Greek and Roman, as well as to the early Arabian, physicians. Cy- prus, the South of Spain, and the African town Mogador, no medicinal value. They are thrown away when the pulp is prepared for use. This consists of exceedingly large and thin-walled parenchyma, enclosing about two per cent, of its weight of bitter extractive (colocynthin). There are two principal varieties of Colocynth, the smaller " Turkey Colocynth,'- from Europe and the Medi- terranean, and the Mogador, which is larger, and consid- ered to be less valuable. Composition.-Besides the seeds and their oil men- tioned above, Colocynth contains two peculiar principles. The first and only valuable one is colocynthin, isolated by Hubschmann in 1847, and afterward, in a semi-crys- talline condition, by Dr. Waltz. As usually to be had, it is either an extract or a yellow amorphous, neutral, ex- ceedingly bitter powder, soluble in water and alcohol, but not in ether. Treated with dilute mineral acids it is decomposed into sugar and colocynthein, a resinous sub- stance. The second substance contained in Colocynth is the crystalline, tasteless, inactive principle called colocyn- thitin. Action and Use.-Colocynthin is a very active dras- tic, causing death in large doses, by the acute gastro-en- teritis which it produces. It is now and then prescribed ; if pure one or two centigrams (0.01 or 0.02 = gr. J) are sufficient to call forth active catharsis, accompanied by distressing griping and pain. Colocynthein acts simi- larly. Injected into the cellular tissue their effect is also the same. The effect of Colocynth itself is similar to that of its active principles just described ; it is a harsh and irritating drastic, and seldom given alone. In small doses, and modified by other cathartics and corrigents, it is an excellent laxative, and in frequent use as a " dinner pill " in chronic constipation. Administration.-There is but one immediate prepa- ration, namely, the Extract of Colocynth (Extractum Colocynthidis, U. S. Ph.), made by evaporating a tinct- ure. The yield is about sixty per cent, of the pulp. Dose, say three or four decigrams (0.3 - gr. v.). It is seldom used alone, but enters into the Compound Extract of Colocynth {Extractum Colocynthidis Compositum, U. 8. Ph.), which is in every-day use. Its formula is : Extract of colocynth 16 Aloes 50 Cardamom 6 Resin of scammony 14 Soap 14 Alcohol 10 It is a fine powder, easily rolled into a pill itself, or mixed with still more substances. Dose, as a laxative; two or three decigrams ; as a cathartic, five or six times as much (gr. v. ad xxv.). The Compound Cathartic Pills {Pilulw Cathartics Composita, U. S. Ph.) contain about one-third of their weight of this extract. Their composi- tion is: Fig. 726.-Colocynth Plant and Fruit. One-half natural size. (Baillon.) supply it for the market. It is collected when the fruit is ripe, or nearly so, and, in the European varieties, is usu- ally peeled while fresh with a knife. The Mogador Colo- cynth is oftener "coated," that is, dried without remov- ing the exocarp. The soft, moist, greenish-white pulp Grains. Grams. Compound extract of colocynth. 130 8.40 Abstract of jalap 100 6.50 Mild chloride of mercury 100 6.50 Gamboge 25 1.60 shrivels considerably as it dries, and becomes nearly white, and very light and spongy. Description.-As usually imported, Colocynth comes in very light and brittle round balls, from one and a half to three inches in diam- eter (0.04 to 0.08 metre), composed of a nearly white, very fragile, cellular tissue ; evidently cut over the sur- face with a knife, and con- taining numerous cucumber- like seeds in six rows. These " balls" are easily broken into three parts, each including one of the placentae, with a row of seeds on each of its two broken faces. The seeds, which, although of little bulk compared with the rest of the fruit, weigh twice as much, contain seventeen per cent, of bland fixed oil, and have Mix and make one hundred pills. Dose, from one to three pills. Allied Pi.ants.-The only other species of Citrullus of general interest is C. vulgaris Schrader, the water- melon, which has been cultivated from time immemorial for its delicious fruits. It is probably a native of trop- ical Africa. The order contains between four and five hundred, generally tropical and unfamiliar, species, but the suborder, Cucumerinea, to which Colocynth belongs, furnishes also a number of other interesting products. Many of its fruits are edible ; but griping, cathartic prop- erties are, on the whole, characteristic of it, and some- times appear unexpectedly, even in those cultivated for the table. Among the most valuable are : Lagenaria vulgaris Ser. ; Gourds ; cultivated in all warm countries for use as vessels, utensils, etc., and for ornament. Many varieties. Roots bitter and purgative. * Fig. 727.-Colocynth Flower (Fer- tile), Fruit, and Seed. (Baillon.) 234 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colocyntli. Colorado Springs. Ecballium Elaterinum Rich. An energetic drastic. See Elaterin. Bryonia dioica Linn., etc. Drastic. See Bryony. Cucumis Melo Linn., etc. Muskmelons, Cantelopes, ■etc. Cucumis sativus Linn. Cucumbers. Cucurbita Pepo Linn., etc. Pumpkins and Squashes. The above have been long cultivated, and exist in nu- merous horticultural varieties and crosses. They are mostly of Asiatic or African origin, but some of them are not known in their original form. Allied Drugs. - The cathartics in general. See Senna. Among those most nearly like Colocyntli may be mentioned Elaterin and Bryony, in the same family ; also the resinous purgatives Jalap, Scammony, Gam- boge, and Podophyllum, as perhaps also Croton Oil. W. P. Bolles. p. 109) are not quoted ; while still another (Table VIII. on p. Ill) is similarly omitted, for the reason that its data can be equally well derived from a comparison of the Signal Service charts to be found under the headings "Denver," "Santa Fe," "Los Angeles," "Boston," "New York," etc., in this Handbook. It is only with regret that the writer feels compelled, by lack of time and space, to pass over any of the ten charts referred to, but it is impossible for him to steal all of Dr. Solly's thunder. Before proceeding to the more strictly climatological portion of this article, it is proper to,insert a few remarks setting forth the attractions presented by Colorado Springs as a place of residence. The town possesses at least one hotel, described as ex- cellent in its accommodations and large in its capacity, while boarding-houses and furnished rooms abound. Comfortable cottages can be had by families desiring to keep house. Information concerning rents and cost of fuel, provisions, rate of wages, etc., may be found in Mrs. Dunbar's article (op. cit., pp, 34 and 36). The streets of the town are wide, and are spoken of as well shaded, thanks to the irrigating trenches which border them upon both sides. There is a public library connected with Colorado College, and a free reading-room under the charge of the Episcopal Church. A gentlemen's club, called the El Paso Club, also exists. " The country roads which di- verge in each direction are good, and the prairie affords fine galloping ground for the equestrian. The livery is good and cheap" (Dr. Solly, op. cit., p. 93). Both Dr. Solly and Mrs. Dunbar speak highly of the educational facilities of the town ; thus the former remarks, " There is an excellent college, good schools, and private teachers for those who have children to be educated." It may in- terest some readers to learn that Colorado Springs is a " temperance town." In this connection it is also interest- ing to note that Dr. Solly testifies to the fact of alcoholic beverages being less well borne, and also less craved by the system in the high and dry climate of Colorado than they are in moister and more low-lying regions. The water-supply is abundant, and the quality of the water is good; its source is Ruxton's Creek', beyond Manitou, whence it is brought to both towns in pipes. These pipes are of iron (Dr. Solly, op. cit., p. 91). Of the soil and the drainage Dr. Solly speaks as follows : ' ' There is a top-soil of about two feet, below which sand and gravel are found to an average depth of sixty feet, when a clay bed is struck which follows the slope of the surface and the fall of the water-shed to the south. The soil, there- fore, is naturally absolutely dry beyond what little mois- ture the top-soil can hold to feed the grass, and with as perfect drainage as could be devised. The drainage is into leaching-pits which have ventilating pipes in them, and in the connecting soil-pipes. As no water is taken from the soil, and the ground is extremely dry and por- ous, this system works without danger. The smaller and older houses, however, mostly have earth-closets." " The surface soil of Colorado Springs," says Mrs. Dunbar, "is a coarse sandy loam into which the moisture sinks rapidly" (op. cit., p. 39). Comparative freedom from the irritating alkaline dust which rises from the ground dur- ing the prevalence of strong winds, and is a great and serious annoyance at many of our far western towns, is said to be one of the advantages possessed by Colorado Springs, and to be attributable to the peculiarity of its soil. There is good skating " on most days through the middle of every winter. Sleighing is seldom possible, and only for a few hours at a time in occasional winters " (op. cit., p. 96). Climate.-The writer follows his usual plan in rely- ing for the most part upon meteorological data in setting forth the climatic features of Colorado Springs. Accord- ingly, he herewith presents to readers of the Handbook, no less than eleven charts or tables, to eight of which and to the source from which they are derived, a reference has already been made. The first of these, Table A, is similar in the character of the data supplied to the more complete Signal Office charts inserted in the Handbook, and elucidated in the article entitled Climate. It should be noticed, however, that the period of observations in this COLORADO SPRINGS. The town of Colorado Springs, Colorado, founded in 1871, and having to-day an estimated population of six thousand souls (U. S. Census for 1880, gives population of 4,226), is one of the most celebrated "high altitude" health-resorts of the Rocky Mountain region. The name of the town is mis- leading, as there are no mineral springs at Colorado Springs.* Situated close to the base of that outlying spur or group ■of the Rocky Mountain system, of which the highest point is Pike's Peak (14,147 ft. above sea-level), the town of Colorado Springs stands upon a " mesa," or plateau, of an irregularly triangular shape, dominating and ex- posed toward the great plains upon the south and the southeast, but sheltered by lofty mountains on the west, and also, although in less degree, by their outlying spurs upon the north and northeast. The elevation of Col- orado Springs above sea-level is 6,080 ft. The summit of Pike's Peak, 8,000 ft. higher, is distant from the town but ten miles in a "bee line." Dr. S. Edwin Solly, in an interesting pamphlet entitled, "The Health-resorts of Colorado Springs and Manitou," calls especial attention to this peculiarity in the situation of the former town, as giving it the advantage of at least partial shelter from winds, without the disadvantage of deficient daily insola- tion, which is so liable to characterize places that lie buried among the mountains, at the bottom of, or upon the sides of, deep and sometimes narrow valleys. To the pamphlet just mentioned, which contains two articles on Colorado Springs, one by Dr. Solly, and the other (devoted chiefly to a general description of the town and of its near neighbor, Manitou), written by Mrs. Sim- eon J. Dunbar, the contributor of the present article is indebted for most of the information which he here pre- sents to readers of the Handbook. Two other pamphlets from the pen of Dr. Solly, a resident of and a well-known practising physician at Colorado Springs, were also kindly sent by their author. These treat of the influence ex- erted by the climate of Colorado Springs upon diseases of the nervous system, and upon kidney diseases, giving the results of their writer's experience in the observation and treatment of such cases at Colorado Springs, and they have been read with interest by the contributor of the present essay; but the essence of the information which they contain may be found in the pages of the pamphlet first referred to. The largest of the meteoro- logical charts accompanying this contribution to the Handbook, and entitled Table A, was very kindly filled out by Professor F. H. Loud, of Colorado College, and was procured through the courtesy of Dr. Solly. Ten other tables, also furnished by Professor Loud, are to be found on pages 108-111 of Dr. Solly's larger pamphlet. Four of these tables and part of three others are quoted in this present article. For the sake of comparative brev- ity, and to avoid the necessity of quoting the rather lengthy explanatory remarks without which they might be misapprehended and misleading, two of these tables (Tables I. and IV. on pp. 108 and 109 of pamphlet), and half of two others (Table II. on p. 108, and Table V. on * Such springs exist at Manitou, five miles distant from Colorado Springs. 235 Colorado Springs. Colorado Springs. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. 7 a.m., 2 p.m., and 9 p.m., instead of the hours 9 a.m., 3 p.m., 11 p.m., selected for recording temperatures at first- class stations of the United States Signal Service. Pro- fessor Loud's notes appended to this chart will serve to make plain the exact value and meaning of the figures in columns AA and N. As will be seen from what Pro- fessor Loud says respecting columns E and F, the figures of both these columns correspond in significance with those of charts from first-class stations. chart is but one year in length, that column B is conse- quently of necessity omitted, while the figures in the re- maining columns have a far less determinate value as indices of " habitual weather," than have corresponding figures in charts whose period of observation has been longer. The standards of comparison adopted in column G and column H, are quite different from those used for corresponding columns of the Signal Service charts, and in column A, the hours of the tri-daily observations are Table A. Climate of Colorado Springs.-Latitude 38° 51', Longitude 104° 48' 50".-Period of Observations, January 1st, 1884, to December 31st, 1884.-Elevation of Place of Observation above the Sea-level, 6,080/eei.-Name of Observer, F. II. Loud, Colorado Springs, Col. January Mean tem at 7 A.M. Degrees. 21.72 19.60 28.93 36.23 48.71 61.00 66.37 60.14 54.17 41.31 29.01 20.18 J K peratui the ho 2 P. Degre 37.7 35.8 45.8 48.6 60.0 70.4 81.3 73.8 72.7 63.9 52.4 31.3 e 0 irs M. es. 5 5 7 i months of 9 P.M. Degrees. 26.46 24.65 35.38 40.08 49.81 60.87 67.45 63.24 59.86 48.77 32.13 22.37 A A d 5 I £ i | Degrees. 28.10 26.18 36.37 41.26 52.09 63.30 70.64 65.11 61.66 50.69 36.43 24.07 43.24 66.35 49.59 26.12 46.32 C g s & a a E-g II 11 a 0 e Degrees. 40.91 39.79 47.64 52.00 62.80 74.05 83.67 76.19 74.93 65.51 53.56 39.96 D g 1 e & 8 « it ■* o 2 o Degrees. 13.29 13.22 23.88 29.18 39.80 54.53 56.42 52.61 47.36 37.08 23.78 10.66 :::::: ■>1p nrocf I Absolute tempera period. Highest. Degrees. 60.0 61.5 63.0 70.5 80.0 84.0 91.0 84.0 84.0 78.0 66.0 66.0 S naximum ture for Lowest. Degrees. 20.0 6.0 23.5 34.0 41 5 61.0 72.0 57.5 61.0 46.0 30.0 7.5 1 Absolute tempers period. Highest. Degrees. 33.5 34.0 35.0 44.0 49.0 57.0 66.0 -58.5 60.0 53.0 29.0 40.0 minimum iture for Lowest. Degrees. - 5.0 -22.0 9.0 18.5 24.0 43.0 52.0 46.0 33.5 9.5 16.5 -15.0 : : : : (Greatest number of days in any : : : : ooooooooocociin single month on which the tem- P : ; • : I perature was 0° and below. g : ; : : : Greatest number of days in any CL. : : : : : ©oowSwwh-oooo single month on which the tem- S ; : : : ; perature was 80° and upward. February March April May June July August September October November December Spring Summer Autumn Winter Year January A O B L s simr ss of subtraction. Annlvimr this met h £ o 3 a 'o o Sa 65.0 83.5 54.0 52.0 56.0 41.0 39.0 38.0 50.5 68.5 49.5 81.0 71.0 48.0 74.5 88.0 113.0 3 > cd O M 57'5 61.0 56.8 54.5 57.4 45.9 53.0 54.0 59.2 56.2 51.0 i M Average number of fair and clear [ days. No trustworthy observations. | Average rainfall. s year, the pre- of wind is, dur- part of the day ,nd early morn- Average velocity of wind. the present instance, we th Colorado Springs during th follows: Table B. - Mean daily Ra month of th Degrees. January 27.62 February.... 26.57 March 23.76 April 22.82 May 23.00 June 19.52 id the mean daily range at e year 1884, to have been as nge of Temperature for each e year 1884. Degrees. July 27.25 August 23.55 September 27.57 October 28.43 November 29.78 December 29.30 February No continuous observations. March April Taking an average of the figures just given, we find that the mean daily range for the entire year (1884) was 25.76° F. Passing over the table of mean temperatures (Table I. on page 108 of Dr. Solly's pamphlet), which is omitted for reasons already stated in the early part of this article, we present next in order (Table C) a portion of Pro- fessor Loud's Table II. Table C (Table II.).-Maximum and Minimum Tempera- tures in Winter and Spring. May June July August September October £ n43 43 8 00 0 0 ^■4? a CO 'S November December Spring ts . Summer Autumn Thro ailing ns th Winter Year simple process of subtraction. Applying this method in the present instance, we find the mean daily range at Colorado Springs during the year 1884, to have been as follows: Table B. - Mean daily Range of Temperature for each month of the year 1884. Degrees. January 27.62 February.... 26.57 March 23.76 April 22.82 Muy 23.00 June 19.52 Degrees. July 27.25 August 23.55 September 27.57 October 28.43 November 29.78 December 29.30 Taking an average of the figures just given, we find that the mean daily range for the entire year (1884) was 25.76° F. Passing over the table of mean temperatures (Table I. on page 108 of Dr. Solly's pamphlet), which is omitted for reasons already stated in the early part of this article, we present next in order (Table C) a portion of Pro- fessor Loud's Table II. Table C (Table II.).-Maximum and Minimum Tempera- tures in Winter and Spring. PART I.-Maximum Temperatures. This sheet, containing the meteorological record of the year 1884 only, is sent as supplementary to the tables for previous years given in the pam- phlet, "The Health-resorts of Colorado Springs and Manitou," a copy of which was lately forwarded by Dr. S. E. Solly. In column E I have inserted the highest and the lowest of the daily maxima for each month, and column F in like manner is filled out with the highest and lowest of the daily minima. In estimating the number of fair days (column N), any day is considered fair in which the mean cloudiness is less than seventy-five per cent. The " mean temperature " of a day is one-f ourth of the sum of observed temperatures at 7 A.M., 2 P.M., and 9 P.M., the last observation being reck- oned twice. F. H. Loud. 1873-1874. 1874-1875. 1875-1876. A B A B A B December 65.0 44.1 59.0 41.7 67.0 51.6 January 63.0 46.6 60.0 35.1 62.0 45.5 February 59.0 40.2 58.0 40.8 64.0 51.6 'Winter 65.0 43.6 60.0 39.2 67.0 49.6 March 61.0 48.2 67.0 42.0 65.5 49.1 April 82.0 53.6 71.0 70:3 79.0 60.8 92.0 74.7 84.0 84.0 67.6 Spring 58.8 59.2 June...7 101.0 85.6 91.0 82.2 93.0 77/2 As has been explained in the article on Climate, the figures for the average daily range of temperature may be deduced from those given in columns C and D, by a Note.-Column A contains the highest temperature of the month or season; column B the mean of the highest temperatures of the several days. 236 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colorado Springs. Colorado Springs. 1873-1874. 1874-1875. 1875-1876. C D C D C D December - 9.0 10.6 - 4.0 15 1 3.0 21.2 January -15.0 14.6 -25.0 3.2 -3.0 12.3 February -17.0 11.6 - 8.0 16.1 -1.0 18.8 Winter -17.0 11.9 -25.0 11.5 -3.0 17.4 March 1.0 19.8 - 4.0 16.8 3.0 18.4 April 5.0 23.5 6.0 27.9 7.5 30.9 May 27.0 41.7 26.0 42.0 26.0 40.4 Spring 28.3 28.9 29.9 June...7 39.0 50.7 32.0 49.7 37.0 46.7 Part II.- Minimum Temperatures. and average daily minimum temperature for each of the twelve months of the year during the two periods, De- cember 1, 1873, to July 1, 1876, and January 1, 1884, to December 31, 1884, i.e., for the seven months, January, February, March, April, May, June, and December, of four years, and for the five months July, August, Sep- tember, October, and November, of three years. These figures are given in the first and second columns of Table E, and figures showing the mean daily range of tempera- ture deduced from them are presented in the third col- umn of this table. Note.-Column C contains the lowest temperature of the month or season ; column D the mean of the lowest temperatures of the several days. Table E.-Mean Daily Maximum and Minimum Tem- peratures, and Mean Daily Range of Temperature, de- duced from observations covering three years and six months. The precise character of the information conveyed by this table is thus explained by Professor Loud (op. cit., pages 101, 102): ' ' A place at the elevation of Colorado Springs cannot escape extreme temperature in winter; and in fact the record shows that in every year the thermometer falls once or more below zero, and sometimes a long way be- low. Table II. shows the history of these extremes, and also exhibits the fact that, though severe they are never either long continued or frequent. To indicate this, the lowest temperature of each month is placed (in the second part of the table) opposite the mean of the minimum temperatures of the several .days ; and the great difference between the two (especially when it is remembered that a number of nights of a temperature slightly above the mean is required to cancel the effect of one which is far below it) sufficiently proves the rarity of the extreme temperatures. On the other hand, the maximum tem- peratures of the winter and spring months (as seen in the first part of the table) exhibit usually a less difference from the mean of the maxima of the several days, show- ing that the high temperature of the middle hours of the day, in those seasons, is more frequent than the excessive cold of nights." The climatological data presented by Professor Loud in the various tables quoted from Dr. Solly's pamphlet, are derived in part from the records of voluntary ob- servers and in part from the published records of the United States Signal Service Station, which existed at Colorado Springs from December, 1873, to July 31, 1876. The point illustrated by the table next following (Table D), which is a portion of his Table III. (op. cit., p. 109), is thus explained by Professor Loud : " During the summer months, as shown in Table III., the minimum temperature of the whole month differs (in general) very little from the mean of the minima of the separate nights of the month ; and this circumstance (as well as the low figures found throughout the columns C and D) shows the constant coolness of our summer nights. Indeed, a warm night, even in the hottest part of the year, is of very rare occurrence." Mean Daily Maximum. Mean Daily Minimum. Mean Daily Range. January 42.0 10.85 31.15 February 43.1 14.93 28.17 March 46.73 19.72 27.01 April * 55.46 27.87 27.59 M*ay 68.85 40.97 27.88 June 79.76 50.41 29.35 Julyt 83.15 55.01 28.14 Augustt 80.46 53.21 27.25 Septembert 73.21 45.88 27.33 October! 65.77 37.19 28.58 November! 52.82 24.12 28.70 December 44.34 14.39 29.95 * Average maximum for three years only. + Average maximum and minimum for three years only. It will be observed that the average daily range, or the nycthemeral variation of temperature, at Colorado Springs is very considerable ; but this is no more than we should naturally expect to find in the climate of a place lying at so very considerable an altitude above sea- level, and where the relative humidity of the atmosphere is so small, and the amount of prevailing cloudiness is so slight as is the case at Colorado Springs. At any such place the heating power of the sun's rays during the mid- dle portion of the day is very great, even in the winter season, while during the night hours the radiation of absorbed heat from the earth's surface is exceptionally rapid. For the purpose of facilitating a comparison of the climate of Colorado Springs (in respect to this special feature) with the climates of other points within the ter- ritory of the United States, the following table has been constructed. The figures in the first twelve lines of the Colorado Springs column of this table (Table F) are identical with those appearing in the third column of Table E. In the other fifteen columns the mean daily variation has been calculated from the figures of United States Signal Ser- vice charts, appearing elsewhere in the pages of this Handbook. A careful examination of Table F seems to indicate a correspondence existing between decrease of nycthem- eral variation of temperature, diminution in altitude above sea-level, decrease in the number of fail- and clear days, and increase in relative humidity. Seemingly, the closest approach to a relation of cause and effect exists between the two climatic factors of humidity and tem- perature variation ; the greater the humidity the less the variation in temperature, and vice versa. Several notable exceptions and breaks in the regular inverse progression, observable in the figures of the seventeenth and twentieth horizontal lines of the Table, do certainly occur, and in some instances of this kind the element of proximity to a large body of water (as in the case of Chicago) is ap- parently the key to the enigma. Variability in temperature is, unquestionably, the chief weak point in the Colorado climate when considered from a sanitary and sanatory point of view. The same thing may be said of the climate of many another " high altitude" resort, but it is only fair to remark in this connection that the very dryness of the atmosphere, which seems to favor such considerable changes in temperature, renders the changes themselves less perceptible and less trying to Table D (Table III.}.-Maximum and Minimum Tem- peratures in Summer and Autumn. 1874. 1875. A B C D A B C D June 101.0 85.6 39.0 50.7 91.0 82.2 32.0 49.7 July 98.0 89.5 48.0 55.5 90.0 76.4 47.0 53.1 August 92.5 85.5 52.0 55.4 93.0 79.7 42 0 51.6 Summer 101.0 86.9 39.0 53.9 93.0 79.4 32.0 51.5 September 87.0 71.0 27.0 42.4 88.0 73.7 27.0 44.9 October 76.0 63.1 20.0 38.6 82.0 68.7 18.0 35.9 November 65.0 52.6 2.0 24.4 74.0 52.3 9.0 24.2 Autumn 62.2 35.1 64.9 35.0 Note.-Column A contains the highest, and column C the lowest, tem- perature of the month or season ; column B contains the mean of the high- est, and column D the mean of the lowest, temperatures of the several days. It will be observed that column B in Tables C and D contains data identical in character with those of column C of Table A, and that column D in Tables C and D is likewise identical with column D of Table A. Combin- ing the figures of these columns in the three tables, we have the following figures of average daily maximum 237 Colorado Springs. Colorado Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Table Y.-Showing the Mean Daily Range of Temperature at Colorado Springs and at Fifteen Regular Stations of the United States Signal Service. Colorado Springs. । Santa F6. Denver. San Antonio. St. Paul. | Augusta. Boston. Washington. St. Louis. Jacksonville. New York. San Diego. Charleston. Chicago. New Orleans. San Francisco. January 31.15 24.5 24.7 20.3 19.5 17.3 18.3 14.3 15.8 16.7 13.6 17.3 14.6 14.9 13.9 8.6 February 28.17 24.2 23.3 21.1 20.0 19.4 18.5 16.2 17.1 16.4 14.2 15.3 14.5 14.2 14.5 11.4 March 27.01 26.5 25.1 21.5 19.0 21.3 16.5 17.2 16.8 17.4 14.6 13.8 15.0 13.6 15.0 10.8 April 27.59 23.7 25.0 22.5 21.4 19.9 17.1 19.2 18.3 16.9 15.8 14.1 14.6 14.3 13.8 10.9 May 27.88 28.3 25.5 20.6 20.4 20.2 19.0 20.2 18.7 16.1 16.7 13.2 14.1 14.8 13.2 12.1 June 29.35 29.7 26.6 19.4 20.2 18.9 19.8 19.8 17.8 15.6 16.4 12.8 14.5 13.9 12.4 11.6 July 28.14 26.4 26.8 22.0 20.1 18.5 18.6 19.0 18.2 16.1 17.4 11.6 14.1 14.3 12.3 10.6 August 27.25 25.6 26.0 21.2 20.5 17.3 18.9 18.4 19.1 15.0 15.5 11.8 12.8 13.2 12.1 10.8 September 27.33 27.9 2S.0 21.5 20.0 18.2 17.5 18.0 19.2 13.8 14.9 14.1 12.0 14.3 12.2 12.5 October 28.58 26.4 26.1 20.5 16.6 18.9 18.5 18.7 17.2 13.3 15.7 15.2 12.7 13.2 12.2 11.5 November 28.70 24.8 24.3 20.8 16.4 18.7 16.4 16.3 15.5 15.6 13.6 18.1 14.1 13.6 13.1 7.1 December 29.95 24.5 23.0 20.6 16.0 19.6 16.5 14.7 14.4 17.0 13.1 15.5 14.6 12.8 13.8 11.1 Spring 27.49 26.1 25.3 21.5 20.2 20.4 17.5 18.8 17.9 16.8 15.7 13.7 14.5 14.2 14.0 11.2 Summer 28.24 27.2 26.4 20.8 20.2 18.2 19.1 19.0 18.3 15.5 16.4 12.0 13.8 13.8 12.2 11.0 Autumn 28.20 26.3 26.1 20.9 17.6 18.6 17.4 17.6 17.3 14.2 14.7 15.8 12.9 13.7 12.5 10.3 Winter 29.75 24.4 23.3 20.6 18.5 18.7 17.7 15.0 15.7 16.7 13.6 16.0 14.5 13.9 14.0 10.3 Year 28.42 26.0 25.2 20.9 19.1 18.9 17.9 17.6 17.3 15.8 15.1 14.3 13.9 13.9 13.1 10.7 Altitude in feet 0,080 7,055 5,291 656 762 167 18 61 485 5 35 49 13 594 8 13 Fair and clear days... 316.3? * 318 307.3 258.5 266.1 270.8 237.6 254 262.9 279.9 252 277.8 274.3 257.1 266.9 284 3 Kelative humidity.... + 43.9 48.6 67.8 69.1 69.8 69.6 68.8 66.8 72.0 69.7 72.9 73.8 70.8 71.4 74.3 Latitude 38.51' 35°.41' 39°.45' 29°.28' 44°.58' 33°.28' 42°.21' 38°.54' 38".38' 30°.20' 40°.43' 32°.43' 32°.47' 41°.52' 29°.58' 37°.48' Period of observa- ) 3 yrs. 11 yrs. 12 yrs. 6 yrs. 13 yrs. 12 yrs. 13 yrs. 13 yrs. 13 yrs. 12 yrs. 13 yrs. 12 yrs. 13 yrs. 12 yrs. 13 yrs. 12 yrs. tion J 6 mos. 1 mo. 1 mo. 3 mos. 2 mos. 1 mo. 2 mos. 3 mos. 1 mo. 2 mos. 1 mo. 10 mos. * This figure has been deduced by calculation from a combination of the data of Table A and of Table G. t No precise data at hand. An average calculated from the spring, summer, and autumn figures of the single year, 1884, would show a decidedly greater degree of humidity at Colorado Springs than at Denver : but a critical examination of the charts at his command would lead the writer to surmise that the year 1884 was probably an exceptionally damp one at Colorado Springs. the human system. That such is the case in the climate of Colorado Springs there is abundant testimony of resi- dents and travellers to prove. The frequency of occurrence and the rapidity of onset of such non-periodical or irregular changes of temper- ature as characterize the so-called "cold waves" which are so pronounced a feature of the climate of the United States east of the Rocky Mountains, are both of them phenomena deserving of the most careful consideration on the part of the climato-therapeutist. The writer re- grets that he has no data at his command for the ade- quate presentation of these irregular variations at Colo- rado Springs. The data in the second part of Table C tell us something, to be sure, respecting the frequency of occurrence of such extreme falls of temperature ; but of their rapidity of onset these data can give us no informa- tion whatever, while of the extent of each such fall we can from them infer but little. Had we at hand, for each separate year of a considerable number of years, such data as are given in Column G of Table A, we could more nearly approach a solution of this problem. For the sake of those who desire more accurate knowl- edge concerning the climate of Colorado Springs, and in particular concerning the variability of that climate, it is important that data showing the changes in temperature should be presented in greater detail than has heretofore been done. A letter to the writer from Dr. Solly, bear- ing date February 26, 1885, contains the interesting infor- mation that self-recording instruments were then being made for that meteorological station. Hence we venture to hope that before long data of the character just in- dicated may be forthcoming. The table next following (Table G.) is a portion of Professor Loud's Table V., headed " Cloudiness and Rain- fall." The data for rainfall have been omitted. The ex- tent of the observations from which the figures for cloud- iness were derived does not explicitly appear in the text accompanying the tables, but as the rainfall statistics are given from recorded observations covering seven spring, five summer, and five fall and winter seasons, the sta- tistics of cloudiness, for which Professor Loud says he had "no lack of observations," and which he couples with the rainfall statistics (pp. 104, 105, of pamphlet), have been rather arbitrarily assumed by the writer of this pres- ent article to be based upon seven years of observation. It is upon this assumption that he has ventured to use them as a corrective of the figure for "fair and clear" days (277.) of Table A, in calculating the corresponding figure (316.3) in the Colorado Springs column of Table F. Table G.-Cloudiness. Average Number of Days. Clear. Fair. Cloudy. January 19 9 3 February 15 11 2 March 15 12 4 April 13 13 4 Afay 11 13 7 June 13 12 5 July 14 14 3 August 13 13 5 September 20 8 2 October 24 6 1 November 19 8 3 December 18 9 4 Spring 39 38 15 Summer 40 39 13 Autumn 63 22 6 Winter 52 29 9 Year 194 128 43 The following remarks concerning the cloudiness and the rainfall at Colorado Springs are quoted from Professor Loud's explanatory text:- "When we turn to the allied subject of cloudiness and rain, we find no lack of observations. The amount of clouds has generally been indicated by summing up at the end of a month the number of clear, fair, and cloudy days. In deciding to which of these classes a given day is to be referred, the rule laid down by the Signal Service is to estimate at each observation the extent (in tenths) of sky covered, and divide by the number of observations. If the result is three tenths or less, the day is clear; if eight tenths or more, it is cloudy; otherwise fair. The strict observance of this rule, which takes into account only the extent of cloud without regard to its density, has caused many a day in the winter to be recorded as fair, which any one who used the terms in an unconventional sense, would call clear, for the sky in that season is frequently more than half covered with a thin cirro-stratus cloud through which a star of the second magnitude can be seen with ease, and 238 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Colorado Springs. Colorado Springs. which hardly affects perceptibly the brilliancy of either sun or moon. On the other hand, owing to the tendency of the clouds to disperse at nightfall, a clear sky at 9 p.m. may occasionally be averaged with a very cloudy one a 7 a.m. and 2 p.m., and the result be recorded as a fair day. Though the ' fair' days are thus unfairly recruited at the expense of both the other classes, they entirely fail to equal the number of clear days, which are incontest- ably proved by the records to constitute here a majority of all the days of the year. "The rainfall has also been well observed, but an in- spection of the results, as collected in Table V , well shows the need of a long series of observations to estab- lish correct means for this, the most irregular of the meteorological elements. . . . The average yearly rainfall comes out 15.87 inches. The frequency with which rain-clouds are seen to move along the ridges of hills which encompass the town-site, as if deflected by them from the space within, suggests the probability that if the average rainfall of an area of five or six miles' radius around the town could be ascertained, it would prove the region in general to be much better watered than is indicated by the rainfall of the town itself." " The rainfall," says Dr. Solly, on page 97 of his pam- phlet, "occurs almost entirely between the middle of April and the middle of October, and falls chiefly in the three summer months.'' The tenth table of Professor Loud's series (with ap- pended explanatory note), illustrating the cloudlessness of the Colorado Springs climate as compared with that of the celebrated Alpine resort of Davos Platz, is likely to be of interest to many readers of the Handbook, and is therefore here inserted (Table H). winds from the eight principal points of the compass is indicated in Table VI., will be seen to be modelled upon the tables annually published, for the stations occupied by the Government's observers, in the Reports of the Chief Signal Office.* There are, however, two differ- ences. The numbers entered on each horizontal line of Table VI. are percentages of the whole number of wind observations for the month in question, while in the tables of the Signal Service the actual number of observations of wind from each quarter is entered ;-a method less applicable when the observations, as in the present case, extend over several years. In the second place, the three observations of the day are separated in Table VI., while in the Report of the Chief Signal Officer all the obser- vations of the day are thrown together, thus obliterating the evidence, which appears on the surface in the present table, of the diurnal change in the course of the winds. It will be seen that while north and northwest winds pre- vail during the morning and evening, the middle of the day has oftenest a wind from the southeast. ' ' The column in Table IX., in relation to wind velocity, will serve to show that this town is not subject to the continuous gales which are often imagined to prevail in the western part of our country. High winds are, in- deed, not unknown here, but the highest on record, that of April 17, 1878, only reached sixty miles per hour ; and velocities exceeding forty miles per hour are rare. With any given velocity, the force of the wind is less here than at lower elevations, in proportion to the atmospheric pressure, which is one-fifth less than at the sea-level. Table J. (Table IX.).-Comparative Velocity. Table II. Total Annual Movement. Year-April, 1878, to March, 1879. Davos Platz. Colorado Springs. Clear. Cloudy. | Clear. | Fair. | Cloudy. ' October 11 12 8 October 24 6 1 November 14 9 November 19 8 3 December 16 8 7 December 18 9 4 January 19 9 3 January 19 9 3 February 16 8 5 February 15 11 2 March 18 7 6 March 15 12 4 Total 94 51 38 Total 55 17 Colorado Springs 70,912 Cape May, N. J 134,455 Milwaukee, Wis 110,924 Philadelphia, Pa 92,211 St. Louis, Mo 90,927 Boston, Mass 85,704 Newport, R. I 84,885 San Francisco, Cal 82,724 St. Paul, Minn 76,096 New York, N.Y 74,642 Chicago, Ill 74,192 Jacksonville. Fla 57,333 San Diego, Cal 55,062 Year-January to December, 1880. The Davos observers divide the days into cloudless, constant sunshine, which I have grouped as coming under the head of clear in the Colorado observations ; clouds and sunshine, as fair ; cloudy days, days when there were showers of rain or snow, wet or snowy days, all have been classed under cloudy days and compared. The Davos observations, which were all I could obtain, were for 1879-80-81, while the Colorado Springs figures are from several years' observations. " During a few months pasta continuous register of the wind's direction and velocity has been kept at the College by means of self-recording anemoscope and ane- mometer. The record of the month of March, 1883, has furnished the material for Table VII., which may serve to illustrate, with greater precision than the mere count- ing of observations can give, that law of the diurnal change in the movement of the air to which reference has already been made. The mean velocity and progress \ Professor Loud presents no less than three tables to illustrate the windiness and the comparative windiness of the climate of Colorado Springs, as well as the prevailing direction of the winds and their daily variation in direc- tion and in velocity. These three tables are given below (Tables I, J, K, corresponding respectively to Tables VI., IX. and VII. of Professor Loud's series). Upon these tables Professor Loud comments as follows (op. cit., pp. 105, 106, 107) : " The manner in which the comparative frequency of * " Such tables of wind direction at Colorado Springs will be found in the Reports for 1874-75, 1875-76, and 1876-77. Table VI. is entirely in- dependent of these, being based upon the work of voluntary observers only. . . ." t "If a particle of matter, starting from the point of observation, should be borne upon the wind for an hour (being subjected at every minute to a wind exactly similar, in direction and velocity, to that blowing at the same instant at the point of observation) its distance from that point at the end of the hour would be the progress, and its direction from the same point, the mean direction, of the wind for that hour. In obtain- At 7 A.M. At 2 P.M. At 9 P.M. Mean Velocity. N NW w SW • SE E NE N NW w SW s SE E NE N NW w SW 8 SE E NE Miles per hour. January 44 31 11 2 0 3 4 5 25 18 4 1 8 31 9 4 35 31 11 1 4 4 3 11 9.74 February 42 26 6 1 3 4 3 15 20 9 12 8 12 27 6 6 22 22 18 3 2 12 4 17 10.30 March 36 20 7 2 2 9 4 20 9 15 7 18 37 4 5 16 32 9 2 6 16 9 10 10.06 April 32 26 8 9 3 10 4 8 14 13 14 11 15 26 2 5 30 20 9 8 7 10 7 9 11.69 May 38 17 3 2 13 15 6 G 10 14 9 25 28 3 4 26 17 11 5 11 16 7 7 9.82 June 33 17 1 8 11 11 7 12 10 8 0 5 18 47 6 6 21 30 10 3 7 17 7 8.33 July 36 40 2 0 4 10 2 6 7 10 7 11 13 32 13 17 29 6 10 8 13 4 13 6.77 August 45 21 4 0 8 9 0 13 12 28 5 3 13 22 10 7 32 36 9 0 3 12 3 6.37 September 38 41 1 3 0 6 0 11 4 14 4 10 8 45 7 8 34 30 8 1 11 9 2 7.48 October 55 28 3 1 4 1 4 4 6 6 6 21 39 13 1 40 33 5 5 2 9 3 3 7.31 November 55 28 5 2 2 5 2 1 21 12 6 4 11 34 10 2 37 45 2 2 4 4 2 4 7.93 December 48 33 7 1 3 3 3 2 20 14 7 3 13 39 2 2 39 32 9 3 1 13 3 0 7.10 Year 42 27 5 3 4 7 3 9 13 13 7 6 15 34 7 5 29 30 9 4 5 11 • 7 8.58 Table I. (Table VI.).- Wind. Proportionate Frequency of Winds from the Several Points of the 'Compass. 239 Colorado Springs. Color-Blindness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (each in miles per hour), and the mean direction of the winds for this single month, are given for twelve periods of ten hours each, extending from midnight to mid- night. cation some of the extravagant claims made by certain advocates of this justly celebrated sanatorium. " Visitors to Colorado Springs," he tells us, " may fairly expect to find a remarkably dry atmosphere, a rainless winter, a large amount of clear weather, a very warm sunshine, and the purest of air. . . . They must not expect to realize all that is described by enthusiasts. . . . They will find that the amount of time which they can spend out of doors will depend somewhat upon their ability to take active exercise and to resist cold ; and they will en- counter severe storms and a goodly number of ' excep- tional' days when they will revile the wind, the dust, the great changes of temperature, the low-hanging clouds, and will avow that the weather is no better than at home ! They will find a winter climate by no means so seductive as that of more southern latitudes, but they will experi- ence some of the finest winter days imaginable, and a sun- shine so warm that I have been able to sit out in it com- fortably when the mercury was only 2° above zero. Moreover, they can stay here, if it suits them, the year round without the necessity of fleeing before a spring thaw or a dangerous summer heat." Concerning wind, snow, mud, and fog at Colorado Springs, this same writer speaks as follows : "Nor is the snow always licked up by the dry air in the mysterious way so often pictured to us. It does disappear very rapidly as a rule ; but a visitor must not be surprised if he occasionally encounters mud and slush, and sees the snow going the way of all eastern snow. " That ' it is never muddy here for more than a few hours ' is not strictly true. I have seen here genuine fogs, very dense, and lasting sometimes all day. But fogs are uncommon and scarcely worth mentioning, were not their existence so often denied. Then, too, there are the winds, which are surely both disagreeable and objec- tionable. . . . Many a clear, sunshiny day is so spoiled by cold wind as to be lost to the invalid, and the winter days when there is not more wind than is agree- able are decidedly in the minority. It is difficult to be- lieve that a climate like this, minus the winds, would not be a better one. . . . Dr. Fisk's tables give an aver- age of only twelve calm days in the whole year in Den- ver. His tables also show that the prevalent wind here is from the south, and he lays stress upon ' a prevailing balmy and salubrious south wind ' as one of the advan- tages. . . . The fact is, I believe, that the south wind here is one of the most chilly and disagreeable of all, and that, if any wind deserves the name of balmy, it is that which comes from the west." The article from which these lengthy quotations have just been made was written by its author at Colorado Springs, in May, 1884. Despite the qualifying clauses it contains, it nevertheless closes with the following re- mark : " Colorado can easily afford to rest on its own merits, which are indisputable, and is only injured by much of the indiscreet praise bestowed upon it by its friends. Despite all objections which may be raised, the climate is probably, as we have already said, the very best of its kind at present available for invalids, and destined to grow in popularity as its merits become more accurately understood." In the early part of his article the writer had said: "Where a moderately high altitude and a cold, dry cli- mate are desired, I believe there is at present no available place in the world that offers more attractions for a win- ter's sojourn than Colorado Springs, and it is to this town that my observations have been mostly confined. The beneficial effect of Colorado climate on pulmonary disease is incontestably proved by hundreds of cases." The testimony of this writer respecting the large number of days during the winter upon which a patient at Col- orado Springs "can enjoy sunshine, pure air, and a life out of doors," and his account of his personal experience in this matter, are worthy of careful reading. Lack of space forbids, however, any further quotation from his interesting letter to the New York Medical Journal in an article which already has been chiefly characterized by its very lengthy and frequent quotations. Table K. {Table VIL).-Mean Diurnal Variation of Wind, in Velocity and Direction, March, 1883. Time. Velocity. Progress. Direction. Midnight to 2 A.M 8.7 6.1 N. 17°.9'E. 2 A. M.to 4 A. M 8.5 5.8 N. 11°.8'E. 4 A.M. to 6 A.M 9.6 7.7 N. 11°.56'E. 6 A.M. to 8 A.M 8.4 6.8 N. 6°.18'E. 8 A.M. to 10 A.M 6 9 3.9 N. 24°.32 E. 10 A.M. to 12 M 10.4 4.6 N. 79°.47 E. 12 M. to 2 P.M 12.5 6.1 S. 6t°.25 E. 2 P.M. to 4 P.M 12.5 6.4 S. 52°.54'E. 4 P.M. to 6 P.M 11.3 4.9 S. 60°.14'E. 6 P.M. to 8 P.M 6 6 2.6 S. 69°.43'E. 8 P.M. to 10 P.M 7.6 2.4 N. 62°.19'E. 10 P.M. to Midnight 8.2 3.3 N. 46°.51'E. " To state briefly in words the contents of the table, it appears that on an average day of last March, at sunrise, the mean direction of the wind differed but little from north, but with the advance of the day it swung rapidly around to the east, and reached this point by noon, or a little before. Still proceeding in the same direction of change, it blew from points farther and farther to the south of east until four o'clock, when its average direc- tion was S. 52° E. It is at this part of the day that the greatest average velocity was attained, amounting, from 2 to 3 p. m. , to twelve and a half miles per hour. After four o'clock, the wind slowly shifted back, and again blew directly from the east at a time averaging not far from eight in the evening. Thence until sunrise the mean direction worked gradually around to the north. "Speculations upon the causes of such a regular law of progress are interesting, but are not here in place." We have now discussed at considerable length and, thanks to the valuable charts of Professor Loud and to his explanatory comments thereon, have examined in de- tail the chief factors in the climate of Colorado Springs. As the result of such examination we learn that this now celebrated health-resort of the Rocky Mountain plateau is remarkably favored in possessing throughout the year an exceptionally large percentage of bright sunshiny weather, a very pure and dry atmosphere, and, as a consequence of this latter and of very considerable elevation above sea-level, that the heat of its summer days is not excessive, while the cold of its winter days is greatly tempered by the powerful rays of a sun shining from a generally cloudless sky through a dry and conse- quently a transparent atmosphere. Furthermore, we have learned that there is at Colorado Springs a com- parative immunity from wind and from dust during the summer months, and that during the winter months the ground is far less constantly and far less deeply covered with snow than it is at the celebrated and rival health-re- sorts of this same "high altitude " class which exist on the Continent of Europe. The great faults or imperfections in the climate are its windiness and its variability of tem- perature. To estimate precisely the amount of weight which should be given to these imperfections in forming an accurate and comprehensive judgment of the merits and demerits of the climate, the inquirer who is unable to make a personal test of the climate must await the production of fuller and still more detailed meteorological statistics. A recent writer who narrates his personal ex- perience of the climate (" A Winter in Colorado," by Edward T. Ely, M.D., Neio York Medical Journal, August 2, 1884), accords a very high meed of praise to Colorado Springs as a winter health-resort, while at the same time cautioning his readers against accepting without qualifi- ing mean progress from the register, the mean direction for each separ- ate hour is first estimated, and by its aid the velocity as recorded by the anemometer is resolved into two components, one in the direction of the meridian and the other perpendicular to it. These components being separately added (algebraically) to those obtained in like manner for the corresponding hour of the other days of the month, the resultant of the two sums, each divided by the number of the days of the month, fur- nishes the mean progress and direction for that hour." 240 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colorado Springs. Color-Blindness. Climatotherapy. - Speaking generally, it may be said that the climate of Colorado Springs is a suitable one for all such diseases as are liable to be benefited or cured by resorting to a "high altitude" health-station. In Dr. Solly's pamphlets the prevailing diseases of the region are passed in review, and the good and bad effects of the climate upon a great variety of diseases and of pathological conditions are considered in detail. Thus the climate is declared to be beneficial in cases of anaemia and chlorosis, of dyspepsia (especially when "due to want of natural tone, to overwork, or exhaus- tion from any cause"), in cases of chronic catarrh of the throat, of chronic bronchitis (unless it be accompanied by a considerable amount of emphysema), of chronic pleurisy, in purely functional disturbances of the heart's action, etc. To all forms of acute disease the climate appears to be unsuited, and in the various chronic conditions the general rule appears to be that patients possessing by nature the erethitic or nervous temperament are apt to do badly, while those of naturally torpid or lymphatic tem- perament do well at Colorado Springs. Chronic renal disease, Dr. Solly seems to think likely to be benefited by the Colorado climate ; but, in view of the low tem- peratures and the changes in temperature which are so common there, the present writer would hesitate to recom- mend Colorado for any pronounced case of this class. Pul- monary phthisis is, however, the disease for which the Colorado climate is especially to be recommended ; and while the general rule, here as elsewhere, is, that it is chiefly such cases as are not far advanced in the disease who may reasonably expect benefit, and sometimes even cure from the effects of the climate, nevertheless experi- ence has shown that, for some who are far advanced in, and greatly reduced by, this formidable disease, a resort to Colorado may hold out hopes of improvement, and at times of very great improvement. Extensive destruc- tion of lung tissue, and the secondary supervention .of marked organic disease of the heart, are contra-indica- tions. " Heart-disease," says Dr. Solly, "where the valves are permanently injured, or there is fatty degenera- tion, or much dilatation, is altogether unsuited to the climate, as is also the case where atheroma of the vessels ■exists. ... It must not be forgotten that this climate, putting more work upon the heart, is in all affections of this organ powerful for good or evil" (Op. cit., p. 128). In conclusion, it may be said that to point out precisely and accurately just what cases of pulmonary phthisis may safely be recommended to resort to Colorado Springs, is a task practically impossible of achievement in such an article as this; and for the better determination of this point the reader must be referred to the article on " Climatic Relations of Consumption," on "Phthisis," on " Health-resorts," on " Mountain Resorts," etc., which are to be found in this Handbook, as well as to such larger and more special and exhaustive treatises as are referred to under these respective headings. To persons intending to pass the winter season at Col- orado Springs, Dr. Solly recommends especially the two months of September and October as those to be selected for making the journey thither, in order that, by begin- ning their stay during the early and middle autumn season, they may " gradually approach the cold nights of winter." Huntington Richards. brought to the notice of the scientific world, before its great importance was generally recognized and1 admitted. In 1777 Mr. Huddart described the case of the shoemaker, Harris, quite perfectly. In 1779 Mr. J. Scott reported his own case. In 1794 Dalton gave so thorough an ana- lysis of his defect as to force attention to it. Since these now classic cases, color-blindness has been variously dis- cussed by such men as Goethe, Seebeck, Szokalski, Pur- kinje, Helmholtz, Wartman, Wilson, Pole, and very many others. But even after Wilson's publications, five and twenty years elapsed before the laity, as well as the profession, were induced to give their attention to it. The very practical applications and warnings, repeatedly spoken of, as by Wilson, were not, however, heeded till Holmgren forced attention to them in 1877. How the color-blind avoid exposure in every-day life is a curious study, and shows why they so readily escape detection by the means and methods we formerly had for testing them. A sure and ready way of sorting out the color-blind from the normal-eyed was needed before we could gather the former in sufficient numbers to study their defect under- standingly. Seebeck, in 1837, examined a few color- blind, and let them use their own judgment in grouping and comparing colors. He first showed the uselessness of asking the names of colors in testing them, since in- sisted on by Helmholtz-a point still either neglected or ignored by physicians as well as the laity. Even with his small number of cases, Seebeck was enabled to sort out kinds of color-blindness and degrees, from the grouping and selections of colored objects the people whom he tested made. He was on the right path, only the special way in which he used this comparison method took too much time to allow one to gather thereby sufficient material. Holm- gren improved on Seebeck's idea, and reduced the time necessary to find out whether a person was color-blind to minutes instead of hours. The method required no lan- guage, and was applicable to the lowest intelligence. Hence its practical value in the detection of color-blind- ness, when this defect was dangerous or debarred from certain employments. Holmgren worked his method out by the application of the Young-Helmholtz theory of color- perception to the facts collected, namely, the color-blind's free choice in the selection and grouping together of colors, the expression of the mental effect on their minds or their color-perception. The application of the theory showed the laws governing them. Whether the Young- Helmholtz theory is the true one, or whether any other is nearer the truth, or better explains and reconciles the facts, does not alter these facts, or the color-blind's de- fects, and does not affect the value or the applicability of Holmgren's comparison method with the worsteds, or the practical results derived from its use. It is impossible here to discuss, or even to explain', the various theories that, of necessity, have been brought forward to fit the curious facts now established in refer- ence to the congenital defects of the chromatic sense. We should not have had these facts except for the methods devised and lately used to detect and measure color- blindness. The practical value and necessity of such de- tection caused their invention. These admitted facts are that there are different kinds of color-blindness, grouped as red, green, and violet blindness, or red-green and blue-yel- low. Violet, or blue-yellow, blindness is so rare, that the term color-blindness, unless modified, means, as now used, red or green blindness. We may formulate the vision of the color-blind thus : All colors containing the one in which they are deficient will be grayish, and this in proportion to their individual amount of defect. The red-blind sees all objects of this color of a darker hue than they are. The same is true of the green-blind as to green. Both confound these colors with each other and with gray. A mixture of white and black in proper proportions to represent the luminosity of any shade of red or green, will give the color-blind the same sensation as that shade. Great mis- understanding of the color-blind's sensation has arisen from the natural lack of knowledge and appreciation of composite colors. Purple, or a combination of red and violet or blue, is rarely otherwise spoken of than as red in popular language. The blue or violet in it, the normal- COLOR-BLINDNESS (Farbenblindheit, Farveblindhed, Kleurblindheid; Cecile des Couleurs ; Cecita di Colore; Dichromatism, Daltonism). The term color-blindness is now so fixed an expression in several languages that it is useless at present to apply any other name to, at least, congenital defects of the color-sense. It designates the trouble sufficiently, and other terms proposed rather tend to confuse, or, perhaps, imply adherence to one or another theory. The defect must be as old as man, and why it was not recognized and spoken of, seems, at first, diffi- cult to understand. Before 1777, when color-blindness was first distinctly recorded as existing, vision and visual defects had been very carefully studied, as had colors, if not the color-sense. It is not, however, more curious than that one hundred years passed after it was definitely 241 Color-Blindness. Color-Blindness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. eyed do not think of, and none would class it with blue. The color-blind, however, do not see the red in it other than gray ; but as their vision is perfect for violet, they see this in the purple, and so class it with blue. Hence the general idea that the color-blind confound red with blue, as they do the sky and a rose. Pure red they never confound with blue. That they see gray when we see color, as was claimed, is now proved by investigation of cases of monocular color-blindness. How the spectrum appears to the color-blind can be, and has been, printed in colors. Such colored spectra are, howTever, so individual that another color-blind, of even the same variety, might not agree to it. The defect exists in varying degrees. To such an extent is this the case that divisions are recog- nized of complete and incomplete red, green, or violet blind- ness. The first will naturally shade into the second, and the second into "feeble color-sense; " this also shading into the normal color-sense. In other words, the color- sense varies in degrees as does the form-sense. The color- sense may be wholly wanting, without loss of the sense of form or light. Total color-blindness is that condition in which no color is seen. Cases have been accurately tested and recorded. To such people all colored objects are only shades of gray or black and white. Frequency of Color-blindness.-Wilson's assertion that probably one in five and twenty were color-blind long remained doubted, because not proved in reference to sufficiently large numbers. Till we had comparison methods, and principally Holmgren's, no satisfactory data could be obtained. His, in proper hands, so quickly de- cides a case (in minutes, or even seconds), that tests have already been made of thousands of people. Based on at least two hundred thousand examinations is the result that four per cent, of males are color-blind in greater or less degree, and one-fourth of one per cent, of females. Any great variation from this would seem, at present, due to faulty methods or lack of skill in testing, or to want of sufficient numbers. Whenever whole groups of people are taken, as in schools of two or three hundred, the percentage may vary from two to six. If these were tested by different observers their results 'would seemingly vary. Color-blindness is Congenital and Hereditary.-The large number of examinations which have been collected and published confirms the statements of Wilson. We have, moreover, color-blind family trees in absolute proof of Horner's general law, that sons of daughters whose father was color-blind, are most likely to be the same, although not without exception ; or color-blindness is transmitted in the revertible type from grandfather to grandchild. The necessary exception to this rule, and to the curious exemption of women from chromatic defect, is the re- markable instance which Cunier reported in 1838, of color- blindness appearing only in the females of a family for four generations. A lady was color-blind ; her mother and two sisters were the same. Her brother was free from the defect. The lady had six children ; one son not color-blind, and five daughters affected like herself. The oldest daughter had four children, two of them (girls) color-blind. The second daughter had a boy and a girl, the latter color-blind. The fourth daughter unmarried. The fifth left a boy myopic, but not color-blind. Thus women may be defective ; they alone transmit the defect, as a rule, to their sons, but with the exception that they may transmit it to their own sex only. It seems now generally conceded that their exemption from chromatic defect must simply be considered as a sexual difference which they naturally hand down, and has no connection with their greater familiarity with colored objects, which but sharpens their normal color-sense. Age does not Alter Color-blindness.-Intelligent color- blind advanced in years, chemists and others, testify to the fact that their defect remained the same through life. The reports of one or another color-blind person that his sense of colors had altered, have been readily shown to be due to mistakes. A person born color-blind dies so, with the color-sense unchanged so far as can now be determined. This being the case, it makes no matter how young or how old the persons are, when we test in a community to as- certain the ratio of the defect among them. Race Differences.-Competent observers have tested already many of the races of man ; all the European races, even the most northern, the Indians of North America, the Pacific Islanders, African descendants, and a few of the Eastern nations. Color-blindness has always been found, and always in greater ratio among males. This fact leads to a doubt whether assertions as to the freedom of the Asiatic tribes are not due to faulty methods of testing. The reports as to the Chinese are, in this respect, not wholly reliable. It still remains to be proved that they have escaped. Civilization does not Preclude Color-blindness.-Not only has it been shown that civilization does not exclude a chromatic defect, but it has even been suggested that the over-civilized eye may have partly lost its color-sense, as it may have deteriorated in its form-sense. But more civilized than uncivilized people have been tested, and naturally with greater care, as the opportunities have been greater. Hence those who were defective in color- sense have been more certainly found. Education does not Alter Color-blindness. - The most highly educated color-blind individuals, in constant con- tact with colors as a part of their profession, have not thereby experienced any improvement of their defect. They have often been deceived, and have even persuaded others that they did see differently, but now that we un- derstand their vision better, we know that such is not the case. It is found that they are governed in their deci- sions by light and shade, to which they become extremely sensitive, so much so that any appliance or condition which gives them a new range or application of this edu- cated feeling, has raised in them false beliefs and hopes of cure. The normal color-sense may be educated to a very high degree within its range, just as the sense of hearing may be, within the range of the ear's highest and lowest notes. The color-blind's sense for the colors he sees (yellow and blue if he is red or green-blind) may per- haps also be educated. The rest of the spectrum is to him light and shade, to which education forces him to become sensitive, even in spite of himself and without his con- sciousness. The congenital defect has not been altered, as can be readily proved by changing the relations of light and shade on which he has depended, and fh which circumstances have educated him. Social Condition.-It has been stated by some observ- ers that color-blindness was less often found the higher the social scale. The idea that it should be so comes from the feeling that there would be greater familiarity with colors among the upper classes. It is, however, by no means proved that color-education affects the disposi- tion to color-blindness. Moreover, the number of people tested in a distinctive higher social grade is altogether too small to base thereon any deductions as to ratio. One school of two hundred boys may give us no color-blind, and another just like it socially, enough to make our per cent, normal. Of course the better the social condition, and hence the home famili- arity with colors, the easier will it be to test. The lowest social classes in primary schools, after even a little proper color-teaching, are as easily tested as the upper. The mistaking ignorance of colors and color names for con- genital color-blindness has been and will be the stumbling- block that only general and wide-spread color-education can remove. Congenital Color-blindness is Incurable.-Physiologists and ophthalmic surgeons are all agreed on this point. By mistaking color-ignorance for color-blindness a doubt was raised which has given rise to wide-spread credulity, and the family physician may be appealed to for a decision as to the cure of the defect. He can only give his answer after he has learned how and wdiere the error in color- sense arose. In August, 1874, Dr. A. Favre, of Lyons, France, reported to the French Congress for the Advance- ment of Science, at Lille, some observations which seemed to him to prove that congenital color-blindness was cur- able both in children and in adults by exercising the chro- matic sense. He reported the results in eleven different 242 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Color-Blindness. Color-Blindness. schools, of the examination of one thousand and two boys between the ages of four and fifteen. In this examination the teachers tested by asking the pupils to name the color of objects exhibited of five principal colors. The teach- ers reported to Dr. Favre that they found at least two hundred and eighteen defective in chromatic sense, and that almost all were perfectly cured by repeatedly sub- mitting colored objects to them, and telling them what were the respective colors. Among one hundred and thirty-eight girls, from seven to fourteen years of age, Dr. Favre himself found only two whom he regarded as color-blind. These girls, he remarks, were under ex- cellent teachers, and a large number had passed through the salles d'asile, where colors are taught. He says that ' * the examination of these several reports shows that many children of both sexes come into the salles d'asile and school without a notion of the elementary colors. The number of children lacking in this sense, in the majority of boys' schools which I have visited, is from twenty to thirty per cent. This ratio diminishes in pro- portion as the attention of the scholars is directed by their teachers to colored objects. Certain exercises, the painting of plans, geographical cards, lessons in natural history, etc., have an evident influence on the scholars' progress in this sense. Among the girls, sewing work, embroidery, the care of the clothing, the handling of flowers, much reduces at eight years of age the number of those who have difficulty in distinguishing one or more of the elementary colors. At this age, the number of boys who make marked mistakes in naming colors is still quite large, and we have found that, if the majority easily acquire a knowledge of colors, many of them need watchful and continued care, requiring to be examined periodically, so to speak, till we are assured of their cure. The treatment of color-blindness in the adult has also given us very conclusive results." He would "call for the introduction of exercises with colors in all the schools, in the army, in the navy, and on the railroads." " I am persuaded," he says, " that by the precautions which I have indicated a great number of accidents may be avoided, and I hope to be so fortunate as to cause congenital color- blindness to be stricken from the neurological list." Dr. Favre, as have others since, simply mistook the lack of knowledge of the name of a color for a lack of perception of the color. In this mistake he was confirmed by the rather extraordinary reports received from his friends who were teachers. These latter were wholly incompetent to decide whether their scholars were color-blind, and they had no apparatus to use. Color-blindness must be proved in an individual before it can be claimed that he is cured. It is next to impossible for even an expert to decide whether a child is color-blind by simply asking him to name the color of pieces of paper or other objects. It is, on the other hand, very possible to teach him a name which he shall attach to the object, as it would also be to teach a congenital color-blind person. These children, supposed color-blind, are reported as cured by more or less exercise with colors, according to their individual quickness and memory in catching and retaining their names. The re- ported percentage also shows the absurdity of the method of testing. For instance, as many as thirty out of fifty, and fifteen out of thirty-five children are reported as hav- ing "no notion of color." But five per cent, is a large ratio, even when we include all cases of only slight color- blindness. Now, these children were from four to fifteen years of age. How many schoolboys at this time of life know the names of five colors, or, having heard them, will apply them correctly when questioned, without being specially taught ? It is very different with girls, as Dr. Favre found. They use the names of colors much more frequently, and have more to do with colored objects in dress, trimmings, etc. All the experts who have tested large numbers of people have made the same report as to the comparative ignorance of males, old and young, and in all classes, of colors and color-names. It has in fact led to the introduction of a systematic education of the normal color-sense in schools. The difficulty of distin- guishing between light greens and blues is well known. This formed a large class among the supposed defective children, and they were reported cured in four or five exercises. The teachers also reported the children as confounding those colors, which the color-blind never do ; for example, red and violet. There were, of course, some real color-blind among these thousand children, as was proved by the statement of one teacher, who said: " I sometimes despaired of curing one child, six and a half years of age, who, after sixty-five exercises, could not tell me a single color without hesitation. Eleven exercises more, however, cured this unexampled Daltonian, who began by first distinguishing green, and finished by not always calling red yellow when shown him." This child was no doubt color-blind, and took this length of time to learn the name of the color, to be re- peated whenever the same object was shown him. If alive, this boy is as color-blind now as he was then, and a proper test would show this to be the case. Professor Helmholtz said in his "Physiological Optics," 1867, p. 299, "As to examination of the color-blind, sim- ply asking them to name this or that color will natur- ally elicit but very little, since they are thus forced to ap- ply the system of names adapted to normal perception to their own perception, for which it is not adapted. It is not only not adapted because it contains too many names, but in the series of spectral colors we designate differences of tone as colors, which to the color-blind are only varia- tions of saturation or luminosity." The lack of practical value of tests for color-blindness which require the ex- aminer to name colors, has been well shown by the ex- perts during these last few years, in the search for defec- tive color-perception among the personnel of armies, navies, and railroads. Wilson, in his mongraph, says: "Congenital color-blindness is certainly incurable, and, when induced by injury or disease, it may become as ir- remediable as if it had been an inherited peculiarity ; but certain forms of this affection from disease or injury are transitory, and admit of cure." Palliation of Color-blindness.-As a physician must tell his color-blind patient that his congenital defect is incurable, the question as to whether it can be palliated is of some importance. It was suggested that the doubt- ful color may be compared with a carefully tinted and named chromatic scale. But then blue may be matched with purple, green with red, as also the defective color with gray, or black and white. Hence the patient would declare a green or red must be gray, because it matched the color so named on the scale. Seebeck the elder, in 1817, proposed and tried looking through a transparent colored medium, and colored spectacles were hence thought of. But Wilson said, "After many trials of colored glasses with my color-blind acquaintances, I have found none who could turn the suggestion to practical account." J. Clark Maxwell, in 1855, tried a red and green glass simul- taneously. Through the red glass red would appear clearly and green obscurely, and the reverse through the green glass. In this way a color-blind would get some advantage. No one would be willing to wear such glasses, and no continued use of them would alter the sensation. The color-blind have generally found out that they did not make such bad mistakes in yellow artificial light; they would, of course, with the white electric or lime-light. Hence Wilson proposed, for the color-blind, such colored glasses as rendered sunlight nearest to arti- ficial light. These are pale yellow or orange, stained with oxide of silver. One patient reported: ' ' The glasses deepen, or rather brighten, the reds, but do not affect the greens so much. I can distinguish the reds by the aid of the glasses much better than I can the greens. On a bright day they give a decided and very marked dif- ference between red and green. Scarlets were made very bright and light; while crimsons were made decidedly red and fiery." Another found he could, through the yellow glass, see the same difference between green and scarlet, and crimson and blue, as by artificial light. In 1878 Professor J. Delbmuf, who is color-blind, an- nounced that by looking through a solution of fuchsine he corrected the usual mistakes as to red fruit and flow- ers, the foliage, etc. Holmgren had discussed the ques- tion some years before. Delboeuf even imagined that 243 Color-Blindness. Color-Blindness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by constant gazing through a fuchsine solution he had overcome his defect. It was, of course, merely another mistake such as the color-blind are constantly making. Professor Magnus well says, " Deception here is very possible ; and one may readily mistake for a cure of color- blindness the practice which a color-blind has gained by any increased sensitiveness to shades of light in distin- guishing colors." The test has been thoroughly applied to intelligent color-blind physicians, and others, who re- ported that they could get but little more benefit from it than they did from gaslight or a pale lemon-colored glass. It is thus seen what any possible palliation of congen- ital color-blindness amounts to. Nothing proposed would be of any practical value to those classes whose defect is a source of danger, namely, to railroad employes and mar- iners. Physical Peculiarities associated with Color- blindness.-Hypnotism.-It has been shown, apparently by reliable observers, that among the color-blind those who can be put in the hypnotic condition will see colors normally with the hypnotized eye. On the other hand, also, of the normal-eyed who can be hypnotized, some become color-blind while in that state. Reduced Mass of the Anterior Lobes.-Niemetscheck and Aubert thought that the pupils were nearer together in the color-blind, and hence the anterior brain-mass smaller. Phrenologists had placed color-perception there. How- ever, Holmgren, Pfliiger, and Cohn disproved this by careful comparative measurements of numbers of color- blind and the normal-eyed. The question is now set at rest. Parental relationship, as causing color-blindness, has been spoken of. Sufficient proof is wanting. The he- redity of the defect must be remembered, and the peculiar way in which it is transmitted to males through females. Color of the iris or hair, as associated with color-blind- ness, must now be considered as wholly accidental. Where light hair and irides are in the majority in the community, they will be so found among the color-blind, and, of course, the reverse will hold true. Visual Power.-Form-perception is, so to speak, an- other sense, and hence we should expect to find, as has been found, that the color-blind vary in visual power as do the normal-eyed. Refraction and Accommodation.-The same is found in reference to these. The shape of the globe and the ac- tion of the ciliary muscle are in no way connected with chromatic defects. Ear and Musical Power.-Association of defects in these respects with color-blindness must be quite acci- dental. Good observers have not been able to connect them, although they have made tests for this purpose. Peculiar Look of the Color-blind.-Wilson noticed "a singular expression in the eye of certain color-blind, which may assist in their detection. In some it amounted to a startled expression, as if they were alarmed; in others, to an eager, aimless glance, as if seeking to per- ceive something, but unable to find it; and in certain others, to an almost vacant stare, as if their eyes were fixed upon objects beyond the limit of vision." Mac- beth's reference to Banquo's ghost- Monocular Color-blindness. - The extensive re- searches of experts have brought to light cases of color- blindness in one eye only. They are seemingly very rare, yet several cases have already been carefully tested by very competent observers. The same brain compares different sensations, and as one of these sensations is like ours, we can better judge of how the color-blind see colors. The results confirm the previously formulated ideas. Such cases are of great scientific value in rela- tion to the establishment of any theory in explanation of the facts now collected. Monocular color-blindness as a possibility is of practical importance in reference to test- ing where this is called for as a matter of safety. Acquired Color-blindness. - Congenital chromatic defect is not due to any trouble from or in the lens or humors of the eye. The study which the color-sense is now receiving may decide where the difficulty lies, namely, whether it be retinal, cerebral, or both, etc. Con- ditions exactly simulating congenital color-blindness are caused by certain diseases of the eye or brain. That a person may acquire color-blindness has been long known by ophthalmic surgeons. Their text-books enumerate the affections in which it occurs, and show how it may be partial or general, and what such symptoms mean-for instance, as whether indicating hereditary optic atrophy, etc. Tobacco and alcohol, either alone or together, may cause a loss of the chromatic sense, and even when the form- sense is so little affected that the person's blindness would not be detected even by himself. Of course thousands of people use alcohol and tobacco inordinately, without their form- or color-sense being thereby impaired. When, however, these drugs poison the system to a certain ex- tent, the chromatic sense is affected. Such cases may come within the range of the general physician. Color-blindness from Disease or Injury.-Aside from such cases of loss of the color-sense which come only within the range of the ophthalmic surgeon, there are others caused by disease or accident which the general physician would have the care of. There are several well-authenticated cases on record in which normal color perception was known to exist before the accident, with- out proof of which the case would of course be rendered doubtful. Wilson reported the case of a physician who was thrown from his horse, experiencing a severe concussion without fracture of the skull, followed by long-continued cerebral excitement. He had been an excellent anatomist and fond of sketching in colors. "On recovering suffi- ciently to notice distinctly objects around him, he found that his perception of colors, which was formerly normal and acute, had become both weakened and perverted, and it continued so." " He has laid aside sketching in colors as a hopeless and unpleasant task. Flowers have lost more than half their beauty for him, and he still recalls the shock which he experienced on first entering his garden after his recovery, at finding that a favorite damask rose had become, in all its parts-petals, leaves, and stem-of one uniform dull color, and that variegated flowers, such as carnations, had lost their characteristic tints. The rain- bowwas to him a white semicircle like a lunar rainbow." Wilson on testing him found, "bright blue and yellow he never mistook; red and green, I may say, he never knew; and he put aside, as incapable of definition, all the more mixed or composite colors. In short, in conse- quence of the accident, he has passed into what is the congenital condition of the color-blind." There is some natural doubt as to the older reports of color-blindness acquired by injury or disease. In 1840 Dr. Hays reported a case. A. young woman, aged twenty, had cerebral trouble, and, with some loss of sight, con- siderable loss of color-perception. When asked whether she could see the figure on her dress, which was a calico one with red spots, she replied : " Yes, I see the brown spots." Her form-perception was not affected. The only colors she could distinguish were yellow and blue. She was not con- genitally color-blind, and, after some months of treat- ment, recovered her form- and color-perception. Dr. Hays, in again recalling this case in 1854, quotes several other similar ones from Cooper and others. Tyndall, re- very happily expresses the peculiarity which I find so difficult to define. When understood and pointed out it is readily recognized by intelligent bystanders. There is a certain liquid look in the eyes, as if slightly suffused. It gives also the color-blind person the appearance of not listening, or not being interested in what is said to him. This peculiar expression of the color-blind varies in amount, and even at different times in the same person. It seems, however, to always hover about the eyes. It is noticeable in color-blind females as well as males. No explanation of it has been attempted. Ocular expression is, of course, due to the muscles of the lids and face. As these, however, are called into play from mental impres- sions derived through the eye, it does not seem impossi- ble that the color-blind eye may have its own peculiar facial expression. " Thou hast no speculation in those eyes Which thou dost glare with "- 244 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Color-Blindness. Color-Blindness. ported one of Cooper's cases-a sea-captain, who worked at embroidery to beguile time. Straining his eyes in the afternoon light, he suddenly lost sensation of the colors. He could see blue Berlin worsted and never confounded it. Two bundles of worsted-one a light green and the other a vivid scarlet-were next placed before him. He pro- nounced them both to be of the same color. A difference of shade was perceptible ; but both to him were drab. A green glass and a red glass were placed side by side be- tween him and the window ; he could discern no differ- ence between the colors. A cedar pencil and a stick of sealing-wax placed side by side were nearly alike. The former was rather brown ; the latter, a drab. He was not congenitally color-blind, and had his remembrance therefore of color. On seeing the electric light through a red glass, he cried " That is red," which he was pleased to see again after several years. At a distance or with gas-light he could not get the impression of red through the glass. Portland light had been changed from green to red, but he could not see any difference. Walton re- ports the case of a railroad engineer becoming color- blind and causing an accident. He had gradually lost his color-sense, and had determined to give up his place. Dr. Favre reports several cases of color-blindness from injury among railroad employes. Apparently the shock to which they are specially liable when hurt, is an addition- al cause of disturbance of the chromatic sense. Of course, when the defect is detected after accident and recov- ered from, leaving a normal color-sense sooner or later, the case is very plain. Dr. Nuel reports a very interest- ing case of monocular color-blindness from disease in a railroad employe. He nad been in hospital with retro- bulbar trouble in the right eye, which recovered to two- thirds vision. One night, being required to set signals, he set the green instead of the red, and went back to his box. Presently, having occasion to pass the signal again, he had doubts about the color, and looking at it with the left eye in close proximity, he found he had made a mistake. He fortunately had time to change the signal and avoided an accident. He then ascertained that he could not distin- guish with his right eye red or green from white light. He was frightened enough to consult a physician, who sent him to Dr. Nuel, who determined the above. Thus it is seen that disease or injury may produce a condition of chromatic defect precisely like congenital color-blindness, and it may do this in one eye. Such cases are quite aside from those presenting themselves to the ophthalmic sur- geon. The danger associated with them among mariners and railroad employes renders them of special impor- tance to the general surgeon. Similar loss of chromatic sense among those engaged in certain industries may also call for recognition on the part of the practising phy- sician. Detection of Color-blindness.-Time has shown how easy the concealment of the defect has been, and hence its detection has been proportionately difficult. In reality it was so till we had proper methods of testing, based upon the facts and condition of color blindness. Although, as already said, physiologists had long ago warned against the attempt to get at a person's chromatic sense by asking him the name of colored objects, the seeming simplicity of such a method has greatly deceived physicians as well as the laity. That something more is necessary is proved by the fact that probably at present there have been already some fifty methods or apparatus devised for detecting chromatic defect, its character, or amount. To simply enumerate them would fill our space, and the list would probably be very incomplete by the time it reached the reader. The larger number are of three different classes: 1, Pseudo-isochromatic, as Still- ing's colored figures or letters on a colored ground; 2, contrast tests, as Pfliiger's tissue-paper over letters on a colored ground ; 3, comparison tests, where the person selects his colors, etc. Then there are others, as where the spectrum is used, or the polariscope, or various arrange- ments with colored glasses, etc. All methods that require those examined to give the names of colors have, of course, an element of uncertainty, calling for greater knowledge and experience on the part of the examiner. Expensive or not easily portable forms of apparatus are out of the reach or range of the practising physician. He naturally asks for the simplest and most inexpensive which will en- able him to decide whether a given person is color-blind or not. Now, we cannot depend on that person's asser- tion, and the only other way we can find out how colors appear to him is to force him to do something, exert his muscles, so as to expose himself by such action. The comparison method that does this in the quickest and surest manner, and with the least expense, while it calls for no knowledge of colors or of anything else on the part of the examined, and least taxes the special knowledge of the examiner, is the one the practising physician will naturally seek, and he wants to know if any such comes within his range and reach. The one that best answers all these demands is most undoubtedly Holmgren's test with the worsted. This is the concur- rent testimony of the most practised and practical ex- perts. But the physician must distinctly understand that there is no method or apparatus which will let him detect color-blindness with the ease and certainty with which he would weigh a calculus or get the specific gravity of urine. Physicians, from their training, can naturally adapt themselves to physical examinations bet- ter than the laity-ophthalmic surgeons, of course, still better when such relate to the eye. The seeming sim- plicity of this method of Holmgren's has deceived officials into the idea that they or any moderately intelligent, even uneducated, person could safely test for color-blind- ness when its presence would be dangerous to the com- munity. The committee of the British Ophthalmic Society from their experience warned against this, saying; " Your committee becomes more and more convinced that a com- petent examiner is not made in a day or a month, and that, even with large experience, much judgment and capacity are needful to interpret rightly the acts of the examined." Holmgren's method was suggested by Seebeck's, which was to let the examined group together, out of a large collection of colored objects, those which seemed to them alike in color. In this way we got hold of the person's perception of color, but it took an hour in- stead of a minute. Holmgren himself says . " It is but just to acknowledge that it was only by weighing the re- sults obtained by Seebeck's method, and following the Young-Helmholtz theory, as well as the principles we have indicated as indispensable to a practical method, that we have succeeded in formulating our own method, which seems, more than any other, to fulfil the conditions we have pointed out as necessary to a practical method, namely, certainty, rapidity, and convenience." It, as do all methods with reflected light, requires daylight, or the electric or calcium light. The method calls for no expen- sive apparatus or special place for testing. We need only a number of variously colored objects. We take one of these and ask the examined to select from the others those that resemble it in color. Theoretically it is of no consequence, but practically of great importance, what special objects are chosen. Pieces of colored glass, paper, silk, etc., have been proposed. The best, however, is Berlin worsted, which comes in all possible spectral colors, and in all shades of these. It can always be pro- cured, and, as purchased, is ready for use. A little skein of Berlin worsted is equally colored on all sides. It has no reflection, is soft, easily packed, handled, and trans- ported, and ready for use anywhere. It is free from all the practical objections to other colored objects-pow- ders, wafers, glass, colored solutions, spools of colored thread, pieces of wood, paper, silk, or porcelain, etc. A large enough collection of little skeins of worsted can be carried compressed in a hat. In actual use they will keep their color well enough after the handling (during the test) of ten thousand public-school children. The worsteds are to be done up in little skeins of the same size and general appearance. The colors are red, orange, yellow, yellow-green, pure green, blue-green, blue, violet, purple, pink, brown, gray, several shades of each color, and at least five gradations of each tint, from the deepest to the lightest. Green and gray, several kinds each of pink, blue, and violet, and the pale-gray shades 245 •Color-Blindness. Coloring IVIatters. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. •of brown, yellow, red, and pink must be especially well represented. They will amount to some one hundred and fifty separate little skeins. As the test calls for the selection of but one color, the large number does not seem called for. The larger the number, however, the more readily will the color-blind expose himself. The normal-eyed easily picks out the right ones from the whole bundle, and the color-blind selects the wrong ones no matter how many right colors are before him. The examiner selects from the collection of Berlin worsteds in a pile, laid on a table on a piece of white cloth (in which they can be kept and transported), one skein of a special color and asks the examined to select the other skeins like it and lay them by the side of it on the cloth at a little distance from the heap, thus exposing his chromatic sense instantaneously, as compared with any other method. The time required depends on how practical or quick- witted the examined is, or how much previously versed in colors, etc. Holmgren says, "What color shall we take for our sample ? This is of importance, for we must, of course, decide on some one color. Experience, as well as the application of the Young-Helmholtz theory to the facts, teaches us that more than one color may serve as the sample in searching for a sure and definite characteristic of defective chromatic sensation. All col- ors do not, however, meet this equally well. The faculty possessed by the eye of distinguishing colors, and that of defining the degrees of light, and color, saturation, are relatively very different, but these special faculties have this in common, that they have their maximum activity in a certain intermediary region of absolute intensity of light, and their minimum at the two limits of this region. Just as we experience the most difficulty in distinguishing be- tween the shades of intensity of light by a very feeble or a very strong illuminator, so it is difficult for us to dis- tinguish colors slightly or strongly luminous, or the deepest and the lightest. It is therefore necessary to se- lect as a suitable color for discovering a feeble chromatic sense, either the lightest or darkest shades." The well- defined kinds and degrees of.a defective chromatic sense confound only colors of mean intensity. But in this case, also, it is a question what tones of color to choose. I have selected, to determine whether the chromatic sense is or is not defective, a light green (dark green may be also used), because green is the whitest of the colors of the spectrum, and is consequently most easily confounded with gray. For the diagnosis of the special kinds of partial color-blindness I have selected purple (pink, rose), that is, the whole group of colors in which red (orange), and violet (blue) are combined in nearly equal propor- tions-at least in such proportions that no one sufficiently preponderates over the others, to the normal sense, as to give its name to the combination. This is the reason for the choice. Purple occupies a singular position among colors ; although a mixed color, it is, we know, a color as well ' ' saturated " as those of the spectrum, and might be, from this point of view, classed with them, although it is not found in the spectrum. In fact, it has been regarded as the eighth color of the spectrum, closing the circle of saturated colors. Purple is of especial importance in the examination of the color-blind, for the reason that it forms a combination of two fundamental-the two ex- treme-colors which are never confounded with each other. In fact, from a color-blind point of view, one of two things must happen, according to the theory ; either it excites but one kind of perceptive organs, or it excites them all. It appears, then, cither like a simple color- that is to say, like one of the two colors of the combina- tion-or like white (gray). Experience and experiment confirm this. The sample test-colors chosen are there- fore the two complementary of each other, green and purple. Methodof Testing.-Apiece of white cloth is spread out in a good light and the worsteds loosely piled to- gether. The test-color is placed at one side and the per- son examined is simply asked to select and place by the side of it the other skeins of the same color, lighter or darker. No color names are to be used. If after repeated explanation they cannot understand, then the examiner can go through the test himself, as he can do when testing one who cannot understand the language which he speaks. When a large number of persons are to be tested, it saves time for all at once to hear and see the explanation of what they are to do. The one who is defective in color- sense gains nothing from seeing the others undergo the test; he cannot select the right skeins any better from having seen them picked out, after they are again mixed with the others. The normal-eyed, however, learns how to do what is required more quickly from seeing others do it. Thus, no sort of knowledge of colors or color names is required of the examined, who need not even speak, and the test is adapted to any mental capacity. A child old enough to understand what to do can be as easily tested as an educated adult. Experienced experts have found the value and force of Holmgren's remarks as to the re- lation of examined and examiner. " The combination of the action of the eye and hands, which plays in general so important a part in the training and uses of the senses, is also of great consequence in this method of examina- tion. An attentive examiner, especially if he have already acquired some experience, can draw important conclu- sions from the manner in which the other executes his task, not only and directly with regard to the nature of his chromatic sense, but generally as to his intelligence and character, and especially, in some cases, as to his previous training and exercise in the use of colors, and his skill in recognizing them. The examination af- fords us also the opportunity of making psychological observations, which contribute, in a great measure, in giving us a clear idea of the nature of the chromatic sense. A practised surgeon can often detect color-blindness by the first gesture of the examined, and make the diagnosis before the end of the trial. He can, according to the man- ner in which the task is performed, form a judgment of a feeble chromatic sense in instances which are proved correct by the final result. He also can and must see whether the result is erroneous simply on account of a misunderstanding or a want of intelligence, just as he can see whether the really color-blind succeeds, in a cer- tain degree, from much previous exercise or a considera- ble amount of caution. In short, the method supplies us with all necessary information ; so that, by an examina- tion made with its assistance, a defective chromatic sense, no matter of what kind or in what degree, cannot escape observation. It also calls upon the examiner to watch the examined very carefully, and note his every motion. Different persons act very differently, and cause the surgeon trouble of more than one kind. People of medium intelligence, whether they are color-blind or not, give least trouble, provided they do not feel called upon to be too shrewd. The examination is most difficult with peo- ple of small intelligence, or of feeble and uncultivated color-perception, or when we have a color-blind already tested who desires to escape detection, or when the ex- amined has not had good school education." All the various modifications of Holmgren's test that have been proposed, in a greater or less degree take away these peculiar and often absolutely necessary advantages of the method which experienced examiners have re- ported as so useful. The examined has elbow-room, so to speak, to exhibit his defect, and the more this is re- stricted, the less easy will be the examiner's task. The latter must have practice, and he must study the whole question of chromatic defect and its detection. The full details of this subject cannot be presented in this article, but they may be found in the author's manual, " Color- blindness, its Dangers and its Detection." The colored plate accompanying this article is introduced for the purpose of illustrating the most characteristic mis- takes which the color-blind make, as also to help the exam- iner in his selection of colors, and assist his decision as to the character of the trouble. There are three test-colors or samples, arranged horizontally on the plate. The vertically arranged colors are what the color-blind choose as resembling the test-color. The plate is not intended to be used as a test for color-blindness. Color-blindness varies in character and in degree. Hardly any two would agree as to their choice, but both would make some of the same 246 Reference Handbook of THE Medical Sciences. PLAT EV Colored Plate, explanatory of Holmgren's Worsted Test for Color-blindness. First Test. 1 2 3 4 5 6 7 8 I ■■■ ■■■ ■■■ ■■ ■■ Second Test. II II •9 10 11 12 Third Test. 13 14 15 16 II II FL BFXCKE, LITH. N. T. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Color-Blindness. Coloring matters. what the examined called the colors, and the examiner should not use or ask for any color names, as they but confuse him and the person he is testing. We want the examined to use his hands perfectly freely, governed only by the impression which the colors make on his eye and brain. Thus only can we decide how they impress him, and how his chromatic sense is defective. As, however, the red- and green-blind are so largely in the majority (violet-blindness being very rare), and as they see blue and yellow as we do, we may use these two names in a still further test, often of some little value. The exami- ner says plainly to the examined, "You see yellow and blue as we do, now pick me out the yellow skeins." At once we notice a difference in the confidence of the color- blind, who quickly collects the yellows, but with them picks up the greens that have yellow in them, even those that to the normal-eyed seem to have no yellow. Again we ask him to select the blues. He shows much assurance at once, and selects the darkest blue first, then adds the purple, like that of the worsted used in the "second test." These two additional tests, as names can be used, are always quite striking to bystanders. Finally, as we can- not show the color-blind his mistakes, we can only ex- plain how far out he is by placing bright yellow, and blue, and gray together, and telling him that he has made as great mistakes as if we should declare that these, which he can distinguish, were alike. Of course, if " con- vinced against his will, he remains to be convinced still." It cannot fail to be seen that success in testing must largely depend on the quickness and experience of the examiner. Physicians can readily study up the subject in necessary detail in the more exhaustive treatises on this subject, and material for experiment is at hand in every school in their neighborhood. In testing only those who offer themselves in a general way, we may miss the color- blind who are shy of being detected. Of course, a proper selection of worsteds is important; such can always be obtained of Mr. N. D. Whitney, 129 Tremont Street, Bos- ton, Mass. ; it is the same as that used by the several de- partments of the United States Government. A careful study of Holmgren's special directions cannot be too strongly recommended. The method is very simple when understood. Measuring Degrees of Color-blindness.-This is only likely to be called for from the special expert. He does it by the colored shadow-test of Holmgren, by that of Donders, or by the other various apparatus for show- ing disks of different sizes by transmitted or reflected light, etc. Donders' apparatus shows a disk of color as a marine side-light or railroad signal would appear. As a standard size and degree of brightness are employed, and as the person examined is required to stand at a fixed dis- tance, we are enabled to express his chromatic defect in numbers. This rather appeals to those interested as some- thing which they can understand. Holmgren's, with the colored shadows, tells us the same, however, without the person examined being called on to use or hear a color name. B. Joy Jeffries. mistakes, and these are simply illustrated by the vertical colors. First Test.-The green skein is laid at one side of the general heap. It must be a light pure green, neither a blue- nor a yellow-green. The normal-eyed will readily pick out all the greens, darker or lighter. The color-blind will, besides the greens, or without them, select some of the colors from 1 to 8, viz., gray, stone-color, brownish-red, pale red, and full red. These also pretty well mark the degree of the defect. A person fully color-blind will be very likely at first to select the red of a luminosity simi- lar to that of the test-green. One less so, at first chooses reddish-browns or fawn colors. One still less so will, be- sides greens, add only grays in his selection. Still another class, with "a feeble chromatic sense," will not select as like the test-skein any of these colors from 1 to 8, but they will hesitate over the lighter shades of them, be in doubt as to whether they should go over or not ; perhaps throw over a pale gray or very light fawn and then with- draw it, etc., thereby showing an uncertainty ; or they may even only handle some of the false colors, or pull them over a little. Their fingers and eyes must be watched by the examiner, whom practice alone can fami- liarize with the peculiar characteristic action of the color- blind in their several degrees. Now, where color-blind- ness is a source of danger these are the worst cases. The value of Holmgren's method, intelligently and fully carried out as he directs, is that by it all degrees of chromatic defect exhibit themselves to the expert, who must, however, be such in order to be able to find them. So far, we have found out that the person has a defective color-sense, is color-blind, which is all that is generally wanted. We can, however, still further test him both as to his color-blindness and its special character, by the next step.x Second Test.-All the worsteds are remixed, and a purple "rose" color is put out. The worsted itself is stronger or more saturated than the color we can give in a plate. The examined is to select all lighter or darker shades of this color, which the normal-eyed do most readily. The color-blind select some of the shades from 9 to 12 on the plate. They put in probably some correct ones, as of course they look like the test to them, but they also put in some of the false colors as also looking like it. Those who by the first test showed themselves only in- completely color-blind, will put only purples like the test, but those, viz., the much larger class of red- and green- blind, will at once show the real nature of their defect by selecting blues and violets, or bluish-greens, or full greens and grays. Those taking shades of the former, 9 and 10, are classed as red-blind, and those taking the latter, 11 and 12, as green-blind. The explanation of these curious facts is best obtained by applying to them the Young- Helmholtz theory, as is done in the manual referred to above. No matter whether we adopt the theory or not, it affords an intelligible explanation of great practical value. This very method resulted from the application of the theory to the facts observed. Violet-blindness is shown by a strong tendency to select blue in the first test, and red and orange in the second. The diagnosis is not so easy, but the defect is very rare, and is not of importance where red- or green-blindness is all important. It must be remembered that in the first test blues will be sorted indifferently with the green by all those not educated to distinguish colors. Confound- ing blue and green in light shades is very common with the normal-eyed; it is no mark of color-blindness, but simply of color-ignorance. Third Test.-This is, of course, quite unnecessary, as we have already decided the character and degree of the defect. However, it is an additional test of considerable practical value, as the red skein used corresponds to the red marine and railroad danger signals. Only those markedly color-blind will show their defect with this test. Besides red, they will select colors corresponding to 13 and 16 on the colored plate. The red-blind will choose darker 13 and 14, and the green-blind lighter 15 and 16 to corre- spond to the red test-skein. All that has so far been done has had no reference to COLORING MATTERS, ANIMAL. I. Coloring Mat- ters Free from Nitrogen.-Carmic acid, CnHieOi0. This is the red coloring matter of the cochenille insect. The free acid is soluble in water and alcohol, and with difficulty in ether. It occurs in crystals of a purple- brown color, which become red on rubbing. Boiled with nitric acid, of sp. gr. 1.37, it forms Nitrococcic acid, which crystallizes in plates. Heated with concentrated sulphuric acid to 120° C. (248° F.) it yields Ruficoccin, of a brick- red color, soluble in alcohol, with a yellow fluorescence. Heated with potassium hydrate carmic acid yields Coc- cinin, which crystallizes in yellowish leaflets from alco- holic solution. All the derivatives of carmic acid have acid properties. Vitellolutein and Vitellorubin. - In the red eggs of Maja squinado R. Maly found two kinds of coloring mat- ter, which he named vitellolutein and vitellorubin. The solution in alcohol gives the same reaction as what has been extracted from birds' eggs, etc., and called lutein. The coloring matter thus obtained gives a peculiar spec- 247 Coloring Matters'. Colotomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trum. The separation of these substances from one another has been effected. Vitellorubin occurs in an amorphous form, soluble in alcohol to a brown fluid. The diluted solution gives a broad stripe at F. By the action of different acids various colors are developed. Vitellolutein is soluble in alcohol to a clear yellow solu- tion, behaves toward nitric acid and concentrated sul- phuric acid like the preceding, but unlike it, does not unite with bases. Tetronerythrin (Zoonerythrin).-This is the red coloring matter obtained from the feathers of Calurus auriceps and Catinga coerulea, but it has also been obtained from a great variety of other sources. It is soluble in ether, chloroform, carbon disulphide, benzol, and alcohol. Kru- kenberg could not demonstrate the presence in it of either iron, copper, or manganese ; whether it contains nitrogen or not is uncertain. Turacin and Turacoverdin.-Turacin has been obtained from the feathers of several kinds of birds. It is soluble in water, but with difficulty ; easily in alkaline fluids. Its spectrum is similar to that of oxyhaemoglobin. There is 5.9 per cent, of copper in its composition. Turacoverdin is free from copper, but contains much iron. It is a green pigment. It has a band just before D in the spectrum. II. Coloring Matters Containing Nitrogen.- Coloring matter of the ink of sepia officinalis.-The ink itself is a black-brown fluid, of a weakly salty taste and alkaline reactions, showing under the microscope exceed- ingly fine black particles. It consists of water, and in its ash are calcium, magnesium, sodium, potassium, iron, carbon dioxide, sulphur trioxide, chlorine, and insoluble organic matters and extractives. This coloring matter may be separated as a black homo- geneous powder containing C, H, N, O. The black pig- ment of the negro's skin contains iron (Floyd). Punicin.-The colorless juices of certain kinds of shell- fish (Purpura lapillus. Purpura patula, etc.) become of a purple color when exposed to sunlight. The coloring matter may be obtained from a solution in boiling ani- line as a crystalline powder. The blue coloring matter of Velella limbosa is soluble in water, changed red by acids, rose-colored by alkalies, and yellow by warming.-(From Drechsel's article in Her- mann's " Physiologic.") T. Wesley Mills. His operation was successful, and the patient existed forty-three years, the opening in his side performing all the functions of a normal anus. From this time the operation began to be practised more often, but was almost entirely devoted to the relief of imperforate anus. The results, however, were not flattering, and in 1796- Callisen, observing that peritonitis was a fruitful source of death in these cases of operation, proposed that instead of opening the colon through the peritoneum, as Littre's method demanded, it should be opened at that point in its circumference where it is not covered by peritoneum. But Callisen's proposition was looked upon as im- practicable, owing to the difficulties which it was sup- posed would be attached to finding the colon at such a depth, and so it was relegated to a place among the surgical impossibilities, and the earlier, or peritoneal op- eration, with the introduction of several minor modifica- tions, continued to be practised (in all about thirty-one; times) until 1841. In this year, or possibly a few years before, Amussat, of Paris, having a patient with impassable carcinomatous, stricture of the rectum, was led to perform colotomy by the extra-peritoneal method, as suggested by Callisen. The operation was successful, and becoming convinced of its practicability, he tried it in five other cases, two only of which died. Such good results attracted much attention, especially in England. The surgeons of that country were the first to thor- oughly test its supposed advantages. As the result of their experience they claimed it to be superior to the Littre operation, and it is chiefly through their assertion of this fact that it has been adopted by the surgical world in place of the latter. Since the introduction of antiseptics into the domain of surgery, Littre's operation has been revived by some of the continental surgeons, but only with varying success. The lowered mortality of colotomy consequent upon the introduction of Amussat's method, led to its more fre- quent performance; and the relief it afforded was ex- tended to a number of affections other than that for which it was contemplated by its originator. The indications for colotomy are the relief or cure of : 1. Obstructions to the passage of the faeces through their natural outlet. 2. Painful affections of the rectum or colon, which are irritated by the daily passage of faeces over them. 3. Communications between the rectum and neighbor- ing organs which are kept open by the faeces. Colotomy was originally proposed for the relief of ob- struction to the outflow of faeces, in cases of congenital imperforate anus. Of late years, the plastic surgery of the rectum has been so much improved that colotomy has fallen into disuse in the treatment of this condition ; and even in those cases in which a plastic operation is not practicable, it is a question if it be a kindness to submit an individual to the life-long encumbrance of an artificial anus, together with the unpleasant conditions thereto attached. The chief cause of an obstruction to the passage of faeces is carcinoma of the colon, or rectum, and in the majority of cases the latter. In these cases the operation is of course only palliative. Other causes of obstruction for which this operation has been performed are : stricture of the rectum, syphi- litic or dysenteric, faecal collections, volvulus of the de- scending colon, invagination of the transverse colon, pressure upon the rectum by morbid growths of various kinds, as cancer of the uterus, fibroids of the uterus, or some form of tumor springing from the promontory of the sacrum. In 1795 Duguesceau performed colotomy to cure a fis- tula-in-ano without obstruction. The procedure, though a formidable one for the relief of so slight an affection, was serviceable in demonstrating that colotomy might be of great service in the treatment of those painful affections of the rectum, consisting for the most part of ulcerations, which are particularly in- tractable to treatment as long as they are irritated by the daily passage over them of faeces. COLOTOMY. The term colotomy is applied to an op- eration by which the colon is opened at any point in its course. In a more limited sense it is used to designate the for- mation of an artificial anus by opening the colon. In England, the term colotomy, unless otherwise stated, has come by general consent to mean the formation of an artificial anus in the left lumbar region. To be in harmony with the nomenclature by which a permanent opening into the stomach is termed a gastros- tomy, and into the small intestine an enterostomy, it would perhaps be advisable to term this formation of a permanent opening into the large intestine a colostomy, reserving the word colotomy to designate that operation which opens the colon, the opening being only a tem- porary one. The history of colotomy dates back to 1776, when Pillore opened the caecum for the relief of a cancerous stricture of the sigmoid flexure. The possibility of such an operation had been sug- gested many years before (1710) by Littre, who proposed the establishment of an artificial anus as one of two pro- cedures to be applied to the relief of congenital imper- forate anus. There is no record of his ever having performed this operation, and his suggestion was lost sight of, or at least not acted upon until 1783, when Dubois, having for a pa- tient a child with an imperforate anus, opened the colon in the left inguinal region, and in this manner relieved the faecal obstruction. This operation of Dubois was unsuccessful, and ten years elapsed before it was again attempted, this time by Duret, who operated for the same kind of deformity. 248 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coloring Matters. Colotomy. In carcinoma of the rectum, if there be much pain on defecation, it is considered justifiable to perform the oper- ation solely for the relief of pain, even though there be little obstruction to the feces. A third class of cases in which colotomy is indicated are fistulous communications between the intestines and some adjacent organ. These communications, the result of ulceration of the intestines, are most frequent between the rectum and bladder, in the male and female, or the rectum and vagina in the female, or even between the rectum and urethra in the male. The first operation for this purpose is attributed by Van Erckelens to Desgranges, who endeavored to cure by this means an ano-vaginal fistula. Mason gives the credit of the first case to Mr. Pennell, for the cure of a vesico-vaginal fistula. Both Mason and Van Erckelens relate cases in which the disability of patients, due to the presence of fistuke, has been removed, and the restoration to health has been complete. These, then, being the diseases for the relief of which colotomy may be performed, the question arises, at what period in their course may the operation be most suitably undertaken ? When the disease is a non-malignant one, and the pos- sibility of a cure by other means remains, colotomy is to be looked upon as a last resort, and is only to be at- tempted after other forms of treatment have failed. In carcinomatous obstruction of the rectum, however, the case is different. Here there is no possibility of a cure; the operation, under the best of circumstances, is but a temporizing, and performed for the purpose of palliating the distress which is present during the later stages of this disease, and which is due to both obstruction to the feces and ulceration of the rectum. At this time diversion of the feces through another channel affords great relief to the diseased bowel, and lessens materially the sufferings of a patient thus afflicted. For these reasons an operation at an early period of the disease is to be commended, and we should not wait for complete obstruction of the rectum to take place ; espe- cially is this true if there be much pain upon defecation, and it is held to be justifiable to operate merely for the re- lief of this pain. Then, too, early in the disease the strength of the patient has not been exhausted, and the operation as an operation is much more likely to be successful. Although the colon has at different times been opened at nearly every point in its course, and in many different ways, the formal operation of colotomy may be included under two divisions, the peritoneal and the extra-peri- toneal methods. The earlier or peritoneal operation, Littre's operation, or Inguinal Colotomy, has for its purpose the formation of an artificial anus in the inguinal region, either the right or the left-usually the latter. The following way of performing this operation is de- scribed by Albert : The patient is placed upon the back with the buttocks raised. The parts having been well washed and shaved, an incision two to three centimetres (about one inch and a half) long is made, extending from the middle of Poupart's ligament up to the anterior supe- rior spine of the ilium. The successive layers of the ab- dominal wall are divided down to the transversails fascia ; this is raised with two forceps, incised, and the same be- ing done with the peritoneum, which next appears, the colon is sought for, and when found is brought to the edge of the wound and is stitched fast; later it is opened. The second method is that known as the ezira-peri- toneal, Amussat's, or lumbar colotomy, in which the opening into the colon is made on its posterior surface, which is not covered by peritoneum. The left side is usually chosen for the operation. The incision recom- mended by Callisen was a vertical one, parallel and near to the ed^e of the quadratus lumborum muscle. Amussat, who first performed this operation, preferred a horizontal incision ; while Bryant has introduced a fur- ther modification in the shape of an oblique incision. The key to the operation is an exact knowledge of the point where the descending colon lies. To find this point Allingham gives the following rule, based upon the re- sults of many dissections of the lumbar region : Measure one-half the distance on the crest of the ilium, between the anterior and posterior superior spines, and one-half an inch behind this is the point under which, under normal conditions, the colon always lies. It is a good plan to mark this point and draw from it a vertical line up to the lower border of the last rib as a guide in making the incision. This latter should bisect the vertical line in,a direction at right angles to it, so that its middle point corresponds to the point at which it crosses this line ; this middle point of the incision is al- most identical with the anterior border of the quadra- tus lumborum muscles, midway between the crest of the ilium and the last rib. The incision passes through, successively, the external oblique muscle, the internal oblique, the aponeurosis of the transversalis, and the border of the quadratus lum- borum, and gives access to the retroperitoneal fat, of which there is sometimes a considerable amount. In this, fat the colon is usually readily found, the only thing with which it may be confounded being a loop of the small in- testine, and this is only present if the peritoneum have been cut. The colon may be distinguished by : 1. Its larger size. 2. Its distention and greenish hue. 3. Its peculiar bands. 4. It does not move with respiration as does the small intestine. 5. Hardened masses of faeces may sometimes be felt through its walls. Having found the colon it is to be seized by a tenacu- lum or forceps, and brought out to the wound and made fast to its edge by several sutures, as in the previous operation. These sutures are so introduced as to pass only through the muscular coat, leaving the mucous coat imperforated. If immediate relief is imperative, the bowels may be at once incised, either vertically or transversely, and the edges of the incision stitched with care to the edges of the wound, thereby completing the operation at one time. But if there be no immediate cause for haste, it is an ex-, cellent plan to open the colon only after the lapse of a number of days ; by which time inflammatory adhesion has taken place between the gut and the wound ; an im- portant consummation, as thereby the escape of gas and faeces into the surrounding tissues is avoided. When the artificial anus is once established, it can be covered with a pad of some kind, and it is a good plan for the patient to get into the habit of emptying his bowels regularly every morning, and, in that way, prevent dis- comfort from the leakage of faeces during the day. The painful tenesmus, which sometimes persists after colotomy has been performed, is due to the passage of faeces into the intestine below the opening, and can only be relieved by syringing them out through the anus. Prolapse of the bowel occurs at times ; such a prolapse, however, is easily reduced, and, while it cannot be pre- vented, its liability to recur diminishes with time. As stated above, colotomy is sometimes a curative, but in the majority of cases only a palliative, measure ; and when performed to relieve malignant disease, the life of the patient, even under the best of circumstances, cannot be long prolonged, for a survival of the operation in these cases for more than twelve months is rare. Besides this, the operation is by no means without dan- ger, the mortality of colotomy for cancer being from thirty-eight to forty-seven per cent.; so that the patient must run forty chances out of one hundred of losing his life immediately, for the sake of a few months of compar- ative comfort. In cases of operation for non-malignant disease, when by it a cure may possibly be effected, it must be deter- mined which is the lesser evil, the disease or the opera- tion ; whether the disease is of sufficient severity to justify an operation with the large mortality which is at- tached to colotomy. 249 Colum^w Adipose. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It seems logical to suppose that the statistics of colotomy performed for the relief of non-malignant disease would be more satisfactory than those performed for the relief of cancer, but such does not appear to be the case, for of 91 cases of lumbar colotomy done for fistulae, stricture, etc. (quoted by Van Erckelens), 49 recovered and 42 died, a mortality of 46.4 per cent. There is no limit to the time that a patient with non-malignant disease may sur- vive an operation for colotomy, but it must not be for- gotten that an artificial anus once established is liable to remain open indefinitely, and that, while its spontaneous closing sometimes takes place after the original disease has been cured, such a consummation is rare, and if this do not occur, there is no operation known to surgery by which its closure can be positively assured. If, however, colotomy be fully determined upon, a further question presents itself for solution, namely, which operation is the preferable one, that of Littre or that of Amussat. With English and American surgeons only one operation-lumbar colotomy-is looked upon as being justifiable. The revival of the inguinal colotomy by con- tinental surgeons has attracted some attention to its sup- posed advantages, which are claimed to be, greater ease in reaching the bowel, and a more suitable position for the artificial opening ; while the risks of peritonitis are very much diminished by the use of strict antisepsis. These two methods of operating have been compared by Van Erckelens, who has analyzed for this purpose 262 cases of colotomy. These statistics show that in inguinal colotomy the death-rate is ten per cent, greater than in lumbar colotomy, It is, however, fair to state that no comparison of the two operations has been made since antiseptic surgery has made its appearance. Of the 262 cases collected by Van Erckelens : Method of Amussat, 165 cases ; recovered, 101 = 63 per cent. ; died, 63 = 38 per cent. ; unknown, 1. Method of Littre, 84 cases; recovered, 44 = 52.4 per cent; died, 39 = 46.4 per cent. ; unknown, 1. William L. Wardwell. Therapeutic Properties. - These are tonic and mildly cathartic saline-sulphur waters, and are beneficial in dyspepsia and its complications. In the form of baths they are much used in rheuma- tism, gout, and some forms of cutaneous diseases. The springs, three in number (two mineral and one pure), are situated in a quiet and rural region, proverbially healthy, and possessing a pure and invigorating atmosphere. The hotel accommodations are good. The season opens May 1st and continues till November 1st. G. B. F. COLUMBO (Calumba, U. S. Ph.; Calumbce Radix, Br. Ph.; Radix Columbo, Ph. G.; Colombo, Racine de, Codex Med.), the root of Jateorrhiza Columba Miers; Order, Menispermacea. The Columbo plant is a large, perennial, herbaceous climber, with a rounded, thick, yellow rhizome, from which numerous fleshy roots are given off. The stems are slender and often very long, reaching to the tops of lofty trees; the leaves are long-petioled and very large (thirty centimetres = a foot long), from three- to five- or COLTSFOOT (Folia Farfara, Ph. G., the leaves ; also Tussilage ou Pas d'Ane, Codex Med., the flower heads); Tussilago Farfara Linn., Order, Composita, is a peren- nial herb with a branched and creeping root-stock which sends up in the early spring numerous simple scaly flower-stems, and later in the season large, angular, heart- shaped leaves. It is common in rich, moist places in Europe and Asia, and occasional in the United States. The leaves contain mucilage, a bitter extractive, and a kind of tannin. They have formerly had some reputa- tion as an expectorant or " pectoral," but are now' obso- lete excepting in domestic practice. The flower heads have the same properties as the leaves. Dose indefinite. Allied Plants.-Coltsfoot is the only species of its genus, but the next genus, Petasites, resembles it very closely, and has several species which have enjoyed about the same reputation as coltsfoot, and are equally value- less. For the order, see Chamomile. Allied Drugs.-All bitter mucilaginous and inert " herbs." IK P. Bolles. Fig. 728.-Columbo; branch reduced; flower enlarged; and drug with section, about natural size. (Baillon.) seven-lobed. Flowers dioecious, on long, drooping pan- icles, small, six-merous. Fruit of three drupes, each about as large as a hazel-nut; seed solitary. The most interest- ing portion is the root, which consists of numerous fusi- form tubers, like long dahlia or sweet-potato roots, at- tached to the also tuberous root-stock. These are dug up, sliced transversely, and dried in the shade. Columbo is a native of Mozambique, Zanzibar, and the adjacent lands of tropical Africa, and is said to be culti- vated. It has been known to European medicine for about two hundred years, and has been in general use for, say half that time. The dried sliced root has a very characteristic appear- ance. It is in circular disks from one to five or six centi- metres in diameter (one-half to two inches), and from one- half to one in thickness; the edge (surface of the root) is brown and rough ; the flat surface (sections of the root) lemon yellow, and depressed in the middle from collapse of the soft, thin-walled cells of the pith in drying. A dark circle marks the cambium, and one or two indistinct cir- cles of woody bundles can be seen within it. The tissue is chiefly parenchyma, loaded with starch. COLUMBIA WHITE SULPHUR SPRINGS. Location and Post-office, Stottville, Columbia County, N. Y. Access.-By New York Central & Hudson River Railroad, and Hudson River boats, to Hudson, thence by carriage to springs, four miles distant. Analysis.-The following is the analysis of one gallon of water : Grains. Chloride of sodium 84.719 Chloride of potassium 1.193 Chloride of magnesium 31.430 Carbonate of lime 21.794 Sesquichloride of iron 3.418 Sulphate of lime 64.941 Phosphate of soda 2.140 Hyposulphite of soda 8.149 Loss 814 218.598 Cub. in. Hydrosulphuric acid 4.491 250 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Colotomy. Columna: Adiposae. Columbo contains several bitter principles. One of them, berberine, is found in several other plants (see Bar- berry). Columbia is a colorless crystalline substance of excessively bitter taste and neutral reaction. Columbic acid is a yellow amorphous powder, also bitter. The medicine owes its value to all these constituents. Besides these, it contains starch and mucilaginous substances. Action and Use.-None of the active principles of Co- lumbo are in any degree poisonous. On the other hand, in small doses they are all tonic, and unite in making the crude drug and its preparations a simple bitter tonic. The dose of the powdered root is from half a gram to a gram (gr. viij. ad xvj.), but it is seldom employed so. A Fluid Extract (Extractum Calumbce Fluidum, U. S. Ph.), strength f, and a Tincture (Tinctura Calumbce, U. 8. Ph.), strength -jV, represent it well. Allied Plants.-See Parelra. Allied Drugs.-See Barberry ; also Gentian. IK P. Bolles. canal1 would seem to be an appropriate name (Fig. 729). The length of this space is about four millimetres, its width rather exceeds that of the hair-follicle above. Its long axis is placed at a slight angle to that of the follicle, which in most cases is nearly perpendicular to the surface, and is nearly parallel to that of the erector pili muscle (b). At about the middle of this axis are given off two horizontal prolongations, usually partially filled with fat-tissue, ap- pearing like a pair of extended arms or the remaining branches of a leafless trunk (p). Near this point is sus- pended the coil of 'a sweat-gland (e), held in place by a few delicate fibres which find their insertion at the top of the canal or cleft. The duct of the gland runs to the top of this space, whence it may be traced to the side of the hair-follicle, where it finds its way to the surface. (In dogs the sweat-duct opens directly into the follicle a short distance from its mouth.) The fibres of the cutis appear, in vertical section, to terminate abruptly at its edges. There does not appear to be any structure resembling a " limiting membrane." At the base there is sometimes a slight widening of the cleft, and on the side toward which its axis leans the fibres of the cutis collect to form a bun- dle which penetrates the subcutaneous fat, cones fibreux de la peau (k). The upper extremity is rounded off in somewhat dome-shape. In lean subjects the fat may be entirely absent. The cleft is then seen occupied by a blood-vessel in its axis, and at its top by a sweat-gland, the lateral space being filled by a loose reticulum of very fine fibres and connective-tissue cells. The erector pili muscle, taking its origin from the pa- pillary layer of the cutis, is inserted partly into the base of the follicle, which its fibres embrace, and partly into the structures forming the apex of the fat-canal. In some sections the fibres seem to penetrate this space, but prob- ably surround it, although some fibres may be attached to those delicate bands of fibrous tissue which traverse the column of fat-cells. The muscle lies on the side cor- responding with the inclination of the hair externally, and appears almost continuous in its direction with the column beneath it. It probably extends some distance down the side of the column. In certain sections, on the other hand, it appears to run between the base of the fol- licle and the apex of the column. The sebaceous gland lies between the muscle and the follicle, at the apex of the angle made by them ; a lobe is found also on the op- posite side. The number of these columns corresponds to the num- ber of hairs, as they do not exist elsewhere. In some sections of skin, half an inch in length, as many as five may be counted. They are seen to best advantage in the thickest portions of the skin, but may be found on the shoulders, arms, breasts, abdomen, and lower extremities. At some points they appear as slight indentations, at others as long canals. They are well shown in the skin of an infant, and in a foetus of nine months. In the pig the lower border of the cutis appears to the naked eye, when seen in section, like the teeth of a saw. Under the microscope the apex of each indentation contains the bulb of a hair. In thick hides these indentations become clefts or canals, and we find frequently a sweat-gland sit- uated at about the middle of each. "The canals are ob- lique, as are also the hair-follicles, and the axes of the two are more nearly parallel than in the human subject. In thin skin the canals are either so short as hardly to pass for such, or, if the hair root is of sufficient length to extend to the bottom of the cutis, are absent. A thick skin and the existence of downy hairs, are, then, the con- ditions necessary for the presence of this structure in its most typical form. They are not found in the skin of the face, on the inside of the arms and thighs, nor on the abdomen, where the skin is thinnest. In order to make a preparation which shows these structures in their entire length, the section must be made vertical to the surface, and in a direction which corre- sponds with the inclination of the cleft or of the hair above the surface. This coincides with the fine folds or "grain" of the skin. Sections made in any other direc- tion give but a fragment of the column, which appears then merely as an isolated lobule of adipose tissue. COLUMN/E ADIPOS/E. These consist of columnar- shaped spaces filled with adipose tissue, and are found in the thicker portion of the cutis vera. On the back and shoulders of hardy adults the true skin is very much thicker than in other portions of the body, measuring 5.5 mm. and even more in thickness, and presenting struct- ural appearances quite different from those usually seen in specimens selected for microscopical examination. It is composed of bundles of fibres interwoven in various directions, on the surface of which lie the flat connective- tissue cells, disposed in rows, the tissue being somewhat analogous to tendon. The cutis is, in fact, a sort of apo- neurosis connected by tendinous bands to the deeper parts, and in some animals actually attached to muscles. In man they form, especially near the upper part of the spinal column, a dense and strong mesh-work in the pan- niculus adiposus. The papillae are but imperfectly formed, and are for the most part represented by an undulating line: at short intervals are the follicles of the lanugo hairs, which penetrate only the superficial layers of the cutis, the sweep of whose deeper fibres would be unbroken were it not for the presence of these columns, which connect the bases of the hair-follicles with the panniculus adipo- sus in which the longer hairs in other parts of the body are always found embedded. This column consists of a nearly vertical cleft or slender columnar-shaped space, extending from the last-named structure in a somewhat oblique direction through the deeper and middle layers of the cutis, and terminating at the base of the follicle which rests upon it. This space is occupied by adipose tissue in its entire length, hence the term fat-column or fat- Fig. 729. 251 Coma.'™ AdipoS8e• REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The blood-vessels are well shown by an injection of Berlin blue in the foetus near full term. In each canal, as well as in the intervals between them, the arterioles which nourish the cutis ascend from the subcutaneous system of vessels, which forms a fine network in the pan- niculus adiposus, those in the canals, on reaching the lateral clefts, giving a branch on either side, which anas- tomoses sparingly through subdivisions with the adja- cent arterioles in the middle layer of the cutis, and gives origin to the papillary and sub-papillary network of cap- illaries, which here can be considered as one and the same. At the point of bifurcation of the main vessel branches are given off which ascend farther in the canal and form a delicate network surrounding the sudoripa- rous gland (Wundernetz). The anastomosis of the vessels about the hair-follicles is particularly rich and fine, and unites intimately with the superficial layer of capillaries. The hair-follicle, with its subjacent fat-column, thus forms the centre of a rich system of arterioles and capil- laries, which extends from the panniculus adiposus to the papillae. A free communication can be demonstrated by injec- tions as existing between the interspaces of the fibrous bundles of the cutis and the subcutaneous tissues: it is therefore probable that these columns contain communi- cating lymphatic branches with the subcutaneous net- work of lymph vessels. The special function of these spaces is not evident. In addition to furnishing a route for the blood-vessels and lymphatics, there seems to be soine connection with the hair-bulb and its apparatus. The constant relation which they bear to this structure and the erector pili muscles would suggest an arrangement designed to facilitate the action of the muscle. According to Biesiadecki,2 this muscle, by its contraction, raises the hair from the posi- tion which it occupies nearly horizontal to the surface to a more vertical one. Any movement of the root of a lanugo hair would be well-nigh impossible, embedded in the dense tissue of the cutis, were it not for a yielding structure like that of the adipose column, an elongation of which would aid the contraction of the muscle. In specimens where the muscle is found in a state of con- traction, the hair-follicle is bent like a bow, the root being drawn through the arc of a circle. The presence of fat near the hair-bulb is made possible by this structure, a condition which is constant with all hairs. That the fat is not an incidental feature of this struct- ure, which might be considered merely a cleft for the transmission of vessels, is rendered probable by the ob- servation of rows of fat-cells beneath each hair in the lip of the rat, where no especial channels exist, and also by the fact that such columns of fat do not accompany the nutrient vessels of the skin in those parts where the hairs are not seen. It seems, therefore, probable that this struct- ure has also some bearing upon the nutrition of the hair. Sweat-glands are found not only in these canals, but elsewhere in the thick cutis. The coil of the gland is then usually situated at a level a little below the middle of the cutis vera, and not in the subcutaneous adipose tissue, as in thin skin. The anatomical structure of this portion of the integ- ument explains the striking peculiarities of carbuncle, a disease almost invariably situated in this part of the body. The cribriform surface of the skin and the honeycombed appearance of the crater can be explained by the anatom- ical condition of the parts, and are not due, as is generally supposed, to a special pathological process. The disease begins as a cellulitis of the subcutaneous cellular tissue, which in this region is traversed by dense, tendinous-like bands, holding the skin down upon the muscular fascia and permitting a limited amount of swelling. For this reason, also, the inflammation cannot diffuse itself over a large surface. The tension of the thick skin is, therefore, very great, and the columnae adiposae, being filled with soft, yielding structures, become so many vent-holes for the escape of pus. The larger pustules seen on the sur- face of a carbuncle are situated, therefore, at the apex of these columns of pus. The very great number of ex- tremely minute pustules are papillae distended into a balloon-shape with pus, which has infiltrated the cutis vera through the lateral clefts in the canals. Below, the tendinous-like bands of fibres, which hold the skin down upon the deeper parts, form partitions, which so separate the suppurating mass that there appear to be several independent foci of pus ; and when the cen- tral portion of the diseased integument.has sloughed, give to the parts below a honeycombed appearance (Fig. 730). As the inflammatory process continues, the spaces be- tween the bundles of fibres of the cutis are much en- larged, and the fibres themselves seem to be partially ab- sorbed ; the tissue becomes so brittle that, in alcoholic specimens, it crumbles readily under the section razor. By this time the plug of cells accompanying the column has softened to a semifluid mass, and is retained in place only by a thin layer of cuticle, which still forms a cover- ing to what has now become a large pustule (Fig. 730, h). Fig. 730. In the subcutaneous tissue the cell - infiltration has spread from one alveolar space to another, while the tendon-like bands of fibrous tissue appear to be but slightly affected (m); in fact the cells do not penetrate them at all, but when the surrounding parts are melted into pus they form the undetached masses of sloughing tissue, which hold down at first the integument and favor spreading in a lateral direction, and at a later stage give to the crater its honeycombed appearance. In specimens of carbuncle on the lip, sections taken from various portions showed the same tendency to a dif- fused cell-infiltration of the structures. The papillae in this case also are worthy of notice. Although naturally diverse in shape and size, and crowded between large hair-follicles, their alteration by the in- flammatory process is evident. In some cases the papillae are distended by a mass of small, round cells, and where this cell-infiltraton is most marked we find extensive ec- chymoses at the apices of the papillae, showing that con- siderable disorganization of the tissue at that point has taken place. The possibility of other diseased products finding their way from below to the surface through these channels is illustrated in the cases of some morbid growths. In the light of these observations, it seems unavoidable to abandon the old view that a carbuncular inflammation is one originating or developing itself in a number of ad- jacent foci, and to conclude that we have a more or less rapidly spreading phlegmonous inflammation of the sub- cutaneous cellular tissue, we might say a purulent infil- tration, the characteristic appearances being produced by the anatomical peculiarities of the part affected. In con- firmation of this view', attention may be called to the fact that the more distantly removed from the region where the structures described exist in their most highly de- veloped form, the less typical is the appearance of the disease. When seated upon the anterior aspect of the body there is little to remind one of its striking charac- teristic. On the other hand, when an abscess, that is, a circumscribed collection of pus, forms in the dorsal re- gion, a protective barrier of cells is thrown around the accumulating pus, there is no infiltration of the tissue, and the pus reaches the surface by pressure upon the superjacent integument, which, softened by inflammatory changes, melts slowly away before it. There is in such a case no injection of certain structures with pus, as in carbuncle, and the characteristic appearances of the latter affection fail to show themselves. The cribriform ap- pearance is also not typically developed where the skin is thin and the columns do not exist, as in carbuncle of the 252 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Columnar Adiposae. Coma. lip. The pus then leaks through, so to speak, only at one or more accidentally less-resisting spots, taking as a route one of the lymph-spaces of the cutis, and reaching the surface through a papilla. In some cases of sarcoma, growing in the subcutaneous cellular-tissue and in naevi developing in this region, the new tissue finds its way to the surface through the co- lumnae adiposae. To what extent certain forms of vesicles and papules, in a cutaneous eruption, conform in their distribution to that of these channels in the skin, is a question which in- vites inquiry. J. Collins Warren. 1 Note on the Anatomy and Pathology of the Skin, by Dr. J. C. Warren, Boston Med. and Surg. Journal, April 19, 1877. 2 Stricker's Handbuch der Lehre von den Gevveben des Menschen und der Thiere. which remains normal in diabetic coma and uraemic coma, is several degrees lower in the coma accompanying severe burns. In cerebral haemorrhage it is not elevated until several hours after the occurrence of the attack, when it may rise six or seven degrees. In the comatose condition of tubercular meningitis more or less pyrexia is constant.* We will refer here to a few of the principal forms of coma and diseases in which it is present. Coma from compression may arise from direct pressure on the surface of the cortical portion of the brain, as from a depressed portion of fractured bone, from growths from the periosteum or dura mater, or from haemorrhage from the vessels superficial to or in the cortical portion of the brain ; or it may arise from pressure from within, as in haemorrhage into the ventricles or into the substance of the brain, in tumors, in abscess, and in effusion into the ventricles, such as is occasionally seen in the scarlet fever of childhood. Similar effusion may result from any dis- eased condition of the brain interfering with its circula- tion, and like results will be produced. Encephalitis, whether as the result of traumatism or of some disease process, may, by the congested state of the vessels in the vicinity of the cortex, press upon them to such an extent as to cause coma. Embolism of some of the cerebral ves- sels, and the resulting thrombosis, may indirectly act in this way. (Edema of the brain is another cause. Any condition by which the capillaries of the cortex are com- pressed, whether on the surface or from within, may act in like manner. The pressure, by arresting the circula- tion in the nerve-centres, cuts off their nutrition, arrests their function, and produces in this way sleep and coma. During the earlier stage of compression, the pulse is slow and full; respirations also are slow, regular, deep, and at times snoring. The temperature is but slightly above normal, unless the compression is the result of some fe- brile condition, or of some local inflammatory affection. The pupils, as a rule, are dilated. The faeces are passed involuntarily, and there is usually retention of urine. Vomiting may or may not have been present previous to the appearance of coma. In cerebral haemorrhage, the temperature, which is either normal or subnormal at first, soon rises, sometimes reaching 105° F., but should the coma last several days, it may again become normal before death takes place. Cerebral haemorrhage is not always attended with dilated pupils. Extravasation into the pons Varolii may be attended with a tightly contracted pupil. Reflex movements, which may be temporarily abolished on the sudden appearance of the coma, frequently reap- pear very shortly, and are then more readily induced than in the normal condition, owing to the inhibitory action of the brain being cut off. This condition is, however, frequently delayed until the coma passes away. Among the varieties of coma arising from toxic agents circulating in the blood, aside from poisons gen- erally speaking, we have two well known forms, viz., coma uraemicum, and coma diabeticum. Other forms of an autochthonous nature are described by some writers. Among these we may enumerate coma dyspep- ticum, coma carcinomatosum, etc. We will describe a few of the more important points in connection with each form. Coma uraemicum is one of the most serious symptoms accompanying some forms of kidney disease. It may set in suddenly, having been preceded by no other symptom than convulsions, attacking a person apparently in perfect health. In other cases premonitory symptoms, such as dropsy, dyspepsia, and vomiting precede these epilepti- form seizures. These convulsive phenomena are very seldom absent, and may consist of but a single paroxysm. More generally, however, there are several succeeding one another at intervals of time varying from a few minutes to several hours. During the paroxysm, there are complete insensibility, biting of the tongue, rolling of the eyes, and foaming at the mouth. In the deeply comatose con- COIVIA (Ko^a, deep sleep, lethargy ; Fr., coma; Ger., Schlafsucht). By this term we understand that condition in which there is complete absence of conscious sensation. The functions of the cortex are suspended, but the great centres of respiration and of cardiac movements continue their functions, hence the heart continues to act and breathing is kept up. The stupor may, however, be so slight that the patient can be aroused, and answers to questions elicited ; on the other hand, the more usual con- dition is that of complete unconsciousness. Coma may arise either directly, from pressure on the cortical portion of the brain, from a depressed fragment of bone, or from haemorrhage, or as the result of inflam- mation of the membranes of the brain or of its substance ; or it may be due to the presence in the blood of some poison supposed to act directly on the ganglion-cells of the cortex ; or, as in epilepsy, it may be due to functional disturbance of the brain depending on irritation, or upon some so-called "discharging lesion;" or, as we see it so frequently occurring in children, it may be associated with convulsions of a reflex character. There is but one symptom which can be said to be com- mon to all the varieties of coma, that is, loss of sensation. The condition of the pupils, pulse, and respiration, and the appearance of the face, vary more or less, according to the cause of the comatose condition. In the coma con- nected with compression, whether of depressed bone or of the serous exudation, one or both pupils are widely di- lated, sluggish in their movements, or do not at all re- spond to light. In the coma of uraemia they are also di- lated, but not to the same extent, sometimes, indeed, only partially so. In the early comatose condition of opium- poisoning the pupils are equally contracted, so are they also in that of chloroform narcosis. As a rule, the pupils are dilated in cerebral haemorrhage ; occasionally, how- ever, as sometimes occurs in haemorrhage into the pons Varolii or vicinity, they are tightly contracted. The pulse, always rapid in diabetic coma, is generally slow in compression of the brain, although later on it may become irregular, and then rapid. The respirations, which are slow in the coma of com- pression and uraemia, are rapid and deep in that of dia- betes. The face, sometimes pale and sometimes livid in diabetic coma, is always deadly pale in uraemic coma; in poisoning by opium it is pale ; in alcoholic poisoning it is flushed ; in the early stage of an epileptic attack it is pale, the pallor giving way soon to a dusky or dark-red hue, with more or less distortion of the face. The retina often presents marked evidence of intra- cranial disease in tubercular meningitis, abscess, and tumor of the brain ; it is usually unaffected in thrombosis, embolism, or cerebral apoplexy. In profound coma reflex excitabilities have quite disap- peared in the greater number of cases ; both cornea and conjunctiva are incapable of arousing any responsive movements. Spontaneous excitations of all'kinds are ab- sent. In other cases reflex processes are present; the eye- lids close, and the limbs move when subjected to sensory excitations. Convulsions frequently accompany the coma of tuber- cular meningitis; as a rule they precede uraemic coma, and are very rare in that of diabetes. The temperature, * As coma is only a symptom of some diseased conditions that are de- scribed in other parts of this Handbook, we will refer the reader to the diseases mentioned for other symptoms and for the treatment. 253 Coma. Comedo. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dition, there are stertorous breathing and dilated pupils. Occasionally cases are observed in which the symptoms set in with drowsiness, advancing gradually to coma. The patient may remain for two or three days in this condition, and then have epileptic seizures terminating in death. It frequently happens that in some cases remissions in in- sensibility may occur, the patient regaining consciousness and being able to answer questions or enter into conversa- tion, with a subsequent onset of the comatose state. But two conditions can be said to be constant in uraemic coma ; the secretion of urine is diminished in quantity, and the urea found in it is much smaller in quantity than is normal. There is yet much uncertainty as to the cause of this comatose state. Many theories have been advocated, the more popular one being that it is an intoxication ; that it is owing to the circulation in the blood of some poison acting directly on the nerve-centres involved. Whatever this substance may be, there can be but little doubt that it is some of the elements existing in the urine, or some of their derivatives, which are retained in the blood. The observations of some recent investigators point to the accumulation in the blood of some of the in- organic constituents of the urine, especially the potash salts, as the noxious agent. Other observers, still more recent, believe they have good reasons for reviving the older doctrine of retention of urea in the blood. This is the theory which since its introduction always has held, and still holds, the larger number of scientific supporters. Coma diabeticum is one of the conditions by which death may take place in diabetes mellitus. It usually sets in suddenly, without any warning whatever. The cases in which it makes its appearance are mostly those of young people suffering from this disease, who have been ex- posed to great fatigue. There appears also to be some relation between the setting in of coma and rigid dieting, as, in many of the reported cases, the coma appeared shortly after the patient had been placed on the restricted diabetic diet. On the other hand, excessive eating has acted as the exciting cause of other cases. The most characteristic symptom, possibly, in connection with nearly all these cases, is the character of the breathing. With the somnolency the respiratory movements become much deeper and more forcible in character-they are of a dyspnoeic nature, evidently involving all the muscles of respiration. This is more marked in expiration, the breath-sounds being frequently associated with those of a gasping and groaning character. These respiratory movements are seldom slower than normal; on the con- trary, they are either normal or slightly increased in rapidity. The lungs are perfectly normal. No diseased condition can be found in them or in the larynx to ac- count for this peculiar breathing. The heart's action is always increased in rapidity. The pulse is small and weak, numbering 120 to 140. The temperature of the body is never elevated ; generally the reverse. The ex- tremities are cold. Death usually occurs in from twenty- four to forty-eight hours after the appearance of the coma. No anatomical changes have been discovered in the brain to account for these symptoms. The comatose phenomena are somewhat varied. They may be divided, according to symptoms, into three prin- cipal groups. The first group will embrace those cases which, while in apparent health, have been attacked with great weakness after some unusual effort. These pa- tients rapidly die in a condition presenting some of the symptoms of collapse-cold extremities and small pulse, followed by loss of consciousness and somnolency. The second group embraces those cases in which there is great dyspnoea with rapid respiratory movements. All the muscles concerned in respiration, both inspira- tory and expiratory, are brought into activity, so that we have deep respiration pointing evidently to disturbances in the respiratory centre. Cyanosis is sometimes present in these cases. There is no oedema. The premonitory symptoms are general weakness, gastric or local disturb- ances, such as pharyngitis, bronchitis, broncho-pneumo- nia, etc. Then follow pain in the head, restlessness, deli- rium, occasional maniacal attacks, rapid, small pulse, somnolence and coma. The third group embraces cases of a milder form, in which the comatose condition has been preceded by pain in the head, an appearance resembling drunkenness, with uneven gait and drowsiness. In all these cases the urine has the peculiar ethereal odor due to the presence of some compound of acetone. What this substance is remains an unsettled question. The urine gives characteristic re- actions described under Acetonuria. The presence in the blood of acetone or some of its combinations is supposed by many to be the cause of the intoxication producing the nervous symptoms of diabetes. Frerichs, however, is opposed to this view, as he has administered it to both man and animals in doses as large as twenty grammes (5 drachms) without producing unpleasant results. Coma is also of frequent occurrence in connection with antemia. Here the symptoms very closely resemble those of diabetic coma; the most characteristic one being the dyspnoeic breathing. This form of coma has been several times observed, immediately preceding death, in various forms of cancer, more especially in connection with some part of the digestive apparatus. Some authors describe this particular form under the name of coma cardnomatosum. It is observed only in those cases in which there is great wasting, and an extremely anaemic condition of the body generally. It has also been fre- quently observed in pernicious anaemia, and in other anaemic conditions, such as are caused by gradual and fre- quent losses of blood, dysentery, etc. When it makes its appearance in these cases, it is only when the symptoms, although previously gradual, suddenly increase in in- tensity. In all these cases there is a marked diminution in the number of red blood-corpuscles. This deficiency in red globules in some indirect manner causes a species of in- toxication or self-infection. Deficiency in red globules means imperfect oxidation; consequently there is good reason for believing that there are changes occurring in the glandular organs by which means urea is increased in quantity. Other decomposition products are formed. These find their way into the circulation, producing, it is supposed, the characteristic train of symptoms. The comatose symptoms in adults set in suddenly with deep and labored respirations. Somnolency of" short duration generally precedes these symptoms. The tem- perature may either remain normal or become slightly subnormal. Should the disease, however, present in- flammatory complications there may be some elevation of temperature. The pulse is rapid and small. The symp- toms are very similar to those present in diabetic coma. No sugar is found in the urine. Acetone, or acetone-like bodies, which are constantly present in the urine of dia- betics, are not invariably met with in this condition. On this point, however, observers are not quite agreed. Some maintain that the burgundy-red reaction of urine with perchloride of iron, which is characteristic of ace- tonuria, can always be obtained in this form of coma. In children, coma is an occasional result of anaemic conditions of the brain, owing to sudden withdrawal of its nutrient fluids. We have examples of this in severe and repeated haemorrhages and also in cholera infantum. There is an absence, however, of the dyspnoeic character of breathing. Thrombosis of the cerebral sinuses is a post-mortem condition frequently found in these rapidly exhausting diarrhoeas, and is supposed to account in some measure for the presence of these symptoms. Coma dyspepticum 1 is a form of unconsciousness de- scribed by some writers as being caused by the absorp- tion of noxious substances from some portion of the digestive system. These nervous symptoms occur in patients otherwise perfectly healthy and well nourished. The premonitory symptoms are those of ordinary stomach derangement. After the symptoms have continued for a few days the patient complains of great muscular weak- ness, and pains in the head and joints. Suddenly the symptoms change. The breath presents the fruity odor of the diabetic patient. Coincidently with this, drowsiness appears. This condition becomes more profound, so much so that they ask for neither food nor drink. Questions are answered only with an apparent effort. This condition 254 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coma. Comedo. may gradually advance to one of profound coma. The pupil is not dilated; no changes are observed in the retina. The breathing, unlike that in diabetic coma, is easy and without effort. The secretion of urine is lessened to a slight extent, and presents no evidences of the pres- ence of either sugar or albumen. Its sp. gr. is 1.015 to 1.020. In the cases observed it had the fruity smell of the diabetic urine, and gave the same characteristic reac- tion with perchloride of iron. This condition lasts from two to three days, when the somnolency and also the fruity smell of the urine gradually disappear, recovery taking place in a few days. In order to account for these symptoms it must be re- membered that even during the normal digestive pro- cesses poisons may be formed in the gastro-intestinal tract. Phenol, indol, and some of the aromatic series which are the results of putrefaction, are occasionally produced here. Sulphuretted hydrogen, marsh gas, bu- tyric acid, and other substances of a more or less poison- ous nature can be obtained during abnormal digestion. Organic alkaloids, formed by the decomposition of nitro- genous constituents of the body, now known as ptomaines, have been obtained from the faeces of healthy persons, as well as from those suffering from diarrhoea and typhoid fever. These ptomaines have a paralytic action very similar to curare, when absorbed into the blood in suffi- cient quantity, as has been proved by experimentation. It is quite reasonable' to suppose that circumstances may arise which will facilitate the formation in excess of some one or more of these poisons, and their absorption into the blood. The incapacity for mental work which the brain-worker experiences when suffering from indi- gestion, the vertigo, tinnitus, dimness of vision, are all symptoms which can be explained in no other way than on the hypothesis of the absorption of these poisons from the mucous membrane of the stomach or intestines. In excessive doses they may cause more serious nervous symptoms, such as convulsions, paralysis, coma, and death. Coma of an autogenetic nature may also arise from other sources, such as abscess cavities or physiological cavities in which diseased processes are going on. We frequently have well-marked examples of the latter in affections of the bladder and urinary passages. In chronic cystitis, where there is a large surface capable of absorb- ing, comatose symptoms frequently present themselves. These may be preceded by depression, disturbances of the digestive processes, and drowsiness. Where these symptoms exist decomposing pus is present. This pus gives rise to some highly poisonous products, such as butyric acid, neurin, trimethylamine ; the latter two hav- ing their origin from the lecithin of pus. It is more than probable that some of the nervous symptoms associated with drowsiness have their origin in the absorption of some one of these poisons. Trimethylamine has frequently been perceived in the breath of these patients. It has been advocated by some good authorities that absorption of ammonia is the cause of these symptoms. This theory, however, is open to very grave objections. Patients suffering from extensive burns frequently die comatose. Post-mortem examination reveals a congested condition of the brain and its membranes, as well as effusion into the ventricles. There are, however, nu- merous cases of extensive burns in which patients re- main in a more or less unconscious state for a consider- able length of time. In these cases there is usually loss of reaction to pain-stimuli. Convulsions occasionally are present. Many theories have been advanced to account for these and other nervous symptoms-alteration of the red-blood corpuscles, the loss of their haemoglobin, the inspissation of the blood, and the formation of prussic acid through destruction of integument interfering with its functions'-so that the question is as yet undecided. We know, however, that in these cases there is decreased formation of animal heat; the temperature falls consider- ably. There is also decreased elimination of urea, show- ing that the oxidation processes are suppressed to a marked extent. This decreased elimination of urea is maintained up to the moment of death. It may be well to remember that in the coma of burns the symptoms are very similar to those of opium-poison- ing. In epilepsy coma usually sets in without any warning whatever, although occasionally cases are met with in which the patient will have sufficient warning to permit him voluntarily to lie down. Generally, however, with a wild scream they fall like a log wherever they may hap- pen to be when the attack seizes them. Convulsive move- ments set in at once, involving all the muscles of the body. At first the spasms are tonic in character, but do not last very long, 'clonic spasms speedily making their appearance. The muscular movements now become very violent, usually more so on one side of the body than on the other. After lasting on an average two or three minutes the spasms cease gradually, sometimes suddenly, and the entire body becomes relaxed. The coma, however, con- tinues for a variable period of time. During the coma- tose state there is complete absence of all reflexes ; the pupils are dilated and insensible to light during the early clonic spasms, and are variable later on. The substances usually known as "poisons," which are capable of producing coma, are so numerous that we propose to refer to only three or four of the most promi- nent ones. We will first speak of that in opium-poisoning. In the comatose condition arising from opium-poisoning the odor of the drug can generally be recognized about the patient. The symptoms are slow in making their appear- ance. The pupils are tightly contracted, the face is pale, sometimes ghastly ; breathing is slow, reflexes are absent. Immediately preceding death signs of asphyxia make their appearance ; the pupils dilate and the pulse becomes rapid and almost imperceptible. In the coma of carbolic-acid poisoning the symptoms usually set in rapidly, and are accompanied with symp- toms of intense collapse. The pupils are contracted. In severe cases the urine is of an olive green. When a large quantity of alcohol has been taken, the patient may become comatose without any previous state of excitement. Coma is, however, frequently ushered in by convulsions. The face is flushed, pupils dilated, con- junctivae are injected ;1 the lips are bluish and usually have a bloody froth escaping from them ; the breathing is snoring, gradually becoming more difficult until death takes place. The possibility of an individual, while in a state of in- toxication, becoming comatose from other causes must always be remembered. An individual while under the influence of alcohol may have an apoplectic seizure. In the alcoholic coma there is an absence of the hemiplegic symptoms. The pulse has not the full character that it has in cerebral haemorrhage. The pupils are dilated, as they are generally in the latter affection, but are more susceptible to the influence of light. The breathing is rarely stertorous, although it may be snoring. The pulse has not the full character of the apoplectic seizure. In uraemic coma there is generally more or less of an oedem- atous condition of the body. The great pallor of the face, and, if urine can be obtained, the presence of albu- men in it, with the other characteristic symptoms, will remove doubt. George Wilkins. i Bitten: Zeitschr. f. klin. Med., Band vii., Supplementheft, S. 81. 2 Catiano ; Virchow's Arch., Bd. xxxvii., Seite 345. COMEDO. Comedo is a disorder of the sebaceous glands, characterized by yellowish or whitish pin-head- size elevations, containing in their centre blackish points. It is observed chiefly about the face, neck, chest, and back. Each single elevation is called a comedo (plural, comedones). The disease consists essentially in the plug- ging up of the sebaceous ducts by inspissated sebum and epithelial cells. The sebaceous plug, which in most cases may readily be expressed by pressure, _ is usually black and discolored upon its distal end. This discolor- ation is not due to atmospheric dirt collected, but, accord- ing to Unna, the dark points are due to pigment granules of a black, blue, or brown color. The disease is a slug- gish one, and is usually found in connection with acne in 255 Comedo. Concretions. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. persons of a thick, greasy skin. More or less constipa- tion, or irregularity of the bowels, with dyspepsia, is fre- quently present. In young women, chlorosis and men- strual difficulties not uncommonly coexist. The common name, "flesh-worms," or "grubs," is cal- culated to convey the erroneous idea that the small in- spissated plug of altered sebum, which can be expressed from the follicle, is a parasitic worm. It is true that a little mite, the acarus or demoder folliculorum, is occa- sionally found in the mass, but this cannot be regarded as in any way essentially connected with the disease. Its presence is merely fortuitous and without significance, the plug, as has been said, consisting of altered sebaceous matter, mingled with epithelial cells. The affection, al- though comparatively trifling and without subjective symptoms, is often extremely annoying to patients. The disease is pre-eminently one of the period of puberty ; patients seeking relief from this complaint are almost in- variably young men and young women, although the disease may occur in infants and young children. Local treatment suffices, in most cases, to relieve the condition. Frequent bathing of the affected surface with hot water will aid the process of removal. Stimulating ointments, especially such as contain sulphur, are useful, as the following : I}. Sulphur, precipitat., 3 j. (Gm. 3.90); ung. aquae ros®, 5 j. (Gm. 31.10). M. Sig., to be rubbed in at night. Sulphur lotions, as those given under the head of Acne, may also be useful, and especially as acne and comedo are very frequently met with upon the same subject and with commingled lesions, the acne papule usually containing a comedo which becomes the " core " of the suppurative mass when suppuration takes place. Should the skin tend to become harsh under the use of these remedies, weak alkaline ointments may be used for a time, as this : 3. Sodii biborat., 3 ss. (Gm. 1.95); glycerin®, TTIxvj. (Gm. 1.32) ; ung. aquae ros®, j- (Gm. 31.10). The application of remedies may be facili- tated by squeezing out the comedones, so as to enable the stimulant applications to come more immediately in contact with the gland ducts. This may be conveniently performed by pressing the end of a watch-key gently, but firmly, down over the comedo. A spe- cial instrument is also sold for this use (see Fig. 731). No force should be used, for fear of exciting inflammation. If the comedo plug does not come out easily, it should be left for another time. It must be remem- bered that so long as the condition which produces co- medo is present and effective, the comedones are apt to be reproduced. Several, in succession, may have to be re- moved from the same glandular opening. Occasionally the contents of the sebaceous follicles be- come even more condensed and hardened than above de- scribed. The firm, almost horn-like, plugs are gradually forced out of the mouths of the follicles, until they pro- ject sometimes as much as one-eighth to one-fourth of an inch above the level of the skin. Hot baths, frictions with sapo viridis, and inunction of officinal sulphur oint- ment may be used in such cases. Arthur Van Harlingen. Comfrey has been long in use, first as a vulnerary, and afterward as a demulcent and "pectoral;" its constitu- ents are similar to most others of its class : mucilage, sugar, asparagin, tannic and gallic acids, and starch. Dose-a decoction may be taken ad libitum. Allied Plants.-See Borage. Allied Drugs.-See Marshmallow, Iceland Moss, Coltsfoot, et id omne genus. W. P. Bolles. CONCRETIONS. Concretions, or calculi, are aggre- gations of substances, which are either precipitated in the fluids or tissues in which they form, or are caused by the absorption of the fluid from semisolid masses, which thereby gradually become hardened, as in the case of be- zoars and enteroliths ; also in most glandular concretions, as in the tonsils, and in the case of salivary, lachrymal, pancreatic, and prostatic concretions ; rhinoliths and otoliths belong in this class of concretions also. Concretions may consist either of inorganic or of organic substances, or of mixtures of the two, these substances usually being composed of materials found in the body normally or pathologically ; but in some instances for- eign bodies become introduced into certain portions of the body, and upon these foreign bodies are deposited or- ganic or inorganic materials, varying in their nature ac- cording to their location. Sometimes they consist merely of salts of calcium, and are formed by the deposition of these salts in the fluids or tissues without any compound with the organic substances of those fluids or tissues be- ing formed. Such concretions are due to a process of calcification, as in the case of the calcification of uterine fibroids, or in that of the deposition of lime-salts in the wall of ovarian cysts. According to Rokitansky, these deposits are formed by the separation of calcium compounds from the fluids, in the same way that lime is separated from lime-water on warming ; at the same time fatty degener- ation occurs, and the mixture of the fatty matters with the lime deposit forms a semisolid mass, which gradually dries up and forms a concretion. Such deposits are signs of retrograde metamorphosis, and they include, in ad- dition to those mentioned above, the deposits which are sometimes seen in fatty tumors, in serous membranes, and muscles ; such concretions are also sometimes found in blood-vessels (especially in the arteries), in the lungs, in inspissated pus, in old blood extravasations, in masses of tubercle, in the placenta, etc. In one fatty tumor of the axilla Von Burow found a concretion consisting of calcic phosphate and cholesterin. The most important concretions-those which occur most frequently, and which most frequently give rise to medical and surgical interference-are biliary and urinary concretions. Biliary Concretions are formed in the gall-bladder or biliary ducts, and vary very greatly in size and shape. Sometimes only a single calculus exists, but usually there are many. In one case two thousand and eleven were found. Where there are numerous calculi, they are usu- ally faceted, the facets being formed by the constant rubbing of one calculus upon another. They are composed of the biliary pigments combined with calcium and cholesterin. The principal pigment is bilirubin, but in most concretions we find also biliverdin, bilifuscin, and biliprasin. In human calculi, calcium gly- cocholate and calcium cholate are also usually mixed with the coloring matters. The color of biliary calculi varies according to the amount of cholesterin contained in them. Some are composed chiefly of cholesterin and contain very little of the coloring matters, in which case the cal- culus is white or nearly so ; whereas others are composed chiefly of the coloring matters combined with calcium and contain very little cholesterin, in which case the cal- culus is dark brown, or even nearly black. Many calculi arc homogeneous in their composition, but others have two or more distinct layers, usually the cen- tral portion or body being dark brown in color and com- posed chiefly of the coloring matters, and the outer layer or crust being white in color and composed chiefly of cholesterin. It is stated that the habitual use of drinking- water largely impregnated with lime salts favors the for- Fig. 731.-Un- na's Comedo Expressor. COMFREY (Consoude, grande, Codex Med., Root), Symphytum officinale Linn.; Order, Borraginacece (Asperi- foliacea Luerssen). This is a coarse, rough, perennial herb, with an upright branched stem, half a metre or so high (one or two feet), oblong, decurrent leaves, and tubular flowers in one-sided cymes. Its root is thick, fleshy, sparingly branched, and rough and scaly near the top. It is twenty or thirty centimetres or more (one foot) long, and two or three centimetres thick. For medicinal use it is gathered in autumn, split longitudinally, and rapidly dried. It is then furrowed and wrinkled, with a black surface and whitish-gray section ; its texture is hard and horny; fracture, cellular ; taste, mucilaginous, slightly bitter and astringent. 256 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Comedo. Concretions. mation of biliary calculi, and it is the fact that all of the constituents of biliary calculi, with the exception of cho- lesterin, are compounds of calcium. Urinary Concretions vary very much in their com- position according to the circumstances under which they are formed. They are always composed of some of the constituents of the urine, which become precipitated un- der certain varying conditions, with the exception of the nucleus, which may be, in addition to a urinary constitu- ent, a foreign body which has been introduced into some portion of the urinary passages from without, or a piece of normal or pathological tissue, or a blood or mu- cous coagulum. The nucleus of a urinary calculus may be, therefore, anything in solid form which has its nativ- ity in the body, whether normal or pathological, and which can get into the urinary passages, or any foreign substance which may have been introduced into them. Among the foreign substances which have formed the nucleus of urinary calculi are pieces of bougies, which have become broken off in the bladder or urethra, bullets wThich have lodged in some portion of the urinary pas- sages, hair-pins, whalebones, pieces of soap or candles, beans or peas introduced into the urethra, by children chiefly, and pins and needles which have worked their way into some portion of the urinary tract. In the War- ren Museum, at the Harvard Medical School, is a phos- phatic calculus which has formed about a piece of sus- pender-buckle as a nucleus,1 this having been introduced into the bladder through the urethra by an insane patient. Other substances, although having their origin within the body, may, nevertheless, act like foreign bodies and form the nucleus of urinary calculi, such as blood and mucous coagula, the former having formed after haemor- rhage into the urinary passages, and detached fragments of morbid growths. The conditions which favor the deposition of those con- stituents of the urine, which are also constituents of uri- nary calculi, are a change in the reaction of the urine, an increased formation of some of the less easily soluble con- stituents, or a diminution in the amount of water excreted. The change in the reaction of the urine may be either an increased acidity, which favors the deposition of uric acid and urates, and of calcic oxalate, or a change from the normal acid to an alkaline reaction, which causes the separation from the urine of the earthy phosphates and ammonium urate. The alkaline reaction of urine may be due either to a fixed alkali or to ammonia ; the latter is the more important change in the formation of urinary calculi, since alkaline urine, w'hen the alkalinity is due to a fixed alkali, may be secreted for a very long time with- out giving rise to the formation of concretions. This is il- lustrated in those cases in which alkaline remedies are given for a long time, as in the treatment of acute rheumatism, and also in those cases in which the urine is habitually alkaline, as in some cases of faulty metamorphosis. An ammoniacal reaction, on the other hand, very frequently causes the formation of concretions, and always tends to increase the size of any concretion already existing. This reaction of the urine is caused by the fermentation of the urea, which is attended by the absorption of water by the urea and its conversion into ammonium carbonate ; it is a change which is due to the action of a ferment, and is facilitated by any irritation or inflammation of the mucous membrane of the bladder which causes an increase in the amount of mucus or the presence of pus in the urine. It may also be caused by the introduction of the ferment spores into the bladder, as in passing an unclean catheter. It always takes place in urine upon standing for a longer or shorter time exposed to the air, and is, of course, only of importance in the formation of concretions when it occurs within the body. When this reaction takes place, the deposits which separate from the urine are termed secondary deposits, because they are secondary to ammo- niacal fermentation of the urine. They are calcic phos- phate, calcic carbonate, ammonio-magnesian phosphate (triple phosphate), and ammonium urate. These sub- stances are frequently deposited upon the surface of a concretion which is composed of other constituents, such as uric acid or calcic oxalate; they are termed secondary constituents of the calculus, and the outer portion of the calculus, which is made up of these substances, is termed the crust of the calculus. The explanation of the deposi- tion of these substances when the reaction of the urine changes from acid to alkaline is, that they are all soluble in slightly acid fluids, but are insoluble in slightly alka- line ones. The other change in the reaction of the urine which increases the tendency to the formation of urinary deposits, is an increase in the acidity of the urine, which diminishes the solubility of the uric acid by diminishing the amount of alkali for it to enter into combination with. Uric acid usually exists in the urine in solution in the form of normal urate of sodium or potassium, which is very soluble in water ; if, for any reason-such as the in- creased formation of acid within the system and its elimi- nation with the urine-the uric acid is deprived of a part or the "whole of its base, either the acid urate of potassium or sodium, or uric acid is the result, and these substances being much less soluble in water than the normal urates, separate from the urine and tend to become aggregated together in the form of concretions. The relative solu- bility of these substances is an important factor in the formation of urate concretions, and is as follows : normal urates are very soluble in water, acid urates are but slightly soluble, while uric acid itself is almost insoluble in water. Any change in the system which causes an increased formation of any of the slightly soluble constituents of the urine, favors the tendency to the formation of con- cretions within the urinary passages, since they do not find a sufficient amount of urine to hold them in solu- tion. The substances which are liable to be formed in excess and to become constituents of urinary calculi, are uric acid and acid urates, calcic oxalate, cystin, and very rarely xanthin. This change in the urine is usually ac- companied by diminished secretion of water by the kid- neys, which also favors the deposition of the slightly soluble constituents of the urine in the form of concre- tions. The constituents of urinary calculi most frequently met with are uric acid, urate of sodium, urate of am- monium, calcic oxalate, calcic phosphate, both crystalline and amorphous, calcic carbonate, ammonio-magnesian phosphate (triple phosphate), and cystin. These may be divided into four groups of constituents, viz., urate, ox- alate, phosphatic, and cystin concretions. In small amounts may be found also the urates of potassium, calcium, and magnesium, phosphate of magnesium, and very rarely calculi are found composed of indigo, xanthin, urostealith (Heller), and silica ; bilirubin (haematoidin) crystals are also rarely seen in urinary calculi. Of the above constituents, the following may form primary deposits : uric acid and urates, calcic oxalate, calcic phosphate, calcic carbonate, cystin, xanthin, in- digo, urostealith, and silica ; the secondary deposits are urate of ammonium, calcic carbonate, calcic phosphate, and ammonio-magnesian phosphate. Urate of ammo- nium, calcic carbonate, and calcic phosphate may, there- fore, be either primary or secondary constituents. Urinary concretions may be formed in any portion of the urinary tract, from the renal tubules to the meatus urinarius. The most common locations are the pelvis of the kidney and the bladder. In rare cases numerous calculi may be found occupying almost every portion of the urinary passages; a remarkable specimen of this kind may be seen in the Warren Anatomical Museum. In the pelvis of each kidney was a calculus about three inches in length and three-fourths of an inch or more in diam- eter ; there were also found in the right pelvis ten, and in the left five, calculi from one-fourth to three-fourths of an inch in width ; one small calculus was also found in the left ureter, and two in the right; the calculus in the bladder was oblong, flat, and smooth, 2| by If inches ; this patient had suffered from urinary symptoms for twelve years. A fine specimen of urethral calculi may also be seen in the same museum ; the specimen consists of four oblong calculi, the ends of which are rounded or hollowed, and polished by rubbing against each other, and articulating by a ball-and-socket joint. Calculi are also 257 Concretions. Concretions. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sometimes formed in sinuses communicating with the urinary passages from the intestines, uterus, or vagina. The size of urinary concretions varies from that of the smallest gravel stone to that of an egg, or even larger, the size only being limited by the dimension of the cavity in which it is formed ; a calculus sometimes weighs sev- eral ounces. Ultzmann reports one as weighing nearly one thousand grammes, and in the Dupuytren Museum, at Paris, is a calculus which weighed 1,596 grammes. The number of calculi which may exist in the urinary passages is almost unlimited ; frequently there is only one, but several hundred may be found. Maisonneuve found 307 in the bladder, in one case. • Where several calculi are present in the bladder they are usually smooth, or even polished in those portions which rub against each other during the natural movements of the bladder- wall, or during the changes in the position of the body. These smooth portions upon the surface are termed facets, and show that in many cases the concretions while in the bladder do not change their position to any great extent. This is also shown by the peculiar form which is some- times seen in some cases of multiple calculi, wdiere some of the concretions have prolongations like teats, which were caused by the deposition of new material in the interstices between the surrounding stones, as in a case re- cently reported by Dr. A. T. Cabot. The surface of urinary calculi varies with their com- position, and also with their surroundings. Uric acid, phosphatic, and cystin calculi are usually smooth, while calcic oxalate calculi are usually rough, and have a lobu- lated appearance, whence their name mulberry calculi; sometimes, however, phosphatic calculi may have a dis- tinctly crystalline surface in whole or in part, in some cases the projecting ends of the crystals being several millimetres in length; the writer has also seen a cystin calculus which had a similar crystalline surface. This crystalline character of the surface appears in some cases to occur only upon those portions of the calculus which are continually bathed in the urinary current. The form of urinary concretions varies according to location and surrounding conditions. They are usually round or oval when located in the bladder, but they may be very irregular in shape, as in cases where there are numerous calculi their form may be modified by con- stant pressure against each other. In some cases a calcu- lus becomes partially encysted in the bladder, so that the deposit takes place only upon one portion, thereby caus- ing the growth of the calculus to take place in one direc- tion only, and giving it a very irregular shape; in a specimen in the Warren Museum, the form resembles that of a duck's body. In the urethra, when the concre- tion is not merely a phosphatic crust adherent to the mu- cous membrane, it is usually oblong or cylindrical in shape, and where there are several the ends may become quite highly polished, as in the case referred to above. In the pelvis of the kidney large concretions usually as- sume the form of that cavity, projections taking place into the calyces, and giving the calculus a shape not un- like that of an elephant in some cases ; small concretions in the pelvis are usually round or oval. In the kidney itself concretions are usually very irregular, in rare cases, as in the one described above, the renal tissue is almost completely destroyed, its place being occupied by the concretion. The color of urinary concretions varies mostly according to their composition. Uric acid and urate calculi are usually of a brownish-yellow color, varying from a pale straw to a dark brown color ; when uric acid crystallizes, it has the property of removing from the fluid a portion of its coloring matter, so that we never find perfectly colorless uric acid in a urinary sediment. Calcic oxalate concretions usually have a dark brown color, which is chiefly due to decomposed blood, since the calcic oxalate calculus is more liable to produce haemorrhage from the mucous membranes than other forms, on account of its rough surface. Phosphatic concretions are usually white, and often have a chalky feel; sometimes they have a grayish color. Cystin calculi are usually pale yellow in color ; if a section be made through the centre of a cys- tin calculus, it is seen to have a distinctly crystalline and radiating structure, the radiations being from the centre outward in all directions toward the periphery ; and if exposed for a long time to the light, the color changes to a green. Urinary concretions maybe either simple or compound in their composition. Several of the constituents may be intimately mixed together in any portion of the calculus, or they may be separated, occupying different layers in the same calculus. The different portions of a calculus are spoken of as the nucleus, the body, and the crust of the calculus. The nucleus occupies the centre, and may have the same composition as the rest of the concretion, but it often consists of some albuminous body, such as a coagulum of blood, or some foreign substance. Most frequently, however, the nucleus is composed of an ag- gregation of uric acid, urate, or calcic oxalate crystals, which were originally held together by a coagulum of fibrine or mucus, as often seen in urinary sediments. If the nucleus consists of quite a large mass of flbrine, co- agulated mucus, or pus, about which are deposited other constituents, this nucleus, after the calculus is removed from the body, gradually becomes dry and shrinks, so that it may become loosened from the surrounding shell and rattle when the calculus is shaken. A calculus may have two or more nuclei, as, for instance, when two or more small concretions become fastened together; they may be surrounded by layers of the same or different con- stituents. The several nuclei can readily be seen by mak- ing a section through the centre of the calculus. The body of the calculus surrounds the nucleus, and may or may not have the'same composition ; a body of calcic oxalate may be deposited upon a nucleus of uric acid, and vice versa. The body may also be composed of several layers, one of uric acid or urates, another of calcic oxalate, and so on for several layers ; or the same substance may be differently colored in the several layers of the body of the calculus. The crust is deposited upon the body of the calculus after ammoniacal fermentation of the urine has taken place, and always consists of some of the second- ary constituents, the phosphates usually predominating. Many calculi do not have a crust, since its deposition is entirely dependent upon ammoniacal fermentation of the urine. The time required for the beginning of the for- mation of the crust varies with circumstances, but de- pends chiefly upon the time required for the calculus to produce inflammation of the bladder. In the case of those concretions with a smooth surface, like the uric acid and urate, this may not happen at all, and very large calculi upon which no crust has been deposited may be removed from the bladder. Calcic oxalate calculi, how- ever, which are rough, produce inflammation very early, and usually a crust begins to be deposited upon them when they are quite small. Urate concretions are the most frequent, and are espe- cially common as renal calculi in children. They are usually smooth, round, or oval, of a pale yellow or brown color, and moderately soft, so that they can easily be crushed with a lithotrite. If some of the powdered cal- culus be heated on platinum foil, it chars and completely disappears if uric acid or ammonium urate be the only constituent; but if sodium urate is present, a residue is left which is soluble in water and has an alkaline reac- tion. When these calculi are being formed, the urine is usually concentrated, has a high color and high specific gravity, and an excessively acid reaction ; it also usually contains an abundant sediment of uric acid and urate crystals, the latter being the rosette-shaped clusters of urate of sodium ; the so-called hedgehog crystal, which probably consists chiefly of the acid urate of ammonium, occurs most frequently in the urine of children when a urate concretion is forming. In addition to the above crystalline sediment the microscope usually shows evi- dence of irritation of the kidneys, produced by the crystals or concretion. This is the form of urinary concretion which is the most amenable to the solvent treatment, viz., the administration of alkaline waters, which gradually changes the acid urates and the uric acid to the form of normal urates, which are easily soluble. 258 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Concretions. Concretions. Oxalate concretions are composed chiefly of calcic ox- alate, which is necessarily mixed with more or less or- ganic matter and color. They are usually dark brown in color, of rough, mulberry-like surface, and very hard, so that they are difficult to crush. If some of the powdered calculus be heated on platinum foil, it chars but slightly, owing to the organic matter mixed with it, and leaves a white residue of calcic oxide or calcic carbonate, accord- ing to the amount of heat used ; if the former, it will dis- solve but slightly in a drop of -water, which will have an alkaline reaction ; if the latter, it w'ill dissolve with effer- vescence in a drop of acetic acid. Urine from which oxalate concretions are being deposited, has about the same character as that in which urate concretions are formed, except that the sediment contains calcic oxalate crystals instead of uric acid and urates. Phosphatic concretions are formed in neutral or alkaline urine. They are usually -white and quite soft, so that they are easily crushed ; the surface may be either smooth or rough ; if smooth, it has a chalky feel. A portion of the powder heated on platinum foil, does not char or burn, and a bulky residue is left, which dissolves in acetic acid without effervescence, as does the original powder. The grayish calculi are harder, and are composed chiefly of calcic phosphate with only a small amount of triple phosphate. Waters rich in calcium salts are said to favor the formation of these concretions. Calcic carbonate concretions are extremely rare in human beings, but are quite common in the herbivora. When they do occur, they are usually smooth, of a grayish color, and very hard. A little of the powder heated on platinum foil to a white heat is converted into calcic oxide, which is but slightly soluble in a drop of water, the solution having an alkaline reaction; the original powder dissolves in a drop of acetic acid with efferves- cence. Cystin concretions may be smooth or rough, of a pale yellow color, and quite soft. A little of the powder heated on platinum foil burns with a blue flame, and the odor of burning sulphur is evolved ; no residue remains after ignition. Upon section they are seen to be crystal- line, and to have a radiating structure. If a little of the powdered calculus be placed in a watch-glass and treated with a drop of ammonia water, it will dissolve, and, if the mixture be allowed to stand until the fluid is evapor- ated, the residue will be found to consist of the colorless hexagonal cystin crystals. Cystin can also be recognized by its solubility in the fixed alkaline hydrates, as well as in ammonia, and in the mineral acids ; it is insoluble in acetic acid. Urine in which a cystin concretion is being formed is usually about normal in appearance, but the microscopic examination usually reveals cystin crystals in the sediment. Xanthin concretions are exceedingly rare. They are sometimes composed exclusively of xanthin, and some- times the xanthin is mixed with uric acid. Their color va- ries from white to dark brown. If a little of the powdered calculus be treated on platinum foil, it will char and en- tirely disappear like uric acid. Xanthin may be detected by a modification of the murexide test. A little of the powder should be treated with a drop of nitric acid upon a porcelain dish and evaporated to dryness ; the residue should then be treated with a drop of potassic hydrate, which will give it a pinkish tint, which will deepen to a violet upon warming ; uric acid treated in the same way will give a violet with potassic hydrate, which will dis- appear upon warming. Hence xanthin can readily be detected in the presence of uric acid. Urostealith concretions are also exceedingly rare, one case having been described by Heller in 1845, and one by Dr. W. Moore in 1853 ; in addition to these, there are two specimens, in the Hunterian Museum, of fatty con- cretions. In Heller's case the concretions, when fresh, were soft and elastic, like india-rubber, but when dry were hard and brittle. They dissolved in caustic potash, forming a soap, and were also soluble in ether and alco- hol ; in hot water they softened but did not dissolve; when heated on platinum foil they burned with a yellow flame, evolving an odor resembling that of shellac and benzoin. These concretions are most frequently covered with a shell of phosphates, and the fatty matter is some- times mixed with phosphates. Indigo concretions are also exceedingly rare, only one having been described by Ord. This was found in the pelvis of the right kidney in a woman whose left kidney was destroyed by a sarcoma. The calculus weighed forty grammes, and had a nucleus of blood coagulum and calcic phosphate ; the- deposit upon one side of the calculus was indigo, derived from the decomposition of the indican of the urine. Fibrinous or blood concretions are quite common as nu- clei about which other substances are deposited ; they are formed by the coagulation of fibrine or blood in the uri- nary passages. They are usually dark brown in color, and are quite friable. When ignited on platinum foil they burn with a yellow flame, and the odor of burnt horn is evolved ; if unmixed with other constituents, scarcely any residue is left. The composition of urinary concretions, if simple, can be determined by a few easy tests. In order to determine the nature of every portion of the calculus, it is of course necessary to make a section through its centre by sawing. If it has a homogeneous structure, the sawdust may be analyzed, but if it is made up of several different layers, a little powder may be scraped from the surface of each layer with the edge of a knife-blade, and subjected to chemical examination. The murexide test applied to a little of the powder will serve to detect the presence of uric acid, whether free or in the form of a urate. This test consists in moistening the powder upon a porcelain dish with nitric acid, evaporating to dryness, and, after cooling, treating the residue with a small drop of ammonia water, which- will give a beautiful purple color if uric acid be present. The modified murexide test will also serve to detect xan- thin (see Xanthin concretions). A little of the powder heated upon platinum foil will give the following reactions : Uric acid, urate of ammonium, and xanthin char with- out flame and leave no residue. Alkaline urates char without flame, and leave a residue (alkaline carbonate) which is soluble in water and has an alkaline reaction. Cystin burns with a blue flame, leaves no residue, and evolves an odor of burning sulphur. Urostealith burns with a yellow flame, leaves no resi- due unless mixed with phosphates, and evolves an odor of shellac and benzoin. Fibrine or blood concretions burn with a yellow" flame, leave no residue, and evolve an odor of burnt horn. Calcic oxalate and carbonate char but slightly, and, if heated to a white heat, leave a white residue (calcic ox- ide), which, when moistened, has an alkaline reaction to test-paper. To distinguish between them a little of the original powder may be treated with a drop of acetic acid; calcic oxalate will not be affected, but calcic car- bonate will dissolve with effervescence. Phosphates char but slightly, and leave a bulky residue, which is soluble in acetic acid without effervescence. Prostatic Concretions are exceedingly common and are sometimes discharged with the urine. Sir H. Thomp- son states that they are almost universal in prostates af- ter the age of twenty. They begin in the form of the round or oval laminated amylaceous bodies deposited in the gland follicles; these become filled, or impregnated with calcareous matter, and may reach a very large size. The largest one recorded is that of Dr. Herbert Barker, which was pear-shaped, and measured 4J inches in length and was 4f inches in circumference in its largest portion ; it weighed 1,681 grains. The inorganic matter, which is deposited upon these concretions, is usually a mixture of calcic phosphate and ammonio-magnesian phosphate. Preputial Concretions sometimes form in those cases in which the prepuce cannot be drawn over the glans, and they usually have for their nucleus dried smegma, around which may be deposited the ordinary constituents of urinary calculi, especially the phosphates. Some of these concretions have been found to consist of 259 Concretions. Condyloma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dried smegma and epithelial scales ; one, analyzed by Zahn, was made up of epithelium, calcium salts, and cholesterin, and another, examined by E. Salkowski, gave fat, free fatty acids, and calcium salts. Otoliths are formed in the same way as the preputial concretions, the dried secretion mixed with epithelium forming the nucleus ; cholesterin and calcium salts usu- ally form the other constituents of the concretion. Salivary Concretions form in the salivary ducts, especially in Wharton's duct, and are usually oblong in shape. They are formed by the deposition of the salivary salts, and may reach a large size ; one weighing seven and a half grammes is recorded. They are composed chiefly of calcic carbonate and phosphate, mixed with epithelium and organic matter. Other glandular concretions, like those sometimes found in the sebaceous glands (seboliths) and in the tonsils (amyg- daloliths), are formed chiefly by the drying up and harden- ing of the glandular secretion; they contain chiefly calcium compounds, cholesterin, and fatty matters. Lachrymal and pancreatic concretions contain chiefly calcic carbon ate and phosphate mixed with organic matter, like the salivary calculi. Enteroliths, or intestinal concretions, are very com- mon in the herbivora, and are formed usually by the de- position of salts from the intestinal fluids about some foreign body as a nucleus. The nature of the nucleus varies very greatly ; most commonly it consists of a co- agulum of blood, some albuminous body, pieces of food, biliary calculi, pieces of hardened excrement, or foreign bodies which have been swallowed. These concretions are usually of a grayish or slate color, and sometimes at- tain an exceedingly large size, weighing several pounds. The stone is made up chiefly of ammonio-magnesian phosphate, calcic phosphate, calcic carbonate, and fatty or albuminous matter. Rhinoliths are found in the nostrils after chronic in- flammation of the mucous membrane ; they arc usually formed by the deposition of the nasal secretion about foreign bodies as a nucleus. They contain a large pro- portion of organic matter. Edward S. Wood. mucous papule ; Ger., Uondylame, Inpperuarze, peucht- warze; Fr., condylome, terrue, recjetation. Definition.-A more or less prominent, villous, or tubercular excrescence of the skin or mucous membranes, notably of those upon the external genital organs or in their vicinity, and due chiefly to the continued action of irritating fluids, usually of venereal origin. History.-Both the word Condyloma and a descrip- tion of the affection to which it is now applied are found in the works of Hippocrates, but they are not associated. The term condyloma with Hippocrates, and many of the authors who followed him, was synonymous with haem- orrhoid, being sometimes employed also to designate a small, callous excrescence. The genital affection to which we now apply it was designated Thymus (&vnos, thyme), from its resemblance to a tuft of the thyme-flower. The same word is employed by Galen, and in the writings of Paulus yEgineta we find a distinction between benign and malignant thymi, a description of their appearances, and directions for their treatment that require little modifica- tion at the present time. The latter author is also the first to attempt a distinction between the condylomata and haem- orrhoids, while Celsus and Aetius apply the former term to a large variety of growths of inflammatory origin. To the earlier authors who refer to the etiology of the venereal wart, its presence was an indication of impure inter- course ; but in the era of the humoral pathology it was quite naturally attributed to the action of thick and mel- ancholic blood, the bile, or evil and corrupt humors. Even for a long time after the supposed importation of syphilis into Europe, and its great prevalence in the clos- ing years of the fifteenth century, this peculiar view was by some maintained; and the credit is due Fallopius of having first declared the relation of certain excrescences upon the genitals to syphilis, asserting that some of them were unqestionably due to that disease, while others arose from mere local irritation. The distinction between the pointed and the broad condyloma is ascribed by Griinfeld to B. Tomitanus, but even subsequent to his writings we find repeated reference to a humoral origin, until finally all such vagaries were silenced by the asser- tions of Benjamin Bell, Bichon de Brus, and others of their time, that such vegetations are the outcome of local irritation. With reference to the specific condyloma, and especially with reference to its true relation to syphilis, many confused statements are to be found in all but the most modern authors. What little there may have been added to our knowledge upon the sub- ject in late years will be found in the writings of Zeissl, K r a n z, Birch -1lirschfeld, Biesiadecky, and a few others. Description. - There are two species of condylomata, designated respectively, ac- cording to nature, the non- specific and the specific ; ac- cording to appearance, the pointed (condyloma acumi- natum) and the broad (condy- loma latum). The former be- ing in itself a disease, the latter but a local manifestation of a constitutional (syphilitic) taint, their separate con- sideration is deemed advisable. (a) The non-specific, or pointed, condyloma appears first as a small, slightly inflamed prominence of the epi- dermis. But this layer is soon removed, accidentally or otherwise, and there is exposed a tuft of few or many small, tapering elevations, which are found to be the hypertrophied papillae of the skin, often so closely massed as to appear as a single projection. As growth advances, and numerous secondary papillae are sent out, the tuft may assume the most varied forms, according to its loca- tion and the existence or absence of pressure. When unrestrained, and especially if springing from a mucous membrane, it may become large and prominent, resem- CONDILLAC is a village in the Department of La Drome, France, lying at an elevation of about three hun- dred feet above the sea ; it possesses two springs whose waters are used for medicinal purposes. The springs are known as the Anastasie and the Lise. The latter is the more strongly chalybeate of the two, and has a strong odor of sulphuretted hydrogen. The composition of the waters of these two springs is, according to the analysis of Henry, as follows : Each litre contains- Anastasie. Lise. Gramme. Gramme. Calcium bicarbonate . 1.359 0 954 Sodium bicarbonate 0.16(1 0.155 Magnesium bicarbonate 0.055 trace Calcium and aluminium silicate .. 0.245 0.713 Sodium sulphate 0.475 0.090 Calcium sulphate trace Sodium and calcium chloride 0.150 0.170 Ferric oxide 0.010 0.031 Salts of arsenic, potassium, and manga- nese, organic matters and iodine trace. trace Total solids 2.460 2.113 Fig. 732.-Pointed Condylomata upon the Prepuce and Glans Penis. (After Griinfeld.) Both springs are moderately charged with carbonic acid gas. The waters are taken internally and are also used in baths. The season extends from the middle of May to the middle of October, and the course of treat- ment for each individual is usually of about one month's duration. The Anastasie water is used in acid dyspepsia, chronic diarrhoea, scrofula, and the uric acid diathesis, while the water from the Lise spring is recommended in anaemia and chlorosis, and certain forms of skin diseases. T. L. S. CONDYLOMA (KorSuXwga, a knuckle-like or callous excrescence, Hippocrates; Condyloma, an inflammatory tumor, Celsus). Synonyms. - Venereal wart or vegetation, verruca, 260 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Concretions. Condyloma. bling a raspberry or the blossom of a cauliflower, or long and pointed like the intestinal villi, while at times it covers quite a large tract with comparatively short, densely crowded, fleshy excrescences. When subjected to pressure the form is modified to correspond to the sur- face with which it is in contact. For instance, when it is found protruding from the bottom of a fold or furrow, as from the anal fissure, the coronal sulcus, or from be- tween the labia, the tumor not infrequently resembles the botanical cock's-comb. Its growth is rapid, the tumor attaining a considerable size within a few days, and if neglected becoming as large as the fist or larger. The color varies, being pink, pale or bright red, or purple, according to the degree of vascularity. The surface may be dry or moist, owing chiefly to the habits of the in- dividual. Unless strict attention is paid to cleanliness, ulceration of more or less depth occurs, giving rise to a thin, yellowish, sero-purulent discharge, having an ex- ceedingly offensive, penetrating odor, especially when situated upon the genitals. This discharge often accumu- lates in the fissures between the individual papillae and condenses into firm crusts, at times tinged with blood, or, flowing down over adjoining parts, gives rise to a new growth of vegetations. Not infrequently, however, con- dylomata remain dry, resembling ordinary warts. The excrescences are not in themselves painful, but by their presence excite painful eczematous inflammation in the surrounding skin. The disease attacks with special preference the ex- ternal genital organs of either sex and the region about the anal orifice, developing with greatest vigor at the junction of a mucous membrane with the integument, contiguous regions becoming rapidly involved. The vegetations are frequently found upon other portions of the body, however, where, owing to the presence of folds or fissures, irritating fluids are retained, as, for example, about the navel, under dependent breasts, in the axilla, in folds of the neck, between the fingers or the toes, and in the mouth. They occasionally appear as a complica- tion of pregnancy, developing early, attaining an enor- mous size, and persisting throughout the period of gesta- tion, causing much inconvenience. (6) The specific, or broad, condyloma is a syphilitic lesion, characteristic of an early stage of that disease, and, as a rule, associated with other integumentary le- sions. It begins its growth in much the same manner as the non-specific condyloma, having, however, a moist, glossy, gray, or reddish-gray surface. Very often, ow- ing to frictions and consequent erosions, it acquires an angry red, uneven surface, emitting an irritating dis- charge, producing erythematous redness, and finally pain- ful excoriations, or even fissures of the surrounding in- tegument. Yet so shallow are all these lesions that, under appropriate treatment, they are recovered from with almost no cicatrix. Owing to pressure the form of the excrescence frequently becomes greatly altered, the papillae being so depressed and ulcerated as to render the growth unrecognizable, and even mistakable for the in- itial lesion. Its development is always rapid, and at times, owing to fibrillar metamorphosis of the cells in the papillary layer, the growth may become prominent and slightly overreach its base of attachment so as to strongly resemble the pointed condyloma. Like the pointed va- riety, its favorite seat is the genital organs and their vicinity; but it, too, may occur upon any cutaneous or mu- cous surface presenting conditions favorable for its pro- duction. It develops rapidly, and quickly invades con- tiguous regions, so that in a short time an entire groove or fissure may be covered and a wide extent of surface in- volved. Etiology.-(a) The non-specific condyloma is due to an alteration in the vitality of the papillary layer of the affected part, caused by mechanical or chemical irrita- tion, usually in the form of a continued contact of erosive fluids. Most potent in this respect are the discharges of gonorrhoea in either sex, simple urethritis, gleet, balan- itis, vaginitis, metritis, etc., or from the accumulation and decomposition of smegma or other physiological se- cretions in individuals of uncleanly habits. During preg- nancy it is due for the most part to the hypersecretion from the vaginal mucous membrane and consequent irri- tation of the parts over which it flows. The pointed con- dyloma, while it is not in itself an indication of syphilitic infection, is very frequently observed upon individuals thus infected. Certain abnormities of anaton#cal confor- mation predispose to the affection, notably a long prepuce with or without phymosis, elongated prepuce of the cli- toris, pendant labia minora, large carunculae myrtiformes, etc. The affection is more frequent in the young than in the old. (J) In the specific condyloma the change in the vitality of the part is due to the presence of syphilitic virus, but the influences that have been referred to as operative in the production of the benign growth, especially warmth, moisture, and friction, may generally be recognized as aiding its prbduction. The secretion from the specific condyloma is capable of producing the initial lesion, if inoculated into the skin or a mucous membrane of a healthy individual, but it is not auto-inoculable. In frozen sections of recently removed vegetations, stained Fig. 733.-Longitudinal Section of the Pointed Condyloma, a, The vas- cular papillary body; d, the epithelial portion; c, the horny cover. (Kaposi.) with fuchsin and gentian-violet, Birch-Hirschfeld dis- covered numerous diplococci with highly refractive quali- ties, most abundant in the cells of the Malpighian layer and the fibrous tissue of the papillary layer. Morbid Anatomy.-(a) In histological structure the non-specific condyloma is a species of papilloma, being simply an enormous hyperplasia of the papillary layer of the skin with comparatively little involvement of adja- cent structures. The earliest indication of its develop- ment is a slight prominence of the epidermis due to se- rous infiltration of the Malpighian layer, recognizable by a slight firmness to the touch, although not discernible by any change of color. Very soon slight inflammatory signs are seen, and the epidermis becomes detached, ex- posing to view the apices of a few already hypertrophied papillae. As growth progresses the individual papillae not only attain several times their normal size, but also throw out numerous secondary and tertiary branches, in 261 Condyloma. Conjunctivitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. structure identical with themselves. Sometimes, however, and especially when springing from a mucous membrane, they remain single. We may now with profit confine our investigation of the growth to the study of a single papilla, considering it composed of two parts, the papil- lary bodwnd the epithelial covering (see Fig. 733). The body consists of a fibrous framework, varying consider- ably in amount in different specimens, and frequently embryonic in character. In it may readily be traced the lymphatics and an afferent and an efferent blood-vessel, united at the apex by a capillary loop. In very large vegetations nerve-fibres have been observed (Kranz.) In the development of secondary papillae, the blood- vessels enlarge and throw off branches which ramify in the new growth. Occasionally the capillaries become dilated or ampullae form, and by their rupture occasion haemorrhages, visible or concealed. In the latter instance the pigment of the blood invades the cellular elements of the tissue, and remains embedded in them. At the base of the papilla the fibrous tissue is continuous with that growth. In the early stages they appear cloudy, those resting between the papillae being somewrhat diminished in size, owing to compression; but soon this layer is lost and the papillary surface is exposed. A marked hyper- aemia is also observed in the tissues of the affected part, extending outward to the limits of induration. The se- baceous and sw.eat-glands sometimes appear in the inter- capillary spaces. Prognosis.-The non-specific condyloma being purely a local affection, the prognosis is generally good ; never- theless it manifests a strong tendency to recur, and, owing to uncleanliness, absorption of septic matter has occurred with accompanying febrile disturbances. It is believed also by high authorities that such growths may undergo a sarcomatous, epitheliomatous, or carcinomatous meta- morphosis. The specific condyloma, as a rule, yields readily to treatment directed against the constitutional taint upon which it depends. Treatment.-(a) The treatment of the non-specific Fig. 734.-Longitudinal Section of a Non-specific Condyloma, consisting of a Primary and Several Secondary Papilla?. The three layers-the horny, the epithelial, and the fibrous with its blood-vessels and lymph-channels-are also represented. At the centre of the middle papilla and at the upper extremity of that to its right are seen transverse sections of the fibrous layer of tertiary papillae arising from them. (From an original draw- ing by the author. Magnified about four hundred diameters and reduced.) of the derma, which also undergoes a limited hyper- plasia. The epithelial covering of the papilla is made up, as a rule, of pavement cells, arranged in the same manner as those in the Malpighian layer of healthy skin, with a horny layer superimposed. Each papilla may receive a separate epithelial covering, in which case the investment is usually rather light, as in the soft villous condylomata, or where the growth is more vigorous several papillae may be grouped under a single, comparatively firm epi- thelial cover, as in the firm, dry condylomata. Even when the growth springs from a mucous membrane cov- ered by columnar cells, its epidermal layer frequently consists of pavement cells. (b) In the specific condyloma the microscope reveals an hypertrophy of the papillae, and a dense infiltration of the corium with round lymphoid cells, most pronounced in the papillary layer, but invading also the upper por- tion of the underlying reticular tissue. The epidermal cells take rather a passive part in the development of the condyloma is, as a rule, very simple. When difficult, it is rendered so by the tendency of the growth to recur after removal, and at times by the great number and large size of the excrescences. The prime object of treat- ment is to discover and remove the cause of the disease. When the warts are small, strict attention to cleanliness, implying frequent bathing and careful drying of the parts, the removal of all sources of irritation (discharges, foreign bodies, etc.), and the repeated application of iodo- form, bismuth, calomel, burnt alum, oxide of iron, or lycopodium, will generally effect a cure. Frequently re- newed cold applications, supplemented by bathing the parts in cold water, will sometimes suffice. Various as- tringent applications, as well as salves and lotions contain- ing the iodides and mercurials, have been recommended, and may be employed with benefit in some cases. Such remedies as the glacial acetic acid, perchloride or persul- phate of iron, although effective, are objectionable be- cause of their severity. Zeissl recommends the use of a salve composed of fifteen centigrams (two grains) of either 262 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Condyloma. Conju nctivltls. arsenious acid or the iodide of arsenic to four grams (one drachm) of vaseline, a small portion of this to be ap- plied to a limited part of the excrescence and renewed several times a day. The treatment with the bichloride of mercury, which has proved of great service, may be accomplished without pain by dusting calomel upon the surface after bathing with a solution of common salt. It is of the utmost importance in all cases to remove the se- cretions from the cavities in which they are retained. Surfaces which lie in contact, as, for example, the labia and folds of the integument, should be separated, and, after they have been cleansed and powdered, prevented from again coming together by the insertion between them of pledgets of dry absorbent cotton. In the same manner, the sides of large cauliflower excrescences should be removed from contact with the adjoining integument. The larger growths may be removed by caustics, of which the fuming nitric and chromic acids are the most effec- tive, by scraping with Volkmann's spoon, by the knife, scissors, or ligature, or by the thermo-cautery loop or knife, the stump being thoroughly cauterized for the two- fold purpose of arresting haemorrhage and preventing the recurrence of the growth. Where a large tract is involved it is advisable to attempt the removal of only a portion of the growth at any one time. In the syphilitic subject, and especially in the presence of other local or general le- sions of a syphilitic nature, we are justified in so far re- garding the specific character of the irritation under which even the pointed condyloma develops as to refrain from active surgical measures until the effect of anti-syphilitic medication has been tested. Before operative measures are commenced the sensi- bility of the part should be obtunded, when practicable, by the application of cocaine, after thorough cleansing. (6) The specific condyloma, as a rule, quickly disap- pears by resorption under mercurial treatment, best ad- ministered by inunction. If, however, for any reason, the immediate removal of the growth is important, the methods advised for the treatment of the non-specific ex- crescence should be resorted to, anti-syphilitic medication being at the same time employed. Cleanliness is of the greatest importance, however, in the treatment of this, as in the treatment of the pointed condyloma, and cannot be too strictly enforced. For Condyloma, Subcutaneous, see Molluscum Contagi- osum. James M. French. varieties ; but occasionally the most experienced observer may find himself at fault in this respect, being unable to determine, simply from inspection, to which class a par- ticular case should be assigned. The history of the case, and especially its behavior under treatment, will, how- ever, dispel the doubt. The three first-named varieties are essentially local disorders ; the last is but a local manifestation of a constitutional derangement; while the fourth, diphtheritic conjunctivitis, since the term is ap- plied to two probably distinct diseases-true diphtheria of the conjunctiva and a diphtheroid inflammation of the conjunctiva-must be regarded as being in some instances a local, and in others a systemic affection. As regards their pathogenesis it cannot be said that very definite views prevail. Catarrhal conjunctivitis undoubtedly arises from a variety of causes. It may, like catarrh of the nasal or bronchial mucous membrane, be produced by exposure of the surface of the body to cold, and is then doubtless dependent directly upon vaso-motor disturb- ance ; or it may be excited by irritant vapors or other substances coming in contact with, and acting immedi- ately upon, the conjunctiva. There is also a variety which is decidedly contagious, and which under favor- able conditions spreads rapidly from individual to in- dividual, direct contact or transferrence of secretion from one eye to another not being necessary to its propagation. Here, doubtless, there is a volatile specific germ which finds in the conjunctival sac conditions especially favor- able to its development, and which during its sojourn there excites in this membrane, in much the same fashion that the irritant vapor does, first a hypersemic, and then an inflammatory condition. Purulent conjunctivitis, on the other hand, which rarely occurs, in this country at least, except in the new-born from infecting vaginal dis- charges, or in adults from gonorrhoeal inoculation, is (in these forms at any rate) essentially a specific germ dis- ease ; and, fortunately for the human race, the germ which gives rise to it, though having an astonishing capacity for reproducing itself, is non-volatile, and, there- fore, communicable only by gross transplantation, and not through the medium of the atmosphere. A priori, there is no reason why a purulent conjuncti- vitis should not be produced otherwise than through the agency of a specific germ, and probably under certain conditions, of climate, etc. (as in Egypt), this may hap- pen ; but, under the relatively favorable hygienic condi- tions which prevail in this country, it may be safely as- serted that a conjunctival inflammation of such intensity as to warrant its being classed as purulent, scarcely ever occurs except as the result of specific inoculation.* True trachomatous or granular conjunctivitis is also doubtless the product of a specific germ. It is decidedly contagious, but, like purulent conjunctivitis, is communi- cated, probably, only by direct transference of discharge from eye to eye. It is customary to speak of this disease as being produced by filth and unfavorable hygienic sur- roundings. This, in all probability, is a mistake. An obstinate form of catarrhal conjunctivitis, which resem- bles it closely in appearance, does originate in this way, but the genuine trachomatous inflammation, the writer believes, does not develop in this de novo fashion, but, being dependent upon a specific germ, is always produced by inoculation. The term "diphtheritic conjunctivitis" has been em- ployed in a very indefinite and unscientific manner, being made to include two entirely different conditions, having only certain outward resemblances-true diphtheria of the conjunctiva, a disease of extreme rarity, because the ocular mucous membrane does not seem to be a favorite habitat for the specific organism upon which diphtheria doubtless depends ; and a diphtheroid inflammation of great intensity, characterized especially by plastic infiltra- tion of the conjunctival and subconjunctival tissues, and a pronounced tendency to necrotic changes, which occurs frequently in North Germany, but is rarely met with else- CONGRESS SPRING, CALIFORNIA. Location.-Santa Clara County, Cal. Access.-From San Francisco, via Southern Pacific Railroad, Northern Division, to Santa Clara or San Jose, thence by stage to springs. Analysis.-One pint contains : Grains. Carbonate of soda 15.418 Carbonate of iron 1.753 Carbonate of lime 2.161 Chloride of sodium 14.894 Sulphate of soda 1.517 Silica, alumina, and trace of magnesia 6.235 Temperature of water 50° F. G. B. F. Total 41.978 CONJUNCTIVITIS. Although authors given to mul- tiplying titles describe many kinds of conjunctivitis, there seems to be no good reason for making more than live distinct varieties, namely: 1. Catarrhal or simple conjunctivitis; 2, purulent conjunctivitis ; 3, tracho- matous or granular conjunctivitis; 4, diphtheritic con- junctivitis ; and 5, phlyctenular or scrofulous conjuncti- vitis. Whether regarded from a clinical or a pathological point of view all of the usually described forms of con- junctival inflammation may very properly, and with practical advantage, be divided into these live varieties, which, though they possess certain features in common, and, with the exception of trachomatous conjunctivitis, may occasionally merge one into the other, exhibit other well-marked and distinctive characteristics. As a rule it is not difficult in practice to differentiate these several * The writer does not recall a single case of genuine purulent conjunc- tivitis met with, in either hospital or private practice, during an experi- ence of more than thirteen years, which could not be traced either to some similar case, or to inoculation with a vaginal or urethral discharge. 263 Conjunctivitis. Conj unctivitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. where (except in the milder form of the so-called " mem- branous or croupous conjunctivitis "), and which, it would seem, deserves to be regarded rather as a type of inflam- mation likely to manifest itself in any case of severe con- junctivitis (but especially in the purulent variety) under certain favoring conditions of depraved health and bad hygienic surroundings, or in consequence of injudicious treatment, than as a disease sui generis. The great rarity of conjunctival diphtheria, contrasted with the frequent occurrence of diphtheria of the faucial and nasal mucous membranes, shows how little susceptible the eye is to true diphtheritic inflammation. That it occasionally occurs, however, there is, of course, no room for doubt, and cases have been observed in which the disease has spread from the fauces to the conjunctiva by direct extension through the nose and the lachrymal canals. The fact noted by competent observers in Germany, that the so- called diphtheritic conjunctivitis which prevails there, is sometimes produced by inoculation with the secretion from a gonorrhoeal ophthalmia, and, on the other hand, that the discharge from a diphtheritic case may give rise to a conjunctivitis of the purulent type,1 goes far to sus- tain the view that the condition to which the term diph- theritic conjunctivitis is usually applied is, as has been said, but a type of inflammation, and not a disease in itself. And it may be added that, in reaching a conclu- sion upon this point, we are bound to consider whether there is not some foundation for the impression, prevalent in England and in this country, that the partiality for harsh remedies in the treatment of conjunctival affections ascribed to our German brethren, accounts in some meas- ure for the undue proportion of the cases of this character which fall to their lot. Having said this much regarding the specific character- istics of the several varieties of conjunctival inflamma- tion, we shall take up separately each variety for more particular consideration, and, having in mind the prac- tical purpose of this article, shall deal with them from a therapeutical, rather than from a pathological stand- point. Catarrhal Conjunctivitis.-In a well-marked at- tack of this disease, decided evidences of ciliary irritation are present. Pain is rarely felt, but, especially at the commencement of the attack, there is photophobia, and with this more or less profuse lachrymation. A sensa- tion as though a foreign body were in the eye is almost always complained of ; and, as at this stage of the disease the symptoms, including the commencing conjunctival injection and the slight mucous discharge, are precisely such as are produced by the presence of a foreign body, it is always best, by careful inspection, to make certain that they are not due to this cause. The cornea, therefore, should be carefully scanned, and the lids everted, and their conjunctival surface scrutinized, so that the pres- ence of a foreign body may not be overlooked. Although catarrhal conjunctivitis almost invariably affects both eyes (differing in this respect from phlyctenular, and still more pronouncedly from purulent conjunctivitis), it sometimes begins twenty-four or thirty-six hours sooner in one than in the other. When, already, both are af- fected there is, of course, small reason to suspect the presence of a foreign body. In mild cases the discharge is slight and mucoid in character, being sufficient only to gum the lids together during sleep, and during the day showing itself only about the inner canthus and in the retrotarsal folds of the conjunctiva ; in severe cases it is muco-purulent in character and quite profuse. Though the palpebral conjunctiva is usually congested and swollen, and frequently the ocular conjunctiva, likewise, is markedly injected and cedematous, the inflamma- tory process rarely involves the cornea-never, perhaps, except in consequence of maltreatment, or when the dis- ease occurs in a badly nourished subject. Under favor- able hygienic conditions the inflammation may disappear, without treatment, in ten days or two weeks' time. Oc- casionally, however, it is quite obstinate, and can be gotten rid of only by careful attention. Epidemics of catarrhal conjunctivitis not infrequently occur in orphan asylums, or other institutions where large numbers of children are brought together. Under such circumstances it is apt to be more severe in type (closely resembling, in some instances, trachomatous con- junctivitis) and less amenable to treatment. Especially in strumous children, a conjunctivitis purely catarrhal at the outset, and due, perhaps, to cold or contagion, may assume a phlyctenular type, and, secondarily, the cornea may become involved. The use of unduly strong astringent collyria tends to bring about this unfavorable change. Catarrhal conjunctivitis rarely assumes a chronic form, except through the operation of special causes. In ob- stinate cases, therefore, complicating conditions must be sought for, and, if possible, eliminated. Sometimes it will be found that the conjunctival inflammation is only a secondary manifestation of a chronic naso-pharyngeal catarrh, or there may be stricture of the nasal duct pres- ent, with blennorrhoea of the lachrymal sac. In other in- stances the strain due to optical errors may prolong the attack, or even excite a mild form of conjunctivitis. Extraneous causes, such as the presence of irritant gases in the atmosphere (as in the neighborhood of certain man- ufacturing establishments), also have their effect, render- ing of no avail remedial measures which otherwise would prove effectual. The treatment of this variety of conjunctivitis can be described in a few words. The most important point to bear, in mind is, that harsh remedies are to be avoided, as they are likely to do harm by producing corneal compli- cations, and so converting a very simple into a very serious condition. When there is considerable ciliary ir- ritation at the commencement of the attack, decided re- lief may be obtained by applying, more or less constantly, to the closed lids, linen cloths wet with a lotion of acetate of lead and opium (ext. opii, .60 Gm. ; plumb, acetat., 1 Gm. ; aq. destill., 128 Gm. ; or ext. opii, gr. x. ; plumb, acetat., gr. xv. ; aq. destill., § iv.)-a most useful prepara- tion in many conditions of the eyes attended by ciliary irritation, which, though formerly much in vogue, is now " out of fashion," and but little used by the modern ophthalmologist. As a collyrium the writer has found nothing so generally efficacious as a 1 : 100 solution of boric acid, with the addition of a small quantity of sulphate of zinc, the proportion of the latter being varied, according to the amount and character of the discharge and the sensibility of the eye, from to | : 100 (zinci sulphat., gr. J-j. ; acid, boric., gr. v. ; aq. destill., § j.). By means of an eye-dropper this should be applied to the eyes freely three times a day, the head being held back, and the solution kept in contact with the eye for some moments. In addition, a simple ointment, such as cold cream or vaseline cerate,* should be applied to the edges of the eyelids at bedtime, to prevent their being gummed together by the drying of the discharge during the night. Under this treatment the inflammation usually begins to subside within a day or two, and at the end of ten days or two weeks has entirely disappeared. When a satisfactory improvement does not manifest itself, some other astringent should be substituted for the sulphate of zinc. Alum and nitrate of silver are the most useful, the former in the proportion of gr. ij. to viij. : § j., the latter in much weaker solution-gr. 1 to | : § j. Tannin (gr. iv. to viij. : |j.) is a favorite remedy with some, while others are fond of employing borax (gr. v. to x. : 5 j.). The latter, which is very mild in its action, may be pre- scribed in those cases in which there is doubt as to the character of the inflammation-whether it be simply catarrhal or phlyctenular - but as boric acid is de- cidedly more efficacious than borax, and as little likely to cause irritation, producing, indeed, in many cases a decidedly soothing effect, the writer prefers it under such circumstances. In obstinate cases the probable existence of complicating conditions is to be borne in mind, and if found to be present, these, of course, should receive the attention they may require. Should the inflammation * Yellow wax, 1 part ; vaseline, 4 parts; melted together and stirred while cooling.- Vide Trans. Am. Ophthalmological Soc., vol. iii., p. 572. 264 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Conjunctivitis. Conjunctivitis. assume a phlyctenular character the use of astringents ought to be discontinued at once, and in their stead the remedies employed which are suited to this form of con- junctivitis. After a severe attack of catarrhal conjunctivitis, espe- cially if its treatment has been neglected, the eyes some- times remain asthenopic and irritable for a considerable time. When this occurs they should be given as perfect rest as practicable, the state of the patient's health, which commonly needs building up, should be looked after, and soothing local remedies, such as the lead and opium lotion referred to above, or a collyrium of boric acid (1 : 100), or of muriate of cocaine (1 : 100) or of the two in combination should be employed. Purulent Conjunctivitis.-Although it is possible, as has been said, for a conjunctival inflammation of such intensity as to deserve the name purulent to be excited in a variety of ways, practically, under the favorable hygienic conditions which prevail in this country, it is scarcely too strong a statement to say that genuine purulent conjunc- tivitits never occurs, except in infants shortly after birth from infecting vaginal discharges, or in adults in conse- quence of gonorrhoeal inoculation. In the severer types of catarrhal conjunctivitis the discharge, as has been stated, frequently assumes a mu- co-purulent character, and in some cases of scrofulous conjunctivitis, too, this iriay happen ; but these are not cases of true purulent conjunctivitis, and should not be described, as they sometimes are, as such. In purulent conjunctivitis the inflammation, though similar in charac- ter, is far more intense than in the catarrhal form. The discharge, which is very profuse, is thick and creamy, and, since the inflammation is not confined to the con- junctiva but involves the submucous tissue, the lids be- come greatly swollen and tense, so that it is impossible to evert them, and the loose texture covering the anterior segment of the ball so cedematous and chemotic that it overlaps and nearly hides from view the cornea. The nourishment of the cornea is seriously interfered with, and, in consequence, ulceration and necrotic changes frequently occur, and may lead to its complete destruction. The prognosis is more grave, and the in- flammation usually runs a more violent course in the gonorrhoeal conjunctivitis of adults than in the infantile form of the disease. Why this should be is not plain, if the prevalent view that both are due to specific inocu- lation, and that in the discharge from each the gonococ- cus of Neisser is present, be true. Possibly, as has been suggested, the explanation is to be found in the fact that the discharge which infects the eyes of infants is seldom the product of a recently acquired gonorrhoea, whereas in adults the inoculation is more apt to occur during the height of the urethritis or vaginitis, when the infecting power of the discharge is greatest. From twelve to about forty-eight hours is given as the interval which usually elapses between the inoculation of the eye and the out- break of the disease (Nettleship); but in infants the in- terval is not so brief, since the inflammation of the eyes does not manifest itself, as a rule, until the third or fourth day after birth. In ophthalmia neonatorum both eyes are usually affected, because each is almost sure to be inocu- lated with the vaginal secretion ; in adults the disease be- gins in one eye, and only spreads to the other if there is an actual transferrence of the discharge. In the begin- ning of the attack there is considerable photophobia and lachrymation, with a sensation as though sand were in the eye. Later on the irritation of the ciliary nerves is so great as to cause severe pain, which may become intense if perforation of the cornea occurs with prolapse of the iris and secondary iritic inflammation. At first the dis- charge is not purulent, but mucoid, or thin and watery in character. This usually gives place very soon to a true purulent discharge, which is thick, yellowfish, and very abundant. In some cases this change is slow in manifest- ing itself, and under such circumstances the inflamma- tion is apt to be more intense, and the appearance of the purulent secretion may be preceded by a plastic infiltra- tion of the subconjunctival tissue, and a membranous exudation upon the surface of the conjunctiva. It is to this type of purulent ophthalmia, it would seem, that the term diphtheritic conjunctivitis is usually, but inappro- priately, applied. After this severe type of the disease, especially, cicatricial bands, like those which occur in the submucous tissue of the urethra and give rise to stricture, form in the conjunctiva, and in the cellular tissue beneath it, and by their contraction frequently cause distortion or incurvation of the lids. Opacities of the cornea, varying in extent and density, due to ulceration, with in many instances anterior adhesions of the iris, are among the frequent consequences of purulent conjunctivitis. Besides the true purulent form of ophthalmia neona- torum, which outside of lying-in asylums is comparatively a rare disease, there is a mild variety of conjunctivitis, very amenable to treatment, which is frequently met with in the newly born. It is characterized by some swelling of the lids, considerable conjunctival injection, and a mucoid discharge sufficient in amount to gum together the lashes. It yields very promptly to the instillation three or four times a day of a 1 :100 solution of boric acid, and as we can never be certain when we encounter this mild form of conjunctivitis that it is not the incipient stage of the more severe ophthalmia, its treatment should in no case be neglected. In gonorrhoeal ophthalmia the prognosis is extremely grave, destruction of the cornea being of frequent occur- rence. Where this destruction is not complete, however, the ultimate result as regards vision is far better, as Dr. Noyes has pointed out, than would seem possible during the height of the inflammation, the portions of the cornea not destroyed clearing up in a surprising manner. The disease runs a tedious course, and, even when the cornea escapes, the conjunctival inflammation may not disappear entirely for two or three months. After the more acute symptoms have subsided, a granular condition of the pal- pebral conjunctiva, which closely resembles true tracho- ma, but should not be confounded with it, as it is less obstinate and more amenable to treatment, frequently makes its appearance. In the treatment of purulent conjunctivitis time is a most important element. If seen at its very commence- ment, it is possible, by active measures, to cut short even a case of genuine gonorrhoeal ophthalmia. The writer's experience furnishes at least one unquestionable example of this. The success which has attended the prophylactic measures recommended by Crede, for the prevention of ophthalmia neonatorum, shows what may be accom- plished in this disease by treating the eye immediately after the inoculation has occurred, and before inflamma- tion has had time to develop. Crede's plan is to drop into the eyes of all children, directly after birth, when there is reason to fear inoculation, a 2 : 100 solution of nitrate of silver. In the large lying-in hospitals of Europe, where this plan has been extensively adopted, every child being treated in this way, the results have been extremely satisfactory, the percentage of ophthalmia, heretofore so large as to be a matter of serious moment, having been reduced to a small fraction of what it for- merly was ; and as the instillation of such a solution into the eyes of the newly born seems to be attended by no unpleasant consequence, this prophylactic measure should never be neglected when there is the slightest reason to fear that inoculation has occurred. The abortive treatment of gonorrhoeal conjunctivitis, which has been practised for many years, is practically the same as that suggested by Crede for ophthalmia neonatorum. It con- sists in the daily application to the everted lids, at the earliest possible moment after the disease has begun to manifest itself, of a strong solution of nitrate of silver (2 : 100 to 4 : 100). When there is reason to suspect that there has been a transferrence of specific matter to the eye, the risk involved is so great as to justify resort to this treatment without waiting for the supervention of con- junctivitis, especially as the pain which the application of the silver solution produces may now be obviated en- tirely by instilling into the eye, beforehand, a few drops of a 4 : 100 solution of muriate of cocaine. When, how- ever, the disease has once become fairly established, we can no longer expect to cut it short. Our efforts, then, 265 Conjunctivitis. Conjunctivitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. must be directed to controlling, as far as possible, the in- tensity of the conjunctival inflammation, and to preserv- ing the integrity of the cornea. Although various remedies have from time to time been recommended as especially efficacious in the treat- ment of purulent conjunctivitis, there is no one which lias proven so generally useful as nitrate of silver. The daily application (to the everted lids, if the swelling is not too great to prevent their being turned out) of a strong solution of nitrate of silver (2 : 100 to 4 : 100, according to the condition of the cornea and the sensitiveness of the eye), anaesthesia having been induced, beforehand, by instillation of a 4 : 100 solution of cocaine ; the instilla- tion with a pipette every two, three, or four hours of a | : 100 to | : 100 solution (gr. j. -iij. to 5 j.) of nitrate of silver, or of a solution of sulphate of zinc f : 100, and alum 1 : 100 in combination ; the application in a similar manner, three times a day, of a 1 : 100 solution of sul- phate of atropia, to diminish pain and to obviate, or fav- orably influence, corneal complications ; together with the more or less constant application of ice-cloths to the lids, if grateful to the patient, or, if more acceptable to him, of cloths wet with a lotion of opium or belladonna (ext. opii velext. belladonnae, 2 Gm. (gr. xxx.); aquae, 256 Gm. (f. 3 viij.)), and the careful cleansing of the eye every hour, while the discharge is profuse and creamy, with a saturated (4 : 100) solution of boric acid, constitute a plan of treatment which, in gonorrhoeal ophthalmia (the most virulent form of purulent conjunctivitis), offers the best prospect of success, and which, with slight modifica- tion, generally is successful in the infantile form of the disease. When ulceration of the cornea is present, the stronger solutions of nitrate of silver are not so well borne, and must be used with more caution, being ap- plied, if practicable, only to the palpebral conjunctiva, and not allowed to come in contact with the cornea; or the silver solution may be neutralized by applying di- rectly after it a warm solution of table salt. When there is pronounced chemosis, scarification of the conjunctiva does good by depleting somewhat the distended vessels ; and when the swollen lids appear to be exerting danger- ous pressure upon the eye, free division of the outer can- thus (a single cut with strong, straight scissors, in a hori- zontal direction, will suffice) is recommended, and is doubtless a judicious procedure, although the writer's experience has not presented a case in which resort to it seemed to be called for. As the transferrence of pus from the inflamed eye to the sound one will almost inevitably cause the disease to develop in it, every precaution should be taken to pre- vent this happening. The patient and attendants should be constantly warned of the danger of handling the sound eye when there is a possibility of the discharge being on their fingers, and of the risk of inoculating this eye while cleansing and applying remedies to the diseased one. To lessen this latter risk, as well as to diminish the danger of the attendant's eyes being inoculated, the writer would suggest that the discharge be removed by means of ab- sorbent cotton and the pipette only, and not, as is usually recommended, with a syringe. While the discharge is abundant the patient should not be allowed to lie with the diseased eye uppermost, as in this position the pus may flow across the bridge of the nose, and so reach the opposite eye. The frequent washing away of the dis- charge with the boric-acid solution, as already sug- gested, will further lessen the likelihood of this accident occurring. Most authorities recommend that the sound eye be hermetically sealed up with diachylon, or India- rubber plaster, and collodion ; and to render this more endurable to the patient, Dr. Buller, of Montreal, inserts a watch-glass between two layers of the rubber plaster, so that the eye may still be used, and leaves the outer and lower angle of the covering open for ventilation. The writer has met with no case in which resort to this ex- pedient seemed necessary, and so far he has had the good fortune (in gonorrhoeal ophthalmia) never to see the dis- ease extend to the second eye. As the intensity of the inflammation subsides, and es- pecially as the discharge diminishes and loses its creamy consistency, becoming muco-purulent in character, the treatment should be less active, the astringent and anti- septic applications being made at longer intervals, and the strong silver solution diminished in strength or ten- tatively omitted. It is in this way only-by carefully watching the effect of the remedies employed, and by modifying the treatment from time to time as may seem necessary-that the inflammation can be kept in some measure under control, and the great danger which con- stantly impends, destruction of the cornea, be obviated. Besides the remedies which have been mentioned, others, such as corrosive sublimate in weak solution (-/u- : 100), carbolic acid (5 : 100), and finely powdered iodoform, to be applied freely to the conjunctiva, have been recom- mended as useful in this disease. In the so-called diphtheritic form of purulent con- junctivitis, in which the discharge is thin and ichorous, and there is a tendency to plastic exudation and infiltra- tion, strong astringent solutions are contra-indicated. Boric acid and atropia should here be chiefly relied upon, until by the application of warm fomentations the type of inflammation has been changed, and the discharge has assumed a purulent character, when the use of the silver and astringent solutions should be begun with cau- tion and their effect carefully noted. Constitutional treatment may not be called for in all cases, but when the patient is in robust health and of plethoric habit, the good old plan of moving the bowels freely by a mercurial purgative will do good ; while, on the other hand, quinine should be given freely, supple- mented by iron and a generous diet, when there is anaemia and an impoverished state of the system. After the acute symptoms have subsided, alum and tannin are especially useful in overcoming the persistent hyperaemia of the ocular, and so-called "granular" condition of the palpe- bral, conjunctiva. The treatment of purulent conjunctivitis in the infant is essentially the same as in the adult, except that, as the inflammation is generally less intense, the caustic and as- tringent solutions should be somewhat milder; and the opium and belladonna fomentations are, of course, out of place. The instillation of atropia, however, should not be omitted, especially if ulceration of the cornea be present or threatening. Chiefly from maltreatment or neglect, this affection probably causes a greater amount of ir- remediable blindness than any other one disease of the eyes. When the destruction of the cornea has not been complete, however, it frequently happens that great im- provement in vision may be obtained by a well-placed ar- tificial pupil. Trachomatous or Granular Conjunctivitis.-The distinctive characteristics of this form of conjunctivitis, which expends its force chiefly upon that portion of the conjunctiva which lines the lids and constitutes the retro- tarsal folds, are its obstinacy, the marked structural changes which it causes in the subconjunctival tissue, as well as in the conjunctiva itself, and the secondary altera- tions which it induces in the cornea. Its pathology is as yet but imperfectly understood, and it is doubtful how much importance should be attached to the so-called "trachoma granules" which have been described as the characteristic product of the trachoma- tous process, or to the particular form of " schizomycetes " which Sattler has discovered in the trachomatous secre- tion, and which he regards as the specific and contagious element of the disease. Certain it is that the papillae of the palpebral conjunctiva undergo great hypertrophy, that the glandular structures are especially involved in the inflammatory process, and that pronounced hyper- plasia of the submucous connective-tissue occurs ; and that ultimately there supervenes a stage of atrophy which in- volves all of these structures, and in the worst cases results in the condition known as xerophthalmia, in which the conjunctiva-itself so atrophied that the retrolarsal folds are obliterated, and free movement of the lids and ball curtailed-loses the character of a mucous membrane, and becomes dry and cuticular, and entropion develops in consequence of incurvation of the tarsal cartilage from contraction of the plastic material previously thrown 266 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coiij unctlvltis. Conj u nctivltis. out in the subconjunctival tissues. As Nettleship has pointed out, the palpebral conjunctiva does not undergo ulceration, and, therefore, the trachomatous condition which it assumes is not due to true "granulations," but to the hypertrophy of its papillae. The secondary changes which occur in the cornea are chiefly, if not entirely, due to the mechanical violence to which it is subjected through constant friction with the roughened inner sur- face of the lids. The first evidence of corneal implica- tion is a slight roughening of the external epithelial layer. Eventually the cornea becomes more or less opaque ; nu- merous blood-vessels develop upon it; its surface be- comes uneven ; and sluggish ulcers occasionally make their appearance-these changes being more marked upon the upper half of the cornea, because here the lid friction is greatest. Although one of the most intractable diseases of the eye with which we have to deal, and in its ultimate con- sequences as disastrous to sight as any, granular con- junctivitis does not, like purulent conjunctivitis, threaten the eye with immediate destruction. The inflammation does not approach in intensity that which characterizes the latter disease; nevertheless, during the acute stage which supervenes upon inoculation (for it seems proba- ble that the malady always originates in this way) there is frequently considerable swelling of the lids, marked conjunctival injection, and great photophobia, lachryma- tion, and blepharospasm. The discharge, which is not abundant, is usually mucoid or muco-purulent in charac- ter. With the subsidence of these more acute symptoms, the chronic stage of the disease begins, and this, if left to itself, may last for a lifetime, rendering the individual's whole existence miserable, and reducing him to a state of helplessness and dependence. The treatment of granular conjunctivitis does not always yield satisfactory results, and even in the most favorable cases must be long-continued to be effectual. Relapses frequently occur, and even when a complete recovery seems to have been secured, it is wise to give a guarded prognosis as to the future. In dealing with this loath- some malady, prophylactic measures are of the first im- portance. In this country, at least, as the waiter has had occasion to remark before, the disease seems to be kept alive in institutions, such as orphan asylums and houses of refuge, in which the young are crowded together. Indeed, in the writer's experience, it is an extremely rare occurrence to meet with a case which cannot be traced, either directly or indirectly, to some such source. If the evil w'ere systematically and energetically attacked in these its strongholds, its complete eradication, it would seem, ought to be only a question of time. Through the criminal carelessness of those who have the management of these institutions, the disease is allowed to spread from inmate to inmate, being transmitted usually by means of towels, which those with diseased and those with healthy eyes are permitted to use in common. To prevent the possibility of contagion in such institutions all those with affected eyes should be placed in dormitories apart from the other inmates, and, as far as possible, should be kept entirely away from them. An intermediate class should also be established, in which the doubtful cases (for, as has been stated, the recognition of the different varieties of conjunctivitis is not always an easy matter) should be quarantined. To combat the disease, when it has become established, local remedies are chiefly to be relied upon, although tonics should, of course, be administered when the state of the system seems to call for them. Nitrate of silver, sulphate of copper, alum, tannin, boric acid, yellow oxide of mercury, and infusion of jequirity bean, with atropia and cocaine, are the remedies which have been found most useful. When, during the early stage of the attack, there is pronounced irritation of the ciliary nerves, manifested by pain, photophobia, and lachrymation, atropine (1 : 100) or muriate of cocaine (2 to 4 : 100) should be applied to the eyes three or four times a day, and astringents should be used with caution, a collyrium of alum (| to 1 : 100) and boric acid (1 to 2 : 100), to be dropped into the eyes three times a day, being, perhaps, the safest to begin with. When the ciliary irritation has somewhat abated, a daily application of a solution of nitrate of silver (2 to 4 : 100) should be made with a brush, or a toothpick armed with absorbent cotton, to the inner surface of the everted lids, the excess of silver being neutralized by chloride of so- dium if the application causes much discomfort. The anaesthetic action of cocaine may be employed to lessen the pain which the nitrate of silver produces. If the photophobia increases under this treatment, the silver solution should be applied less frequently, or, instead, the everted lids may be touched once in twenty-four or forty-eight hours with a smooth crystal of sulphate of copper. In the meantime the patient should continue to apply, three times a day, the alum and boric acid solution, or, if this does not seem to be doing good, a weak solution (i to | : 100) of nitrate of silver, or of alum (| to 1 : 100) and sulphate of zinc (i to i : 100). As a substitute for the silver and copper, when these are not well borne, Dr. Noyes recommends a 2 to 6 : 100 solution of tannin in glycerine. When the disease has assumed a chronic character, the crystal of copper, and the solutions of silver and of tannin are still among the most valuable remedies. The " lapis divinus " (sulphate of copper, alum, and nitrate of potash, each 1 part) is also a favorite remedy, and a simple crys- tal of alum, which may be applied to the palpebral con- junctiva three or four times a day, is another, which the writer has sometimes found extremely useful. Again, there are cases which are greatly benefited by the daily application of yellow oxide of mercury ointment (hydrarg. ox. tlav., 1 part; vaseline, 30 to 60 parts), combined with the instillation of atropia. Whenever there is great ciliary irritation, the use of a 2 or 4 : 100 solution of cocaine may advantageously supplement any other treatment. Although in a few instances disastrous consequences have followed the employment of jequirity in the treat- ment of "granular lids" (cases having been reported in which destruction of the cornea has occurred as a result of its use), it has, on the other hand, so often proved of the greatest value, in the very cases, too, in which all other rem- edies have failed, that it may be looked upon as having secured a permanent place among the standard remedies of the ophthalmological pharmacopoeia. Its therapeutical ac- tion is dependent upon the acute inflammation which it ex- cites in the conjunctiva and cornea, and which supplants, so to speak, the chronic trachomatous inflammation. A similar effect was formerly sought to be obtained by the more dangerous procedure of inoculating the eye with pus from a case of ophthalmia neonatorum. When this practice was in vogue, the universally accepted rule was that inoculation was never justifiable unless the cornea of the eye to be inoculated was opaque and vascular, as under such circumstances the danger of necrotic changes occurring in its texture was known to be greatly dimin- ished. It is not necessary that this rule should be ad- hered to so strictly in the production of jequirity ophthal- mia, since the inflammation is not so intense as that which follows purulent inoculation ; nevertheless, it should not be entirely lost sight of. If it is justifiable at all to use jequirity when the cornea is clear, it certainly should be employed, under such circumstances, in the most cautious manner. As its use, however, should be restricted to cases of chronic trachoma only, and as in these the cor- nea is almost always more or less opaque and vascular, it will seldom happen that we shall be called upon to decide upon the propriety of inducing a jequirity oph- thalmia in an eye with a transparent cornea. Experience has shown that there is an astonishing dif- ference in the susceptibility of individuals to the action of jequirity, a single application of a 2 or 3 : 100 infusion causing, in some persons, a higher grade of conjunctival inflammation than a dozen applications of a 5 : 100 in- fusion in others. For this reason it is wise, in all cases, to exercise caution in beginning the use of this potent remedy. A 2 : 100 infusion suffices in most cases to excite the requisite degree of inflammation. A stronger infusfbn, therefore, need not be employed (and certainly should not 267 Conjunctivitis. Conju nctivitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. be at the commencement of the treatment), unless an in- susceptibility to its action be manifested, when it may be necessary to use a 5 : 100, or even a 10 : 100, in- fusion. After the first application, which should be made with a brush to the everted lids, an interval of at least twenty-four hours should elapse before the treatment is repeated, in order that we may carefully observe the effect produced. Occasionally it will hap- pen, in those peculiarly susceptible to the action of the jequirity, that this first application will suffice to excite the requisite degree of inflammation. More fre- quently the treatment must be repeated once in twenty- four hours, for three or four days, to attain this end, and not rarely several applications a day, for as long a period, may be required. The inflammation which ensues is of the " croupous " or " diphtheritic " character, and the degree which it is desirable to produce is attended by decided oedema of the lids, considerable increase in the previously existing cloudiness and vascularity of the cornea, and the formation of a " croupous " membrane upon the palpe- bral conjunctiva. Pain in the eyes and headache are generally present, and not infrequently there is consider- able fever, with rest so broken that a liberal use of anodynes is called for. After the jequirity applications are discontinued, the ophthalmia usually subsides rapidly, and unless complications have occurred (such as ulcera- tion of the cornea), no further treatment is demanded. With the subsidence of the inflammation the corneal opacity begins to diminish, and the trachomatous con- dition of the lids to disappear, and in favorable cases the improvement in vision which results is most grati- fying. In consequence of the " diphtheritic" character of the induced conjunctivitis, cicatrices are not infrequently left in the palpebral conjunctiva ; but the writer is not aware that any case has been reported in which they were of such a nature as to give rise to inconvenience. Relapses occasionally occur after the jequirity treat- ment, as they do after every other plan which has been proposed for the cure of this proverbially obstinate affec- tion, and even temporary improvement is not attained in every case. When benefit results, but only to a moder- ate degree, a reproduction of the jequirity ophthalmia may be indicated, and under such circumstances it will generally be found more difficult to establish it, because of an acquired tolerance to the irritant action of the bean. It has been suggested that the property of exciting a peculiar type of conjunctivitis possessed by the jequirity is dependent upon a specific bacillus which develops in the infusion ; but there appears to be no substantial basis for such a belief, which, like many other crude and errat- ic suggestions recently put forth, is but an expression of the present unbalanced state of the medical mind on the subject of bacteria and their influence upon disease. Doubtless this property is due to the irritant action of an active principle resident in the bean, which, in due time, will be isolated for our m«e convenient use. It has seemed to the writer that in preparing the infu- sion of the bean, uniformity of strength is more certainly secured by allowing the maceration to continue for twenty-four hours, as first suggested by De Wecker, than by filtering it after three hours' maceration, as he has more recently recommended. To preserve the infusion from putrefactive changes, which soon take place, espe- cially in warm weather, boric acid (2 : 100) should be add- ed. By this means the infusion may be kept unchanged for weeks. The beans should be hulled, and then finely ground up or crushed. Cold water should be used in making the infusion, and a single filtration through ab- sorbent cotton is better than a slower and more perfect filtering through paper. A "granular" condition of the palpebral conjunctiva, which closely resembles true trachomatous conjunctivitis, occasionally occurs in consequence of the long-continued use of a collyrium of atropia, and sometimes, when there is a peculiar " belladonna idiosyncrasy," is excited by only one or two applications of the atropia solution. It promptly disappears, however, upon the withdrawal of the exciting cause, and in superficial appearance only re- sembles true granular lids. Diphtheritic Conjunctivitis.-True diphtheria of the conjunctiva-to which condition it would seem, in the interest of scientific medicine, the term diphtheritic conjunctivitis should be restricted-is, as has been said, a disease of extreme rarity. It occurs more frequently in children than in adults, and is one of the most danger- ous affections to which the eye is subject. Destruction of the cornea, in consequence of the rapid and extensive infiltration of the ocular conjunctiva interfering with its nourishment, is the result which is most to be dreaded. Speaking of its mode of origin, Nettleship says, " Very rarely the process creeps up to the conjunctiva from the nose in cases of primary diphtheria, or is caused by in- oculation of the conjunctiva with membrane ; while in a few the ophthalmia forms the first symptom of a general diphtheria." The onset of the disease is sudden, and its development rapid. The lids are not only greatly swol- len, but owing to the solid infiltration into their texture, are tense and brawny. The membrane which forms upon the conjunctiva is thick and coherent, and when forcibly removed leaves a bleeding surface. It is more apt to de- velop upon the palpebral than upon the ocular conjunc- tiva. The discharge is at first thin, ichorous, and scanty, but at a later stage may become purulent. As in faucial diphtheria, necrotic changes not infrequently occur, and extensive sloughs, involving the subconjunctival, as well as the conjunctival tissues, result. This leads to the formation of scar tissue, the contraction of which may eventually produce incurvation of the lids and its attend- ant ill-consequences. In the treatment of diphtheria of the conjunctiva the same constitutional measures are called for as in the faucial variety of the disease. Quinine and iron should be administered when the patient is anaemic, bichloride of mercury (which has become so popular a remedy in faucial diphtheria) when he is robust and plethoric. The local treatment consists in the application of cold or heat (ice-cloths or warm fomentations), as may be more grateful to the patient, unless the cornea be seriously in- volved, when the former is contra-indicated ; the local abstraction of blood (leeches to the temple), if the state of the system warrant it; and for direct application to the conjunctival sac, in addition to atropia or cocaine, anti- septic, rather than caustic or astringent, remedies. Among the former finely powdered iodoform, to be freely dusted into the eye, boric acid in saturated solution, and weak solutions of bichloride of mercury and of carbolic acid are, perhaps, the most useful; although it must be ad- mitted that not infrequently all remedial measures fail in this disease, and that in spite of our best efforts de- struction of the cornea ensues and the sight of the eye is lost. When the disease is confined to one eye, the same precautions should be taken to prevent inoculation of the other as in purulent conjunctivitis, and those in attend- ance should be warned of the need of caution lest they should infect their own ocular or faucial mucous mem- brane. In regard to the pseudo-diphtheritic conjunctivitis, which has been spoken of under the head of purulent conjunctivitis, and considered simply as a malignant type of that disease, nothing further need be said here, except to state, in reference to its treatment, that it is practically the same as in genuine diphtheria of the conjunctiva, from which it seems impossible to differentiate it clini- cally, so far, at least, as local manifestations are con- cerned. Phlyctenular or Scrofulous Conjunctivitis.-It is only for lack of a better name that the variety of con- junctivitis we are about to consider is designated as " phlyctenular or scrofulous for, though it frequently manifests itself in persons who deserve to be regarded as " scrofulous," it occurs very often in those who do not ; while, on the other hand, the phlyctenulae, which are sup- posed to be characteristic of the disease, are by no means invariably present. The essential feature of this form of conjunctivitis is its dependence, upon a constitutional cause. The exact nature of this dependence has not 268 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Conjunctivitis. Conjunctivitis. nea, and usually leads to the development of phlyctenulae upon it, when previously they may have been confined to the conjunctiva. Inflammation of the edges of the lids (blepharitis marginalis) is frequently present in stru- mous conjunctivitis. All of the varieties of scrofulous ophthalmia occur much more frequently in children than in adults ; indeed, adults very rarely suffer with the dis- ease unless they have had similar attacks in childhood, which have permanently damaged their cornese, and so rendered their eyes susceptible to recurrent attacks of in- flammation. The treatment of strumous conjunctivitis is very simple, and the results obtained are almost invariably extremely satisfactory, and yet there is scarcely a malady to which the human frame is liable (at least the writer hopes so) that is so often improperly treated. In the average medi- cal mind there seems to be an indissoluble connection be- tween the idea of a conjunctival inflammation and that of an astringent collyrium. Given the former, the mind turns intuitively to the latter, as the one only therapeutic resource. No exception is made in favor of the variety of conjunctivitis under consideration, and, as may be sup- posed from what has been said, the consequences of this singular fatality, always unfortunate, are sometimes most disastrous. As has already been pointed out, whenever there is even a doubt as to the strumous character of a conjunctival inflammation the use of astringents should be scrupulously avoided ; for, not only are the photo- phobia, blepharospasm, and lachrymation aggravated thereby, but the danger of serious corneal complications is greatly increased. The treatment which rarely fails to ameliorate the symptoms almost immediately, and, when supplemented by proper attention to the constitutional disorder upon which the local disease depends, in the large majority of cases effects a prompt cure, is the application to the eye three times a day of a solution of sulphate of atropia, and once a day of an ointment of yellow oxide of mer- cury and vaseline. It is better that the atropia should be dissolved in distilled water, and the strength of the solu- tion should vary from i to 1 : 100 (gr. j.-iv. to 5 j.) ac- cording to the severity of the symptoms and the obstinacy of the attack, the weaker solution being effective in most cases. The proper strength for the ointment is 2 : 100 (hydrarg. ox. flav., gr. j. ; vaseline, 3 j.). For the ef- fectual application of the atropia solution an "eye drop- per" is indispensable, and even with its aid, owing to the spasm of the lids, this is not always easy of accomplish- ment. The patient should be placed in a recumbent post- ure, and if a child, will probably require to be held firmly while the application is being made. The oint- ment (which should be gotten well into the conjunctival sac) may be conveniently applied on the end of a flat toothpick, or, if the treatment is to be carried out by un- skilful hands, more safely by means of a camel's-hair brush. It should be inserted between the lower lid and the eyeball, the patient (if he can control the movements of the eye) being directed to look upward while this is being done. An ointment of this strength, if properly prepared, does not irritate the eye in the least degree. Some care, however, is necessary in its preparation, for if it be mixed in a mortar, or upon a tile, which has the slightest trace of iodine, iodide of potassium, or iodoform about it, the oxide of mercury is soon changed to a green iodide, which few eyes can tolerate. For the same reason it frequently happens that the ointment is not well borne when iodide of potassium is being given inter- nally. The ordinary doses of iodide of iron do not give rise to the same inconvenience. Calomel dusted into the eye once a day acts in a similar manner to the yellow oxide ointment, and many use it in preference to it. In the catarrhal type of strumous conjunctivitis, a 1 or 2 : 100 solution of boric acid dropped into the eye three times a day sometimes acts extremely well; a solution of borax of similar strength is also useful. An ointment of yellow oxide of mercury and vaseline cerate, 4 : 100 (gr. ij. to 3 j.) should be applied to the lids at bedtime, when blepharitis'is present. As for constitutional treatment, which is, of course, of been clearly set forth. In decidedly strumous subjects the resisting power of the tissues is so poor, the cellular instability so marked, that the most trivial irritation, act- ing locally, may set up a conjunctivitis, as it may excite an inflammation of other mucous membranes, or of the skin, or lymphatic glands. Very often, however, sys- temic conjunctivitis occurs, as has been said, in subjects who cannot properly be considered as scrofulous. This happens especially in young children ; and here we fre- quently find associated with the ocular disease eczema- tous inflammation of the auricle, of the upper lip, of the tissues about the roots of the finger-nails, and not infre- quently suppurative inflammation of the middle ear. A furred tongue, " feverish " breath, loss of appetite, and constipation of the bowels, are the other usual accompan- iments of this condition. That in this latter class of cases, to be distinguished from true scrofulous conjunctivitis, we have a condition allied to septicaemia, the writer has for some time thought probable. This view is supported not only by the clinical features of these cases, which are of exactly such a character as we might expect would result from the presence in the blood of a relatively benign septic organism, but also by the nature of the treatment which proves most effective. For, of all remedial measures none produces so prompt and decided a change for the better as the administration of a generous, old-fashioned, calomel purge, a remedy the value of which the radical progressists in medicine are now quite ready to acknowl- edge, since it has been demonstrated that the salts of mer- cury are pre-eminent among germicidal agents ; while, for local application these same germicidal salts (calomel and the yellow oxide of mercury) have come to be regarded almost as specifics. In the typical form of phlyctenular conjunctivitis the conjunctival injection is not uniform, but is confined to the neighborhood of one or more small vesicles which make their appearance upon the ocular conjunctiva, and are quickly converted into superficial ulcers through loss of their epithelial covering. In many cases, however, the conjunctival injection is diffuse, and the phlyctenulae are absent or not distinguishable, so that the eye presents almost precisely the same appearances as in catarrhal conjunctivitis, with which this variety of strumous oph- thalmia is very apt to be confounded, if only the con- dition of the conjunctiva be relied upon as a diagnostic guide. In genuine catarrhal conjunctivitis, however, both eyes are almost invariably affected, and there are no evidences of constitutional derangement; whereas, in the catarrhal type of strumous conjunctivitis, it frequently happens that only one eye is affected, or that the disease makes its appearance in one eye some days before it de- velops in the other, while it is seldom the case that there are not present other evidences of the constitutional dis- order upon which the ocular inflammation depends. In the latter affection, too, there are usually more decided evidences of ciliary irritation, manifested by pronounced photophobia, blepharospasm, and lachrymation, while the discharge, which is mucoid in character, is consider- ably less in amount. As the treatment which is called for in catarrhal conjunctivitis (the use of astringent col- lyria) is almost sure to do harm in strumous ophthalmia, it is of the first importance that these two conditions should be distinguished one from the other. When there is uncertainty upon this point, it is wise to treat the case as one of strumous character. In children, particularly, this rule should be followed, as they are especially sub- ject to phlyctenular conjunctivitis, and with them the doubtful cases are almost sure to be of this nature. In strumous conjunctivitis the cornea is very frequently involved in the inflammatory process. In fact, in scrofu- lous inflammation of the eyes the rule is that both the cornea and the conjunctiva are affected. When this is the case the photophobia, lachrymation, etc., are usually more severe than when the inflammation is confined to the conjunctiva. Extensive ulceration of the cornea sometimes occurs, but very rarely, except in consequence of neglect or injudicious treatment. The use of astrin- gents (nitrate of silver, sulphate of zinc, sulphate of cop- per, etc.) always aggravates the inflammation of the cor- 269 Connective-Tissue. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the first importance, when there is a well-marked stru- mous diathesis, the iodide of iron, and cod-liver oil with hypophosphites are especially useful. The phosphates of iron, quinia, and strychnia given in combination (in the form of a syrup or an elixir) are also among the most valuable remedies under such circumstances, as well as in the less distinctly strumous cases previously spoken of as so common among young children. In this latter form of the disease the writer has also found the preparations' of "beef, wine, and iron" very useful, also the " elixir of gentian and tincture of chloride of iron," both of which have the advantage of being palatable, a matter of not little importance when children are concerned. As a rule, however, and especially in acute cases, and when the ocular inflammation is accompanied by other evidences of constitutional derangement (septicaemia ?), such as nasal catarrh, otorrhcea, eczema of the face, scalp, auricles, etc., a purgative dose of calomel and rhubarb, or of calomel, rhubarb, and scammony, repeated once or twice at inter- vals of two or three days, if necessary, should precede the exhibition of other constitutional remedies, and not infrequently it will happen that when this has had its effect the case will be so far on the road to recovery that the tonics, which are to follow, will have but little left to do. The exanthematous fevers are frequently accompanied or followed by inflammation of the conjunctiva, and writers commonly make of these cases a distinct variety of conjunctivitis, which they denominate "exanthematous." There seems to be no good reason for doing so, however, as they differ in no essential respect from the systemic conjunctivitis we have just considered, and, like it, present at times a distinctly phlyctenular character, with marked tendency to corneal implication, and at others a catarrhal type. The treatment, too, which they require, is exactly the same. Samuel Theobald. 1 Wells: Diseases of the Eye. Philadelphia : Henry C. Lea's Sons & Co. 1883. Note by the editor, Dr. C. S. Bull, p. 160. hold the bones together. As fasciae and aponeuroses it occurs in variously formed sheets or membranes which separate spaces, cover muscle-bellies, etc. It forms en- casements for the bones as periosteum, or surrounds the cartilages as perichondrium ; it invests solid internal or- gans as a capsule, and as the so-called interstitial tissue it penetrates their interior and gives support and carries the blood-vessels to the specialized forms of functionating cells which make up their parenchyma. It forms an en- closing membrane for the great serous cavities and the Fig. 735.-Subcutaneous Connective-tissue, showing fibres and cells. X 500 and reduced. joints; passes throughout the body wherever the larger blood- and lymph-vessels and nerve-trunks penetrate. It is, in fact, in one form or another, universally present, forming one great continuous framework for all the softer parts of the body. The differences which it pre- sents, both gross and microscopical, are largely due to the direction, arrangement, density, and abundance of its fibres, and to the associated structures, such as blood- vessels and nerves, which are often intimately combined with it. The number and character of its cells also con- tribute somewhat to the determination of the differences which its varying forms present. The fibres, which form a large part of the intercellular sub- stance of connective- tissue, and, indeed a very large part of the entire bulk of the tis- sue, are of two kinds, the fibrillated fibres and the elastic fibres. The fibrillated fibres appear in the fresh condition as trans- lucent, moderately refractile cord- or thread-like structures with fine longitudinal striations upon their surfaces. They d o not form anastomoses with one another, although they fre- quently cross and in- terlace. They are sometimes straight, sometimes wavy (Fig. 735). On treatment with acetic acid they swell and become almost invisible, owing to changes in their refractile powers. Boiling in water con- verts them into gelatin. By treatment with appropriate reagents-osmic acid, picric acid, and various other sub- stances-they may be separated into their constituent ul- timate fibrils by the solution of the small amount of albuminous cement substance which binds the latter to- gether (Fig. 736). These ultimate fibrils are of the ut- CONNECTIVE-TISSUE. Thereisa large and important class of lowly organized tissues in the body which form a supporting framework and bind the various organs and more highly organized tissues together. They all serve somewhat similar purposes; they are all derived from the mesoblast; they possess many analogies in structure ; and finally, under a variety of normal and pathological conditions, some of them are capable of di- rect transformation into others. These tissues are classed together under the name of the Connective-tissue Group, which embraces Fibrillar Connective-tissue, Embryonal or Mucous Tissue, Carti- lage and Bone. The Reticular Connective-tissue, which forms the supporting framework of the lymphatic glands, and the Neuroglia or supporting tissue of the central ner- vous system, are frequently classed in the connective- tissue group, although genetically as well as structurally they differ considerably from the other members of it. The most wide-spread of these tissues, the fibrillar con- nective-tissue, is usually designated simply as connective- tissue, and it is with this, in its various modifications, that the present article primarily deals. It will be convenient, however, to consider under the same heading the mucous or embryonal tissue, which is an immature or develop- mental form of connective-tissue, and the reticular con- nective-tissue of the lymph-glands. Connective-tissue is composed of cells and of intercel- lular substance. The cells are of various shapes, but usually more or less flattened ; the intercellular substance consists of fibres and of a structureless matrix or cement substance, which is sometimes abundant, sometimes very scanty, and which more or less fills in the spaces between the fibres, or binds them together. Connective-tissue pre- sents various appearances to the naked eye and under the microscope, corresponding to the exact nature of the of- fice which it fills in the body. Corresponding to the dif- ferences in structure and office, its different forms have received special names. Thus in the tendons and liga- ments, as straight dense bundles or fascicles, it serves to join the muscles to the parts which they move, and to Fig. 736.-Tendon, teased after treatment with osmic acid, showing ultimate flbrils. X 700 and reduced. 270 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. connectlv^Tissue. most fineness and delicacy, and it is their presence which gives the longitudinal striation to the fibres. The intercel- lular, or basement substance, of some forms of con- nective-tissue consists almost exclusively of these fibril- lated fibres. In some forms, on the other hand, these are associated with elastic fibres ; or the elastic fibres may be alone present. The elastic fibres are more strongly refractile than the fibrillated ; they usually form frequent anastomoses with one another, forming broad- or narrow- meshed nets (Fig. 737). They are sometimes broad, known as oedema. Occasionally the cells of connective- tissue occur in the form of very thin plates, which form a mosaic over the surface of masses of fibres, as over the surface of tendon bundles or aponeuroses. Connective- tissue cells have in general rather large nuclei, the bodies being usually quite transparent, or finely granular. They frequently form anastomoses with one another. In some parts of the body, particularly in the choroid and iris, the Fig. 737.-Elastic Network from Submucous Tissue of Frog's Mouth. X 200 and reduced. sometimes very narrow ; they are not longitudinally stri- ated ; are unaffected by dilute acetic acid, and do not yield gelatin on boiling with water. The same material that composes the elastic fibres is sometimes present in the basement substance of connective-tissue in the form of granules and laminae. Owing to the elasticity of these fibres, when their ends are freed, as in the separation of bits of tissue which contain them, for purposes of study, they usually curl over on themselves, thus presenting very characteristic appearances. Or, the whole fibre may curl or roll up. The broader elastic fibres (Fig. 738), such as are found in the walls of the larger arteries, are frequently crossed at un- equal intervals by short ir- regular lines or grooves. The cells of connective-tis- sue are usually flattened, but their shape is quite variable. They may be fu- siform, rectangular, round, ovoidal, or branched ; or they may send off wings in different planes from that of the main part of the cell-body. The shape of the cells seems to be determined largely by the arrangement and relative abundance of the intercellular fibres. Thus, in the looser-textured varieties of connective-tissue, the so-called areolar tissue, in which the fibres cross and interlace loose- ly, leaving considerable spaces between them, the cells are usually of some of the shapes seen in Fig. 735, and lie loosely along, or among, the fibres. In the tendon, on the other hand, in which the intercellular fibres are straight and densely packed together into a series of com- pact bundles, the cells (Fig. 739) appear to be squeezed in between the fibres which they closely enwrap, and to send off in different planes narrow wings between the ad- jacent fibres. In the cornea, in which the basement sub- stance is arranged in dense lamellae, the flat corneal cells lie between the lamellae and send off numerous slender branches in all directions. It is through the spaces oc- cupied by the cells that the lymph circulates as it passes through the connective-tissue on its way to the well- defined lymph-vessels, which convey it back to the blood. In this way the cells receive their nourishment from the lymph which bathes them. Under pathological conditions, the spaces in which the connective-tissue cells lie may become widely dilated by the accumulation of fluid, thus producing the condition Fig. 739.-Tendon, showing Cells. A, side view of tendon fibre from tail of rat; B, transverse section of tendon of rabbit. bodies of connective-tissue cells contain a varying amount of pigment (Fig. 740). Under certain conditions the cells of connective-tissue may contain fat droplets in consider- able numbers. This, however, does not constitute the fat tissue proper of the body, which is the result of a special modification of embryonal development. The above-de- scribed cells are often called fixed connective-tissue cells, to distinguish them from leucocytes (or wandering cells), which not infrequently escape from the blood-vessels and make their way through the spaces of connective-tissue in virtue of their capacity for performing amoeboid move- Fig. 738.-Elastic Network from Wall of Artery. X 700 and reduced. Fig. 740.-Pigmented Connective-tissue Cells. A, from human iris ; from choroid of ox. X 350 and reduced. ments. The movements which the fixed connective-tissue cells of the human body are capable of performing are apparently very slight, and largely confined to the pro- cesses which may extend off from the bodies. In some of the lower animals, however, the movements of the branches of pigmented connective-tissue cells may be so considerable as to cause changes in the color of the skin. In addition to the fixed, or connective-tissue cells proper, and the leucocytes, which are but temporary components, we frequently find in connective-tissue large, coarsely 271 Connective-Tissue. Consanguinity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. granular cells of various shapes, which are called plasma cells. They most frequently occur in the vicinity of the blood-vessels. They are said to be capable of performing slight amoeboid movements. The flat cells which line the great serous cavities of the thorax and abdomen, and which are usually called endo- thelial cells, have for a long time been regarded as a modi- fied form of connective-tissue cells, but more recent embryological researches seem to indicate that genetically, at least, they are not so closely related to the connective- tissue as has been believed. (See Endothelium.) Although connective-tissue in greater or less amount accompanies the larger blood-ves- sels and nerves, masses of connec- tive-tissue are not usually very abundantly supplied with these structures. Development of Connective - tissue.-In the earlier stages of its development, connective-tissue consists simply of a congeries of small spheroidal cells closely packed together, with but a small amount of fluid intercellular sub- stance. A little later the cells be- come separated from one another, at first by a homogeneous semi- fluid substance which later con- tains delicate fibrils ; some of the cells in the meantime becoming elongated, ovoidal, or fusiform, or branched. The basement sub- stance now gradually increases in amount and becomes more and more dense and fibril- lated, while the cells become more elongated and flat- tened and relatively less numerous (Fig. 741). Finally, by a continuation of this process-increase of the inter- cellular fibres and flattening and decrease in the relative number of cells-with special groupings of the fibres, the various mature forms of connective-tissue are produced. The exact way in which the intercellular fibres are formed is not in all cases well understood. It is believed by some observers that the fibres are formed out of periph- eral portions of the cell-bodies, which become changed and split off from the cell, or that they grow out from its ends (Fig. 742). Others believe that the fibres are de- veloped in the ho- mogeneous base- ment substance, independently of morphological changes in the cell- body, though, per- haps, in some way under its influence. It is not unlikely that both of these modes of origin exist. Mucous Tissue. -The homogene- ous intercellular substance of young connective-tissue usually contains a considerable quantity of mucin which may be precipitated from it in granular form on the ad- dition of acetic acid. Such young forms of connective- tissue which contain a considerable amount of basement substance are usually called mucous tissue. Such a form of developing tissue is seen in the so-called Wharton's jelly of the umbilical cord. In this, fusiform, spheroidal, branching, and anastomosing cells lie in an abundant ho- mogeneous or finely fibrillated basement substance. Mu- cous tissue is not found in typical form in the adult under normal conditions; but under pathological conditions very large masses of mucous tissue may grow in various parts of the body (Myxoma). Reticular Connective-tissue (Adenoid Tissue).- The supporting framework of the lymphatic glands or nodes consists of a very delicate reticulum of slender fibres which form numerous anastomoses with one another in all directions, at frequent intervals, and thus make up a sponge-like mass. The irregular spaces be- tween these fibres are more or less loosely filled with variously shaped cells and with fluids, in the natural con- dition of the glands. The reticular framework, which alone concerns us here, presents slight enlargements at many of the points of anastomosis of the fibres, and at these points, as well as over the general surface of the reticulum, very delicate flat cells are closely attached, forming an endothelial investment to the fibres. In a section from a carefully preserved lymphatic gland, one, for example, hardened by interstitial injection of one per cent, osmic acid, the reticulum looks like a network of branching anastomosing cells (Fig. 743, A), on account of the flat cells which cover its surface, and as such it has commonly been described. But, as Ranvier has shown, if a lymphatic gland be soaked for twenty-four hours in a saturated aqueous solution of picric acid, or if it be Fig. 741.-Developing Con- nective-tissue Ceils from Subcutaneous Tissue of Foetal Calf, five inches long. X 800 and reduced. Fig. 743.-Reticular Connective-tissue from Lymph Gland of Ox. A, hardened in osmic acid showing cells in situ; B. hardened in dilute alcohol showing reticulum with cells shaken off. X 350 and reduced. soaked for a couple of days in dilute alcohol, and sections are then carefully pencilled so as to remove all loosened cells, the anastomosing network may be found almost entirely devoid of cells or nuclei (Fig. 743 B). This shows that the fibres are a modified form of the basement substance of connective-tissue, and that the cells are sim- ply upon the surface. The reticular tissue is continuous, at the surface and in the substance of the glands, with the ordinary fibrillar connective-tissue which composes the capsule and the coarser internal supporting trabeculae. For bibliography of connective-tissue consult "Index Catalogue" of Surgeon-General's Office, U. S. A., head- ing, Cellular Tissue; also, " Quain's Anatomy," ninth edition, vol. ii., p. 72. T. Mitchell Prudden. CONSANGUINITY. This term denotes blood-relation- ship, and is to be distinguished from affinity, which sig- nifies relationship by marriage. The husband bears the same relation to certain individuals by affinity that the wife bears by consanguinity. But two persons, each re- lated to a third person by affinity, have thereby no affinity for each other. The principal importance, from a medical point of view, of the subject of consanguinity is in the effect pro- duced upon offspring by the fact of such a relation ex- isting between the parents. In part from a belief in the injurious effects upon offspring of marriages between near kin, in part from the influence of authority, and in part from a natural repugnance to such unions, legal prohibi- tions have been placed in many countries upon marriages between persons who were within certain specified de- grees of consanguinity. In some instances these restric- tions have been extended from the field of consanguinity Fig. 742.-Development of Fibres of Connective- tissue from Foetal 1'ig, eight inches long. X 800 and reduced. 272 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Connective-Tissue. Consanguinity. to that of affinity. In England, for example, for the past two hundred years it has been illegal for a man to marry his deceased wife's sister, a relation obviously not within the bounds of consanguinity at all. Consanguinity may be either lineal or collateral. The former is reckoned between persons in the direct line of descent, either downward from progenitor to descendant, or upward from descendant to progenitor. Collateral consanguinity exists between two persons descended, not the one from the other, but both from some common an- cestor. The degree of consanguinity is measured in the first instance by the number of generations separating the two individuals. Thus grandfather and grandchild are in the second degree of lineal or direct consanguinity. In defining the degree of collateral or indirect consanguinity two different methods have been used, which have given rise to some confusion. By the civil law the degree is measured by counting the number of generations upward from one individual to the common ancestor, and thence downward to the other. By the canon law the number of degrees are counted only in one line (that which is the longer of the two) from the common ancestor. Thus, supposing F and G to be great-grand- children of A, and hence second-cousins, as by the accompanying diagram, according to the 3 C civil law they would be in the sixth degree of 1 1 consanguinity, while by the canon law they would y be in the third. The imperfectness of the latter p q mode of reckoning is shown by the fact that 1 1 G would also be in the same degree of con- H I sanguinity, viz., the third, to A, B, and D ; but in the fourth degree to H, the count then being made in the other, or longer line. Evidently, a prohibition of marriages within the third degree, made by the civil law, would become much more onerous if interpreted in ac- cordance with the canon law. This was actually done by Pope Gregory I. (a.d. 590-604). Much diversity has prevailed among different nations in their views concerning the marriage of kin. The traditions of the ancient mythologies, in their account, for instance, of the relations between Jupitei- and Juno, and between Osiris and Isis, show that unions in the closest col- lateral degrees of consanguinity were not considered ab- horrent. On the other hand, the story of (Edipus and Jo- casta indicates that marriages in the direct line of descent were looked upon as impious. The ancient Egyptians intermarried very closely, and in the history which we possess of the dynasty of the Ptolemies, a large proportion of the marriages are seen to be between brother and sister. In other nations of the East, notably among the Persians, marriage in the nearest degrees, even of direct con- sanguinity, prevailed. There is evidence that prior at least to the time of Moses this custom prevailed among the children of Israel. This very nation was descended from consanguineous unions. Abraham married his half- sister, Sarah, Isaac married Rebekah, his first-cousin once removed, and Jacob his two first-cousins, Rachel and Leah. Yet no one has ever questioned the vigor of the Israelites, who, in the first fourteen generations from their origin, became six hundred thousand fighting men. In- deed, a literal interpretation of the record in the Book of Genesis would indicate that the sons of Adam must have married their sisters, and the whole human race are the product of a consanguineous marriage in the closest degree. The restrictions placed upon the marriage of re- latives by the Mosaic law are worthy of special attention, because they have remained, to a great degree, in the usage of Christian nations in modern times. The follow- ing marriages were prohibited on the score of kinship by the Levitical law (Leviticus xviii.): That with a par- ent, or with a step-mother ; with a sister, or half-sister ; with a granddaughter ; with an aunt, or an uncle's wife ; with a son's wife ; with a brother's wife ; with a step- daughter, or a step-granddaughter ; with a wife's sister, during the lifetime of the former. The Greeks, while forbidding marriages in the direct line of descent, per- mitted them between half-brothers and sisters; the Athenians allowing of the marriages of brothers and sis- ters by the same father, but not of those by the same mother ; and the Lacedaemonians, on the other hand, al- lowing uterine brothers and sisters to marry, but not those having a common father-an obviously arbitrary distinc- tion. The Romans held still stricter views. Not only the direct line of consanguinity, as well as brothers and sis- ters, either in whole or in half, were excluded from inter- marriage, but any union within the degree of first-cousin was practically illegal, the occasional marriage of uncles with nieces in the times of the Tarquins and of the em- perors being held to' be a stretch of despotic authority. The Institutes of Justinian, the basis of the modern civil law, forbade marriages in the direct line, and in the col- lateral line within the fourth degree. First-cousins and all remoter kin might marry. The Roman Catholic Church extended the restrictions, discouraging, and then forbidding unions between first-cousins. Various coun- cils in the early centuries altered the rules, usually in the direction of greater exclusiveness. The present canon law, that of the fourth Lateran (twelfth general) Coun- cil, a.d. 1215, in force in most Roman Catholic countries, permits marriages only outside the fourth degree, i.e., third-cousins are forbidden to marry. The Church, how- ever, reserves and exercises the power of allowing dispen- sation from this prohibition. The civil law permits mar- riage in the fourth (civil) degree, that is, allows first- cousins to marry. The Greek Church allows third-cousins to marry, but prohibits all nearer relations. In England the ecclesiastical prohibitions on this subject were at first even more stringent than those of the present canon law, but under Magna Charta they were modified so far as to admit marriage outside the fourth canonical degree. The restrictions of the canon law were set aside in England by the Marriage Act of 1540, in the reign of Henry VIII., and the prohibitions of the civil law, prac- tically the same as those of Leviticus, were substituted. Marriages may be made in the fourth and all remoter de- grees, computed according to the civil law. Hence first- cousins may marry, as may also nephew and great-aunt, or niece and great-uncle. Indeed, by the letter of the law, as has been pointed out, while a man may not marry his grandmother, he may marry her sister. This law affects England, Scotland, Ireland, and all the British colonies. It is worthy of remark in this connection that the prohibition of marriage with a deceased wife's sister, which is not Levitical, and which, in spite of an annual effort to remove it, is still maintained in the home coun- try, has been recently removed in Canada and in Aus- tralia. In the various States of this country the degrees of con- sanguinity in which marriage is prohibited are practically those of the Levitical code. A few of the States, how- ever, forbid by law the marriage of first-cousins, among them New Hampshire, Ohio, and Indiana. In a majority of the States a man is not allowed to wed his aunt or his niece, but such unions are permitted in New York. The difficulties in the way of obtaining accurate knowl- edge as to the production of evil effects in offspring by consanguineous marriages are very great. In the first place, in the absence of State registration covering this point, people are apt to resent inquiries as impertinent. Espe- cially is reluctance manifested if the children have any physical or mental defect. Secondly, upon persons who collect and record such cases among their own acquaint- ances, instances of evil results are liable to produce more effect than negative cases, which, presenting nothing of importance, drop out of notice, and the fact of consan- guinity on the part of the parents is quite forgotten. Thirdly, in some of the unfavorable cases collected, too little attention is paid to the moral elements of the case. For instance, in the family of the Ptolemies, where the intermarriages were very close, whatever may be claimed as to the physical degeneracy of the stock (and certainly there is very little ground for Mr. Francis Galton's re- mark as to its sterility) may be in considerable degree ascribed to the enervating physical and moral effects of unlimited despotic power. Other tabulated lists prepared to show the evil effects on offspring of marriages between relatives, include unions nearer than the fourth degree. 273 Consanguinity. Consanguinity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. But close incestuous unions presuppose moral degrada- tion, and this cannot fail to have its effect on the phy- sicpie both of parents and of children. Some of the figures collected upon this subject have been obtainable only from records of public institutions, and are based, for the most part, only on the lowest classes of society. But where, as in the individuals included in Dr. Howe's statistics, " most of the parents were intemperate," it would evi- dently be unfair to conclude that the large percentage of idiots among the children was due entirely to the con- sanguinity of the parents, and not in large part to their intemperance. Again, accounts have been published of certain European communities, geographically isolated, where numerous consanguineous marriages have occurred. Granting that there is no moral obliquity in these indivi- duals, there is certainly very little ambition or enterprise in men who are content to stagnate in the same spot where their ancestors have lived for generations, with no curiosity to learn what lies outside the borders of their hamlets. Fourthly, confusion exists between the effects of con- sanguinity and those of hereditary morbific transmission. Where two relatives wed, both of whom possess a simi- lar disease, or tendency to disease, the offspring are very likely to inherit the disease, the latent tendency even be- coming a patent actuality. But this is the fault of the morbific strain multiplied into itself, and thus raised, as it were, to its second power, and not of the mere fact of consanguinity in the parents. For the same result would follow the union of two persons not related if they pos- sessed some defect in common ; and, on the other hand, in the breeding of animals, while the parents are blood- relations, yet such care is taken to select perfect speci- mens that no chance is allowed for the propagation of a fault. This point, which is of great importance, will be again alluded to later on. Fifthly, and finally, it should be remembered that positive cases in which the marriage of relatives has been found to give numerous and per- fectly healthy children, are more significant and important than negative instances, where perfect children did not follow such unions. Because in the latter case the imper- fection may have been due to other elements than the consanguinity, whereas, if the fact of consanguinity in the parents constitutes per se an obstacle to the propaga- tion of healthy children, defective offspring should follow in all or neafly all cases wherever that bar to perfect off- spring, to wit, consanguinity, existed in the parents. With the above provisos as to the interpretation of statistics bearing upon this point, we will now examine some of these reported facts. Dr. Bemiss (" Report on Influence of Marriages of Con- sanguinity upon Offspring," Transactions of the Ameri- can Medical Association, 1858, vol. xi., p. 334) collected a large number of cases of marriage between relatives, which tell strongly against the safety of such unions. Eight hundred and thirty-three such marriages are reported, in- cluding cases of incest between parent and child, and brother and sister. The average number of births was 4.6. The following extract from his table is given : Classes of Relationship. Number of ob- servations. Average num- ber of births. Defective, per cent. Deaf - mutes, per cent. Blind, percent. Idiots, per cent. Insane, per cent. Epileptic, per cent. Scrofulous, per cent. Deformed, per cent. TV Died young, per cent. A. Incest with parent, or between brother and sister. 10 3.1 93.5 .... 61.2 3.2 16.1 35.4 B. With niece or aunt. 12 4.42 75.4 1.9 5.6 5.6 1 9 1.9 20 7 26 4 43 3 C. With blood-relations the issue of blood-relations. 56 4.18 53.8 4.2 5.1 12.8 1.2 1.7 18.8 3.8 26.9 D. With double first-cousins 27 5.7 27.2 1.2 1 2 2.5 3.8 1.2 6.3 1.2 35.0 E. With first-cousins 580 4 8 24.9 4.2 2 2 8 3 1.6 6 2 1 9 22 5 F. With second-cousins 112 4 58 13.0 1.7 3 3 1.1 2.9 1.7 16.5 G. With third-cousins 12 4.92 27.0 5.0 1.7 1.7 3.4 16.9 13 5 H. With first-cousins, irregularly reported 24 5 0 17.5 2.5 2.5 1.6 12.5 10.0 Total 833 4.6 28.7 3.6 2 1 7.0 2.04 1.5 7.6 2.4 22.4 Compare marriages with persons in no way related.. 125 6.7 2.1 0.35 0.1 0.71 0.1 0.35 0.1 16.0 This table presents the case against consanguineous marriages with its full strength. Yet, as the author him- self says, " It is natural for contributors to overlook many of the more fortunate results of family intermarriage, and furnish those followed by defective offspring or sterility." One other vulnerable point in these figures presents it- self. Marriages between third-cousins are much more productive of evil results in the offspring than marriages between second- or even first-cousins. In other words, the eighth degree of consanguinity, which is so remote that persons occupying it must often be ignorant that any kinship at all exists, really constitutes a greater danger to marriage than relationship in the fourth degree. Dr. Mitchell's statistics (" Memorandum before the An- thropological Society of London," vol. ii., 1866, p. 403), also classical upon this point, are based upon 45 cases of consanguineous marriage. Eight couples were barren, and the remainder produced 146 children ; an average of about 4 for each fertile marriage, or of 3 for all mar- riages, barren and fertile. Eight children were idiots, 5 imbecile, 11 insane, 2 epileptic, 4 paralytic, 2 deaf-mutes, 3 blind, 2 defective in vision, 3 deformed, 6 lame, 1 ra- chitic, 22 consumptive, scrofulous, or manifestly of weak constitution. Dr. S. G. Howe's tables, computed from Massachusetts statistics (Journal of Psychological Medicine and Mental Pathology, July, 1858), have been already referred to. These marriages produced 95 children, an average of 5.5 each. Forty-four were idiots, 12 scrofulous, 1 deaf, and 1 a dwarf. Huth, in the appendix of his work (" The Marriage of Near Kin "), from which some of the above observations have been taken, has gathered a series of 299 cases from many sources, a considerable portion being from writers who disapprove of consanguineous marriages. The cata- logue of diseases referred to this cause is long, numbering nearly forty. The total children born were at least 1,155 (3.8 per marriage), and in 83 of the families there were no unhealthy children. It will thus be seen that those who condemn consanguine- ous marriages ipso facto have presented a very extensive catalogue of charges. Those most generally dwelt upon have had relation to what may be called the social func- tions of the individual. As Guipon, representing this opinion, puts it (Comptes Rendus, vol. Ivii., p. 513), "con- sanguinity exerts a depressing effect on the vital forces, notably upon reproduction, so that if sterility is not ob- served in consanguineous marriages themselves, it at least shows itself in their children. It affects the functions of relation and the organs of sense, hearing, speech, and sight. The genital sense is exalted, but its natural end and aim is thwarted." On the other hand, numerous and reputable observers have reported many cases where consanguineous mar- riages were unattended by any degenerative conditions in the offspring. For example, we have an instance re- ported by M. Dally (Anthrop. Review, May, 1884, p. 95), where two families continually intermarried for five gen- erations, no marriage being in a more distant degree than first-cousins, except two of second-cousins. The total number of branches direct and collateral was 120 to 140. There was not a single case of deaf-mutism or 274 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Consanguinity. Consanguinity. idiocy, but there were 2 cases of consumption, 1 caused by a cold, and 1 case of senile insanity in a woman of sixty-eight. It should be remarked that there was no predisposition to disease in the family. Perhaps the most striking instance on record of con- sanguineous marriages without ill effect upon offspring is furnished by M. Bourgeois (Comptes Rendus, vol. Ivi., p. 178). The family in question is his own. A genealogical table is given covering seven generations. In one branch of the family, of five successive genera- tions four married their cousins, and the offspring of the fourth successive consanguineous marriage consisted of six children all perfectly healthy save one, who is defec- tive mentally, a defect, however, ascribable to an acci- dental traumatic injury. The founder of the race him- self married a kinswoman, and among the descendants seven others have married cousins. Indeed, of the sixty- eight unions that have occurred, all feeling more or less the influence of consanguinity, but one has been infertile, and that infertility was due to disease of the mother, who was an alien ; on the husband's side, moreover, it was necessary to ascend three generations to reach the first union of cousins. Among the two hundred individuals of this remarkably inbred family, all are very healthy, except the children of one of the latest marriages, in some of whom a scrofulous taint has appeared. M. Voisin collected some observations bearing strongly on the favorable side of consanguineous marriages. In the commune of Batz, in Brittany, was a population of 3,300 souls, quite isolated from the rest of the depart- ment. In 1864, M. Voisin found in that community 5 marriages between cousins-german, 31 between cousins of the next degree below, and 10 between cousins of the de- gree after that. The first class produced 23 children free from all constitutional disease, 2 only having died of casual disorders. The 31 marriages of second-cousins produced 120 children, all free of constitutional taint, 24 dying of acute disorders. The 10 marriages of third- cousins gave 29 healthy children, of whom 3 died of acci- dental diseases. Sterility occurred in only two families, the parents being related to each other in the third degree (canonical). Mental disorders, idiocy, deaf-mutism, and hemeralopia were all unknown. The general health of the population was good. The same author states, as the result of a careful ex- amination of 1,077 of his patients at the Bicetre and Sal- petriere hospitals, that in no one instance of his idiotic, epileptic, or insane patients, could healthy consanguinity be legitimately regarded as the cause of the affection. M. Seguin gives the result (Comptes Rendus, vol. Ivii., 1863, p. 253) of ten consanguineous marriages oc- curring in his own family. One marriage was barren, but the average children in. each of the ten marriages was over six. There was not a single case of deaf-mutism, hydrocephalus, impediment of speech, or supernumerary digits among all the children. One great difficulty has been, in considering the returns of defective children born from consanguineous mar- riages, that we have no means of knowing what the pro- portion of consanguineous marriages themselves is. Un- til this latter element is learned we cannot tell whether the defective children of relatives are or are not numerous out of proportion to the children of the non-related. It is very desirable, therefore, that by some authority, like that of the census, the number of consanguineous mar- riages be ascertained. This, unfortunately, has never been done. Mr. George H. Darwin, however, has collected some valuable and novel observations upon this point (Journal of the Statistical Society of London, July, 1875 ; also, Fort- nightly Review, July, 1875). This writer, by means of ingenious computations which space is insufficient to allow of giving in detail, con- cludes that in London, comprising all classes, the first- cousin marriages are about 1| per cent, of all marriages ; in the urban districts, 2 per cent. ; in the rural districts, 2J per cent. ; in the middle and upper middle class, or in the landed gentry, 3| per cent.; and in the aristocracy, probably 4| per cent. Mr. Darwin then collected returns from a number of lunatic and idiotic asylums regarding the proportion of the inmates who were the offspring of consanguineous marriages, and found that where the figures obtained were most reliable, the proportion exceeded but slightly, if at all, the ratio of first-cousin marriages in the country at large, being from three to four per cent. Among deaf- mutes, also, the offspring of first-cousin marriages was almost exactly the same as the proportion of such mar- riages for the town an'd country. Regarding the fertility of first-cousin marriages and of the descendants of such marriages, against which Pro- fessor Mantegazzo, M. Boudin, and others have pro- nounced, Mr. Darwin finds, from figures obtained from "Burke's Landed Gentry" and the " Peerage," that the fertility, as shown by the number of sons surviving infancy, is somewhat greater in marriages of first-cousins, and where one of the parents was the child of a first-cousin marriage, than when the parents were not consanguine- ous, the average number of sons in each of these three classes being respectively 1.92 to 2.07, 1.93, and 1.91. As to the youthful death-rate, the evidence, from the small number of families (37) for which these data existed (all from the peerage), gave a slightly increased death-rate in early years for the children of consanguineous parents. While admitting a certain amount of truth in the popu- lar sentiment in regard to the evil effects upon offspring of marriages of kin, Mr. Darwin holds that the evil has been much exaggerated. The writer of the present article collected a series of cases of consanguineous marriage, whose results were embodied in a paper read before the Massachusetts Medical Society, June, 1885, and published in its "Proceedings" for that year. In 108 such unions 103 were fertile, pro- ducing 413 children. Excluding from the category of the ' ' healthy " all wdio had any physical defect, includ- ing even polydactylism and strabismus, all who were be- low the average in mental or bodily vigor, all who devel- oped phthisis or any other constitutional taint, even though it did not appear till late in life, and all who died in infancy, except when the death was known to be from some acute malady, 312 of the children, being 75£ per cent, of the whole number, were classed as healthy. The principal diseases and defects comprised 12 cases of deaf-mutism (all occurring in a small isolated community on the island of Martha's Vineyard), 7 of insanity, 13 of idiocy, and 15 of consumption. The fertility of all of the unions which were known to have lasted twenty-five years or over, 57 in number, was on an average 5 chil- dren to each couple. There were 17 consecutive consanguineous marriages, i.e., those in which one or both the parties marrying in kinship were themselves descended from a similar union. Of these marriages only 9 had lasted the whole child- bearing period, and these produced 50 children. In all, from the 17 marriages, 15 being fertile, 68 children were born, of whom 48 were " healthy." There were also 128 marriages not consanguineous, but to which one or both of the parties were descended from persons related. Some of the marriages had lasted but a short time, but 110, or eighty-six per cent., had already proved fertile, with at least 372 children, and probably many more. Only 47 of the unions were known to have lasted twenty-five years or over, and these produced 240 children. An analogy of considerable significance to the question of consanguineous unions in the human subject is to be drawn from the so-called in-and-in breeding of animals. Bakewell, the brothers Collings, and Bates, in England, were the first to advocate and practise incestuous breed- ing among cattle. The Leicester breed of sheep, and a breed of long-horned cattle were created by Bakewell on this plan, and with a good measure of success. The " Duchess" short-horned cattle, produced by Bates in the same manner, were also famous for a time, but have now become nearly extinct. Cattle-breeders at the present time are divided in opinion as to the advantages of thor- ough in-and-in breeding, some claiming that this method in time will impair the fertility of the stock, and point- 275 Consanguinity. Consciousness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing for proof of this to the numerical deterioration of some of the breeds first formed on this plan. Their op- ponents say, on the other hand, that as long as Bakewell himself lived to give the benefit of his judgment to the selection of the individuals to be bred from, the stock re- tained its excellence. Moreover, there are numerous ex- amples to be adduced in which incestuous breeding has succeeded in not only developing, but perpetuating a breed for long periods. M. Beaudouin tells (Comptes Rendus, August 5, 1862) of having inbred merino sheep very closely for twenty-two years without in any degree di- minishing their fertility. The "Jersey" cattle have for one hundred and fifty years been bred on a small island only six miles by eleven (no larger than a western ranch), with no intermixture of foreign blood; yet, when first known to the outside world they were already an estab- lished breed, noted not only for their excellence as butter- makers, but for their beauty, docility, and intelligence. The early importations of these cattle to this country were, of necessity, very closely inbred. Indeed, some of the most striking instances of in-and-in breeding on record are among Jersey cattle. Take, for instance, the St. He- lier strain. This bull was put successively to his daugh- ter and granddaughter, and by the latter begot a son (Oxoli), which was also a great-grandson, and a daughter (Chromatella), which was also his great-granddaughter. Each of these animals had 87| per cent, of the blood of their great-grandsire (seventy-five per cent, more than has a child by a non-consanguineous union). Chromatella was bred to the son of her brother Oxoli, and dropped two daughters, both healthy and good breeders. Oxoli also bred to three daughters of St. Helier (having fifty per cent, of the latter's blood), one of them being his own (Oxoli's) granddam. He also bred to several cows having seventy- five per cent, of the blood of St. Helier, of which he himself had 87| per cent. In fact, the history of this strain shows a large number of unions of the very closest possible nature, a great majority of the descendants hav- ing more than fifty per cent, of the blood of their progen- itor. Yet for excellence not only of the butter record, but of general health, and for fertility, the strain is most remarkable. Again, the bull Favorite, himself highly in- bred, was put successively to his daughter, daughter's daughter, and daughter's daughter's daughter, he being the sire in each case. The result of this last union was a cow having 93f per cent, of the blood of Favorite, and the mother of some of the most remarkable animals known. Among racing horses "Rysdyk's Hambletonian " may be mentioned as an example of a closely inbred horse. Yet it is stated on good authority that during the year 1883, among 190 new performers that entered the list of 2.30 trotters, forty-one per cent, were by Rysdyk's Ham- bletonian, his sons and grandsons ; while twenty per cent, of the residue were more or less closely related to Ham- bletonian. It is important to bear in mind that what is called " in- and-in breeding " among cattle-breeders, means a close- ness of mating which is not only out of the question in the human subject on ethical considerations, but is far beyond the bounds of physical possibility. In mankind, a marriage between first-cousins would give the offspring but twenty-five per cent, of the blood of the common ancestor of the parents. The child of parents who are uncle and niece will have thirty-seven per cent, of the blood of the common ancestor ; and even the product of the union of brother and sister will have but fifty per cent, of the blood of one of its grandparents. In other words, unions equivalent in closeness to the nearest con- sanguineous marriages made among men, are not consid- ered by cattle-breeders worthy the name "in-and-in" at all. Mr. Campbell Brown, speaking (as a disbeliever in incestuous breeding) of a horse that had been claimed as closely inbred, says "that he had only twenty-five per cent, of the blood of a certain other stallion," and adds ' ' that that is a degree of inbreeding to which there can hardly be rational objection." Yet this is just the per cent, which the child of first-cousins has in the blood of their common ancestor. Of course, selection plays an important part in the suc- cess of in-and-in breeding of animals. It is equally true that this consideration is frequently absent from marriages made between those near of kin. In estimating, how- ever, the effect of consanguinity pure and simple, as an element in the determination of offspring, it is proper to take it where it is free from all possible complication by inherited morbid influences. If cattle-breeders, in their endeavors to perpetuate a line breed by the principles of natural selection, can win success out of incestuous unions, it follows that there is nothing in the fact of con- sanguinity itself in parents which of necessity deteriorates the offspring. When, therefore, it is objected that human consanguineous marriages should not be compared to in- and-in breeding among animals, for the reason that in the former the principles of natural selection are not observed as they are in the latter, it may be answered that what is the same in the two classes of animals is unions of kin- dred, and that it is those similar conditions only which it is sought to compare. It is not denied that "like pro- duces like," whether of bad or of good, and if a union of two imperfect individuals of allied blood produces dis- eased or defective offspring, it is in obedience to a law of nature too universal to be affected in any way by the ac- cident of consanguinity. The objection has also been made that the product of in-and-in breeding is not a perfect animal, but, is as Dr. Mitchell has expressed it, "a saleable defect," "a perfect pathological specimen " less useful to himself if he were to be left to himself and deprived of artificial care and keeping than the natural animal would be under like cir- cumstances. Here again the influence of consanguinity has been confounded with that of natural selection. In accordance with the latter principle, any quality may be selected as the aim of breeding-as speed or strength in the horse ; milk, draught, or flesh in cattle; wool or fat in sheep, etc. According to the point of view of the ob- server will the product of such breeding be intrinsically beautiful and valuable, or the reverse. A breed of pigs may be produced so fat that they cannot stand, and cer- tainly " less useful to themselves " than in a natural state. Yet we have it on the best authority that no horse bears fatigue so well, or recovers from its effects so soon, as the thoroughbred. " Indeed," says an eminent hunting au- thority, " there is scarcely a limit to the work of full-bred hunters of good form, constitution, and temper." The argument that the thoroughbred animal is less " useful to himself," because he has become dependent on artificial conditions of food and shelter, would prove equally well that civilized man is inferior to the aborigines. Boudin asserted that deaf-mutism was specially selected by Providence as the punishment for the violation of "nature's law" involved in consanguineous marriages, in order that man, as the "talking animal," may bear the brunt of the penalty. But Dr. Child has shown that deaf-mutism is simply a congenital deafness to which mutism has succeeded because the individual cannot hear himself speak, and that the same defect, congenital deaf- ness, may and does exist in the lower animals. Indeed, the whole drift of modern science is against such at- tempted distinctions. Man is physiologically an animal, and in the manner of his propagation is subject to the same laws as any other animal. If, then, as seems to be the case, analogies drawn from the lower animals show that even " in-and-in breeding," in the hands of practical men working for pecuniary returns, gives good results in the form, usefulness, and fertility of their stock, it is a fair inference that at least the occasional admixture of a comparatively small amount of kindred blood, involved for instance in a marriage of cousins, is innocuous in the human species. How, then, shall we reconcile the above conclusions with figures such as those published by Bemiss, Howe, Mitch- ell, and Boudin ? Have no unfortunate results been found from consanguineous unions ? Undoubtedly ; but such results .have followed for the most part, and probably ex- clusively, where consanguineous marriages have intensi- fied morbid characteristics of both parents. Such unions may transmit and intensify admirable attributes as well 276 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Consanguinity. Consciousness. as undesirable ones. But because many families have some marked pathological tendency of mind or body, es- pecial care should be taken that such tendencies be weak- ened by what may be called the dilution of a social intermixture. Of the evils that have been formerly as- cribed to marriages of kin, some, such as phthisis, scrofula, rickets, may be often traced to a similar or allied defect in some immediate or remote ancestor, whose peculiarity, transmitted by the two wedded descendants in accordance with the law of selection, appeared in something like a geometrical increase in their issue. Other maladies, such as hemeralopia and congenital deafness, which there is some evidence are more frequent among the children of kin than in the community at large, are not always to be recognized in the ancestors in the same form ; but, as has been suggested by Dr. Child, they may be, through a relation not as yet recognized, allied to certain apparently totally unlike diseases, some- what as chorea, once thought to be an affection quite alien from rheumatism, has been discovered to be connected with it, or as hydrocephalus has proved to be akin to tu- berculosis. To conclude: 1. Facts seem to contradict the theory that consanguinity has a specific effect, by reason of the " non-renewal of the blood," to produce degeneration in the offspring. 2. It may amend or it, may depreciate the character of the progeny, according as the two individuals it brings together are healthy in mind and body or depraved. 3. Because of the tendency of abnormalities, equally with excellences, when present in both parents, to perpet- uate themselves in the offspring in an augmented degree, and because many persons show some deviation from per- fect health', a deviation which they may share in common with their kindred, proposed marriages in consanguinity should be scrutinized to see if they are to involve a selec- tion of untoward qualities ; but a similar scrutiny is de- sirable when the persons contemplating wedlock have any morbid tendency in common, even though they be in no way related to each other. 4. Marriages in consanguinity up to the limits permit- ted by the civil law are, where there is clear evidence of soundness of the family and of the individuals in ques- tion, not to be opposed on physiological grounds. Charles F. Withington. ity. The necessity of conditions one and two is apparent. As to the third, experiment has shown that reflex and automatic actions are performed more rapidly than con- scious acts. The time required for a simple spinal reflex act is from 0.066 to 0.057 second. The time required for a conscious sensation and response is from 0.16 to 0.22 second (Exner). It is a law that " no nervous action, the duration of which is less than that of psychic action, can arouse consciousness" (Ribot, "Diseases of Memory"). It is for this reason in part that when conscious acts are repeated until they are done very rapidly, they are done without arousing consciousness. As to the fourth condition, consciousness is kept alive by the new stimuli which the brain constantly receives, cours- ing along new paths, stimulating the cells anew, or awak- ening new associations. After constant repetition, objects no longer excite our attention or rouse conscious sensa- tions ; the work of our hands is done automatically. If a person concentrates his mind fixedly and continuously upon a single object, consciousness after a time disap- pears, and lie passes into a state of sleep or of trance. Anatomical Seat.-The anatomical seat of conscious- ness is undoubtedly in the cortex of the cerebral hemi- spheres. The attempt to limit it further is difficult. The simpler conscious sensations-sight, hearing, smell, taste, and touch-are presumably located in the corresponding sensory cortical areas (see Cerebral Cortex, Functions of). The more complex conscious states are probably seated in the frontal lobes. Ross ("Diseases of Nervous System") suggests that the conscious mental states involve the cells of the second and external part of the third layer of the cortex. Development and Function of Consciousness.- Consciousness exists in a dim rudimentary form in ani- mals, even as low down in the scale as Coelenterates. As animals become more complex in organization, and re- ceive new stimuli calling for new adjustments, conscious- ness develops in order to enable them to compare and co-ordinate these new impressions. Consciousness is at the basis of all intelligent readjustment and progress. Classification of Disorders.-The disorders of con- sciousness may be divided into : I. Those in which con- sciousness is depressed or suspended. II. Those in which consciousness is perverted. III. Those in which it is ab- normally exalted in intensity. I. Depression of Consciousness.-The keenness of con- scious feeling is constantly varying. States of delirium, of high-pitched feeling, or of absorbed attention, are exhaus- tive and do not continue long. They are followed by a lassitude in which we see consciousness lowered and depressed. When a person passes gradually under an anaesthetic, or into a syncope or asphyxia, we can note the stages from depression to entire loss of consciousness. Anaemia, exhausting diseases, epilepsy, insanity, hysteria, various drugs and toxic agents, depress or suspend con- sciousness. The morbid states produced are known as those of coma, lethargy, syncope, asphyxia, catalepsy, carus, and cataphora (ride these topics). The usual symptoms of impending loss of conscious- ness in healthy brains are giddiness, sense of impending danger, loss of the sense of personality. Giddiness is often the bridge between normal consciousness and syn- cope. II. Perversions of Consciousness.-Consciousness, as has been said, shows us our relation to the external world, and determines for us our identity and personality. There are certain conditions (apart from insanity) in which the individual's personality becomes changed, although con- sciousness appears in a measure to be present. Cases of automatism might be referred to this class (see Automa- tism). But the most conspicuous illustrations of per- verted consciousness are those that have been described as cases of double-consciousness, or Periodical Amnesia. Conditions of this kind are not numerous, and I shall best illustrate my subject by giving brief histories of those which have been heretofore reported, so far as I have been able to collect them. Case 1.-A young girl, eighteen years of age, previously healthy, swallowed by mistake a large amount of un- CONSCIOUSNESS, DISORDERS OF. The disorders of consciousness are frequently described under the terms delirium, stupor, or coma. This is not correct, be- cause in those states the whole mind is profoundly affected. Disorders of consciousness are, properly speak- ing, those mental states in which consciousness is con- spicuously depressed, perverted, or exalted. But as con- sciousness is not a separate faculty, but rather a mental state completing and rendering effective other mental states, there can be no disorders which affect it exclu- sively. Nevertheless, there are certain aberrant conditions in which, while the other psychical functions are not seri- ously impaired, consciousness is morbidly affected, and it is of these that I shall write. Consciousness is not a faculty of the soul, as used to be taught; so far as similes can illustrate, it is rather an illu- mination of the mind's activities, a portal through which the Ego catches glimpses of itself; a point d'anantage from which we are able to distinguish the external world from the internal, the objective from the subjective. Physiology of Consciousness.-Modern psychology does not attempt to define consciousness or say what it is. The most that can be done is to state the conditions of its existence. The brain, through its activity, produces cer- tain mental states which are called psychoses. Conscious- ness attends and forms part of some of these states; of others it does not. For example, we are conscious in feeling and in willing, but associations of ideas may take place beneath consciousness (see Automatic Actions). There are four conditions which are necessary to the ex- istence of consciousness : (1) There must be a functional activity of the brain ; (2) the mental state resulting must have a certain intensity ; (3) duration, and (4) changeabil- 277 Consciousness. Constipation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. guentum lyttse. She had a long series of disturbances, referable to the lungs, head, and bladder. These left her in an acutely sensitive state, so that sudden sounds or contacts would throw her into a state of insensibility. She finally would pass into temporary conditions of ab- normal consciousness. In these she would be excited and restless. They came on suddenly and lasted days or weeks. She remembered what occurred in her previous abnormal states, but not what occurred in the intermedi- ate normal state. In the normal state she was apathetic and dull. She did not seem to know her parents or as- sociates during the attacks. She was hysterical, and there was a suspicion of simulation. The attacks gradu- ally disappeared. (Thos. Mayo : London Medical Gazette, 1845, n. s., i., p. 1202.) Case 2.-Miss R , healthy, single, arrived at adult age without disease ; was well educated and intelligent. On one occasion she unexpectedly fell into a sleep which lasted several hours longer than usual. AV hen she awoke, she had no knowledge of her previous state. Her mind was a tabula rasa. She had to learn everything over again. She had made some progress in this when she again fell into a prolonged sleep, from which she awoke in her nor- mal state of mind. (Dr. Mitchell: " Medical Repository," n. s., vol. iii., p. 185, 1817.) Case 3.-A young woman, single, aged nineteen, who suffered severely from trigeminal neuralgia, was subject daily to attacks during which she was in an abnormal mental state. At these times she would talk to imaginary persons, and seemed to be living in a different world. These states differed in length and intensity, and were not always sharply defined from the normal. (S. Jackson : American Journ. of the Med. Sciences.') Case 4.-A young woman, aged sixteen, well devel- oped, fell sick, and was attended by a respectable, middle- aged physician, with whom she fell violently in love. Her advances became so marked that she was removed to another place. She suffered from mental depression. After a time she began to pass daily into an abnormal mental state, in which she was oblivious to her surround- ings in a measure, but talked to absent friends, and seemed to live in an imaginary environment. She was cured by travel. (Jackson: loc cit.) Case 5.-A delicate, hysterical girl, aged fifteen, suf- fered from daily attacks of a hypnotic character, lasting some hours. They came on suddenly. During them she would play, sew, work as usual, though her manner was abrupt and rude. On coming out of them suddenly, she would remember nothing of what she had done. (Jackson: loc. cit.) Case 6.-This case resembles very closely that of Dr. Mitchell (Case 2). It was reported by Dr. Druar (" Trans. Royal Soc. of Edinburgh," 1822). Case 1.-A farmer, twenty-three years of age, of a tuberculous family, an intelligent man, developed incipi- ent phthisis. Becoming discouraged about himself, he one day settled into an apathetic condition almost resembling anergic stupor. He noticed nothing about himself, and had to be washed and cared for like a child. His lung disease remained nearly stationary. At the end of fifteen months he suddenly emerged from this state and spoke in his natural voice. His memory dated back to the fifteen months before ; the time between was a blank. He be- came mentally as well as ever, but his lung disease pro- gressed rapidly, and he died in eighteen months. (Dr. F. B. Scull: Amer. Med. Weekly, July 18, 1874, vol. i., No. 3.) Case 8.-An intelligent, well-developed girl of fifteen, not hysterical, suffered for a long time from excruciating pain in the brow and back of the head. She had no par- alysis of sense or motion. She finally developed abnor- mal mental states, coming on daily, oftener at night. She was very restless, excited, and talked of events in her early childhood. She seemed to be conscious all the time, but to be transferred in imagination to other and earlier surroundings. These attacks continued for six months, when she got better. (Dr. Elisha Bartlett: Amer. Journ. of the Med. Sciences, vol. xxiv, p. 49). Case 9.-A young lady, intelligent, well-educated, suf- fered from sudden attacks of disordered consciousness. She would sometimes be merry, and sometimes was rest- less and seemed to be in pain. She could play on the piano even better than in her normal state. She knew every one, and appeared so much like herself that stran- gers would not know that she was in an unnatural mental state. The attacks would last from a few hours to three days. She did not remember what occurred on-coming out of them, but while in one attack remembered what she had done in those previous. (Related by Dr. G. Bar- low, in Mayo's "Physiology," p. 197.) Case 10.-A Scotch gentleman, a lawyer by profession, who had been very indiscreet in diet, suffered from dys- pepsia, hypochondriasis, and, finally, religious melan- choly. Dr. Skae, who relates the case, says, "Heappears to have a double consciousness, a sort of twofold exist- ence, one-half of which he spends in the rational and in- telligent discharge of his duties, the other in a state of helpless hypochondriasis, amounting almost to complete aberration." He remembered nothing of what he did when in the aberrant state of mind, and when in that state remembered nothing of what he did on his good days. He was one day well, the next day sick. Dr. Skae states that Dr. Abercrombie related to him the history of a sim- ilar case. (Northern Journal of Medicine, 1845, iii., p. 10.) Case 11.-A farmer, aged twenty-three, of not very great intelligence, had eight years before been struck on the head with a pointed hammer. He was unconscious for several hours, but finally recovered. He continued to work and seemed as well as ever, though there was a noticeable depression in his skull. Four years later he moved to another town, purchased a farm, and married. His mind seemed normal until six months previous to his being seen by the writer. He then showed evidences of insanit/, and finally became acutely maniacal. Dr. Mc- Cormack examined him and found a deep depression, the size of a silver quarter, at the junction of the sagittal and coronal sutures. He was trephined and the depressed bone removed. He recovered immediately after the op- eration ; however, he seemed impressed with the idea that he had just recovered from the blow on his head. Everything since that time was a blank. He did not know his wife, or know that he had one. His neighbors were strangers, and everything he had done had to be ex- plained to him. He had to learn the roads in the neigh- borhood. He talked intelligently and candidly. Before the operation he had been boisterous and turbulent in dis- position. After it his manners were quiet. Dr. McCor- mack does not think he could be feigning. (Dr. J. N. McCormack, Medical Record, May 26, 1883, p. 570.) Case 12.-M. Azam, under the title of " Amnesie pe- riodique ou Redoublement de la Vie " (Annales Medico- psychologiques, Juillet, p. 5, 1876), describes the history of the most remarkable case of double consciousness on record. A young woman, aged fifteen, after suffering from violent hysterical symptoms, began daily to fall into a brief sleep, from which she awoke in an abnormal mental condition that continued three or four hours. In this state she remembered her past life and previous acts ; she was lively, active, and perfectly sane. When this passed off and she found herself in her normal state, she remem- bered nothing of what she had done. In her normal state she was apathetic, dull, and melancholy, but indus- trious and fairly skilful in her work. She married and had children. The attacks intermitted for two years. They then came on again, and finally the second, or ab- normal, state encroached on the first until it made up most of her life, and she passed into the first and origin- ally normal state only rarely and for a short time ; these attacks resembled those of larvated epilepsy. Case 13.-M. Azam cites another case (Revue Scien- tifique, December 22, 1877), of a hysterical boy who suffered from periodical attacks resembling closely those of spontaneous trance, but lasting from twenty days to two months. Somewhat similar is a case reported by Sandras (" Pa- thologic du Systeme Nerv., Chap. Somnambulisme "). Cases 14 and 15.-Ferrus (Annul. Med. Psycholog., Oc- tober, 1857, p. 612) and M. Berthiere (Annul. Med. 278 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Consciousness, Constipation. Psycholog., September, 1877) report cases resembling the second one of M. Azam. Case 16.-Dr. Jules Voisin reports a case of hysteria major with "double personality" occurring in a young man. He had had two amnesic attacks, one lasting for a year, the other for about three months. This patient had also a third mental state produced by mesmerizing him. {Archives de Neurologic, Sept., 1885.) Typical cases of double personality in which the indi- vidual lives two lives, each attended with a consciousness almost equally normal, are, as may be seen by the fore- going, extremely rare. All the cases approaching this character, except that of Azam's, were reported imper- fectly, and many years ago. In no instance are the pa- tients said to be epileptic, while, on the other hand, al- most all of them were decidedly hysterical. It may be said, as a general conclusion, that persons who have illus- trated what is called double-consciousness, are hysterics or epileptics who are periodically attacked with states of spontaneous trance or epileptic cerebral automatism. In- stances of double consciousness are observed among the insane. III. Abnormal Exaltation of Consciousness.-Conscious- ness reaches its most intense phase in powerful concentra- tion of thought, strong emotions, and in states of delirium, mania, and intoxication. More remarkable and abnor- mal phases of exaltation, however, ai;e shown in the status raptus of hystero-epilepsy and trance, and in the devo- tional absorption of mystics ; in tine, in the condition known to physicians as ecstasy. In ecstasy some single image, or series of images, is held before the mental vision, and the whole psychic force is expended on it. The in- dividual sees, hears, feels nothing else. The ecstatic image differs, even with devotees. Among feebler minds it is a vision of the Virgin, or angels, or saints. With the more intellectual it is the abstract idea of God among Christians, the Nirvana among Buddhists. St. Theresa, w'ho was of this intellectual class, and who is aptly called the " metaphysician of the saints,'' describes her feelings thus: " It is as though one who longs for death were already holding in his hand the blessed candle, and had but to draw one breath more to attain the fulfilment of his long- ings. It is for the soul an agony full of inexpressible de- lights, wherein it feels itself dying almost entirely to all the things of the world, and reposes with rapture in the enjoyment of its God. No other terms do I find to portray or to explain what I experience. In this state the soul knows not what to do ; knows not whether it is speaking or silent ; whether it laughs or weeps ; it is a glorious delirium, a heavenly madness, a supremely deli- cious mode of enjoyment." This ecstasy of the mystics is a kind of intoxication with the products of their own cerebral activity. The condition known as clairvoyance, or second-sight, is one of the somnambulic or trance states, and is closely allied to ecstasy. Peculiar states of exalted conscious- ness may be produced by such drugs as cannabis indica and opium. There are rare instances in which, just be- fore death, the mind seems to show an unusual clearness and intensity of conscious feeling. This condition has been exhibited oftenest by religious enthusiasts, and has been dwelt upon by poets and devotional writers. Aretaeus has given a description of it (Aretaeus, ix., lib. it, cap. iii.). Mr. More Madden, says Laycock, calls it the " lightning before death," and refers it to the stimulus of the venous blood upon the brain. Such an explana- tion does not account for the phenomenon. Charles L. Dana. to be in health require to have a stool daily. Exceptions do occur ; some people habitually have an operation only once in two days, and show no signs of suffering for the lack of a daily evacuation ; others habitually have more than one discharge a day. The dejection should be mod- erately soft in consistency, and cylindrical, not spherical, in form. Among the symptoms, other than infrequency and in- completeness of defecation, may be mentioned headache, furred tongue, foul breath, muddy complexion and con- junctivae, a sense of weight in the abdomen. The con stipated condition may even be masked by a diarrhoea affecting Only the lower bowel, while an actual impaction exists above. At times, moreover, in the caecum and colon hard masses may accumulate in sacculi in the pe- riphery, while a moderate amount of liquid faeces flows along the centre of the gut. Many of the symptoms of constipation are those of dyspepsia, the two conditions often co-existing, and mutually aggravating one another. The causes of diminished bowel-action are numerous. First may be mentioned mechanical or structural causes, including adhesions, bands resulting from inflammatory deposits, new growths within and without the intestine, constrictions, invaginations, twists, for whose discussion the reader is referred to their appropriate heads. The non-structural causes only will be considered in this arti- cle. Dilatation of the intestine with atony is, perhaps, the commonest cause of constipation. The fault lies es- pecially in the large intestine, which is intended espe- cially as a receptacle for the ffeces. Normally, they rest in the intervals of defecation in great part upon the sig- moid flexure, and the rectum is, for the most part, empty. The passage of a portion of the dejecta into the rectum and the vicinity of the sphincter sets up that irritation, which by reflex action produces the phenomenon of defecation. If this call is habitually neglected, the sen- sibility of this portion of the bowel is blunted, so that a great accumulation of faecal matter may take place. This dilates the bowel and still further obtunds sensibil- ity, so that a vicious circle is established and the evil is increased. Another cause of this condition of things is the lack of a regular habit of defecating at a fixed time daily. It seems possible to train the intestine, as it were, to send its contents into the rectum at a stated time daily, and if this periodicity can be secured, one has a powerful aid toward regular and complete evacuation. From the atony above described one finds various degrees, up to paralysis of the peripheral nerve-endings in the intes- tine, and of the centres in the cord presiding over peri- stalsis and defecation. Again, the atony may not be con- fined to the unstriped muscles of the intestine, but may affect the voluntary muscles as well. This is especially the case in obese persons, and those having lax, pendu- lous bellies, as after numerous pregnancies. Deficiency of secretion of the intestinal glands contributes to con- stipation, by lessening the fluidity of the chyle. Over- active absorption of the fluids of the chyle may act in the same way ; this occurs in febrile states, and when the perspiration is abundant. Anaemia is usually given as one of the causes of constipation ; perhaps it would be truer to say that the two conditions have some causes in common ; among them an indoor life and sedentary occupations. Probably a large proportion of individuals engaged in sedentary callings suffer at some time from constipation. This is especially the case in those who have changed their mode of life from a more active one, as students who have formerly been active bodily work- ers. Any change in surroundings, even though it do not involve a lack of exercise, may cause constipation, as when a person removes from one climate and soil to an- other. The change of wrater very possibly adds to this effect. Most landsmen taking a sea-voyage suffer more or less from constipation. Congestion of the mucous membrane of the bowel has sometimes a constipating effect, especially when it is due to chronic venous ob- struction. For this reason diseases of the liver involving passive congestion of the portal system are often at- tended with constipation. The explanation seems to be that long-continued passive congestion leads to thickening CONSTIPATION. This term is applied to an abnormal sluggishness in the movement of the intestinal contents through their canal. In extreme cases, when the bowel becomes entirely closed up, one speaks of the condition as obstipation. When there is a movement daily, but the amount is small, so that an accumulation takes place within the intestine, it is called costiveness. It is obvi- ous that there is no sharp line separating constipation from health. But in general it may be said that most persons 279 Constipation. Contagion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the mucous and submucous coats, which impairs peri- stalsis. Some forms of cerebral disease, notably tuberculous meningitis, are attended with constipation to a greater de- gree than other maladies of like febrile intensity. An important aggravating, if not primary, cause of constipa- tion is the use of cathartics. These are seldom if ever required in the treatment of constipation, laxatives al- ways being preferable to purgatives. But, through a mis- taken notion of w hat is needed, the laity are much ad- dicted to the use of powerful cathartics, which, though they relieve temporarily, in the end aggravate the diffi- culty. Enormous quantities of cathartic pills, chiefly of the proprietary order, are consumed by the public, and no small proportion of their users arrive at that unfortu- nate condition when nothing but a repetition of these drastic purges will procure them an evacuation. Im- proper foods are another cause of constipation; among such we may mention those which are specially concen- trated, so that they leave little residuum ; a certain bulk of unassimilable residue is necessary for the intestine to act upon. Foods that are too bland, as milk, act in the same way, not affording an irritation sufficient to stimulate peristalsis. This effect of faulty foods is specially ob- servable in young children. Finally, chronic lead-poi- soning has among its symptoms marked constipation ; here of course, ordinarily, one can obtain the collateral evidence of colic, blue line on the gums, etc. Much of the importance attaching to constipation de- pends upon the effects which it produces. Among these that upon the digestive function has been referred to. It is perhaps to the latter that the mental depression so often observed in constipated persons is more directly due ; but however this may be, the coexistence of constipation with mental irritability and melancholy is often marked. Intestinal catarrh may be induced by constipation, and may, as already hinted, show itself by a diarrhoea actually coincident with constipation in other parts of the bowel. The catarrhal process occasionally localizes itself, notably about the ileo-csecal valve ; inflammation here (typhlitis) may go on to ulceration, and even perforation, or may by extension cause perityphlitis, with or without ulcers. Other neighboring viscera may suffer from overloaded bowels ; a distended and dilated rectum may cause uter- ine congestion, thence proliferation of tissue, added weight, and finally displacement. More frequently is its aggravation of symptoms due to uterine disease that had an independent causation. Neuralgias, ovarian, and es- pecially of the sciatic nerve, may be determined by con- stipation. In the male, seminal emissions are sometimes so caused. Haemorrhoids constitute one of the most an- noying and serious consequences of constipation, the dis- tention of the haemorrhoidal plexus being evidently ag- gravated by a loaded rectum. The general effects of the irritation of the blood by the absorption into it of the contents of the lower bowel, through the prolonged ex- posure of the latter to an absorbing surface, are shown by the fact that repair of traumatic injuries and operative wounds is observed to be delayed when the bowels become long constipated. From this it seems reasonable to sup- pose that other vital processes, depending upon a healthy state of the blood, are similarly hindered by habitual in- action of the bowels. Treatment.-This is often a matter requiring great judgment and patience. Some of the essentials of treat- ment have been hinted at in what was said of the causes of constipation. Special attention should be paid to the prevention of this trouble in young children, by training them from their earliest years to regular habits in this re- gard. The person who is suffering from constipation must be enjoined to select a definite hour (if possible, directly after breakfast), when he will be able daily to devote at least fifteen minutes to securing a proper evac- uation. This attempt should be made daily, whether the desire is felt or not, and in time the endeavors will begin to become more and more successful. The water-closet should be made comfortable enough, so far as tempera- ture and accessibility are concerned, so that the individual can spend that amount of time in it without danger of taking cold. Unsheltered and exposed privies are a fer- tile source of constipation in delicate females. After a stool occurs, a few minutes should be given to see if a further amount of faecal matter finds its way into the rec- tum, a thing which often happens. It should never be allowed to remain in the rectum, for that will blunt the sensibility of the mucous membrane, and so delay the cure. A call to defecate, no matter when it occurs, should never be neglected for a moment. The diet is of great importance to a constipated subject. Fruit is usually of benefit, particularly figs, berries, stewed prunes, and baked apples. Oatmeal has a popular reputation in this regard, though occasionally persons are found upon whom it seems to have a binding effect. Brown bread and mo- lasses are anti-constipative. An orange, or a pear, taken immediately on rising, will sometimes act as a laxative. In infants, after the fifth or sixth month, costiveness is usu- ally an indication for introducing starchy substances into the diet. Among hygienic measures, we mention out-of- door exercise-in particular, horseback riding ; massage, or kneading of the abdomen, which should be practised daily on rising, the manipulation being over the ascend- ing, transverse, and descending colon, in that order. Elec- tricity similarly applied has proved effective. It may be mentioned that tobacco-smoking acts with some persons as a laxative. The ingestion of a considerable amount of water is to be recommended, and a glass taken on an empty stomach in the morning is particularly effective. Mineral waters are, many of them, of value chiefly by at- tracting patients to ingest large quantities of fluid, which otherwise they would neglect to do. Some mineral waters, of course, have a distinct laxative character by virtue of their dissolved ingredients. Such are Hunyadi Janos, Friedrichshall, Congress, Carlsbad, etc. Laxative waters that can be drunk on the spot, i.e., among diverting and pleasant scenes and society, are particularly useful. One to five glasses daily, according to the strength of the water, may be required. The drug treatment of consti- pation always requires caution. Purgatives are almost never indicated, except, perhaps, once at the beginning of a course of treatment. Laxatives in the form of mineral waters, just alluded to, or as salines, magnesia, potassii ctsodii tartras, etc.,maybe given in small repeated doses if necessary. Probably no better drug exists for the treatment of chronic constipation than aloes, which acts specially on the lower bowel, and but little upon the se- cretions. This should be given in small doses (say .01 to . 02 Gm., | to | grain in pill ; two pills to be taken two or three times a day). Unlike other cathartics, this does not require to be increased in dose to maintain its effect, but one pill can be dropped at a time till the motions are nat- ural. Belladonna in the form of the extract, .01 to 0.15 Gm. (| to i gr.), once or twice a day, is highly recom- mended by Trousseau. Nux vomica and strychnia have given good results, but are most reliable when combined with other remedies. They act not as cathartics, but probably by increasing the reflex irritability of the spinal centres which preside over peristalsis. The buckthorn (rhamnusfrangula, r. purshiana, etc.) has been advocated, and the cascara sagrada, in the form of the fluid extract, in doses of 2 Gm. and over ( 3 ss.), seems to be a valuable addition to the therapeutics of constipation. Cold-water injections may be practised daily as an adjuvant to other treatment; suppositories of soap immersed in oil are sometimes effective, especially in children. Finally, in cases of obstinate rectal impaction, mechanical removal of the faeces by the finger or by a scoop, may be neces- sary. (See also Digestion, Disorders of.) Charles F. Withington. CONTAGION; INFECTION. Contagion may be de- fined as that property and process by which diseased con- ditions of organized bodies are communicated to other bodies. It is obvious that the term applies equally to vegetable and animal organisms, but in the present ar- ticle its application to the latter only will be considered. The agent in the process is known as contagium, or virus, and is generally admitted to be neither gaseous nor liquid, but either solid or semi-solid. 280 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Constipation. Contagion. Here it may be suggested that heredity in disease is closely akin to contagiousness, and explicable on the ground that the germs never fail to find suitable pabulum for life and growth, and favorable conditions for repro- duction (unless, as in case of syphilis, suitable therapeutic measures destroy their life); and that these germs, tra- versing the blood-current of the parent, infect the repro- ductive element and are thus transmitted to the progeny. The tenacity with which they hold to their habitat is analogous to that of the trichina spiralis, which fails of hereditary transmission, perhaps because the reproductive elements could not entertain or withstand so large and rapacious a guest. The definite course and duration of most contagious diseases are best explained on the ground that the prodig- ious multiplication and growth of the germs exhaust their pabulum, and leads to their starvation in the affected body; while enough escape alive through the emuncto- ries to attack other susceptible individuals whom they may encounter. Exhaustion of suitable pabulum also explains loss of susceptibility to another attack of most contagious ailments ; which is, however, recovered in some instances after a lapse of time. This is strictly analogous to exhaustion of the soil for the production of certain plants by repeated cropping, while it is still ca- pable of producing others, and will in time regain produc- tiveness for those once starved out. The nature of such pabulum can only be conjectured, and cannot be studied until more is known of the true nature of specific disease- poisons. The susceptibility of different persons to particular contagious complaints is far from uniform, and of the same individual to a given malady extremely variable at different times. A depressed state of the general health invites many infections, while those of cholera and yellow fever are indifferent to hardihood and delicacy of consti- tution alike. No explanation of these discrepancies can be given. Again, some diseases-notably yellow fever and scarlatina-pursue an epidemic course for a period and then abate, leaving a large fraction of the population apparently exempt; but many of these individuals are subsequently attacked. A remarkable observation in New Orleans has been the limitation of epidemic yellow fever to a duration of three months, though this period might considerably antedate the appearance of frost. In this disease, as in many others, a person may be exposed thoroughly and often before sickening, and some few ap- pear totally unsusceptible. Some soldiers pass through many battles unharmed simply because bullets never hit them, but this reasoning would hardly apply to escape from contagious disorders in epidemic form. It is usual to speak of a person's power of resistance, like an armor withstanding violent assaults. There can be no doubt that epidemicity of contagious distempers is largely affected by conditions external to the persons exposed. A confined atmosphere favors con- centration and energy of poison-germs, while free venti- lation dissipates and weakens them. This explains the greater prevalence and severity of the eruptive fevers during the cold season of the year and in cold climates, where houses, and especially the apartments of the sick, are insufficiently ventilated. Undisturbed collections of matter contaminated with emanations from the sick are especially dangerous as foci of disease. Neglected spots naturally become filthy and are favorite nests of infec- tion, simply because the virus is neither dissipated nor destroyed. While it would be incorrect to suppose that infection originates in such nests, it is always best to break them up, for fear they might harbor it. A low temperature enfeebles but does not destroy most infections. In the winter season inhabited rooms are warm enough to keep them active, with the exception of the yellow-fever poison. Heat and moisture greatly promote their growth and ac- tivity. The above remarks apply especially to such dis- ease-poisons as may be reproduced outside living bodies, and to those which are transportable in fomites. Diseases of contagious character sometimes remain ab- sent from extensive regions for prolonged periods, after Contagion and infection are used as synonymous terms bv some writers, while others attempt to make a discrimi- nation, but usage is by no means exact. Whether we have regard to activity of virus or mode of communica- tion, it is impracticable to lay down any precise line of distinction. The poisons of the eruptive fevers and of whooping-cough are transmissible through the common atmosphere, and might be termed infectious, while those of puerperal fever, charbon, glanders, and the venereal diseases need direct application to an absorbing surface ; and some, like those of hydrophobia and syphilis, require inoculation or contact with an abraded surface. The variolous poison may be transmitted both through the at- mosphere and by inoculation, and successful experiments of implanting morbid secretions have been made with measles. Intermediate between the above varieties are the poisons of cholera and enteric fever, which undoubtedly are carried in foods and drinks, and are absorbed through the mucous surfaces of the alimentary canal; so that, if an attempt were made to distinguish between contagion and infection by distance between the affecting and af- fected parties, it would be difficult to establish a precise classification. Disease-poisons remain active for more or less time af- ter escape from the body, and may be conveyed in fo- mites for long distances. This is the case with the virus of the eruptive fevers and of yellow fever in marked degree, and in less degree with those of cholera and typhoid fever. Why some contagia require abrasion of surface or actual inoculation, while others are absorbed through the unbroken mucous membrane, is explicable by vary- ing diameter of the contagious particles. But' apart from this, different contagia, for some unaccountable rea- son, show a definite selection of certain avenues of ad- mission to the body, as the oral, guttural, respiratory, and alimentary surfaces, and this selection generally holds di- rect relation to the parts chiefly affected ; but exception must be made of small-pox, scarlatina, and measles, which are communicated generally through the respiratory sur- faces, while their lesions are most marked upon the ex- ternal surface and throat. One of the characteristic features of spreading diseases is the fact that the absorption of an imperceptible portion of the specific virus is followed by the production of an enormously increased amount in the affected body. This is conclusive proof of the property of self-multiplication, and indicates that the virus is a distinct organism in every disease. Another proof is the fact that every con- tagious affection is as specific and true a copy of the case which preceded and caused it, as are animals and plants of their progenitors. Variations occur in both instances, and the law of evolution probably applies to both equally. The reproduction of disease germs in most cases takes place within the body affected, but there is reason to suppose that the specific cause of yellow fever is gen- erated outside, while that of cholera, and perhaps that of enteric fever, does not attain full development till after expulsion. The specific action of disease-poisons is also exempli- fied in the uniformity with which certain organs and parts are affected. Exceptions to this rule are found in venereal maladies, whose poisons produce local effects wherever absorbed ; while others, such as malignant pus- tule, glanders, pyaemia, and septicaemia, profoundly af- fect the system at large. The determinate course and duration of certain diseases seems allied to specific selec- tion of their seat. The variations in respect to extent of the organism affected, and of duration in any given dis- order, constituting the relative severity of the attack, may be explained by the varying fecundity of the virus, which may depend upon the amount of pabulum it finds in the diseased body, or upon its own inherent force. The limitation of contagious diseases in affecting par- ticular parts or tissues, and in running a definite course, finds exception in syphilis and leprosy, and also in cancer and tuberculosis, if these are to be reckoned among the contagious diseases.' This exception seems to be a corre- lation of the property of heredity, which belongs to all four alike, while their contagiousness is quite unlike. 281 Contagion. Contagion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. epidemic visitations. The plague and the sweating sick- ness have been unknown in Western Europe for two hundred years, and never known on the American con- tinent. Their disappearance is attributable to improved hygienic conditions, which broke up the nests that har- bored their infections and favored their reproduction out- side the body. Temporary disappearance, followed by reappearance, is a common occurrence in sparsely inhabited districts, while the infectious diseases of childhood are rarely ab- sent from large cities. It is probable that the germs of these diseases are reproduced only in the body, and soon die in the emanations and excretions, though that of scar- latina is known to retain vitality for many months in fomites not exposed to ventilation. It is evident that contagious diseases often die out completely in small com- munities, for want of susceptible subjects, and reappear by fresh importation of the infection from abroad. The supposition of their spontaneous origin arises from ina- bility to trace the source in certain cases. The foetus in utero shares some of the contagious affec- tions of the mother-certainly small-pox, syphilis, and enteric fever ; probably also measles and scarlatina. This could not be, unless the disease-germs traversed the blood- current. Artificial inoculation diminishes the energy of some disease-poisons, as of small-pox and the bovine plague. Repeated reproduction in culture-fluids has the same effect, and Pasteur has taken advantage of this discovery to give light attacks and subsequent immunity in case of char- bon and chicken cholera.* On the other hand, the poison of septicaemia gains energy by cultivation. The domestic animals share some contagious diseases with humanity, of which variola, charbon, glanders, and hydrophobia are familiar examples. The three latter obviously originated among these animals, but prepon- derance of evidence indicates that variola was of human origin. In general every genus of animals has peculiari- ties of susceptibility to disease-poisons, and does not share most of its contagious maladies with others. This is much more marked than the adaptability of plants to different habitats, and is further exemplified in the fact that actual contact is needed to propagate a disease which did not arise with the genus. In all contagious diseases a period of time intervenes between reception of the virus and the first manifestation of its effects. This is termed period of incubation, and it varies greatly in duration and precision in different dis- eases. The obvious explanation is, that the amount of poison first received is insufficient to produce the disease, and one or more generations must elapse before that ef- fect follows. The period of incubation marks the time of reproduction and growth to maturity. The relative vitality of disease-germs, after escape or expulsion from the body, varies largely. Those of cholera and enteric fever are believed soon to perish, while those of scarlatina are known to survive for months in fomites, and those of charbon for years in the ground ; though this last example is probably due to continued reproduction. The influence of differences in tempera- ture and moisture, and the effects of chemical agents, are multiform and deserve careful study and experimentation with reference to prevention. With respect to morbid action of various contagia, a differentiation has been made between the catalytic or disintegrative, and the anaplastic or constructive. The former is exemplified in the purely zymotic diseases ; the latter in tuberculosis, cancer, and leprosy (on the supposi- tion that they are truly contagious). But it is certain that the neoplasm of the latter class grows at the expense of surrounding tissues-their disintegration. Mr. John Simon makes two general classes of living contagia, viz., the parasitic and the metabolic. By the former he means those animal and vegetable intruders which produce diseased action simply by mechanical dis- turbance, and by preying upon the aliment and blood of their host. The whole tribe of entozoa, the trichina spiralis, hydatids, the acarus scabiei, and the numerous skin affections dependent upon microphytes are examples of this class. Their effects are not specific nor general, except in derangement of general nutrition ; they have no definite period of operation, but continue their ravages until either they are destroyed or their victim perishes ; hence they are not contagia in the proper sense of the term. The other class operate by producing changes in the structures affected-the blood, the cutaneous, mucous, and cellular membranes, and glandular organs-of a de- structive character, deranging their functions, disturbing the processes of nutrition, of circulation, of calorification, and of secretion. Fever, loss of appetite, emaciation, prostration of the muscular and nervous forces, are the usual results. The effects of the former class are merely local, while the metabolic contagia give rise to general maladies known as zymotic. Those commonly recognized as belonging to this class are the following: variola (including cow-pox, sheep-pox, and grease), scarlatina, measles, Roetheln, varicella, ty- phus, enteric fever, relapsing fever, whooping-cough, mumps, diphtheria, influenza, yellow fever, dengue, cholera, malignant pustule, glanders, septicaemia, hydro- phobia, syphilis, chancroidal ulcers, gonorrhoea, plague. To these some would add leprosy, tuberculosis, pneu- monia, croup, hospital gangrene, erysipelas, cerebro- spinal fever, rheumatic fever, acute endocarditis, dysen- tery, diarrhoea, and the malarial fevers ; but evidence of communicability of rheumatic fever and malarial fever * is wanting, and pneumonia and the diarrhoeal complaints certainly have other causes. The foregoing views respecting contagion are com- monly accepted, but, in considering the nature of the agents of the morbid changes, we enter on disputed ground. Three distinct theories have had able advocates, which may be designated as : 1. The vital germ theory, of which Lionel Beale is the chief exponent. 2. The 'ner- vous theory, advocated most prominently by Dr. B. W. Richardson. 3. The microphyte theory, at present the favorite among pathologists, and rapidly gaining ground. A brief explanation will now be given of these hypo- theses. 1. Dr. Beale uses the term bioplasm to designate the physical basis of life and growth. This consists, in his view, of separate particles of matter, less than one-thou- sandth of an inch in diameter, originating in the blood and destined for the nourishment and growth of all the tissues of the body. It is described as soft, without color or structure, and enclosed in a colorless capsule, through which liquid pabulum passes for its growth. New bio- plasts are formed by division of mature ones, and the new ones continue to grow by imbibition until they divide or contribute to the formation of solid tissues. Microphytes are considered by him as the lowest form of bioplasm, existing in all the fluids and solid tissues of both plants and animals, as well as on all kinds of min- eral substances and under all meteorological conditions, though dormant under some conditions of temperature and desiccation. Being omnipresent, and, as he believes, undistinguishable from each other by any precise phys- ical characteristics, he denies their relation to disease of any kind. Contagious diseases are attributed by him to degraded or perverted bioplasm, descended from originally healthy bioplasts. These constitute what he styles "disease- germs," which have the property of self-multiplication, like healthy bioplasts, both within the diseased body and in any healthy susceptible body to which they may gain admission. The contagious bioplast has a diameter less than one-hundred-thousandth of an inch, and, though pos- sessing specific characteristics for every disease, one can- * It is reported (1885) that Professor Gerhardt lately inoculated two healthy persons with blood from an individual in the febrile stage of in- termittent. In both cases a periodic fever followed, at first irregular, afterward becoming quotidian like the original case. Other successful experiments are needed to establish evidence. * His experiments with hydrophobia are still too recent and too few to establish positive conclusions. Even more doubtful are the inocula- tions of Freire, at Rio de Janeiro, for the prevention of yellow fever, and those of Ferrdu, in Spain, for the prevention of cholera (18S5). 282 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Contagion. Contagion. not be distinguished from another either by the micro- scope or by chemical analysis ; neither can the healthy bioplast be distinguished from the diseased by any test except its effects. Disease-germs become noxious only after entering the blood, and pass from the blood into the solid tissues and secretions. Multiplication of these dis- ease-germs in the body always elevates the temperature, and this may continue after the death of the victim, which proves, in his opinion, that the fever is not caused by oxidation of tissues. Death is occasioned by change of composition of the blood and derangement of the cap- illary circulation. On the supposition that disease-germs are only abnor- malities or deviations from healthy bioplasts, the question naturally arises, why they are not constantly happening, so as to produce an infinite number of new diseases, to speedily corrupt and eventually exterminate the 'whole race. It is not claimed that diseased bioplasm can be dis- tinguished from the healthy, except by consequences, so that the hypothesis has neither physical facts nor analogy to sustain it-in fact it is nothing but an ingenious suppo- sition. 2. The nervous hypothesis of Dr. B. W. Richardson seems to have originated in his studies of the theory of Liebig on fermentation and its relation to nitrogenous matters. Ex- periments, made between 1856 and 1863, convinced him that zymotic disease coujd be communicated from one animal to another by inoculation of various secretions, and that the poison increases in virulence by successive inoculations. * He also succeeded in producing from such fluids alkaloidal substances of crystalline structure. In- oculations of these in solution were followed by the same specific diseases as had yielded the alkaloids (ptomaines ?). Hence he concluded that any animal secretion might be made to yield a contagious principle, to which he gave the name of " septine," and the maladies he called " sep- tinous." The true contagia, in his belief, are, therefore, all of glandular origin, and the venom of serpents serves as a type of their source and action. The effect depends not on multiplication of germs, but is catalytic-the agent changes other substances without undergoing change itself. The poison, therefore, is reproduced only in the infected and diseased body through its own secreting or- gans. He believes also that ordinary secretions may ■change character and become poisonous without previous infection. Thus the exudation in ordinary peritonitis may give rise to puerperal fever, typhus may be produced in overcrowded apartments by absorption of animal ex- halations ; and in this way contagia of various kinds may constantly arise de novo. In furtherance of his hypothesis, Dr. Richardson ob- serves that the number of separate communicable mala- dies has a close relation to the number of secretions : hydrophobia is derived from the saliva of rabid animals ; glanders from the nasal mucus ; enteric fever is traced to the intestinal mucous glands ; diphtheria to the mucous glands of the throat; scarlatina to the secretion of the lymphatic glands. He admits, however, that in some in- stances the blood-corpuscles become the seat of the cata- lytic change. As he maintains that communicable dis- eases may arise without intervention of contagious matter, he supposes that the virus may arise through nervous impression upon glandular organs, and refers the origin of such cases to fear or anger, when no mode of com- munication can be discovered. If this were true, adventitious occurrence of specific disorders should follow passional outbursts habitually, and there is no reason why the consequences should be the familiar phenomena of specific diseases rather than new and infinitely variable symptoms. In fact, the same difficult question arises here as in case of spontaneous origin of contagium in perverted bioplasm : Why should the deviation, as often as it occurs, pursue definite and familiar lines and not wander off into new and strange processes ? This explanation of a mystery by supposition of an agency equally mysterious does not help us to un- derstand an effect without a tangible known cause. Inas- much as specific disease is generally traced to antecedent cases, it is better in questionable examples to own that we fail to discover the mode of communication than to sup- pose that it arose de novo in the sick person. The customs officials give us an instructive lesson, when they find dutiable goods in unlawful hands : the holder must give a better account of the property than to allege that he made it himself. The glandular hypothesis for the origin of contagious disorders might be satisfactory, if the secretions were habitually poisonops, like the venom of certain reptiles and insects ; in other examples it would be more reason- able to suppose that such secretions become poisoned through admission of extraneous contagia.' If we admit this of the glandular secretions, then still more should we admit it of infected blood. It is not many years since most of the epidemic diseases were supposed to originate in mysterious local conditions, nor many generations since frogs, mice, and other small animals were believed to be independent of parentage. To-day the doctrine of arche- biosis is rejected by men of science as a superstition, and Charlton Bastian's experiments to demonstrate its occur- rence in the lowest living forms fail when subjected to the more rigorous methods of his critics. 3. The last hypothesis attributes contagious diseases to the agency of microbes, or minute living objects. By most authorities these are all classed in the vegetable kingdom, and might be termed microphytes of the fun- gous order, being mostly destitute of pigment. A particu- lar description of these growths belongs to another article. By some they are denominated parasites, but a distinction has been drawn in the early part of this article which excludes this definition. A general resemblance between the symptoms of con- tagious maladies and the processes observed in the fer- mentations, led to the use of the terms zymosis and zymotic, and the discovery of the dependence of the alcoholic fermentation upon presence of the yeast-plant was natur- ally followed by search for similar organisms in the blood and morbid secretions of persons affected with zymotic diseases. Numerous efforts of this kind have resulted in discovery of various microphytes in connection with many spreading disorders, acute abscesses, and open wounds. These receive the generic name of bacteria, and are classified as micrococci, or spherical B. ; bacilli, or rod-shaped B. ; and spiro-bacteria, with spiral fila- ments. Multiplication takes place by fission and through spores, which latter show great vitality under circum- stances unfavorable to growth. The following have been assigned by the observers whose names are appended : The rinderpest germ (Smart, 1865); micrococcus vaccinae (Cohn), found in fresh vac- cine and in variolous pustules ; M. diphtheriticus (Cohn), found in all the diseased tissues ; M. septicus (Cohn), found in the serum of epidemic puerperal fever, in all the tissues, vessels, etc., of pyaemia and septicaemia; M. rubeolae (Hallier), in the blood and sputa of those affected ; M. scarlatinas (Hallier), in and on the blood-corpuscles ; M. of epidemic diarrhoea (Hallier), in the intestinal con- tents ; M. of spotted typhus (Hallier), in the blood ; M. of enteric fever (Hallier), very small in the blood, and larger, with active movements, in the intestinal discharges ; M. of fowl-cholera (Pasteur); M. of pneumonia (Fried- lander, 1883), in the exudations ; M. of glanders (Ziirn), in the blood-globules, and with rapid movements in the lymphatic ganglia, mucus of the frontal sinuses, and in the ulcers ; M. of syphilis (Hallier), in the primary sore and in the blood of those constitutionally affected ; Bacil- lus anthracis (Pollender, 1849), found in the blood of those affected with charbon ; B. choleras (Koch, 1884), comma-shaped and found in the vomit and stools of Asiatic cholera; B. tuberculosis (Koch, 1882), in the sputa and all tuberculous parts ; Spirochaete Obermeieri (Cohn ; Obermeier in 1872), in the blood of relapsing fever, during access, but never in remission. To the above should be added bacillus malarias (Klebs ; Tomassi-C'rudeli, 1879), found in the water of marshes and the blood of those affected by malarial fevers ; B. Leprae (Paul Gutmann); and M. of acute endocarditis * This is true only of the septic poison, however. 283 Contagion. Contusions. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (Klebs ; Osler, 1884), found on the vegetations of the en- docardium, whence they are carried by the blood-current. The observations made and discoveries announced by the above-named writers have by no means obtained general confirmation. The true test is reproduction of the microphytes and their spores in culture-liquids, and production of the same disease in other individuals by in- oculation. But experiments on human beings are not justifiable, and the lower animals are not subject to these maladies like mankind. Rabbits, guinea-pigs, rats, and mice have been inoculated in this manner by many ex- perimenters, some of whom have observed symptoms to follow similar to those of the original disease. The proof of causative relation between microphytes and charbon and relapsing fever is stronger and more generally ad- mitted than is the case with any other diseases, but evi- dence is rapidly accumulating, and this hypothesis is steadily gaining ground. As long ago as 1833, Dr. Tytler connected Asiatic chol- era with a fungus on rice, and in 1838 Boehm found cryptogamic vegetations in the intestines and stools of those affected with cholera. In 1866 Hallier made cul- tures of this rice-fungus. In 1884 Koch discovered the comma-bacillus, and Drs. Reitsch and Ricati made suc- cessful experiments by inoculating animals with these microphytes; but Klein, as the result of observations in 1884 at Calcutta, reported the same bacilli in the mouths of healthy persons, and in the dejections of cholera mor- bus ; also, that the use for domestic purposes of water contaminated with cholera dejections was harmless. This last observation is at variance with general belief of the diffusion of cholera through matters from the alimentary canal. In septicaemia most authorities are agreed in finding bacteria, but they are not agreed that these are the effi- cient cause. Zuelzer has found an alkaloid (ptomaine ?) in the blood of septicaemia. Having inoculated animals with cultures of the bacteria, no septic results followed until atropia was added to the solution. G. V. Black (1884) supposes that, in the growth of the bacteria, fer- ments are produced similar to pepsin, ptyalin, etc., which act as poisons. By like action the yeast-plant decom- poses sugar into alcohol and carbon dioxide ; and other microphytes cause the acetic, butyric, and putrefactive fermentations. He attributes the symptoms of many acute diseases to rapid development of poisons similar to vegetable alkaloids, by the bacteria, in remoleculizing the normal fluids. This might explain the sometimes too rapid operation of cholera for the reproduction and dis- tribution of the bacilli. It is evident that this view of the mode of action of microphytes does not detract from their agency in the production of disease. If it be the true one, it follows that the morbific alkaloids may equal in number the specific zymotic disorders, and a new field of research is opened for identifying and analyzing these various chemical substances. The hypothesis of the dependence of contagious dis- eases on microbes does not necessitate as many species of these organisms as there are separate communicable maladies, though this is an obvious deduction; and de- scriptions more or less distinctive have been made by microscopists. Professor Jaccoud, while admitting the important role of microbes in infectious disorders, holds that there is not a distinct form for every one, but that the liquids inhabited by them are frequently infectious. They are therefore carriers of contagion ; in some in- stances they become so infected themselves as to transmit this property through several successive generations. But the bacteria of infection are undistinguishable by most observers from the harmless ones, except by their effects. Dr. G. M. Sternberg supposes that microphytes differ physiologically without necessary morphological distinction. Change of character is derived from culti- vation or the influence of special media. Satisfactory classification is at present impossible. In his microscopic examinations of the blood of persons affected with mala- rial and yellow fevers, syphilis, and leprosy, Sternberg found nothing uniform or characteristic. It may be said that this has the usual value of negative testimony in com- parison with the positive testimony of other investigators, who see much more ; but the disagreements of different workers depend largely upon their personal equation, which no mathematical calculations have succeeded in solving. Cohn resolves the bacteria into distinct species, like other plants ; while Hallier, Hoffmann, Billroth, Robin, and Nageli regard the various forms as phases of devel- opment of one or a few species. It has not been proved that any unusual form of microphyte appears simultan- eously with an epidemic of a particular disease ; while common forms are always present in the alimentary canal of man and have been inoculated without harm. Change in pathological character by cultivation has been shown by Pasteur's attenuations of the virus of charbon and chicken-cholera, and by the intensification of septic poison through successive inoculations in the ex- periments of Davaine and Koch. Greenfield and Buch- ner have found repeated cultures of B. subtilis (the agent of the butyric fermentation) to develop pathogenetic prop- erties, and that B. anthracis may lose the same by re- peated cultures in the aqueous humor of the eye. A fair deduction from the discordant results of so many researches would be, that the time has not yet arrived for definite conclusions. The field of inquiry is vast and constantly widening ; it has been worked only a few years by scientific methods ; experiments must be extended, repeated, and varied immeasurably, to form just deci- sions ; and it is doubtful whether, at last, a demonstra- tion of the true nature of contagia will be of essential advantage in curing or preventing their effects ; there- fore we need not complain about the progress of the workers, nor need they hurry in their labors. The prob- abilities are strong that the contagia of spreading dis- eases will be found to depend upon microphytes, mainly if not entirely, rather than upon bioplasts or glandular secre- tions which have fallen from grace through original sin. As to the mode of action of disease-germs, on the sup- position that they are living objects, our views for the present must be largely speculative. By enormous mul- tiplication they may act mechanically through their bulk, obstructing the capillary circulation, and by pressure on solid tissues causing their gradual destruction, as in tuberculosis, syphilis, leprosy, enteric fever, and cholera; by catalytic action on the blood, as in septicaemia and pyaemia (and catalysis is no explanation, but merely a supposition, evasion of the question, or confession of ig- norance) ; by robbing the blood of the pabulum used for growth of the microphytes, with the effect of causing emaciation by spoliation, and fever by conversion of molecular motion into heat; by derangement of secre- tions through presence of intruders in the glandular structures, in scarlatina and mumps : by similar action on nerve-structure in hydrophobia and pertussis. These suppositions approach nearer an understanding of bottom facts in pathology than any suggested by bioplasts or glandular secretions. But the paramount consideration in connection with contagia is their destruction. Without attempting to understand their real nature or precise mode of action, sanitarians have experimented in various ways, and can operate probably as successfully as if satisfied on these points. Now, as anciently, the most important measures are the separation of the sick from the well and the at- tenuation of contagia by free ventilation. Cold has been found untrustworthy, and heat requires the boiling-point sustained for a considerable time, and a still higher de- gree of dry heat. Of chemical agents, chlorine and sul- phurous acid vapors, and chlorine compounds and car- bolic acid in solution are the most efficient. Rigorous ex- clusion of disease-poisons from foods and drinks demands the utmost watchfulness. Contamination of the water of wells and small streams by the germs of enteric fever and cholera, of milk by whatever germs may be wafted in the atmosphere, and perhaps by the tubercle bacilli of the cow, and of vegetables and fruits by objects light enough to float in the air, is universally recognized. Under circumstances of danger the boiling of milk and drinking-water, thorough cooking of vegetables, and 284 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Contagion. Contusions. conditions may be made by examining a section of the skin-which, if the injury was ante-mortem, will be found infiltrated with blood, and firmer and thicker than natural ; but if post-mortem, the blood will be beneath, or upon, but not in, the cutis. Moreover, the post-mortem mottling will generally occur at the most dependent parts, and the effused blood will be found fluid.1 Of medico-legal interest also is haemophilia, as those subject to this diathesis are liable to extensive extravasa- tions resulting from slight violence ; and this is also true of certain chronic cardiac, hepatic, splenic, renal, and blood diseases, in which the blood is unhealthy and the vessels of diminished resisting power. The amount of extravasation in any contusion will vary with the extent of vascular involvement, the degree of vascular tone, and the density of the surrounding tissues. If the bleeding take place from an artery of some size, a false aneurism, either circumscribed or diffused, may result. Or, it may be that there is no immediate escape of blood from a large vessel, and yet its walls have been so injured as finally to disintegrate, and permit a violent secondary haemorrhage beneath the skin. Or, again, an immediate true aneurism may be produced through par- tial rupture, usually involving the inner and middle coats. We sometimes see cases in which the pulsation entirely ceases in the main artery of a limb beyond the point of injury. Here there has generally been rupture of, at least, the inner coat, with consequent thrombosis ; or, if pulsation is only lost after some time has elapsed, this is due to obliteration from adhesive inflammation. Such instances may well be followed by dry gangrene, or moist, if the accompanying vein or veins be occluded. Diagnosis.-It is impossible to estimate the gravity of any case of contusion from mere inspection of the patient. The weight and velocity of the missile, or the distance fallen, the posture in which the injury was received, etc., should be ascertained. The surface may show no evi- dence of a contused and ruptured viscus within. If the vascular lesions have taken place deep in the tissues, sev- eral days may elapse before the extravasated blood reaches the skin, becoming thus of diagnostic value ; and not in- frequently it makes its appearance several inches distant from the seat of contusion, having dissected between lay- ers of dense fascia its way to the surface. Contusion presents a certain superficial resemblance to gangrene, but is to be differentiated by the following points : 1. The discoloration, although present in both, becomes gradually less marked and lighter-colored in ecchymosis, and steadily more marked and darker in gan- grene. 2. There is often numbness and diminished sen- sibility over a contused surface, but in gangrene the dead part is devoid of sensibility, while the dying portion ad- joining is often hyperaesthetic. 3. The local temper- ature is frequently elevated in a contusion, whereas in gangrene it is lowered. 4. In moist gangrene, more frequently than in contusion, the epidermis becomes raised in blebs ; these are less sharply defined and more easily moved about in gangrene. 5. Emphysematous crackling may be felt in gangrene when decomposition with consequent liberation of gas has set in. 6. The foul odor of putrefaction, very faint at first, may be detected in gangrene. The diagnosis between haematoma and abscess, or soft malignant disease, is not always easy; but the history, the aspirating needle, and microscopic examination of the fluid withdrawn will suffice. In the scalp a haematoma with hard, sharply defined border and soft centre is sometimes mistaken for depressed fracture. Here deep pressure, if need be, preceded by aspiration, will show the bone to be at its proper level. Symptoms and Coukse.-The immediate pain from a contusion is, commonly, not great. There is usually numbness of some degree, followed by heavy aching, or throbbing during the inflammatory stage, and accom- panied by loss of function. The inflammatory symptoms are simply those occur- ring after any traumatism, but with less tendency to be- come of the septic or the suppurative order than those following similar lesions exposed to the air. avoidance of such fruits as cannot be cooked, contribute greatly to safety. Every possible harbor of infection requires careful and skilled attention. Clothing, bedding, carpets, curtains, and upholstered furniture should be kept, as far as possi- ble, out of the way of infection, and, if exposed to danger, be suitably dealt with. Cesspools, drains, and heaps of refuse receive infected excreta, and become dangerous nests when neglected ; the first should be dispensed with if possible, the second kept free of obstructions, and the third never be allowed to accumulate. Suitable develop- ment of this part of the subject properly belongs to a separate article on Disinfection, and, therefore, does not require prolongation of this article. S. S. Herrick. CONTREXEVILLE is a village lying in a valley, at an elevation of about one thousand feet above the sea, in the Department of Vosges, France. It is much frequented by invalids who come to take the waters, of which there are several springs. The most important spring is the Pavilion, the composition of which is, according to the analysis of Henry, as follows : One pint contains- Grains Carbonate of sodium 1.438 Carbonate of magnesium *.. 1.606 Carbonate of iron 0.066 Carbonate of calcium.. 4.997 Carbonate of strontium traces Chlorides of potassium and sodium 1.022 Sulphate of potassium traces Chloride of magnesium 0.292 Sulphate of sodium 0.949 Sulphate of magnesium 1.387 Sulphate of calcium 8.395 Phosphate of calcium. Organic matter and arsenic. Silica 0.876 0.511 Total 21.469 Oxygen gas undetermined Carbonic acid gas 0.29 cub. in. The other springs are less rich in solid constituents. The waters are laxative and diuretic, though when taken in excessive quantity they are said to cause suppression of urine. They are used in the treatment of cutaneous and scrofulous affections, and especially in cystitis, gleet, spermatorrhoea, chronic intestinal catarrh, chronic nephri- tis, gout, and gravel. They are usually taken internally, although occasionally baths are made use of as an auxil- iary measure. T. L. S. CONTUSIONS. A contusion is a surgical injury- other than fractures or wounds proper-in which the skin remains intact. If there be a solution of continuity of the skin also, the term contused wound is used. The force producing a contusion is necessarily blunt in its nature-a blow or a fall with resulting violent, com- pression. The lesion produced thereby is chiefly a lacera- tion of the subcutaneous structures, varying in amount according to the degree of force applied and the resist- ance or state of health of the part subjected to injury. A contusion may, of course, involve the skin alone (without breaking it), or any deeper structures, as mus- cle, blood-vessel, nerve, viscus, or bone. There is, in a contusion, probably always vascular rupture of some degree. The resulting extravasation has received various names, according to its apparent shape, its amount, etc. For instance, haemorrhagic spots when small and round are called petechia ; when elongated, as in stripes from a whip, tibices; when of irregular shape, though small, ecchymomata or ecchymoses. Hamatomata are localized collections of blood, of some size. The term purpura, while sometimes applied to small extravasations into the parenchyma of the cutis, is more generally given to a systemic disease (Werlhof's) in which such haemorrhages are a prominent symptom. Peliosis is used in a similar sense. Suggillation is sometimes considered synonymous with ecchymosis ; some medico-legal writers, however, have employed the former term to indicate certain post-mortem appearances produced by the settling of the blood beneath the skin. The diagnosis between these 285 Contusions. Convulsions. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Shock, in contusion, is generally proportionate to the amount of injury inflicted ; but bruising of certain parts -as the breasts, testes, and large joints-induces shock in an unusual degree. Pulping of the tissues, or injuries of the large vessels, will often be followed by gangrene. The discoloration of the tissues, and the swelling, are due sometimes to the extravasation of pure blood, and sometimes to blood-tinged serum. In extravasation un- der a mucous membrane-as the conjunctiva-a red, aerated color is maintained ; but in other parts the well- known " black and blue " is observed in varying intensity, according to the distance from the surface and amount of blood in the effusion. Subsequently, as the blood-cor- puscles gradually disintegrate and become absorbed, the purplish hues fade, giving way successively to violet, olive-brown, greenish, and yellow, and the abnormal col- or finally disappears in about ten days to a fortnight. Several of these colors may generally be seen at once in different parts of the same contusion. When, owing to the depth at which extravasation takes place, it does not show itself for several days, it will usually appear in the form of irregular yellow spots, marbled with green and blue.2 The blood in a haematoma may remain fluid for months or years, becoming, however, gradually darker and dis- integrated, and often mixed with inflammatory products. More often it is completely absorbed in a few weeks. In rare cases the clotted blood may become organized. If air be allowed to enter a haematoma, rapid decomposition of its contents and suppuration ensue. The discussion of the symptoms and treatment of rup- tured viscera comes more properly under another head. Treatment.-The indications are: 1. To limit the amount of extravasation. 2. To subdue pain, shock, and inflammatory action. 3. In severe cases, to maintain vitality in the part. 4. To promote absorption of effused blood. 5. To treat complications and sequelae. 1. Here we obtain the greatest benefit from cold, to- gether with rest, gentle pressure, and such a posture as will aid the return circulation. In the more superficial contusions, dry heat, as intense as can be borne, and ap- plied intermittingly, is also effective, and is sometimes more grateful, quieting pain better than cold. Either heat (not warmth) or cold contracts the calibre of the smaller vessels, and hence diminishes congestion and extravasa- tion. If the heat be too long applied-as for several hours continuously-there will, through temporary exhaustion of the vascular muscles, be paralytic dilatation, and the congestion will no longer be diminished by this means. Moisture should not be conjoined with the use of heat, since it softens and relaxes the tissues, and, although this might give comfort by somewhat relieving tension, it would do harm by permitting still further effusion. The neatest and least troublesome way of applying lo- cally either heat or cold is by the rubber coil. This I prefer to the metallic, because it is lighter and more easily adjusted to any part. In water-supplied rooms, the simplest method is to fasten the inlet end of the pipe over the cold- or hot-water faucet. If this cannot be done, siphonage must be used. 2. To subdue pain, either heat or cold is of value, but some other analgesic agent, such as opium, belladonna, or cocaine hypodermics may be needed. In severe cases, systemic shock may require the use of stimulants. The treatment of the inevitable inflammatory reaction in the irritated or partially disorganized tissues is mainly, still, by cold. Local blood-letting, by leeches or other- wise, may be used, but I prefer to accomplish the same result by aconite, a watery purge, and low diet. 3. Whenever a case presents itself of such severity that from disintegration and pulping of the tissues local slough- ing threatens, or where coldness and a lack of pulsation beyond the injury point to occlusion of a large vessel and probable gangrene, or where local tension from extrava- sation or serous effusion interferes with circulation and thus indicates danger, we must not employ cold, lest we diminish still further the vitality of the part. In the first two cases local warmth should be applied, the limb being also swathed in cotton wadding, and somewhat elevated. The best way of applying heat to tissues threatened with death is again the coil. Fasten the inlet end to the hot-water faucet, and regulate the temperature of the application by varying the number of layers of cloth between coil and skin. If the whole limb is becoming cold, place hot bottles about it. If sloughing actually take place, poultices aid the separation of the sphacelus ; and, since a poultice is simply warmth and moisture, our simplest way is to moisten (preferably with an antiseptic solution) the dress- ings beneath the hot coil. In the third contingency mentioned under this heading -in cases threatening gangrene from local tension-this must be relieved by free quincuncial incisions, made with antiseptic precautions ; after which warmth may be used, if needed, to aid the circulation. Tho severest cases of contusion may call for immediate amputation, or this may be demanded by subsequent gangrene. 4. Extravasation having ceased, and inflammatory reaction subsided, moderate heat, pressure, or gentle fric- tions are to be employed to remove the effused blood. The warmth is of use by increasing the local circulation, thus aiding rapid absorption. Occasional brief cold affusions have a similar effect. Frictions, in the direction of the venous flow-and preferably with some counter- irritant, such as arnica-are valuable for the same reason that heat is useful. According to Gross, the following application proves a satisfactory sorbefacient: Apply upon folded flannel a strong solution of hydrochlorate of ammonia, plus a small quantity of vinegar. Cover with oil silk, and renew six or eight times in twenty-four hours. To hasten the disappearance of haematoma we should use elastic pressure-as by Martin's rubber bandage-or frictions. Blisters also aid absorption, as does the use of watery purges or diuretics. If under these means there still remain a collection of fluid blood, we may, as a final resource, either aspirate, or freely and antiseptically open and drain the cavity. Should suppuration or septic change in the contents of the sac occur at any period in the history of a haematoma (indicated by local heat, pain and throbbing, and constitutional disturbance), free in- cisions and irrigation are demanded. 5. For the treatment of aneurisms, ruptured viscera, paralyses, neuralgias, hypertrophy, atrophy, etc., some- times complicating or forming sequelae of contusions, the reader is referred to the sections devoted to these subjects respectively. Robert H. M. Dawbarn. 1 Beck's Medical Jurisprudence. 2 Devergie, Medecine Legale, Tome ii., p. 57. CONVULSIONS. Convulsions consist of abnormal, exaggerated muscular contractions. Classification.-Some modern writers make the term convulsion synonymous with hyperkinesis, and thus in- clude under it all the different clinical forms of abnormal exaggerated muscular contraction. This is, however, an arbitrary extension of the common and accepted use of the word. The true relation of convulsions to the other hyperkineses is shown in the following table : The hyperkineses or spas- modic disorders. Tremor. Contracture. Cramp. Muscular tension. Fibrillary. General. Tonic spasms. Clonic spasms. Convulsions. Thus the term convulsions does not include those forms of hyperkinesis known as tremor, cramp, muscular ten- sion, and contracture. Convulsions, as indicated above, may be of a clonic char- acter, that is, the muscles rapidly and alternately contract and relax, or they may be of a tonic character, that is, the affected muscles remain persistently contracted for minutes or hours. Clinically we find that these two types are often combined, as in epilepsy. Convulsions may 286 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Contusions. Convulsions. affect the voluntary or the involuntary muscles. In the former case they have been termed external convulsions, in the latter internal. Convulsive affections of the involuntary muscles are, from physiological necessity, of a tonic character. Some- thing almost like a clonic convulsion, however, occurs in post-partum uterine contractions, in colicky affec- tions of the stomach and intestines, and probably in the movements of the stomach in vomiting. The spasmodic disorders of the involuntary muscles, such as asthma, vaso-motor spasms, intestinal spasms, etc., are not gener- ally considered under the head of convulsions, and the reader is referred to these special topics. The term inter- nal or inward convulsions has become popularly applied to laryngismus stridulus. Convulsions, as regards their extent, may be divided as follows : I. General convulsions. II. Partial convulsions : (a) unilateral; (J) those af- fecting certain muscles or muscular groups, known as local spasms or " tics." The term spasms has come to be used as a very general one, identical with hyperkinesis, and it is in this general sense that I shall employ it. To avoid confusion, how- ever, the reader should remember that older writers (Willis, Cullen, Linnaeus) used the word spasm to desig- nate the tonic form of convulsion ; later writers, especial- ly those of the French school (Savary, Georget, Brachet, Ferrand, Fauvel), define spasms as a convulsion of the muscles of organic life ; while some German and English writers use the word -when referring to localized convul- sions. A convulsion is only a symptom, and its presence may indicate in different cases very different pathological con- ditions. In many cases, however, the fact of the convul- sion is about all that we know of the morbid state. In accordance with this we divide convulsions into the symptomatic, or those which are the expression of a tangible morbid change, and the idiopathic, or essential. Practically we cannot perfectly carry out such a divis- ion, since such diseases as epilepsy, eclampsia, and cho- rea, although usually idiopathic, are sometimes caused by a morbid structural change or irritant, which is not recognized. It is customary, however, when an organic lesion is known to be at the bottom of those convulsive attacks, which are ordinarily idiopathic, to indicate the fact by some change in the terminology. Thus symp- tomatic epileptic convulsions are spoken of as epileptoid. Much confusion in terms exists as to the terminology of the different pathological forms of convulsions. It is bet- ter, however, to adhere, as a fundamental distinction, to the division of convulsive disorders into only two types, viz., the idiopathic and the symptomatic, while the much- used terms sympathetic and reflex should be made sub- divisions of these. For certainly the convulsions that re- sult from a gross intestinal irritation or a pronounced blood-poison are truly symptomatic. On this basis we make the following classification : I. Essential or Idiopathic Convulsive Disorders.-(a) Those of a general character: Eclampsia, epilepsy, hysteri- cal and hystero-epileptic or hysteroid convulsions, chorea, latah or myriachit (Gille de Tourette's disease), trismus, tetanus, rabies. (b) Those of a partial character: Wry-neck, writer's cramp, spinal trepidation, salaam spasm, various periph- eral nervous spasms or "tics." II. Symptomatic Convulsions.-(a) Reflex, from wounds, injuries, inflammatory, or other irritations of excito-re- flex nerves, (b) Direct, from meningitis, tumors, hy- drocephalus, focal brain lesions, brain compression, cerebral anaemia or hyperaemia, blood-poisons, acute dis- eases. There is such considerable confusion in the terms used by medical writers on this subject that the following fur- ther explanations are necessary. Eclampsia in infants is in many cases only symptomatic. In other instances, however, no known direct or reflex cause exists, and these form the genuine "essential" convulsions. In puerperal eclampsia, also, there is often a toxic agent at wrork. of which the convulsion is the clinical expression ; but at other times it is a true convulsive neurosis. These true non-symptomatic cases of eclampsia are spoken of as acute epilepsy. It is very evident that, as pathological knowledge ad- vances, many of the convulsive neuroses will be relegated to the category of symptomatic diseases. This seems to be already the case for hydrophobia. Etiology.-In studying the general etiology of con- vulsions I necessarily exclude tetanus and hydrophobia, which are markedly distinguished from the other forms. Predisposing Causes.-There is a certain unstable condition of the nervous system which predisposes toward convulsions. The nerve-cells are like a too inflammable tissue, which flares out at the smallest spark. The state may be spoken of as one of convulsibility. This ' ' con- vulsibility " is greatest during the first two years of life, during which time eclamptic attacks are most frequent. It then falls till the fifth year, to rise again as puberty approaches. During these years, from six to sixteen, most cases of epilepsy develop. Convulsibility then gradually declines, and few cases of the convulsive neuroses arise after the age of thirty. Convulsibility is somewhat greater in girls and women ; and is heightened at the menstrual periods and climacteric. It is, as a rule, les- sened during pregnancy, and is increased by sterility in women, and by sexual excesses or depletions in both sexes. The convulsive diathesis may be inherited, con- nate, or acquired. It is inherited in about one-third of the cases from ancestors of a neuropathic or tubercular constitution. It is connate as the result of frights, inju- ries, or nutrition-disturbances received by the pregnant mother; perhaps also as the result of intoxication of the father during the sexual act. Convulsibility is acquired, in the young, by infectious fevers, bad food and air, chronic diarrhoea, haemorrhages, and especially by rickets. As the child grows older convulsibility may occasionally be de- veloped by bad systems of domestic and school training, and over-indulgence in emotion. At the time of puberty the abuse of the sexual function, great excess in the use of alcohol, tobacco, and absinthe, worry, fright, and men- tal strain, come into play. After manhood or woman- hood is fully reached, it is only by the powerful and per- sistent action of depressant and disturbing forces that a convulsive temperament is acquired. Latent tendencies may, however, be brought out at this period. Climate and season have a slight influence over con- vulsibility. Tetanus occurs oftener in cold weather; epileptic and choreic attacks occur oftener in the spring and autumn, and on wet, cloudy days, and these diseases are more frequent in temperate climates. Race is undoubtedly a factor in predisposing to convul- sions. Exciting Causes.-These are very numerous, but vary in character chiefly with age. For details on this point the reader is referred to the special articles. Here it can only be said that in infancy the most frequent ex- citing causes are : pressure on the brain from meningeal, hydrocephalic, or haemorrhagic effusions, and depressed occiput; blows, acute diseases, fright, and dental or gastro-intestinal irritations. At an older age we find scrofulous tumors, uraemic poisoning, sunstroke, sexual irritations, intemperance, syphilis, the puerperal state, as active factors. Still later, cerebral tumors or haemor- rhages, and injuries to the skull are potent. At all ages there is a large class of drugs which can excite convul- sions : among these are lead, strychnia, thebaine, papa- verine, and narcotin. Physio-pathology.-For the special pathology of the convulsive neuroses, the reader is referred to the special articles on these diseases. There are certain facts in the mechanism of their production, however, which are com- mon to all. In a convulsive attack there are brought into functional activity- 1. A nerve-centre, which is discharging its force with excessive violence. 2. Out-going or efferent nerves. 3. Their peripheral end-plates, and the muscle or end- organ. In reflex convulsions we must add- 287 Convulsions. Copaiba. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 4. Afferent excito-reflex nerves, carrying excitations to the irritable centre. In order that a convulsion may occur, the nerve-centre (1) must be unduly irritable or unduly stimulated, until it is made unstable ; the other factors in the mechanism (2) and (3), must be intact, and the convulsion will be favored by their being in an over-irritable state. The agents which affect the nerve-centre (1), making it over-irritable and explosive are : (a.) Some inherent defect in cell-nutrition, as in essen- tial convidsions. (b.) Some direct chemical or mechanical irritation, as in toxic and sympathetic convulsions, and in those caused by organic disease. (c.) Powerful excito-reilex impulses. Local and limited convulsive movements may be caused by irritation or interference in the regular conduction of the efferent nerves (2). To the machinery thus described modern physiology adds another factor, viz. : 5. An inhibitory mechanism. Certain parts of the cerebral nerve-centres have an inhib- itory action over the function of other parts, rendering the motor cells more stable and less liable to part unduly with their energy. A convulsion may result from a too great weakening or entire loss of this inhibitory force. In the developing and undeveloped nervous system of the child, the inhibitory powers are imperfect ; hence a greater convulsibility at this age. In applying this general out- line of the mechanism of con- vulsions we find that modern physiology teaches two differ- ent views; one, that of Noth- nagel, that the convulsive cen- tre is in the medulla oblongata ; the other, that of Hughlings Jackson, that the cause of the convulsive phenomena is the explosive discharge of cells in the cerebral cortex. The evi- dence is at present in favor of Nothnagel's view, or some mod- ification of it. It is probable that a certain part of the me- dulla oblongata, including the vaso-motor centre, acquires the power of periodically pro- ducing vascular changes and explosive discharges in the motor nerve-centres. The more localized convulsive movements in chorea and the "tics," or local spasms, have a different origin from the foregoing. Here there is some irregular irri- tation of the motor cells or nerve-fibres; or else there is some interruption in the regularity of motor conduction. Thus, choreic movements are produced by irritation of some parts of the voluntary motor tract; facial spasm generally by some injury to the seventh nerve. The part that the spinal cord plays in producing convulsions in man is not great and has been exaggerated. Eclampsia infantum, for example, is not the result of the defective inhibition of the brain upon the spinal cord, but rather a defective inhibition of certain higher brain centres upon lower. We see instances of true spinal convulsion (spinal epilepsy, spinal trepidation) in chronic diseases of the spinal cord implicating the pyramidal tracts, at the be- ginning of the third stage of anaesthesia, and in infants, children, or sensitive adults just as they are dropping off to sleep. Symptoms.-The general convulsions of eclampsia, epilepsy, hysteria, and hystero-epilepsy have common features. There are often prodromal symptoms, indicat- ing an over-irritable or depressed state of the nervous system. The attacks themselves come on suddenly, some- times with an immediate prodromal symptom or aura. The muscular movements are irregular and unco-ordi- nated, except in some phases of hysterical and hystero- epileptic convulsions. Consciousness is generally abol- ished, as are also sensibility and the reflexes. Very marked secretory disturbances occur. The vaso-motor system is greatly involved, especially that part which controls the blood-supply of the brain. The face, and probably parts of the brain are at first blanched, but the anaemia is soon followed by pronounced passive hyper- aemia. In eclampsia infantum, however, the first sign of the impending attack is sometimes a cerebral hyperaemia, and the convulsion may be arrested by pressure on the carotids. Respiration is disturbed, and the heart beats more slowly at first, then more rapidly than normal. Diagnosis.-The diagnosis of a convulsion is easy. One has only to differentiate it from malingering. The state of the pupils, of the reflexes, and of the sensibility, and the want of art upon the part of the malingerer, are generally quite sufficient to clear up the case. As to the form of convulsion, the difficulty in diagnosis may lie first in determining whether an attack is one of eclampsia or epilepsy. Eclampsia occurs oftenest before the age of two years; the attacks are less sudden, more irregular, more prolonged, and less severe than in epilepsy. Usu- ally there is no frothing at the mouth. After the age of two, idiopathic convulsions are most probably epileptic. It is important to distinguish between hysterical, hys- teroid, and epileptic convulsions. All that I can say here, however, is that in the two former types the movements are more co-ordinated, consciousness is not entirely lost, sensibility may be present, and hallucinations develop. It is very important to determine whether the convul- sion is idiopathic, or symptomatic of some general dis- ease, reflex irritation, or organic central affection (see Chorea, Eclampsia, Epilepsy, Hysteria). In some forms of convulsions it is necessary to make an anatomical diagnosis. If the symptoms are in the main bilateral, the cause is to be referred provisionally to the medulla ; if they are unilateral, or involve special mus- cular groups, the convulsion is presumably symptomatic of a lesion in some part of the intracranial pyramidal tract, basal ganglia, or motor cerebral cortex of the op- posite side. There is a certain probability that convulsions in in- fancy are essential; in childhood are meningitic, febrile, or epileptic ; in maturity and old age are symptomatic of syphilis or structural lesions; in women are hysterical. Prognosis.-As regards the attacks, the danger to life is greatest in infantile and puerperal eclampsia ; next in danger comes a special form of convulsion, viz., laryn- gismus stridulus; then follow choreic and epileptoid con- vulsions, epilepsy, hystero-epilepsy, and hysterical con- vulsions. As regards recurrence and final cure no general comparisons can be profitably made. Treatment.-The general principles gQverning the therapeutics of convulsions are nearly the same for all. For the attacks, removal of irritations, the use of chloro- form, ether, morphine, amyl, nauseants, bromides, and chloral are indicated. For the disease, removal of all direct or reflex irritants, and a treatment calculated to lessen the irritability and increase the tone and nutrition of the nervous system are indicated. Charles L. Lana. Fig. 744.-Diagrammatic Illus- tration of Convulsions. I, controlling centre; N, motor nerve - centre, from which nerves run to M, groups of muscles, and S, excito-reflex nerve. A convulsion may be caused by an over-irritation of N or of S, or by a depression or paralysis of I. COOPER'S WELL. Location and Post-office, Cooper's, Hinds County, Miss. Access.-From Jackson, Miss., via Natchez, Jackson & Columbus Railroad, to Raymond Station. Analysis (Professor J. Lawrence Smith).-One pint contains : Grains. Chloride of sodium 1.045 Chloride of magnesium 0.435 Chloride of calcium 0.540 Sulphate of potassa 0.076 Sulphate of soda , 1.463 Sulphate of magnesia 2.910 Sulphate of lime 5.265 Sulphate of alumina 0.765 Peroxide of iron 0.420 Crenate of lime 0.039 Silica 0.225 13.183 Gases. Cubic in. Carbonic acid 4.0 Oxygen 1.5 Nitrogen 4.5 Temperature of water, 50° F, 288 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Convulsions. Copaiba. This is an artesian well, one hundred and seven feet deep, with an ample flow of water. It has been a fav- orite resort for the inhabitants of the Southwest for a long time. Therapeutic Properties. - The characteristic in- gredients of this water are alum and iron, which, together with the carbonic acid gas, render it an agreeable and popular tonic and astringent. G. B. F. 3. C. guianensis Desfont., similar to the above, is a na- tive of Guiana and Brazil. 4. C. coriacea Mort., very variable in size. Brazil. 5. C. Martii Hayne. British Guiana. • Several species furnish also ornamental woods for cab- inet work, the so-called "Amaranth," or purple wood, being one of them. C. multijuga of the older writers is considered a doubtful species by recent botanists. It is not known to what extent each of these different species contributes to the supply of the drug, but the two first probably yield the greater share. Collection.-The stems of the copaiva trees contain numerous oil canals and cavities, in which the liquid is accumulated as turpentine is in those of the pine trees. But the copaiba canals appear to be much larger, and some- times even exceed an inch in diameter, and traverse the whole length of the stem. Into these the copaiva is freely secreted. Indeed, the pressure of it in them is said to be sometimes so great as to split the trunk itself, and so find spontaneous exit. The same accident is also re- ported to happen to one or two other oleiferous trees. As may be supposed, the process of collection is simple enough : a deep gash cut into the trunk, reaching the heart-wood, hollowed and slanting below so as to collect the flow, provided with an improvised spout made from the bark itself, or with a leaf, and a receptacle to contain the oil as it flows in a steady stream, are the essentials. It is carried on mostly by the Indians. The yield is enor- mous and may reach several gallons from a single tree. The principal amount, as well as the finest quality of this drug, is exported from Para, in Brazil, generally in barrels. Other Brazilian ports, as well as Angostura, Cartagena, Maracaibo, and Trinidad, also export that which is collected in their respective neighborhoods. The products of different countries differ a little in their sen- sible qualities, and are, in trade, designated by their geo- graphical names ; that of Para is thinner and paler, and rotates the polarized ray to the left ; those of Venezuela and Trinidad are thicker and brownish, and rotate to the right. Some species are, moreover, opalescent, others perfectly clear. There does not appear to be any well-es- tablished difference in their medical efficiency. Copaiba has been known in Europe something more than two hundred and fifty years. Its usefulness was learned from the aborigines of Brazil, among whom it was highly esteemed. Description.-The consistency and color of this sub- stance, although probably depending in part upon its natural amount of oil, varies also with age and exposure, becoming thicker and darker as the oil evaporates. Fine fresh Para Copaiba is a clear liquid, about as thick as Canada turpentine, and of about the same color. It is often darker, however, and may have a deep golden yel- low, or even a sherry tint. It has a peculiar, aromatic, somewhat terebinthinous odor, and a persistent, bitter, biting, disagreeable taste. Its specific gravity is 0.940, and its solubilities those of oleo-resins in general. Some varieties, as noted above, are not quite clear, and are sometimes fluorescent. The officinal description is ap- pended : "A transparent or translucent, more or less vis- cid liquid, of a color varying from pale-yellow to brown- ish-yellow, having a peculiar, aromatic odor, and a persis- tently bitter and acrid taste. Sp. gr. 0.940 to 0.993. It is readily soluble in absolute alcohol. It is not fluorescent, and when heated to 130° C. (266° F.), does not become gelatinous. When subjected to heat it does not evolve the odor of turpentine, and, after distilling off the vola- tile oil, the residue, when cool, should be hard and friable (absence of fixed oils). The essential oil distilled off from the oleo-resin, when rectified, should not begin to boil below 200° C. (392° F.). On adding 1 drop of Copaiba to 19 drops of disulphide of carbon, and shaking the mixt- ure with 1 drop of a cold mixture of equal parts of sul- phuric and nitric acids, it should not acquire a purplish- red or violet color (absence of gurjun balsam)." Composition.-It contains from forty to sixty per cent., according to its fluidity, of an essential oil of the composi- tion CioHie, or C20H32, of high boiling point, and the odor and taste of the drug itself. This is also officinal COPAIBA (U. S. Ph., Br. Ph. ; Balsamum Copaii'ce, Ph. G. ; Copahu, Codex Med.), copaiva, capivi, etc. An oleo-resin from several species of Copaifera growing in South and Central America, and the West Indies. Order, Leguminosce, Casnlpinea. Of the dozen species of this genus ten are tropical American, and of these ten about half are supposed to contribute to the copaiba of the market. They are shrubs, or trees, with large, abruptly pinnate leaves and rather smallish, perfect flowers, the latter in lateral or terminal racemes and panicles. The calyx is slightly irregular, four-sepalled by the coales- cence of its two upper segments; the upper sepal, so formed, is larger than the others and encloses them in the bud. Stamens, eight or ten, in two rows. Pistil single, simple, often borne upon a short stalk ; ovary ovoid, one- celled, two- or three-ovuled; style, long, curved. Petals Fig. 745.-Flowering Branch of a Copaiba Tree. C. Langsdorfii Deaf. (Baiilon.) wanting. Fruit, a short, one-seeded pod. The flowers are nearly alike in all the species, which are distinguished, in the main, from each other by their leaves ami habit. An abundant oleo-resinous secretion is also a character- istic of the genus. The following, in particular, yield the copaiba of commerce : 1. Copaifera Langsdorfii Desfont., a very variable plant, usually a shrub or small tree, but sometimes grow- ing to a large size. It has a freely branching trunk, brown, smooth branches, and pubescent twigs. The leaves are alternate, from three- to five-paired ; leaflets smooth, entire, ovate. Pod, about as large as a filbert, brown. It is a native of Brazil. 2. C. officinalis Linn., a medium-sized tree, with its leaflets (excepting the last pair) alternating, or, at least, not exactly opposite ; grows in the northern part of South America-Guiana, Venezuela, Colombia, also in Central America, etc., but not in Brazil. 289 Co paiba. Copper, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. {Oleum Copaiba, U. S. Ph.), and characterized as "a col- orless or pale yellowish liquid, having the characteristic odor of copaiba, a pungent, bitterish taste, and a neutral reaction. Sp. gr. about 0.890. It is soluble in an equal wreight of alcohol." The crude resins left behind in the distillation are also officinal, under the name Resin of Co- paiba {Resina Copaiba, U. S. Ph.). It is a brownish-yel- low, brittle substance, with the appearance of common resin, but having the odor and taste of the oleo-resin. Reaction acid, soluble in alcohol. The "resin" of Bra- zilian (Para) Copaiba is really a natural mixture of at least two substances-an amorphous indifferent resin, probably itself compound, and the crystallizable copaivic acid, ob- tained in large, -white, nearly odorless prisms. The latter is insoluble in water, and sparingly so in ether, but strong alcohol and the fats dissolve it freely. Oxycopaivic acid is an analogous substance, sometimes also met with. "Maracaibo Copaiba," that is the product from the north- ern coast, yields in a similar way, together with its amor- phous resins, crystalline metacopaivic acid instead of co- paivic acid, which dissolves freely in ether as well as in alcohol. Copaiba is apt to be adulterated ; one of the commonest additions is castor- or some other fixed oil; oil of turpen- tine and other volatile oils are also sometimes added. Action and Use.-Large doses of Copaiba occasion vomiting, purging, and colic, symptoms due to its lo- cally irritant action upon the alimentary canal; they also may cause some difficulty in micturition, with burning pain in the urethra, or even strangury, but the latter is rare. It is mostly eliminated with the urine, which it increases and changes in odor. Acccording to Brunton,1 "it forms a conjugate glycuronic acid in the system, and is eliminated in the urine, which with nitric acid gives a precipitate of copaibic acid, easily mistaken for albumen, but distinguished by disappearing on the application of heat. The conjugate acid renders the urine antiseptic, as it is secreted by the kidneys, so that it does not readily decompose, and bacteria either do not appear in it at all, or only in very small numbers, even after the surface has become covered with mould." This, if true, may ex- plain at least a part of its usefulness in the urethral and vesical catarrhs, for which it is so much employed. Its elimination products, if sufficiently diluted, appear also to be soothing to the lining membrane of the urinary tract. A portion of the copaiba taken makes its exit from the lungs, as shown by the breath. The principal call for this medicine is in catarrhs of the genito-urinary system, especially of the urethra and bladder. In gonor- rhoea and gleet, its employment at one stage or another is almost universal. In chronic vesical catarrh it is also some- times useful, and more rarely so in chronic bronchitis. Its value in chronic diarrhoea and dysentery, and as a diu- retic in cardiac dropsy, is more doubtful. In the acute stage of the above affections it is not to be advised. An erythematous eruption occasionally appears during the use of the medicine, which departs as soon as it is omitted. Administration. - The oleo-resin itself is generally given. From ten to twenty drops (a gram = 1T(xv.), three or four times a day, is the usual dose. Dropped upon a lump of sugar, it can be quickly chewed and swallowed, or an emulsion can be made of it with fla- vored Syrup of Acacia or yolk of egg. In either case its taste is very disagreeable and persistent. It may be so- lidified by adding six per cent, of Magnesia (Massa Co- paib®, U. S. Ph.), and made into pills, but the value of this preparation is doubtful. A sort of soap may be made by adding enough Liquor Potassa to cause it to mix with water. More than by all these methods it is at present given in gelatine capsules, which are prepared on an extensive scale by numerous manufacturers; they contain from five to ten drops each, and two or three can be taken at a dose, two or three times a day. They are perfectly free from its taste, but the odor will appear in the breath, after an hour or so, as well as when it is taken undisguised. The Oil and the Resin {Oleum and Resina Copaiba, U. S. Ph.) may be given in similar doses and ways. Their action is not very different from that of the undivided oleo-resin ; the resin, however, is probably the more valuable portion. Allied Plants.-See Senna. Allied Drugs.-Copaiba differs in degree more than in kind from the numerous class of essential oils and re- sins, being milder than some (turpentine), and more stimulating than others (the carminatives). Cubebs, Bu- chu, Oil of Sandalwood have similar action and are em- ployed for similar conditions. Gurjun Balsam has also similar qualities, and has been substituted for Copaiba. Uva Ursi, and the Arbutin and Benzoic Acid class of remedies may also be compared with it, and in a certain sense, as used for the same disease (gonorrhoea), the vege- table and mineral astringents, Hydrastis, and several inert powders used in injections ; but the action and charac- ters of these substances are not at all like those of Co- paiba. W. P. Bolles. 1 Pharmacology, Therapeutics, and Materia Medica, 1885, p. 768. COPPER. I. General Medicinal Properties of Compounds of Copper.-Impregnation of the blood with a copper compound tends, as usual with the heavy metals, to affect nutrition. In medicinal doses too small to produce any obvious derangement, the influence tends to the abatement of spasmodic nervous disorders, but not to a sufficient degree to enable copper to compete with zinc and other remedies, in the practical treatment of these complaints. In excess of medicinal dosage copper salts are readily poisonous. Locally, soluble copper salts, such as are alone used in medicine, are powerful irritant astringents. Applied in concentrated form to a moist surface they combine with the albuminous elements of the part, forming a thin, practically invisible slough, and at the same time constringe and irritate. So far as the caustic effect is concerned, it is so superficial as to be of little moment, so that practically the action is simply con- joint astringency and irritation. Such action, however, may determine absorption of easily absorbable tissue, such as granulations, or the healing of indolent ulcers, or the abatement of a catarrhal process. Taken internally, the irritant action of soluble copper salts in any beyond quite small dosage, declares itself by producing at once full and free vomiting. Such vomiting is attended with little nausea or depression, and the emetic dose is itself discharged with the ejecta. Copper salts thus become medicinally available as emetics, and because of power and promptness of action are peculiarly appropriate for the dislodgement of poisons by vomiting. In consider- able single overdose copper salts are irritant poisons. The therapeutics of copper compounds are comprised in the applications set forth above-locally for an astrin- gent irritant operation, internally to provoke vomiting, or in smaller dosage for an astringent effect in diarrhoeas. For the latter purpose, however, other more agreeable astringents than copper compounds are commonly pre- ferred. II. The Medicinally used Compounds of Copper. -These are two only, namely, cupric sulphate and acetate. Cupric Sulphate ; CuSO4.5H2O. Cupric sulphate, com- monly called blue vitriol, or blue stone, is officinal in the U. S. Pharmacopoeia as Cupri Sulphas, Sulphate of Copper. It occurs in "large, translucent, deep blue, triclinic crystals, efflorescent, odorless, having a nause- ous, metallic taste, and an acid reaction. Soluble in 2.6 parts of water at 15° C. (59° F.), in 0.5 part of boiling water, and insoluble in alcohol. When heated to 100° C. (212° F.), the salt gradually loses 28.9 per cent, of its weight" (U. S. Ph.). Cupric sulphate may be used locally in substance, a smooth crystal, with its edges rounded by a file, being selected, or cylindrical or conical pencils may be made by fusing one part of alum with two of the copper salt and shaping in suitable moulds. Lotions are made by aqueous solution, the strength rang- ing from one-half to two per cent. As an internal astrin- gent the dose is about 0.015 Gm. (one-fourth grain); as an emetic from 0.12 to 0.30 Gm. (two to five grains), or more if the stomach be insensitive from narcotic poison- ing. When a full dose is given, however, if it fail to vomit, it must be removed by the stomach-pump lest 290 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Copaiba. Copper. undue gastric irritation result. The salt is best given in powder, mixed with powdered sugar. Cupric Acetate ; Cu(C2H3O2)2.H2O. This salt is now officinal in the U. S. Pharmacopoeia, in substitution for verdigris (an impure mixture of basic acetates), and is entitled Cupri Acetas, Acetate of Copper. It is in " deep green, prismatic crystals, yielding a bright green powder, efflorescent on exposure to air, odorless, having a nauseat- ing, metallic taste, and an acid reaction. Soluble in 15 parts of water, and in 135 parts of alcohol at 15° C. (59° F.), in five parts of boiling water, and in 14 parts of boil- ing alcohol. When heated above 100° C. (212° F.), the salt loses its water of crystallization, and at a temperature above 200° C. (392° F.), it is gradually decomposed" (U. S. Ph.). The effects of cupric acetate are practically identical with those of the sulphate, but the salt is com- paratively seldom used. Edward Curtis. occurred as early as four hours in a child ; twelve hours in an adult. As a rule, it does not take place till after the lapse of three or four days, and may be delayed for a week or more. Recovery is very frequent, even after large doses. In such cases the nervous symptoms may be nearly all absent. Convalescence is usually estab- lished in three or four days, and recovery is complete in two or three weeks. Occasionally dyspepsia, obstinate gas- tralgia, and trembling of the limbs persist for a long time. Copper in Food.-A not infrequent source of acute copper-poisoning is the use of copper or brass utensils for the preparation of food. The following facts have been es- tablished with reference to the action of water and various articles of food upon copper. Dry air and water free from air do not act on copper at the ordinary temperature. When in contact with ordinary air, or with water containing carbonic acid, copper takes up oxygen and carbonic acid, with the formation of a green coating of basic carbonate of copper which is soluble in acids. Moisture, oxygen, and carbonic acid are all necessary for the production of this coating. Articles of food, prepared in copper or brass vessels, which have been allowed through careless- ness to become coated with carbonate, are liable to con- tain more or less copper salt. In contact with substances containing common salt, copper is slowly covered with a coating of oxychloride of copper, which may become mixed with the food. Acid solutions and fatty or oily substances, if allowed to remain in contact with copper at the ordinary temperature, readily act upon it. If, how- ever, these substances are boiled in perfectly clean copper vessels and poured out while hot, none of the copper is dissolved. The risk of contamination appears, therefore, to be very slight if the vessels are kept clean and bright, and the food is removed from them as soon as it is pre- pared. It has been asserted that the amount of copper in ar- ticles of food which have been prepared in copper or brass vessels is insignificant, and altogether too small to account for the symptoms which have been observed, and that the symptoms have been due to other causes. These assertions are based essentially on the following considerations : 1. That salts of copper have been admin- istered, in practice, in much larger doses than can be as- sumed to exist in food thus prepared, without producing any injurious effects. 2. That in many cases of sus- pected poisoning the metal could not be detected upon analysis. 3. That unwholesome food may give rise to symptoms similar to those which have been attributed to copper. This subject has been investigated experimen- tally. The most interesting of the later researches are those of M. Galippe, who lived for a month at a time on food which had been prepared in copper vessels, in some cases with the addition of acetic acid, and experienced no disagreeable effects. There are, however, a sufficient number of cases of poisoning recorded to warrant the conclusion that the use of copper utensils is not wholly unattended with danger. Salts of copper are frequently added to preserved fruits and pickles in order to give them a green color. The amount added is probably too small, as a rule, to produce any bad effects. Two or three cases, however, have been reported in which death followed the use of articles thus colored (Kramer, Percival). The symptoms produced by the ingestion of food con- taminated with copper do not appear, as a rule, till after the lapse of three or four hours. They are of the same general character as those-which have been described. Chronic Poisoning.-A chronic form of poisoning, resulting from the repeated administration of small doses of copper salts, has been described. Different opinions are entertained, however, in regard to the existence of this form of poisoning. It is believed by some authori- ties that small doses, frequently repeated, are more dan- gerous than a single large dose, since they are not ex- pelled by vomiting, as large doses are, and are, therefore, more surely absorbed into the circulation. On the other hand, salts of copper have been administered daily in small doses for a long time without producing any effects other than a trifling diarrhoea. The studies of Ellen- COPPER, POISONING BY. Metallic copper doesnot appear to be directly poisonous. Many cases are recorded in which copper coins have been swallowed, and retained for a long time without producing any effects other than those due to mechanical obstruction. Copper filings ad- ministered to dogs in doses of 7.7 to 31 grammes (2 to 8 drachms), in a state of admixture with albuminous, sac- charine, and fatty substances, do not produce any trouble- some symptoms (Drouard,. Leportier, Burq, and Ducom). Cases are related, however, in which the swallowing of copper coins and copper filings has been followed by nausea, vomiting, salivation, and other symptoms of cop- per-poisoning, as a result, probably, of a partial oxidation and solution of the metal within the alimentary canal. Workmen in establishments where alloys of copper, es- pecially brass and bronze, are used in the finely powdered form for gilding, are sometimes attacked with symptoms of acute poisoning in consequence of inhaling the finely powdered alloy floating in the atmosphere. The in- jurious effects in such cases may be explained by the readiness with which copper, in a state of fine division, can be oxidized and dissolved. It is possible that the metals alloyed with it play some part in producing the symptoms. " The two most important salts of copper, from a medico- legal point of view, are the sulphate (blue-stone, blue vitriol) and the subacetate or artificial verdigris, which is a mixture of acetates of copper. Nearly all the salts of copper, however, even those insoluble in water, may pro- duce serious and even fatal results. The poisonous prop- erties of the arsenite of copper are due to the arsenic which it contains; it is, therefore, considered with the compounds of arsenic. The salts of copper are rarely administered for criminal purposes, since their taste and color direct immediate attention to their presence. They have been taken for the purpose of suicide, and have fre- quently given rise to accidental poisoning, owing to their presence in articles of food. Acute Poisoning.-Symptoms.-When a large dose of one of the salts of copper has been taken the symptoms generally come on in about a quarter of an hour. They may be delayed for two or three hours if the conditions are unfavorable for their absorption. There is a strong coppery taste in the mouth ; frequently marked saliva- tion ; a sense of constriction in the throat; violent vomit- ing, accompanied by severe colicky pains. The vomited matters are at first green or blue. There is nearly always purging, abdominal pains increased by pressure, and tenesmus. The stools are sometimes colored green, sometimes dark, due to sulphide of copper ; they are rarely bloody. The urine is scanty or suppressed ; some- times bloody. In one case haemoglobinuria was devel- oped on the third day (Starr). The symptoms indicative of gastro-intestinal irritation are usually followed by others resulting from the action of the poison on the nervous system. The pulse becomes small and quick ; there is difficulty of breathing, with intense thirst, great weak- ness, severe headache, cold sweats, and cramps in the ex- tremities. If the patient survive for one or two days, jaundice is usually observed. Death, which is frequently preceded by insensibility, convulsions, or paralysis, has 291 Copper. Cornea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. berger and Hofmeister upon the action of small but gradually increasing doses of sulphate of copper, when administered to sheep, are interesting, since they point to the existence of chronic copper-poisoning in these ani- mals. The most important symptoms observed were al- buminuria, icterus, and toward the end htemoglobinuria, and, under certain conditions, hsematuria, with great mus- cular weakness and loss of appetite. Chronic copper-poisoning occurs, though with great rarity, among workers in copper, especially in establish- ments where particles of copper salts are abundant in the air. The symptoms are, a persistent coppery taste, nau- sea, vomiting, distress in the stomach, colicky pains, im- paired digestion, cough, and night-sweats, without, how- ever, any lesion of the lungs. The gums are retracted, and there is a purple line at the junction of the teeth and gums (Corrigan). Clapton has observed a green line on the margin of the gums, and a similar green stain extend- ing for some distance on the teeth. Later symptoms are muscular weakness, progressive emaciation, and anaemia. According to Orfila, the colic produced by copper dif- fers from lead colic in being attended with a greater de- gree of fever and gastro-intestinal irritation ; in copper colic the abdomen is distended and tympanitic, instead of retracted, and the pain is not fixed at one point, as in lead colic, but extends over the whole abdomen, and is in- creased by pressure. According to Corrigan, copper, in chronic poisoning, seems to exert its influence on the functions of nutrition and assimilation, while lead acts energetically on the nervous system. Fatal Quantity.-This has not been determined, ow- ing to the comparatively small number of fatal cases of acute poisoning. In a case quoted by Taylor 1.3 gramme (20 grains) of the oxychloride of copper proved fatal to a child ; in another case 15.5 grammes (4 drachms) of verdi- gris caused the death of a woman. A case is reported in which 27.2 grammes (7 drachms) of the sulphate, with 11.7 grammes (3 drachms) of sulphate of iron, caused the death of an adult in three days ; another, in which 31.1 grammes (one ounce) of the sulphate proved fatal to an adult in twelve hours. Recovery has frequently taken place after doses of 15.5 to 31.1 grammes (4 to 8 drachms). Post-Mortem Appearances.-The mucous membrane of the stomach and intestines is usually thickened and in- flamed ; sometimes softened and ulcerated. In some cases the intestines have been found perforated. The mucous membrane of the oesophagus, especially at its lower end, may be inflamed ; in one case ulcerations were found in the oesophagus, near the stomach. The inner surface of the oesophagus, stomach, and intestines sometimes pre- sents a blue or green appearance, due to the presence of the copper compound. Occasionally the entire alimentary canal is found in a perfectly normal condition. Fatty degeneration of the liver, kidneys, and heart hits been ob- served. Absorption and Elimination.-The amount of cop- per which is absorbed into the circulation is comparatively small. The greater part of that which is not removed by vomiting is separated, as sulphide of copper, with the faeces. The absorbed copper may be detected in all the organs and tissues of the body. The investigations of Ellenberger and Hofmeister, which have been referred to, show that the liver contains the largest amount. The kidneys contain about one-fourth as much as the liver. The deposition in the nervous tissue is small, and still smaller in the muscular tissue. According to these writers, the deposition of copper is proportionally much greater if it has been administered in numerous small doses. Copper is eliminated chiefly with the bile, in part with the urine. It has also been detected in the saliva and perspiration. Ellenberger and Hofmeister state that the bile contains six to ten times as much copper as the urine does. Elimination through the kidneys ap- pears to cease within a few days after the last adminis- tration of the copper salt, while elimination with the bile continues for a much longer time. These authors de- tected copper in the urine in thirty-six hours after the first administration, but failed to find it in the urine later than nine days after the last administration. They de- tected it in the faeces, however, for forty-one days after the last administration. Orfila administered sulphate of copper to dogs for a considerable time, and detected the metal in the liver, lungs, and tissue of the stomach, sixty to seventy days after the last administration. Rabuteau and Yvon found, in the liver of a person who had taken during life forty-three grammes of ammonio-sulphate of copper, 0.239 gramme of copper, although the patient had taken none for three months before death. Normal Copper.-It has been alleged that copper is a constant and therefore normal constituent of the body. This subject is one that has given rise to considerable discussion. Many observers have detected traces in the bodies of animals not poisoned with the preparations of the metal, and in the blood and organs of the human body (Wackenroder, Sarzeau, Ortila, Bergeron and L'Hote, Rauolt and Breton, and others). Bergeron and L'Hote examined the livers and kidneys of fourteen bodies and found traces of copper in all. They found traces in six foetal livers. These authors think that copper continually finds its way into the human body, in consequence of the daily use of copper vessels, copper coins, etc.; that the greater part of the metal is again eliminated ; but that a minute quantity is retained by the secretory organs under any condition of age or sex or mode of living. They conclude that the amount in the whole liver and kidneys never exceeds 0.0025 or 0.003 gramme, unless copper compounds have been taken as medicine, and in most cases does not reach 0.002 gramme. Rauolt and Breton examined four livers and found in each three, fifteen, seven, and ten milligrammes of copper, respectively, per kilogramme. Cloez detected copper in the blood of wild herbivora. The blood of a deer contained 0.0055 gramme cupric oxide per kilogramme. Other competent ob- servers have failed to detect even a trace of copper in the body in its normal condition (Christison, Flandin and Danger, Tardieu, Roussin). The evidence is, therefore, not sufficient to warrant the statement that copper is a normal constituent of the body. There are reasons for believing that, when present, it has been introduced with the food ; either with food which has been prepared with copper utensils, or with food which contains copper in- dependently of the method of preparation. Investiga tions have shown that many vegetable substances, such as cereals, coffee, cocoa, chocolate, and garden vegetables contain traces of copper (Sarzeau, Galippe, Van der Berghe, and others). Sarzeau and some others believed that copper is a normal constituent of vegetables. Bou- tigny, however, states that these substances contain cop- per only when the manure used in raising them con- tains it. Treatment.-Vomiting should be encouraged ; or the stomach-pump may be used. Albumen, in the form of white of eggs, and milk are among the best antidotes, and have the advantage of being easily obtained. They form, with salts of copper, compounds nearly insoluble in the liquids of the stomach. They should be administered freely, and the stomach should then be emptied by pro- voking vomiting or by the stomach-pump. Sugar has been recommended as an antidote. It probably has no value. Calcined magnesia, hydrated sulphide of iron, iron filings, and ferrocyanide of potassium have all been recommended. The latter is probably the most efficient of these. It forms, with copper salts, a reddish-brown ferrocyanide of copper, which is quite insoluble. It may be administered in solution in water, and the stomach should then be emptied ; or the stomach may be washed out with a solution of the salt. The after-treatment de- pends upon the symptoms. William B. Hills. COPYRIGHT. The copyright law of the United States does not accord any peculiar privileges to authors of medical works. Such works may be copyrighted like any others. The chief requirements are . 1. Before publica- tion mail a printed copy of the title to the Librarian of Congress, Washington, D. C. 2. Upon the title-page or its back, print the customary notice that the book is copy- right. 3. Within ten days after publication send two copies, by mail or otherwise, to the Librarian. A letter of 292 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Copper. Cornea. inquiry addressed to the Librarian will bring a printed circular giving full directions as to details. Compliance with the prescribed conditions secures, if the author is a citizen or resident of the United States, the sole liberty of publishing the work for twenty-eight years ; and there is a qualified right of renewal which, in the case of a work of permanent character, is valuable. A book duly copyrighted cannot be republished in full, or copied in its substantial or important parts. But it is not every use of a treatise, on the part of subsequent writers, that is considered an unlawful infringement of its copyright. Limited and reasonable use of the contents of earlier works, though copyrighted, by way of study or quotation of extracts, is allowable. Moreover, there is a clear distinction between a book as a literary property and the science which it explains. Copyrighting a text-book on the composition and use of medicines does not secure an exclusive right to compound the medicines described, not even if they are newly devised by the author ; the very object of pub- lishing a medical work is to communicate to practitioners the knowledge of symptoms and prescriptions which it contains, for their use in current practice. Photographs skilfully showing diseases or deformities, etc., may be copyrighted. Mere labels, such as are placed upon bottles to designate the medicines which they contain, and the dis- eases for which they are adapted, are not within the pro- tection of the copyright law ; such labels often bear notice that they are "copyright," but this is nugatory. Medical lectures, if unpublished, are not, strictly, a subject of copyright; for the required two copies cannot be supplied to the Librarian of Congress. But they are protected by a statute which forbids publishing any manuscript with- out obtaining the consent of the author or proprietor. Oral delivery of a lecture to a class of students does not give them the right to take notes for any purpose of pub- lication, or of selling copies to other persons ; the right of members of the class is limited to memorizing and taking notes of the lecture for their individual instruction and guidance in future practice. The copyright law impor- tant to medical writers and publishers is embodied in "United States Revised Statutes," Title lx., Chapter 3. Drone on " Copyright " is the most recent law treatise. Morgan's "Law of Literature" is comprehensive and readable. Abbott's "National Digest,"title "Copyright" states the decisions and statutes to 1884, with a legal bib- liography. Benjamin Vaughan Abbott. almost naked umbels. Fruit nearly globular, the meri- carps remaining adherent to each other after drying. D E SCRIPTION.- The dried fruits are about as large as white peppers, and of about the same color. They comprise two carpels (meri- carps) adherent to- gether, but separable by rough handling. They are spherical, finely eight-ribbed, with intervening wavy markings, sur- mounted by the stumps of two styles, and contain two flat- tened concavo - con- vex seeds. Vittaetwo on the ventral faces of the mericarps, none in the periphery. It contains about one-half per cent, of essential oil, eleven of fat (in the seeds), and fourteen of nitroge nous matters, etc. The only constituent of value is the oil (Oleum Coriandn, U. S. Ph.), a colorless or yellowish liquid, hav- ing the characteristic aromatic odor of Co- riander, a warm, spicy taste, and a neutral reaction, sp. gr. 0.870. It is readily solu- ble in alcohol. Uses.-Coriander is a very mild and agreeable carminative, of the same proper- ties as Anise. Dose of the oil, ten drops or so-on sugar or suspended in syrup or mucilage. Allied Plants and Drugs.-See Anise. IK. P. Bolles. Fig. 746. -Coriander Plant, one-tenth nat- ural size. (Bailion.) Fig. 747.-Fruit, natural size. CORNEA, DISEASES OF THE. In order to recog- nize and understand the various pathological lesions to which the cornea is subject, an accurate knowledge of its anatomy and histology is essential (see under Sclera and Cornea, Anatomy of). All inflammatory processes affect- ing the cornea cause certain deviations from its normal uniform transparency, which are, as a rule, easily recog- nized by simple inspection with the naked eye ; but the method of examination known as focal illumination affords a ready means of detecting changes of slight degree which might otherwise easily escape observation. Structural changes resulting from inflammation are either transitory or permanent. The former are to be regarded as an ex- aggeration of the normal processes of nutrition, in which there may be loss of transparency due to disturbance in the compact fibrillar arrangement of the corneal tissue, caused by the imbibition of fluid material as well as of the more solid cellular elements which have migrated into the cor- nea from the surrounding vascular system. This subject has been very thoroughly studied by many observers, and the free migration of leucocytes into the cornea from this source is one of the pathological questions which may be regarded as definitely settled. It is still an open question as to what part the fixed corneal corpuscles take in the inflammatory process. If this has been of such a character as to cause permanent alteration in any part of the cornea, both the fixed cor- puscles and the fibrillar structure involved are found to have undergone more or less destruction and elimination. Three types of corneal inflammation are generally rec- ognized : they are infiltration, abscess, and ulceration. 1. Infiltrations are characterized by the presence of leucocytes in such numbers as to cause loss of transpar- ency, with more or less displacement of the fibrous paren- chyma of the cornea. Crowding the lacunae and canali- culi, they may give rise to an ill-defined streaky opacity, CORAL, RED. The calcareous skeleton of Isis nobilis Linn.; Order Octatinia (corallina) of the Mediterranean Sea-a branching, tree-like polyp community, about a foot or so high, and an inch or two in diameter at the base. The prepared coral is in hard, bony fragments of the " branches," from the size of a straw to that of a pipe- stem, and a few centimetres in length, of compact struct- ure, pink or red in color, and of stony hardness. It is the refuse of that selected for jewelry and fancy articles. The principal constituent is carbonate of lime, accom- panied by a little magnesia, oxide of iron (which gives it its color), and traces of iodine. Coral is an old-fashioned remedy, now used rarely and only as a tooth-powder. The finer pieces are in demand for ornamental work. Allied Animals.-Several other species of coral have served their turn as medicine, mostly for the carbonate of lime they contain. Allied Drugs.-Marble, Oyster Shells, "Crab's Eyes," and Cuttle-fish bone, are equally obsolete. IK P. Bolles. CORIANDER {Coriandrum, U. S. Ph.; Coriandri Fruc- tus, Br. Ph.; Coriandre, Codex Med.), Goriandrum sati- vum Linn.; Order, UmbeUiferce, is an annual European herb, also cultivated in Europe and the United States. It has been so long cultivated that it is scarcely known in an indubitably wild state. It- has a slender branching stem half a metre or so high. Leaves of two forms, the lowrer roundish and deeply lobed or pinnate, with a few broad-lobed pinnae ; the upper twice or thrice divided with linear pinnules. Flowers small, white or pink, in 293 Cornea. Cornea, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or, when they are accumulated in larger masses, the cloudiness may be more uniform and circumscribed ; not- withstanding this the corneal tissue may remain so far in- tact as to permit of perfect restoration, when resolution takes place. If, however, the process has been of long duration and considerable intensity, some degree of per- manent opacity will result; the migratory cells may in- deed become transformed into fibrous tissue (sclerosed), and blood-vessels may become developed in the substance of the cornea as a part of the permanent alteration of its structure. Corneal infiltrations may be superficial or deep-seated, circumscribed or diffuse ; and, although the tendency is to recovery without destruction of tissue or loss of transparency, the more unfavorable terminations in sclerosis or ulceration are quite common events, espe- cially if the infiltration has been injudiciously treated with remedies which exaggerate the irritation already existing. Superficial infiltrations of the cornea cause more irritation than deep-seated ones, on account of the corneal nerves being most abundant toward its anterior surface. 2. Abscess of the cornea occurs when an infiltration reaches such a degree of intensity that the nutrition of the part is interfered with to the extent of destroying the proper corneal tissue, while the infiltrating elements be- come transformed into pus-cells. The distinctive char- acters of an abscess are its circumscribed appearance and yellowish color; it often gives rise to an accumulation of pus in the anterior chamber (hypopyon) in one of the sev- eral ways to be mentioned presently. So much of the corneal tissue as may have been actually destroyed can only be imperfectly regenerated ; for this reason, more or less of an indelible opacity remains. For the reason al- ready mentioned, an abscess near the anterior surface of the cornea is more painful than one that is deep-seated. The duration of corneal abscess is variable; sooner or later the surface is apt to give way, and the abscess be- comes transformed into an ulcer. 3. Ulcers of the cornea, many varieties of which have been described, all have one characteristic in common, that is, loss of substance. They may result from an in- filtration or an abscess, or the ulceration may be the pri- mary lesion, commencing as a superficial loss of substance of irregular outline, first of the epithelium, then speedily extending through Bowman's membrane to the cornea proper. Deposits of lymph and pus in the anterior chamber are also quite common in certain types of cor- neal ulcers. The surface of the ulcer, in its progressive condition, is generally covered with an opaque material, the residue of broken-down tissues, while the margins are surrounded with a grayish zone of infiltration. When the healing process sets in, the base of the ulcer becomes cleaner, its margins smooth and rounded, and the periph- eral opaque zone less conspicuous. As the healing progresses the ulcer becomes shallower, and its surface smooth and glistening; now being partly covered with epithelium which has grown from the margins toward the centre. Beneath this, new tissue is developed, and the excavation due to loss of substance is gradually filled up by the process of cicatrization ; an opacity remains of variable depth and extent, from a slight cloudiness (nebu- la) to a dense white cicatrix of a pearly or tendinous char- acter (leucoma). Corneal ulcers, especially when situated near the margin, frequently become vascularized during the healing process. An ulcer may remain stationary for a long time, or the surface may not attain the level of the surrounding cornea (corneal facet). Sometimes a relapse of the ulceration may occur instead of continuous repair. Perforation of the cornea, with adhesion or prolapse of iris, is a common occurrence. Extrusion of the crystal- line lens is to be feared in large ulcerations ; or the ulcera- tive process may involve the entire cornea and result in its total destruction; or panophthalmitis may occur if suppuration extends to the internal structures of the eye- ball. Inflammation of the Cornea (Keratitis, Cornei- tis). -The term keratitis is now generally applied to all forms of corneal inflammation, the different varieties of which have been variously classified. All varieties may conveniently be included under the headings . 1, Super- ficial Keratitis ; 2, Parenchymatous Keratitis ; 3, Suppu- rative Keratitis. Under the first heading are included phlyctenular, vas- cular, and traumatic keratitis. Phlyctenular Keratitis is closely allied to phlyctenular conjunctivitis (see Conjunctivitis), and is often associated with a more general conjunctivitis. It commences as one or several superficial infiltrations, of small size, perhaps not larger than the head of a pin or a millet-seed, on any part of the corneal surface, from the extreme periphery to the centre. Each little infiltration is surrounded by a slight zone of opacity, and causes some elevation of the epithelium covering it; if it be in the form of a vesicle this is seldom demonstrable. The epithelial covering is soon shed, leaving a small excoriation of the surface, or a tiny ulceration which occasionally extends, and may as- sume the more formidable characters and dimensions of a suppurative keratitis-an event usually traceable to im- proper treatment or to a very defective state of nutrition. Phlyctenulae often become vascularized, and, after re- peated attacks of this kind, a form of pannus, known as pannus phlyctenularis or scrofulosus, may become devel- oped (see section of this article relating to Vascular Kera- titis.) More or less pericorneal injection, with other irritative phenomena, sometimes very pronounced, are always pres- ent, and are probably due to the fact that the infiltration tends to follow the course of certain nerve-filaments (Iwan- off), which are thus imbedded in exudation corpuscles, and other products of inflammation. Intolerance of light, lachrymation, and spasmodic closure of the eyelids are the most conspicuous signs of irritation. Restless- ness and pain at night are quite common. Often the eye- lids are more or less swollen, and the overflow of acrid secretions causes excoriation of the integument, and an eczematous, or impetiginous eruption may spread over the integument of the face and head. The subjects of phlyctenular keratitis are usually children, sometimes in apparently good general health ; but, as a rule, they are of strumous habit and show other signs of faulty nutrition. An inquiry into their mode of life will usually reveal grave errors in the matter of diet and general hygiene. Any of the ordinary diseases of childhood are apt to be followed by this form of ophthalmia, presumably only in subjects otherwise predisposed to its occurrence. In slight cases, the disease may quickly pass off, leaving little or no trace of its existence ; but far more frequently circumscribed opacities remain for a long period, and sometimes for life, as a permanent blemish. When sit- uated over the centre of the cornea such permanent opaci- ties, though apparently slight in degree, may cause serious impairment of vision. The affection tends to relapse, and is consequently apt to be of long duration, especially when the infiltrations are remote from the corneal margin. Many young persons are subject to repeated attacks, at intervals, until adult age has been reached. Treatment.-So long as there is active irritation, sooth- ing measures are indicated. Solution of sulphate of atro- pia, gr. ij.-iv. ad § j., may be instilled two or three times daily. Heat, applied either in a dry or a moist form, for fifteen minutes or half an hour at a time, and several times daily, is a remedy of great value. A warm solu- tion of boric acid, one or two percent., may be used freely as a wash, if there be increased conjunctival secretion. Careful cleansing is of importance also in preventing ex- coriation of the lids. The latter condition may require the use of local astringents, such as the mitigated nitrate of silver crayon, acetate of lead in glycerine, oxide of zinc as an ointment or in some form of drying powder. When there is swelling of the conjunctiva, with hyperse- cretion, it will be well to touch the everted lids, once every two or three days, with a solution of nitrate of sil- ver, gr. iij.-v. ad § j., taking the precaution to wash off the excess before replacing the lids. When the irritability of the eye has subsided some- what, the use of yellow oxide of mercury ointment, gr. x. to xv. ad § j., a small portion placed under the upper eyelid, or calomel insufflations, may be resorted to once daily, care being taken not to use these remedies in the 294 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cornea. Cornea. presence of augmenting irritation. With this precaution their use is likely to be remarkably beneficial. To pre- vent relapses the ointment may be used once every other day for several weeks after apparent recovery has taken place. Counter-irritants, such as iodine painted over the brow, or touching the skin of the upper lid lightly with solid nitrate of silver, are sometimes very beneficial; but the use of blisters cannot be too strongly condemned. Solution of eserine sulphate (gr. ij. ad § j.) is occasionally more efficacious than atropine in relieving pain, blepharo- spasm, and intolerance of light. Intense blepharospasm may require canthotomy, and protracted photophobia may often be greatly relieved by forcible exposure of the eyes to strong light for ten or fif- teen minutes, or by dropping iced water upon the cornea (Oppenheimer), or dipping the face in cold water. A four per cent, solution of cocaine dropped into the eye, often affords temporary relief, and seems to assist the action of other remedies. Treatment which has for its object an improvement in the general health, is of primary importance. The diet should be simple and wholesome, with strict avoidance of dainties between meals. Occasional small doses of hy- drarg. cum creta with rhubarb at night, are often bene- ficial. Cod-liver oil and syrup of the iodide of iron, are favorite remedies in strumous subjects. At the outset quinine, in full doses for two or three days, is highly lauded by De Wecker and others, or in smaller tonic doses during the course of the disease (Noyes). Tepid or cold salt- water baths, followed by friction of the skin, and cloth- ing suitable for the climate and season, are means which must not be neglected for promoting recovery and for preventing fresh attacks. A change of air, especially a sojourn at the sea-side, will often promptly cure when other remedies fail. Plenty of fresh air, and a fair amount of out-door exercise, are indispensable. There can be no greater mistake than the common practice of keeping a child suffering from phlyctenular ophthalmia shut up in a darkened room on account of intolerance of light. When out in the open air the eyes can be suffic- iently protected by wearing a large shade. Further pro- tection can, if deemed necessary, be secured by means of a bandage. A firm compressive bandage may be of great service if there be ulceration of the cornea. The ulcera- tion may, indeed, be so considerable as to require the same treatment as suppurative keratitis. The condition in which a circle of exceedingly minute phlyctenulae sur- rounds the extreme margin of the cornea is perhaps, strictly speaking, an affection of the conjunctiva. It is apt to be attended with severe irritation and great peri- corneal injection, only yielding slowly to treatment, which, in the main, need not differ materially from the measures just recommended for the purely corneal affection. A modified form of phlyctenular keratitis, known as fascicular keratitis, must also here receive mention, as it is not of infrequent occurrence, tends to run a protracted course, and is often very troublesome. In this form a rather large phlyctenula appears at the corneal margin and slowly advances across its surface, and a leash of blood-vessels follows in the wake of the advancing infil- tration, which often has a yellowish color at its most prominent part. Should the band thus formed extend as far as the centre of the cornea, it there curves upon itself and assumes a sort of horse-shoe figure. Severe irrita- tion is characteristic of this affection ; when this has been allayed by suitable measures, the oxide of mercury oint- ment (gr. ij. ad 3 j.), as a rule, will promptly complete the cure. A streak of opacity always persists for a long time after the inflammation has passed away, and is sometimes permanent. Herpes cornea is not to be confounded with phlyctenu- lar keratitis, from which it differs widely in symptoms, causation, and pathology, true corneal herpes being un- doubtedly identical in character with herpetic eruptions elsewhere. In this affection one or more small vesicles, containing a transparent fluid, form on the surface of the cornea, and leave superficial excoriations when ruptured. Severe neuralgic pains accompany vesication, but may cease when the vesicles give way; they return, however, as often as fresh ones are formed. During the attack, which is almost always unilateral, there is pericorneal injection, and the eye is often extremely irritable. There are three forms of corneal herpes recognized (De Wecker, "Then Oculaire," p. 169, 1879): 1. II. catarrhalis, which occurs in conjunction with ca- tarrhal affections of the air-passages. 2. H. zoster cornea, which probably depends upon an inflammatory affection of the fifth nerve, and is very of- ten associated with the cutaneous eruption known as zos- ter ophthalmicus. Intense pain, both preceding and fol- lowing the corneal eruption, is characteristic of this affection. Superficial ulceration and infiltration of the cornea, which is slow in healing, is more conspicuous than in the catarrhal form. 3. II idiopathica cornea differs from the second variety mainly in its tendency to recur, sometimes periodically, and in not being associated with an eruption of cutane- ous zoster. Treatment.-The first variety requires no other treat- ment than such as may be necessary for other co-existing catarrhal affections. In the second and third varieties hot applications of belladonna or chamomile in the form of fomentations are beneficial, and atropine instillations are also to be employed ; large doses of quinine have been found beneficial, and, later on, applications of electricity (the constant current), puncture of the vesicles, followed by their ablation with a pair of iridectomy forceps, are said to have a salutary effect in relieving pain. Keratitis bullosa is a rare affection which might readily be mistaken for herpes corneae, as it is characterized by the rapid formation of transparent vesicles on the corneal surface, which come and go with sudden attacks of severe pain in the eye. In this disease the vesicles are much larger than in corneal herpes ;-there may be only one large flaccid bleb, four to five millimetres in diameter, or several of these of various sizes. When these burst or are removed, the subjacent cloudy cornea is laid bare, but in the course of a few days the epithelium is restored again, only to un- dergo a repetition of the process. Again, eyes affected in this way are usually otherwise in an unsound condition ; for example, there may be absolute glaucoma or old irido- choroiditis, and the formation of vesicles probably de- pends upon a disturbance in the lymph-channels of the cornea, which is always the seat of chronic interstitial changes - keratitis parenchymatosa (Grafe-Saemisch : Ges. Augenhlk., vol. iv., p. 272). The treatment of this condition is not very satisfactory in its results, removal of the blebs is only palliative ; shaving off a layer of subja- cent cornea has been known to prevent their recurrence. The operations of iridectomy and sclerotomy have also proved curative in some instances. Enucleation of the eyeball is justifiable as a last resort, and will prove a wel- come relief after months or years of suffering. Vascular Keratitis.-Superficial infiltrations of the cor- nea, with roughness of the epithelial layer, caused by erosions and hypertrophic irregularities of its cellular elements, may occur without obvious reason, or in conse- quence of repeated attacks of phlyctenular keratitis, or as the result of trachomatous conjunctivitis. With these changes blood-vessels develop more or less abundantly between the epithelial layer and Bowman's membrane, as well as in the corneal substance immediately beneath ; this constituting, when the vessels are numerous, the con- dition known as pannus, that is to say, a superficial vas- cularization of the cornea, known as pannus tenuis, when the new formed blood-vessels are comparatively few and scattered ; pannus crassus, when they are so numer- ous as to give the cornea a distinctly red appearance. When this process encroaches upon the pupillary area of the cornea, vision becomes correspondingly impaired, being reduced in some instances to qualitative perception of light. In the presence of pannus the eye becomes liable to attacks of an inflammatory character, attended with pericorneal injection, pain, lachrymation, and photo- phobia. At such times the cloudiness and vascularity are notably increased. The cornea may undergo further changes in the way of ulceration, partial thinning, and 295 Cornea. Cornea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. permanent alterations of curvature. In any case, after recovery more or less permanent cloudiness remains, as may readily be seen by focal illumination. Treatment.-So long as any acute symptoms are present every form of stimulating treatment is to be avoided, but may be resorted to, when these have subsided of their own accord or under the use of atropia, warm fomentations, and the frequent introduction of vaseline into the con- junctival sac. The red oxide of mercury ointment is often very efficacious in all forms, especially in phlyc- tenular pannus. Tannin and glycerin, or a spray of cupric sulphate, gr. v. ad § j. (Schweigger), are often of service in the pannus of granular ophthalmia. In these cases the conjunctiva will, of course, require suitable treatment, and the pannus may disappear with the cure of the granulations. The operation of peritomy may be required for high degrees of pannus, and often yields ex- cellent results. Formerly, inoculation with the pus of ophthalmia neonatorum was much in vogue, and in se- lected cases of dense pannus was found very satisfactory, but was always open to the objection that the inflamma- tion once set up could not be controlled, and sometimes proved destructive. Since the introduction of jequirity brilliant results have been obtained by its use, in just such cases as would have been deemed suitable for inocu- lation. By varying the strength of the solution used and the number of applications no difficulty will be experi- enced in regulating the intensity of its action. Opera- tions for relieving undue pressure of the eyelids (cantholy- sis or canthoplasty), or for obviating inversion of the eye- lashes (entropion and trichiasis) are sometimes required. Traumatic Keratitis.-See Wounds of the Cornea. Parenchymatous Keratitis (Interstitial Keratitis) is a form of inflammation characterized by infiltration of the cornea in its entire thickness, without tendency to ulcera- tion or abscess ; the whole cornea is more or less involved. The epithelium has a stippled appearance, which, with the subjacent opacity, gives to the cornea, in some cases, a resemblance to ground glass (Plate VI., Fig. 6). The onset of the disease is preceded for some days by symp- toms of irritability, lachrymation, and slight pericorneal injection. Corneal opacity, either peripheral or central, now soon makes its appearance ; the former is attended with the formation of fine, closely set blood-vessels grouped together as a vascular patch, which slowly ad- vances from the corneal margin toward its centre. In this way the entire cornea may become densely opaque and highly vascularized, although in the worst cases a yellowish infiltration occupies its central portions. In another class of cases a central cloudiness of the cornea appears, and, while gradually extending toward the periph- ery, becomes more and more opaque, but not vascular. Between these two types there are mixed forms ; there are others in which the opacity has a patchy appearance, some of the patches being vascularized, others not. The disease runs a slow course. As a rule, six or eight weeks elapse before it reaches its acme ; then, after remain- ing stationary for some weeks longer, it slowly subsides. Irritative phenomena may last from three months to a year, while the clearing process is proportionately pro- tracted and rarely terminates in complete restoration of transparency. Symptoms of irritation, with deep ciliary injection, may be very slight or intense, according to the severity of the case and the degree of vascularization. Vision is always greatly reduced for the time being ; both eyes are likely to suffer, though rarely attacked simulta- neously ; the interval may be weeks or many months ; relapses after partial recovery are not unknown. When of syphilitic origin the iris nearly always participates in the inflammation and by a further extension of the dis- ease there may be iritis or irido-choroiditis. The disease is always of constitutional origin. In this respect, hereditary syphilis is clearly the predisposing cause far more frequently than any other known dyscrasia. Acquired syphilis will account for a few cases. The strumous diathesis is assigned an important place by some observers" (v. Arlt). The subjects of inherited gout are also said to be liable to this form of keratitis (Noyes). When it occurs in hereditary syphilis other well-known signs of this taint are commonly present, especially the so-called syphilitic teeth (" Syphilitic Diseases of the Eye and Ear," by Jonathan Hutchinson). The affection oc- curs, as a rule, in young persons of from five to twenty years of age, rarely at an earlier or later period of life. Treatment.-If the disease can be traced to hereditary syphilis, mercury in some form should be administered, preferably a mild course of inunction, which may be continued for a long period if care be taken not to push it so far as to cause or increase debility. It should be omitted for a time the moment the gums begin to show redness and swelling. Iodide of potassium in moderate doses may be resorted to later on. Throughout the course of treatment roborant measures are indicated ; existing anaemia is best combated with the syrup of the iodide of iron, though iron with quinia or strychnia may sometimes be found better adapted to the requirements of the case. Cod-liver oil is also a valuable remedy in these cases if the patient be of strumous habit; under these circum- stances mercury must be employed with great caution, if used at all. In lieu thereof various preparations of the iodides may be used. Errors of digestion must be cor- rected with suitable remedies. Good plain food and abundance of fresh air are of course essential means in keeping up the general health. A large shade and tinted glasses may be worn when the patient is in the open air or exposed to strong light. In the local treatment one leading principle is to be steadily kept in view: No as- tringent or irritating remedy is to be employed until all signs of irritation have subsided. The moderate use of atropine is always indicated during the active stages of the disease. A two- or four-grain solution may be in- stilled once or several times daily, according to the de- gree of irritation ; in other words, the pupil must be kept moderately dilated. Fomentations with hot water or chamomile infusion may be employed for twenty minutes at a time, frequently during the day, until the disease is well on the decline. Used in this way they are said to shorten the course of the disease and mitigate its severity. The presence of conjunctivitis of slight degree does not call for astringent treatment, though solutions of borax and boric acid may be used under these circumstances with benefit. Solution of atropia sometimes sets up a characteristic conjunctivitis, in which case it must be abandoned, and, if necessary, some other mydriatic chosen (duboisia, homatropine, hyoscyamine). Some protracted cases may require an iridectomy (or sclerotomy, De Wecker) before they begin to improve, par- ticularly if there be undue tension of the eyeball. After all irritation has subsided, the careful use of stimulating applications, such as the oxide of mercury ointment or in- sufflations of calomel once or twice daily, may assist in removing the residual corneal opacities of parenchyma- tous keratitis. When this disease occurs in gouty subjects (usually adults) pain and photophobia are prominent symptoms (Noyes). Constitutional remedies suitable to the diathesis are to be administered. Muriate of pilocar- pine, gr. i to | by hypodermic injections, once daily, is also recommended, particularly if atropine instillations are not well borne. The local treatment must be of the soothing character already mentioned. Paracentesis of the cornea is also useful in relieving pain. (This operation is best done with the patient in a recumbent position, and in a good light, so that the point of the instrument used for penetrating the cornea can be steadily kept in view ; a small bent keratome or a straight broad needle, so sharp as to cut with the least possible resistance, is commonly employed for this purpose. The lids are to be held apart with a speculum, and the eye steadied by fixing forceps made to firmly grasp the conjunctiva close to the corneal margin opposite to the intended point of puncture, which will usually be at the lower or outer side of the cornea. The instrument should penetrate the sclero-corneal junc- tion, in a direction nearly perpendicular to the surface, and as soon as the point has entered the anterior chamber, the handle must be depressed sufficiently to bring the blade parallel to the iris, and then pushed on sufficiently far to make an incision about three millimetres in length. In withdrawing the blade it must be thrown still more 296 Reference Handbook of THE 'Medical Sciences. PLATE VI. I II ni IV VI VII VIII IX X Affections df the Ecrnea. H. H E K C KF , LITH. N.T REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cornea. Cornea. forward, and tilted a little so as to allow the escape of a few drops of aqueous. A somewhat larger incision and more complete evacuation of the chamber is allowable, if the operation is done with a view to removing hypopyon. If, in this condition, the exudation in the anterior cham- ber prove to be so tenacious as not to flow out, it may be withdrawn by the careful use of an iridectomy forceps. Should a prolapse of iris occur, it must be returned or re- moved. A paracentesis seldom requires to be repeated. If, however, an interval of not more than one day has elapsed since the last opening, the anterior chamber may, if necessary, be reopened from day to day with a blunt probe. In small deep ulcers the paracentesis may best be made -with a narrow needle through the bottom of the ulcer. After paracentesis, a compress bandage must be applied. Division of the ulcer, as recommended by Saemisch in the treatment of ulcus serpens, is performed as follows : The eyelids are separated with a stop speculum, the eyeball is fixed with suitable forceps, and the incision is made with a von Graefe's cataract-knife, penetrating the anterior chamber through the healthy cornea about one millimetre from the margin of the ulcer, behind which it is then carried far enough to make the counter-puncture at a corresponding point at the opposite side of the ulcer. Care must be taken to divide the ulcer as nearly as possible across its centre, and the incision is completed slowly in order to avoid a sudden evacuation of the chamber.) Suppurative keratitis is a term applicable to all inflam- matory affections of the cornea which are attended with purulent infiltration, and it includes abscess of the cornea as well as several forms of corneal ulceration. Either abscess or ulcer may originate spontaneously, or as the re- sult of some, perhaps, trivial injury ; either may commence as a simple infiltration, or the formation of pus may take place from the outset. Deposits of pus in the anterior chamber (Plate VI., Fig. 3), called hypopyon, are of common occurrence in suppu- rative keratitis. The occurrence of this phenomenon may be accounted for in several ways : (1) The pus-cells may travel through the posterior corneal layers and Descemet's membrane (Horner) ; (2) or they may pass between the layers of the cornea on to its lower periphery, reaching the anterior chamber through the interstices of the ligamen- tum pectinatum (Stromyer); (3) by direct rupture of a corneal abscess, the pus may escape into the anterior chamber; (4) the epithelial cells of Descemet's membrane may undergo purulent proliferation ; (5) an associated purulent iritis or irido-cyclitis may contribute to the for- mation of pus in the anterior chamber, or, according to von Arlt, it may perhaps wholly account for the phenom- enon. Whatever its origin, the purulent mass in the anterior chamber may be of a semi-solid or gelatinous consistence, and so cohesive as to admit of being withdrawn bodily from the chamber after an incision sufficiently large for a iridectomy, has been made. Suppurative affections of the cornea attended with hypopyon, are either sthenic, with great pain and inflam- matory symptoms of an active character, or asthenic and sluggish, with little or no pain, etc.; the latter are indic- ative of a very low state of nutrition, or of torpor of the fifth nerve. A circumscribed purulent infiltration of the cornea without superficial loss of substance, constitutes an abscess and may be attended with hypopyon, etc., while in this condition ; but sooner or later the surface is likely to give way, and the abscess then becomes an ulcer. Whenever hypopyon results from suppurative keratitis the corneal lesion always presents more or less of a dull yel- low color, caused by infiltration of the part with pus-cells. In the sthenic form there is pain, often intense, deep-seated injection of the eyebgll, photophobia, and lachrymation. The appearance of the cornea varies according to the ex- tent of the disease and its mode of progress. The sthenic abscess or ulcer is surrounded with a zone of gray infil- tration, sometimes of a streaky appearance; the ulcerated surface may be excavated or nearly on a level with the •surrounding cornea; its surface is always more or less covered with a layer of grayish or yellowish-gray broken- down material. Pus in the anterior chamber may appear at its lower edge as a narrow yellow streak, a wide space of clear cornea intervening between this and the lower edge of the ulcer or abscess : or a streak of purulent de- posit behind the cornea or between its lamellae, may extend from the ulcer to the hypopyon. A large accumulation in the anterior chamber may extend to the level of the ulceration, so that they appear to blend with each other. Perforation of the cornea, with or without prolapse of the iris, may occur before the ulceration has extended very widely ; or the ulceration may involve so much of the cornea that it becomes transformed into a dull yellow necrotic mass. The term serpiginous corneal ulcer has been applied by Saemisch to those " forms of suppurative keratitis which are distinguished by the tendency to penetrate into the parenchyma and extend superficially, especially in one direction." Such ulcers are apt to pro- gress slowly, and prove very destructive. Eyes subject to chronic conjunctivitis, with blennorrhcea of the lachrymal sac, seem particularly prone to destructive suppurative keratitis, probably owing to the continued presence of septic material in the conjunctival sac. Purely asthenic suppurative keratitis commences as a rule about the centre of the cornea. In this affection all signs of active inflammation are wanting ; the absence of a gray zone of infiltration around the suppurating area is also to be noted; and the surrounding cornea may even appear unusually pellucid, only becoming infiltrated and cloudy when healing has commenced. The changes which take place during the healing of corneal ulcers have already been briefly described ; we may here add that with this, in asthenic cases, a certain degree of irritation develops, while the sthenic existing irritation tends to subside. Treatment.-Rest and protection of the eye are of primary importance ; both these indications are best se- cured by the judicious use of a compressive bandage. The eye must also be kept free from unhealthy secretions, by washing several times daily with a warm two per cent, solution of boric acid. In addition to this, the mod- erate use of warm water fomentations, or warm carbolic lotion, 1 to 1,000, followed by instillations of solution of atropine (gr. iv. ad 3 j.) will be necessary. This measure will often arrest the suppurative process in its early stages, the ulcer taking on a healing action, and hypopyon rapidly disappearing. Should a fair trial of this treat- ment fail to arrest the disease, and especially if the ulcer- ation, etc., continue to increase, a more energetic inter- ference will be necessary. Paracentesis of the cornea (done at the margin), with or without iridectomy, and di- vision of the ulcer according to the method of Saemisch, are the means usually employed ; and if the corneal de- struction has not progressed too far, say not beyond one- third of its extent, these operations will generally suffice to stay the destructive process. Opening the anterior chamber allows the escape of its purulent contents, and, by relaxing the tension of the cornea, promotes its nutri- tion. The performance of these operations is now greatly facilitated by placing the eye under the local anaesthetic influence of cocaine. An opening about three millimetres in length, made with a broad needle at the corneal mar- gin, will suffice for a paracentesis, but must be somewhat larger than this if an iridectomy is contemplated. As the knife is withdrawn it may be tilted a little, in order to open the lips of the wound and facilitate removal of exu- dation in the anterior chamber ; should this prove to be so tenacious as not to flow out, it may be withdrawn by the careful use of an iridectomy forceps. A paracentesis seldom requires to be repeated. The operation of Saemisch is perhaps preferable when there is extensive ulceration of the cornea. The narrow cataract-knife of von Graefe, is made to penetrate the sound cornea, close to one mar- gin of the ulcer, behind which it passes to emerge in a similar position at the opposite side of the ulcer, care being taken to avoid the iris and lens ; the contents of the anterior chamber escape through the opening. If the exudation be partially tenacious, the use of the iridectomy forceps may be required, as already mentioned in regard to paracentesis. 297 Cornea. Cornea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. quired, the instillation of a solution of eserine (1 to 100) every two or three hours, and paracentesis of the cornea if the ulceration threatens to perforate, are the principal means to be employed. A small, transparent, central ulceration is rather com- mon in early life (absorption ulcer). It may occur under the same conditions as phlyctenular keratitis. The ulcer may be overlooked unless a careful examination is made ; its symptoms, both subjective and objective, being com- paratively trivial. There is some weakness of the eye with slight intolerance of light and lachrymation, espe- cially in the morning. It is a chronic affection, and, after healing, leaves an opacity which, from its central posi- tion, may cause permanent impairment of vision. The treatment should be partly soothing and partly stimulat- ing, with measures to strengthen the general health. Somewhat similar small, deep ulcerations, tending to per- forate, are met with occasionally in other parts of the cor- nea in children as well as adults. Such idcers, when in- volving pretty much the whole thickness of the cornea, may present a clear, bead-like projection in the centre, caused by protrusion of the unruptured Descemets' mem- brane into the ulcer ; for this condition the term kerato- cele has been applied. Only after spontaneous rupture, or artificial opening of the part, can such ulcers be brought to heal. They may give rise to a troublesome corneal fis- tula, especially if allowed to rupture spontaneously. Crescentic ulcers, forming a deep groove around the periphery of the cornea, and without infiltration, are oc- casionally seen in elderly debilitated subjects. They are destructive if allowed to progress so far as to cut off nu- trition from the central portions of the cornea, which may then exfoliate. The operation of iridectomy is the most efficient means of arresting the progress of such ulcers. Active inflammatory symptoms are present in the vast majority of corneal ulcers ; superficial ulcerations being, as a rule, more painful than those which have extended deeply into the cornea, owing to the fact that the ter- minal filaments of the corneal nerves are at the surface. The asthenic type is, however, not uncommon in simple ulcers ; these have a tendency to spread superficially, and are sharply defined with little or no surrounding infiltra- tion. It is to be remembered that ulcers of the cornea, especially when large, may have extended more deeply than appears to be the case, on account of the intra-ocular pressure pushing the thinned base of the ulcer forward ; such a condition always constitutes a serious obstacle to healing, and forms a positive indication for operative in- terference. Spontaneous perforation should never be permitted if it can be avoided, because it increases the liability to permanent anterior synechia (as in Fig. 9, Pl. VI., where a perforating ulcer has healed with the iris ad- herent to the cornea, and the pupillary aperture is drawn up to the corneal opacity). Such an eye is always dam- aged in vision, disfigured, and more liable to deep-seated disease than if healing without synechia, or prolapse of iris, had taken place ; it is also more liable to deposits of lymph on the lens capsule, or even to rupture of this structure, and perhaps other intra-ocular lesions. When a prolapse of iris occurs from perforated ulcer, it should be punctured with a fine needle from day to day, or, after puncture, the flaccid portion may be seized with iridec- tomy forceps, and cut off with a fine pair of scissors. In the treatment of corneal ulcers, their progress and the effect of remedies employed must be scrupulously watched. The use of a compressive bandage is generally indicated as a protection from external irritation, and for the purpose of securing rest, so essential to the healing process. The use of atropine instillations is generally in- dicated. The atropia should be absolutely pure neutral sulphate, and the solution should be of the strength of from two to four grains to the ounce. For allaying irri- tation and keeping in check iritic complications, which are apt to occur in many corneal inflammations, it is the standard remedy. Solutions of eserine are of considerable value in certain cases of corneal ulcerations, more particularly those which belong to the asthenic type; if, however, a ten- dency to, or actual, iritis be present, eserine may act very Borated lint, to be retained on the eye with a compres- sive bandage, may be kept applied until the next day ; after this, repeated fomentations with a warm solution of boric acid (1 to 30), will be required. Under this treat- ment, the plan recommended by Saemisch, of reopening the wound daily with a small probe, until the ulcer be- comes clean, will be found unnecessary (Noyes). Or the operation may be followed by instillations of eserine, one- half per cent, solution several times daily (De Wecker), instead of further instrumental interference. If the necrotic process is arrested, the ulcer will become clean and slowly heal, perhaps with adhesion between iris and cornea if the ulcer has been large, in -which case also a staphylomatous bulging may occur and require ap- propriate treatment. In many cases more or less of a permanent scar will remain, often a dense leucoma, with impairment or complete loss of vision. Total destruction of the vision will sometimes occur despite all treatment, especially if panophthalmitis develops ; the ruined eye, under such circumstances, may be eviscerated or enucle- ated, in order to save the patient from the long period of suffering which would attend suppurative inflammation of the eyeball. In suppurative keratitis a tonic treatment is always indicated, and in the asthenic forms stimulants can be used with benefit, and the hygienic conditions must be made as favorable as possible. Ulcers of the cornea, not associated with hypopyon, are of frequent occurrence. They vary much as to appear- ance, situation, course, duration, and importance ; they originate from abrasions or injuries of various kinds, from the injurious effects of certain morbid conditions of the conjunctiva, or other diseases of the eye, and from de- fective states of nutrition generally. They may be super- ficial or deep, clean and smooth, with rounded edges and no surrounding infiltration, or irregular in outline, with opaque gray, or yellowish-gray surface, and steep or excavated edges, and well marked surrounding zone of infiltration. They may be situated at the extreme cor- neal margin or occupy any part of its surface, remain stationary or extend in depth and area, and last only for a few days or become chronic. So long as an ulcer re- mains small and superficial, without encroaching on the centre of the cornea, it is not likely to be of serious im- portance. There may be very little pain and irritation, or severe and acute symptoms may characterize the affection from the outset, such as acute pain, great pericorneal in- jection, intolerance of light, and profuse lachrymation. Small, deep ulcers at the corneal margin, of a yellow color, and tending to perforate and cause a peripheral prolapse of iris, are not uncommon ; they sometimes par- take of the character of a strumous keratitis-that is, they originate as phlyctenulae in a strumous subject,-or they may occur in otherwise healthy subjects. The attendant inflammatory symptoms are of an acute character, and soothing treatment will be essential so long as this condi- tion lasts. Catarrhal and purulent affections of the con- 1'unctiva are often attended with ulceration of the cornea, n the former, the ulcers are usually small, and peripher- ally situated ; they do not require any special treatment beyond that adapted for the conjunctivitis, but may ne- cessitate some care in the use of astringent collyria. Solu- tions of atropia may be used if the eye becomes more than slightly irritable or painful. Ulceration of the cornea occurring in the course of purulent ophthalmia, on the other hand, is too often a disastrous complication, and frequently causes hopeless destruction of the cornea. The earlier its occurrence in the course of the blennorrhoea the more serious is likely to be the result. The worst form of ulceration is that which makes its appearance about the centre of the cor- nea, as a diffuse gray infiltration, while the conjunctival inflammation is at its height or still increasing. Such in- filtrations rapidly become extensive erosions, and the cor- nea sometimes melts away, so to speak, in the course of a few days. Furrow-like marginal ulcerations, without much infiltration of their edges, though likely to result in perforation and prolapse of iris, are not nearly so dan- gerous. In addition to the treatment suitable for puru- lent conjunctivitis, warm antiseptic fomentations are re- 298 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cornea. Cornea. injuriously. Warm fomentations are, as a rule, benefi- cial in allaying irritation and promoting the nutrition of the cornea, but in the presence of active irritation they must be employed cautiously, for fear of unduly increas- ing this condition. Astringent collyria, and astringents or caustics, such as nitrate of silver, applied to the ulcer- ated surface, are not to be employed at all during the pro- gressive stage of corneal ulcerations. If ulceration be as- sociated with con junctival disease, which requires the use of astringents, the cornea must be carefully protected from their action. When the healing process is well es- tablished, especially when the ulcer is becoming vascu- larized (Fig. 2, Pl. VI.), and also in some chronic indolent ulcers, stimulation in the form of oxide of mercury oint- ment, calomel insufflations, or strictly localized applica- tions of nitrate of silver solution (2 to 4 : 100) may be employed with advantage. Opiates at night, in doses suf- ficiently large to allay pain, are often of great service. Latterly, the actual cautery heated to a dull red has been highly spoken of by several ophthalmologists of large ex- perience. It is claimed to have the effect of arresting the progress of suppurative keratitis, and of setting up healthy action in all indolent and chronic ulcers. With- out defining the precise limits of its usefulness, we may say that the procedure has gained a substantial reputation in ocular therapeutics. Excellent results have been ob- tained by touching the ulcer, in certain cases of suppura- tive keratitis, with pure carbolic acid ; this procedure, however, like the former, has not yet come into general use. Neuro-paralytic keratitis in its objective symptoms does not differ materially from ordinary asthenic inflammatory affections of the cornea. It may never pass the stage of infiltration, but is very liable to become suppurative. There is absence of photophobia, little or no pain in the eye, and the circumcorneal congestion is of a dusky, sluggish character ; but the characteristic feature is loss of sensibility of the cornea, and with this there may be anaesthesia of other parts supplied by the fifth nerve. Treatment.-The first essential is a protective bandage, borated cotton being placed next the eye, which must be cleansed with warm boric acid or other mild antiseptic lo- tion several times daily. Eserine instillations are strongly recommended by some writers, and if there be paralysis of the fifth nerve, the galvanic current (from six to eight elements) is likely to be of service, the positive pole being placed over the superior cervical ganglion of the same side, and the negative over the brow or eyelids. Corneal opacities are commonly the result of some one or more of the morbid conditions already described ; they tend to grow less marked with the lapse of time, but whatever opacity remains a year or two after the cessa- tion of the inflammatory process which caused them, may be considered permanent. The effect on vision varies with the degree and extent of the opacity, although slight, almost invisible central clouding may seriously impair vision by causing dispersion of light and irregular astig- matism. The extreme degree of opacity indicated in Fig. 4, Pl. VI., represents a large central leucoma adhse- rens, which has become vascularized, the pupil being completely obliterated, and the anterior chamber ren- dered very shallow. For large opacities encroaching on the pupil an iridectomy, by bringing the pupillary aper- ture opposite a clear portion of the cornea, may improve vision very considerably, provided the parts beyond are in a faifly normal condition. The appearance of the eye may likewise be greatly im- proved by the operation of tattooing with India ink any dense cicatricial opacity; for this purpose a group con- sisting of several fine needles set in a handle are to be smeared with a thin paste of the ink, and the white tissue of the cornea punctured obliquely until it retains a suffi- cient amount of the pigment to hide the opacity. Only one, or several sittings may be necessary. The operation can be rendered painless by the use of cocaine, and is seldom followed by any considerable reaction. The local use of medicinal agents is of problematical value in clear- ing up cicatricial opacities of the cornea; other things being equal, the younger the subject the greater is the power of repair in this respect. A large loss of substance in the cornea of an infant will often disappear almost en- tirely, though the same amount of destruction in an adult woidd leave a conspicuous permanent opacity. The stimulating remedies already mentioned are gener- ally conceded to assist in clearing up recent opacities, by promoting the functions of nutrition and absorption. Of these the most efficient is the oxide of mercury ointment, gr. ij. ad 3 j., a small portion of which is to be introduced beneath the upper eyelid once daily ; or, if this excites a good deal of pain and redness, the strength of the oint- ment must be diminished. When the cornea has been entirely replaced by opaque tissue, vision is of course de- stroyed under these circumstances. Attempts to restore vision by transplantation of transparent cornea to replace the opaque tissue, have met with a limited success (Wolfe, Medical Times and Gazette, November 22, 1879). Transverse opacity of the cornea, in the form of an opaque band of a gray or yellowish color, two or three millimetres in width and corresponding in position to the palpebral fissure, is sometimes seen in elderly or prema- turely senile persons, or in eyes affected with chronic deep-seated disease, and having a tendency to glaucoma (von Graefe). In the latter form the opacity is made up of minute specks situated deeply in the cornea. Tim transverse opacity observed in elderly people is due, ac- cording to Nettleship, to minute calcareous crystals lodged beneath the epithelium. Lead stains often occur as dense white, sharply defined opacities after the use of lead lotions in abrasions or ul- cerations of the cornea ; they may be cut away with a thin sharp knife, or scraped off with a small sharp scoop. Col- lyria containing lead, if used at all in ophthalmic prac- tice, should never be entrusted to the patient for use at home. Fine punctate opacities are met with, in the early stages of certain cases of sympathetic iritis, scattered promiscu- ously over the posterior surface of the cornea ; they look like minute drops of tallow. Somewhat similar dots, ar- ranged in the form of a pyramid with its base at the lower corneal margin (Fig. 7, Pl. VI.), are characteristic of the so-called Descemetitis. With these are associated more or less turbidity of the aqueous humor, discoloration of the iris, circumcorneal injection, and sometimes posterior sy- nechia ; larger opacities (infiltrations) may also develop in the substance of the cornea. Vision is apt to be consid- erably impaired in these cases. The fundamental lesion appears to be a serous irido-choroiditis, which, by ex- tending along the lymph-channels, may involve the endo- thelium of the sheath of the optic nerve as well as that of the cornea. Sclerosing opacities in the peripheral portions of the cornea sometimes occur without inflammatory symptoms, or as the result of localized sclerotitis passing over to the adjacent parts of the cornea. Arcus senilis (gerontoxon) is a peculiar marginal opacity, which, commencing above and below, may in the course of time encircle the cornea in the form of a narrow, ill- defined, gray or silvery rim, between which and the white sclera there is always a zone of clearer cornea. This change is seldom met with before middle life, and has no special pathological significance; though essentially a fatty degeneration, it has not been shown to indicate a similar tendency in other organs. Pterygium (Fig. 10, Plate VI.) will be considered un- der its own proper heading, but it derives its chief im- portance from the visual disturbance which may result from an extension of the growth to the central portion of the cornea. This can be prevented by timely operative interference. Fistula of the Cornea.-Penetrating wounds and ulcers which have perforated the cornea, occasionally fail to heal, a small aperture remaining through which the aque- ous humor constantly leaks away, or, if temporarily re- tained, is repeatedly evacuated by rupture of the thin retaining membrane ; such eyes are always more or less irritable, and liable to attacks of inflammation, which sometimes results in pan-ophthalmitis. According to Wecker (Annales d' Oculistique, Ivi., 305), the fistula is due 299 Cornea. Cornu Cutaneum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to an eversion of the membrane of Descemet, which thus comes to serve as a lining to the walls of the fistulous track, and he recommends that it be lacerated with a fine pair of forceps, or that the aperture be converted into a crucial incision by means of delicate, smooth-pointed scissors. After either of these manipulations, atropine instillations and a compressive bandage will be required until the part has healed firmly. The prolonged use of eserine and the compressive bandage has also been found beneficial. Malformations of the Cornea, Congenital and Acquired.-Congenital defects of the cornea present deviations from the normal in regard to size, shape, and transparency. The cornea may be smaller than normal, as in C. microphthalmos, or larger, as in C. megaloph- thalmos. Important structural abnormalities in the in- terior of the eye are present in both these conditions, in all or nearly all such cases (Manz : " Handb. d gesammt. Augenheilkunde ; Graefe u. Saemisch," Band ii., 131). The cornea of microphthalmos is small and may be flat- tened, or its curvature may be the same as that of the sclerotic ; the latter structure .often encroaches upon the cornea ; their mutual relations as to size present consid- erable variations. In outline the cornea may be nearly circular, distinctly oval, or quite irregular. In congen- ital megalophthalmos the cornea is actually and rela- tively too large, but at the same time thinner than nor- mal ; this thinning involves also the anterior portion of the sclerotic, which thus acquires a bluish appearance, and the anterior chamber is increased in depth and width (hy drophthalmos anterior). Diffuse or circumscribed opac- ities of such cqrneae are often present. The condition just described does not, as a rule, remain stationary, but goes on slowly increasing after birth, and the entire eye- ball often becomes enormously enlarged. Congenital faults in the curvature of the cornea, with- out anomalies as to size or structure of the eyeball, are of frequent occurrence, and account for a large proportion of the errors of refraction known as astigmatism. Congenital opacity of the cornea may be partial or com- plete, apart from the congenital opacities of microph- thalmos and megalophthalmos. A condition resembling arcus senilis is sometimes seen at birth (embryotoxon) (Manz : loc. cit.). A form of opacity so complete as to give the impression that the cornea is entirely absent has also been observed. Dermoid cysts involving the cornea are always con- genital (see Tumors of the Cornea). The progress of hydrophthalmos anterior may some- times be arrested by the operation of iridectomy. If vision is destroyed and the enlarged eyeball the source of annoyance, a staphyloma operation may be advisable. Conical cornea (transparent anterior staphyloma), see Fig. 8, Plate VI., is a somewhat rare condition, which is said to develop, as a rule, about the age of puberty, or a little later, and more often in the female than in the male sex. Nothing definite is yet known in regard to its causa- tion. Without any other pathological manifestations the cornea gradually becomes thinner at its central part and assumes a more or less conical shape, and though usually retaining its normal transparency in high degrees of conic- ity the apex occasionally becomes clouded. In slight degrees the diagnosis is not always easy. At first the eye may become somewhat short-sighted, vision, however, remaining subnormal, even when the error of refraction has been as far as possible corrected with concave and cy- lindrical glasses. In advanced conditions a profile view of the cornea at once determines the nature of the diffi- culty. The ophthalmoscopic mirror, when used as in re- tinoscopy, shows a bright central reflex surrounded by a crescentic shadow, which moves around the centre, but never crosses it when the mirror is rotated. The optic nerve and retinal blood-vessels, when seen with the oph- thalmoscope, appear distorted, rapidly changing in appa- rent size and shape with every movement of the obser- ver's head. Vision is commonly impaired in proportion to the corneal alteration ; sometimes to such an extent that only large print can be deciphered. Treatment.-If vision can be materially improved by any combination of glasses, these may be used ; but if they fail to improve vision, and if the latter be so defec- tive as to justify surgical interference, the apex of the cone may be removed (1) by cutting out a small circle with Bowman's trephine, (2) by excising a small elliptical portion with a narrow knife and scissors, (3) by removing a thin slice with a sharp knife, and then exciting a lim- ited suppurative keratitis by touching the raw surface every few days with a pointed crayon of silver nitrate. When the central ulcer thus produced has healed, under suitable treatment (see Suppurative Keratitis), the cornea will have acquired a more normal curvature. An iridec- tomy may be required after any of these operations. Lateral displacement of the pupil by iridodesis, as recom- mended by G. Critchett, has not met with much favor on account of the danger of sympathetic mischief which it involves. Staphyloma of the cornea (opaque anterior staphyloma) (Fig. 5, Pl. VI.), as already stated, results from ulcera- tion of the cornea with perforation. The perforation must have been of considerable size to be followed by the bulging forward of new scar tissue, which constitutes staphyloma. According to Saemisch, an aperture in the cornea of less than 2 [_T" is not likely to cause staphy- loma. Narrow perforations are less likely to give rise to this condition than when the aperture is rounded. Cor- neal staphyloma may be partial or total. When a large perforation occurs, the aqueous humor escapes, and the iris comes in contact with the opening and may protrude ; thus exposed, it speedily inflames and becomes covered with lymph which undergoes organization, and a weak cicatrix is formed which yields before the intra-ocular pressure, thus increasing the degree of protrusion. The cornea at the circumference of the aperture, softened by the inflammatory process, also yields to the pressure from within, and becomes involved in the staphyloma, which, at first of small size, may gradually involve a large part of the cornea if measures are not taken to arrest its de- velopment. In other cases extensive destruction of the cornea gives rise to a bulging cicatricial formation, which, from the outset, involves the greater part of the corneal area ; very large perfora- tions are, however, apt to lead to ex- trusion of the lens and shrinking of the anterior part of the eyeball (phthisis anterior). The new-formed tissue which constitutes the front wall of the staphyloma becomes densely opaque, and is often con- siderably thicker than the original cornea, or thicker in some parts and thinner in others (see Fig. 748). Its surface is covered with an irregular layer of epi- thelium, while the disorganized and attenuated iris, often reduced to a few shreds of pigmented tissue, imperfectly lines it internally. The lens becomes dislocated forward (Fig. 749), opaque, and often partially absorbed. When very large, the staphyloma leads to stretching of the anterior portion of the sclerotic, ob- literation of the pericorneal sulcus, and elongation with thinning of the ciliary processes (see Fig. 750). Dis- turbance in the normal relation be- tween the functions of secretion and absorption of intra-ocular fluids is a constant result of staphyloma ; a form of consecutive glaucoma sets in ; sec- ondary changes in the choroid, retina, and optic nerve finally reduce vision to quantitative perception of light, or destroy it entirely. This is likely to be the result even when the staphyloma only involves a small portion of the cornea. Treatment.-To prevent the formation of staphyloma, prolapsed iris should be removed ; instillations of eserine, with the use of a firm compressive bandage, are then in order until cicatrization is completed, If this fails, or if healing has already taken place with the formation of a Fig. 748.-Corneal Sta- phyloma, natural size. (After Saemisch.) a, Cicatricial tissue; b, crystalline lens. Fig. 749. -Corneal Sta- phyloma, natural size. a, Cicatricial tissue: &, dislocated lens. (Af- ter Saemisch.) 300 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cornea. Cornu Cutaneum. partial staphyloma, the question of performing an iridec- tomy is always to be considered, and a decision in favor of the operation is to be given when there is sufficient clear cornea to permit of the opera- tion, when there is evidence that the trouble is progress- ing, and when there is in- creased tension of the eye- ball. Under these circum- stances a broad iridectomy may be of great optical advan- tage, and will usually arrest the progressive and destruc- tive tendencies of the disease. In other cases of incomplete staphyloma there may be no hope of improving vision by an iridectomy, but the deformity may be so considerable as to make an opera- tion desirable for its cosmetic effect. Under these cir- cumstances an elliptical piece may be removed from the projection, the lens if present evacuated, and the edges of the wound brought together •with two or three fine sut- ures. Or a compressive bandage without sutures may be used until the wound has healed. For total staphyloma, abscission of the entire projection, or evisceration or enucleation of the eyeball, is the best means of doing away with the deformity, trouble, and annoyance which it causes. The first is to be recom- mended when the eyeball is otherwise fairly healthy. Various methods of performing the operation have been devised. In any case, the lens must not be allowed to remain in the eye after removal of the staphyloma. Critchett's operation of carrying several curved needles armed with sutures through the ciliary region before ab- scinding the staphyloma, is objectionable on account of the danger of injuring some of the ciliary nerves, and thus exciting sympathetic inflammation; and also be- cause it is liable to be followed by suppuration of the re- maining portion of the eyeball. A less objectionable method is that of Dr. H. Knapp (Arch. f. O., Bd. xiv., I., 273). Before abscission is per- formed, the conjunctiva is dissected back for some dis- tance around the base of the staphyloma, and a sufficient number of sutures are inserted to bring the edges of the conjunctiva together over the opening. Evisceration or enucleation is to be recommended in old and large staphy- loma with considerable distention and thinning of the ad- jacent sclerotic, as in such cases abscission is almost sure to be followed by haemorrhage or deep inflammation. Tumors of the Cornea seldom, if ever, take their origin in the cornea itself, but extend to this structure from adjacent parts, usually the episcleral tissue around the cornea. Dermoid tumors, probably always congen- ital, are situated partly on the sclerotic, and partly over the cornea. Such a growth is smooth or slightly lobu- lated, pale or yellowish-white in color, more or less prominent, and usually, though not always, remains sta- tionary. Its dermoid character is assured if one or more hairs are found growing from the surface. When re- moved, dermoid growths are not likely to recur. If large enough to cause conspicuous disfigurement, excision of the growth is advisable, care being taken not to pene- trate the cornea or sclerotic. Sarcoma, usually pigmented and consequently of a dark color, may develop from the ciliary portion of the scle- rotic and extend to the cornea. The growth is more likely to extend deeply into the sclerotic than into the cornea. Melano-carcinoma sometimes grows from the same re- gion and covers the cornea, spreading beneath the epithe- lium. The mass is of a dark color, soft, and vascular. Epithelioma, commencing at the limbus as a small nod- ule resembling a phlyctenula in this situation, may remain for a long time inactive, but sooner or later it begins to grow rapidly. The age of the subject, and the persist- ence of the nodule in its early stage, are of diagnostic im- portance. Tumors, such as these involving the cornea, should always be removed with as little delay and as thoroughly as possible. If the operation involves pene- tration of the eyeball, enucleation will probably have to be resorted to ; and this is also necessary when the growth recurs and cannot be removed again completely. Frank Buller. CORN SILK {Mate, Codex Med. ; " Stigmata Maidis"). The long, thread-like styles of Indian Corn, Zea Mays Linn., Order Graminece, gathered shortly after flowering and while still green and succulent. They arise one from each kernel, and pass along beneath the husks to the end of the ear, and then project five or ten centimetres (two or three or more inches) beyond it. Their total length is from ten to twenty or more centimetres, their diameter about half a millimetre; they are pubescent along the entire length, and bifid at the upper extremity. They have a "grassy," peculiar taste, something like that of the fresh inner husks which enclose them, and a similar odor. The composition, as far as known, is not very remark- able : some fat, some form of tannin perhaps, and a doubtful substance called by Dr. Vauthier maizenic acid. Corn Silk is a recent addition to the already long list of .mildish substances, employed to relieve the pain and spasm of chronic and subacute cystitis, and called, not always correctly, diuretics ; vesical sedatives would be a more appropriate name. It is also commended in gonor- rhoea, gravel, nephritic colic, rheumatism, gout, etc. Mai- zenic acid is reported also to " dissolve vesical calculi and other calcareous concretions by its chemical action." This medicine is undoubtedly useful in some cases of chronic cystitis, but can hardly be said at present to have any peculiar superiority over others of its class ; for the other troubles its value is slight. Administration.-From the dried or green styles a watery decoction may be made as desired ; a " fluid ex- tract" and a "tincture" are to be had, but of no author- ized strength. The following formula for making a green tincture is offered by G. W. Kennedy in the Am. Journ. Pharm. for 1883 : " Tincture of Corn Silk," twenty-four parts of green corn silk are cut up and beaten with a little diluted alcohol to a pulp ; after forty-eight hours' macera- tion enough diluted alcohol is percolated through the mass to make one hundred parts. "Dose one or two fluidrachms (four to eight grams)." For his " fluid ex- tract'' two hundred parts of the silk are similarly re- duced to pulp, and mixed with twenty parts of glycerine and eighty of diluted alcohol. After a similar period of maceration enough diluted alcohol is percolated through to exhaust the drug, and the last portion (after reserving seventy parts) reduced to thirty and added to the first. "Dose, from one-half to one fluidrachm (2 to 4 grams)." Allied Plants, Allied Drugs.-See Couch Grass. Ustilago Maidis, Corn Smut, although also found in the ear of corn, is a parasite there, and is not botanically re- lated. IF. P. Bolles. Fig. 750.-Posterior View of a Cor- neal Staphyloma, natural size. a, Elongated ciliary processes; b, remains of the iris; c, dislo- cated lens. CORNU CUTANEUM. A cutaneous horn is a circum- scribed hypertrophy of the epidermis, forming an out- growth of horny consistence and of variable size and shape. In appearance these growths resemble those seen in the lower animals, differing, if at all, but slightly. The formation is rare. Cutaneous horns are usually tapering, and may be either straight, curved, or crooked ; in a few instances so crooked and twisted as to appear not unlike the horn of a ram. Their surface is rough, irregular, laminated, and fissured, the ends pointed, blunt, or clubbed. Occasionally the horn assumes a flattened form ; in these cases the growth is but slightly elevated. The color varies ; it is usually grayish-yellow, but may be even blackish, depending mainly upon their age. As commonly seen they are small in size; in exceptional cases they may attain considerable proportions. In a case reported by Porcher,1 the growth attained a length of eighteen centimetres (seven inches), with a base of the diameter of seven centimetres (two and three-quarter inches). As a rule, the base rarely exceeds the diameter, at its thickest part, of one and a quarter centimetre (one- half an inch). The base, which rests directly upon the skin, may be broad, flattened, or concave. The under- lying and adjacent tissues may be normal, or the papillae 301 Cornu Cutaneuni. Coroner. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. may be hypertrophied, and in some cases there is more or less inflammation, which may be followed by sup- puration. Not infrequently groups of greatly enlarged papillae, extending some distance into the horny mass, have been observed. Horns are usually solitary; in some cases, however, there are several present, and in a case recorded by Botge? the whole lower part of the body was studded with these growths ; with the exception of two, all were of small size. In cases in which there are more than two or three horns present they are rarely large. No part of the body is exempt, but they occur most frequently on the face, scalp, and penis. They oc- cur, as a rule, late in life, although they have been ob- served in the young. Appearing about the genitals, they usually develop from acuminated warts ; a case in point is recorded by Pick? This same author refers to nine cases of horns occurring about the penis. Cutaneous horns are hard, solid, dry, and somewhat brittle. They are not, as a rule, painful, unless knocked or irritated. Their course is usually slow, and after having attained a certain size, not infrequently become loose and fall off ; they are almost always reproduced. They rarely disap- pear spontaneously. The cause of these growths is unknown. They bear a close resemblance to warts ; are, in fact, essentially hy- pertrophic warts. They consist of closely agglutinated epidermic cells, forming small columns, or rods ; in the columns themselves the cells are arranged concentrically. In the base of the horn are found a number of hypertro- phied papillae and some blood-vessels. Cutaneous horns have their starting-point in the stratum mucosum, either from that lying above the papillae, or that lining the fol- licles and glands. As is the case with nearly all cutane- ous excrescences, these may be folio wed by epitheliomatous degeneration. The treatment of these growths consists in their de- tachment, and subsequently the destruction of the base. The former is accomplished by dissecting it away from the base or forcibly breaking it off ; the latter by means of any of the well-known caustics, such as caustic potash, chloride of zinc, and the galvano-cautery. Another method is to excise the base, the horn coming away with it; this necessitates, however, considerable loss of tissue. Henry W. Stelioagon. 1 Charleston Medical Journal and Review, 1855. - Deutsche Zeitschrift fur Chir., Bd. vi., 1876. 3 Viertelj. fur Denn, und Syph., 1875, p. 315. the small county of Huntingdon, with sixty thousand in- habitants, has also five, and Dorset, also a small county, has eleven.1 Every freeholder is entitled to vote in the election of coroner. No professional qualification is required for the office, the only requisite being that the candidate should possess a freehold interest in the county. For more than fifty years complaints with reference to ignorance, and culpable neglect in the management of the office, have been so common, as to direct popular at- tention to the necessity of reform ; and while no statute has been enacted with reference to such reform in Eng- land, the persistent efforts of prominent medical men have been so far successful, that professional men are now usually elected to vacant offices. The elections are often hotly contested, and as much as £12,000 is said to have been expended to secure an elec- tion. By a recent act it is provided that the polls shall not remain open more than one day. A coroner usually holds office for life, but may be re- moved by the Lord Chancellor for misconduct, or incom- petence. The county coroner receives a salary. He may ap- point a deputy to act during his absence or illness. This deputy must be either a barrister, solicitor, or a physician. The coroner is ex-officio a justice of the peace, and may therefore cause any one suspected of murder to be arrested, even before the jury have found their ver- dict.1 The office is regulated by common law, and also partly by forty-nine statutes, beginning with 1275 and ending with an act of 1882. Functions of the Coroner.-The powers of this magistrate were formerly much more comprehensive than at present. In addition to the duty of holding inquests upon the bodies of persons found dead from violent, sud- den, suspicious, or unknown causes, he was also charged with the duty of inquiries concerning incendiary fires, shipwrecks, treasure trove upon land and sea, including whales and sturgeons cast upon the shore, and deodands. Any personal chattel, animal, or thing, forfeited to the King for pious uses, on account of its having caused the death of a human being, was termed a deodand (deo dandum). Blackstone traces the custom back to Greek and Jewish laws, which required the destruction of any- thing which caused a man's death, the notion of the punishment of the animal or thing being implied. Certain peculiar distinctions existed in relation to deodands, as, for instance, between objects in motion and others stand- ing still. If a horse or other animal in motion killed any one, either infant or adult, or if a cart ran over him, it was forfeited as a deodand. If death was caused by falling from a cart, or a horse at rest, the law made the chattel or animal a deodand, if the person killed were an adult, but not if he were a child. If death was caused by a thing not in motion, that part only which was the immediate cause of death was forfeited. If one be climb- ing upon the wheel of a cart, and is killed by falling off, the wheel only was a deodand. If the cart be in motion and run over some one, the whole cart and its burden also are forfeited. Similar distinctions prevailed with refer- ence to vessels at anchor and under sail? The finding of a jury was necessary, not only to de- termine the facts, but also the value of the chattel which was thus decided to be a deodand. The nature and value of the weapon or chattel must be distinctly stated. This singular custom became deservedly unpopular, and juries interfered with the action of so unjust a measure, until the act of 1846 (9 and 10 Victoria, c. 62), provided that there should be no forfeiture of any chattel for, or in re- spect of, the same having caused the death of a man ; and no coroner's jury sworn to inquire, upon the sight of any dead body, how the deceased came to his death, shall find any forfeiture of any chattel which may have moved to, or caused the death of the deceased, or any deodand whatever; and it shall not be necessary, in any indictment or inquisition for homicide, to allege the value of the in- strument which caused the death of the deceased, or to allege that the same was of no value? CORONER, An officer existing among English-speak- ing nations, whose chief duty is the investigation of cases of violent, sudden, or suspicious death. The early history of the coroner's office is involved in obscurity. Its origin has usually been attributed to the Saxon period of English history, but some of the ancient customs connected with it would seem to indicate an earlier origin. It is known to have existed as early as the reign of King Alfred (871-900). Both this office and that of sheriff are apparently as old as the civil division known as the county, or shire. This arbitrary division, peculiar to English-speaking nations, was evidently of earlier date than the kingdom itself, the latter being com- posed by the aggregation of the former, which constituted petty kingdoms in themselves, the counties being made up of subdivisions (hundreds) of still earlier origin. The name of the office was derived a corona, since the coroner was at first a royal officer. For many centuries county coroners have been elective officers. The right of the counties to elect their own coroners is confirmed by the Statute 3 Edward I., 10. Municipal boroughs also elect their own coroners. Certain franchises also have coroners of their own, within whose precincts the county coroner cannot act. In such places the coroner is ap- pointed by the lord of the manor, and in one English franchise the coroner holds office by hereditary right. There are fifty-five franchise coroners, and one hundred and seventy-five coroners acting for counties, or parts of counties. These are very unequally distributed. Middlesex, with about three million inhabitants, includ- ing the populous part of London, has five coroners, while 302 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cornu Cutaneum. Coroner. With the numerous accidents constantly occurring at the present day, on sea, and on land, on railways, horse- cars, steamers, and other conveyances, such a law would be productive of great inconvenience and obstruction to public travel.2 Appeals of wounds, rape, and mayhem were also com- mitted to the coroner. Many of these functions have be- come obsolete, and with the exception of his assumption of the powers of the sheriff, in the event of that officer's ab- sence, or his inability to act in consequence of a criminal action against himself, the coroner's duty is mainly that of inquest upon the bodies of persons found dead. In England at the present day this duty is limited to cases of death by violence, deaths of persons in prison, and deaths by sudden or unknown causes. It is also cus- tomary to hold an inquisition in the case of a suicide or felo-de-se. The term is nearly synonymous with suicide. It has, however, occasionally a more restricted significa- tion, when applied to " any one who commits an unlaw- ful malicious act, the consequence of which is his own death, as if, attempting to kill another, he runs upon his antagonist's sword, or shooting at another, the gun bursts and kills himself." For many centuries it was the cus- tom in England to bury each felo-de-se on the highway with a stake driven through the body. This ignominious form of burial was abolished in the reign of George IV., by an act of Parliament which ordered the burial of the body of a felo-de-se within twenty-four hours after inquest, between the hours of nine and twelve at night, and with- out the rites of Christian burial.2 An inquest must be held with, or in presence of, a jury consisting of twelve men. It must also be held super visum corporis; that is to say, the body must be seen both by the coroner and by the jury. The jury are sworn by the coroner, and are then charged to inquire how the de- ceased came by his death. Witnesses are also examined under oath, and the coroner has power to order an au- topsy, and the attendance of medical witnesses. The finding of the jury (verdict) is recorded on parchment, and is attested by the signature and seals of the jury and of the coroner. If, on such finding, any one is found guilty of murder or manslaughter, the coroner commits him to trial, and the accused may be indicted on the in- quisition without any presentation before the grand jury. Practically, an independent inquiry is always held before a justice in the ordinary way.1 Other Modes oe Inquiry.-Neither the coroner nor his jury exist among the continental nations of Europe, and the modes of procedure in the case of bodies found dead by violence or unknown causes, in all continental countries, and in Scotland, agree in the absence of these officials. In France the investigation is conducted by two offi- cers, whose functions are entirely distinct, a legal and a medical officer. The former, the procureur de la repub- lique, an officer somewhat analogous to the district at- torney, takes the initiative in each case, proceeds to view the dead body, summons witnesses, and takes the evi- dence. Liberal power is granted to him, and he can seize articles, or papers, connected with any crime, restrain persons from leaving the premises, and employ experts and detectives, as the case may require. In the latter direction the French system is, beyond question, an unusually efficient mode of procedure. The other officer, the medical, is selected for his supe- rior training and knowledge, and has charge of the med- ical examination of the body. Sometimes two medical officers are employed. The medical. officer is also still further associated with the subsequent prosecution of suspected parties, when the legal officer has decided that a crime has been committed. His report must be signed by a police official and submitted to a magistrate. If the evidence presented to the magistrate is deemed sufficient, an indictment is prepared for the cour d'appel, and a trial may then take place before a jury.3 In Scotland the process employed is similar to that of France. The procurator-fiscal, who has the investigation in charge, has for his guidance a code of instructions drawn up by the lord-advocate. This code also gives de- tailed directions to the medical men who have the charge of the medical examinations, two medical officers being employed in each case. The reports of these officials are sent to the office of the crown-agent at Edinburgh, and by him are transmitted to the advocate-depute. If he de- cides that there is suspicion of crime, he refers the report back to the procurator-fiscal for further investigation. If he is in doubt, he may bring the case before the crown officers. Beyond this, a criminal trial is much the same as in England.4 In Germany there is neither coroner nor any analogous officer, nor a jury, on the preliminary investigation. A judicial officer has charge of the proceedings (Staats- anwalt). His powers are like those of a district attorney. The police are under his control in all matters relating to the investigation of crime. They are also bound on their own part to investigate suspected crimes, cases of sudden or violent death ; and no interment is allowed in such cases till after the consent of the district attorney or a com- petent court is obtained. Medical officers are regularly appointed to make autopsies and medical examinations, and report upon them. The German code of regulations as to the modes of procedure in examinations of bodies, both judicial and medical, is very explicit. If the dis- trict attorney believes that a crime has been committed, he institutes a trial, and if the court believes that suffi- cient reasons are presented, it orders a preliminary in- quiry (gerichtliche Voruntersuchung) before a justice, the result of which is usually decisive. (Law of October 1, 1879.) In Russia the law is similar in its provisions to that of France. In Denmark the system is also very efficient, a judicial officer being appointed who has charge of all cases, which he decides without the intervention of a jury. He refers all medical questions to a medical officer who is appointed for the purpose, and reports to the judge the result of his examination, and autopsy, if one is made. He also makes a similar report to the Royal Bureau of Health. The trial which follows, in case of indictment, is first before the county judge, from whom appeals may be made to higher courts.3 United States.-The laws relating to inquests in the United States, all bear the marks of English origin, and were evidently introduced by the early settlers, with most of the peculiarities of the English law, though stripped of some of the singular customs of early times. The coroner, the coroner's jury, and the inquest, exist in nearly all of the United States, at the present time, practically in the Eng- lish form. Massachusetts made a radical change, abol- ishing the office of coroner, and also the jury, in 1877, since which time inquests have been conducted with greater care and economy, and to the entire satisfaction of the people and of the State (see Medical Examiner Sys- tem of Massachusetts). Connecticut and Rhode Island have also recently enacted similar laws, of a less radical nature. In the other States there are certain points of difference, chiefly of minor importance, relating to the functions of the office of coroner, the mode of his election or appoint- ment, his fees, the number of the jury, and the employ- ment of medical officers. Some of the singular provisions of the English law rel- ative to the vicarious duties of the coroner, were intro- duced into the early colonial statute-books, and are still retained in nearly every State of the Union. Instances, however, in which the coroner officiates as a sheriff are of rare occurrence. The chief function of the coroner in all of the United States, as in England, is the holding of inquests upon the bodies of persons found dead, either from violent, suspicious, or unknown causes ; and while there is consid- erable variability in the definition of this function by the statutes of different States, the intent or spirit of the law is evidently similar in all. In Massachusetts, under the old law, the coroner was authorized to hold inquests on the bodies of such persons only as were "supposed to have come to their death by violence," a special provision 303 Coroner. Corpus Striatum. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. requiring an inquest in every case of death by railroad accident. In California, and in several other States, it is specified that inquests may be held upon the body of ' ' any person who has been killed, or has committed suicide, or has suddenly died under such circumstances as to afford a reasonable ground to suspect that the death has been oc- casioned by the act of another by criminal means." In a few States an inquest may be held in the case of a person who is seriously wounded, and in imminent danger of death. In Alabama, in addition to the usual duties, it is re- quired that the coroner shall be keeper of the jail when the sheriff is imprisoned, and when the coroner is im- prisoned a special coroner may be appointed. He also performs the duty of sheriff when required, as provided under the English law. In Kentucky inquests may be held in cases of house- breaking. In several of the Southern States the coroner is a conservator of the peace, and is required to suppress riots and disturbances, and may apprehend and commit felons and traitors. In Mississippi the coroner is also the county ranger, and performs the duties of that office. The modes of election in the different States are quite diverse. In Alabama, Arkansas, Colorado, Kansas, Louisiana, Minnesota, New Jersey, North Carolina, Ohio, Pennsylvania, and South Carolina, the coroner is elected by the inhabitants of the county. In Tennessee he is ap- pointed by the county court. In Virginia a county court may nominate two persons, one of whom the governor appoints to be a coroner. In Illinois, Indiana, and Maine the governor appoints the coroner. In Texas, Vermont, and West Virginia, the office of coroner is unknown, a justice of peace acting in all cases in which the presence of such an official is required.5 The fees of coroners are also varied. In New Hamp- shire the fee for holding an inquest is $1.50. In some States it is $5, in others $10. The fees for recording, for mileage, and other items also present a wide range of variation. In some States physicians are regularly appointed to perform the necessary examinations for coroners. In others the coroner selects any physician whom he may choose for each case requiring such assistance. The compensation of physicians thus employed ranges from $6 in Minnesota, to $50 in other States, for an autopsy, and $100 in Mississippi, in cases where the body is ex- humed.5 In several cities of the United States, the coroner is a salaried officer, such being the case in New York, Phila- delphia, Charleston, Wilmington (Del.), and other cities, a plan which has obvious advantages. The requisite number of jurors is usually either six or twelve. In New Hampshire it is limited to three, in Louisiana five, and seven in Tennessee. Samuel W. Abbott. 1 Chalmers, M. D. : Local Government. London, 1883. 3 Encyclopedia Britannica. Ninth edition, vols. vi., vii., and ix. 3 Bell, Clark: Bulletin of the Medico-Legal Society of New York, Jan- uary, 1881. Art. The Coroner's Office. 4 Maclagan, Douglas, M.D., F.R.S.E. : Forensic Medicine from a Scottish Point of View. Edinburgh, 1879. 6 Lee, JohnG,, M.D. : Handbook for Coroners. Philadelphia, 1881. structure to the optic lobes of frogs, birds, and fishes. These ganglia are not the centres of consciousness of visual impressions, but rather centres of co-ordination between retinal impressions and the movements of the iris. If one optic lobe be destroyed, blindness of the op- posite eye results, though contraction of both pupils may occur after unilateral injury. In the rabbit, destruction of one anterior tubercle (nates) causes blindness of the opposite eye, with degeneration of its optic nerve ; while conversely, destruction of one eye causes atrophy of the anterior tubercle of the opposite side. Besides their relation to sight, the optic lobes and cor- pora quadrigemina have other functions. Cayrade, Goltz, Ferrier, and McKendrick have proved that lesions of the optic lobes produced disturbances in the harmony of movement and in equilibration. Ferrier's experiments on rabbits showed that disorganization of the corpora quadrigemina caused not only blindness with dilatation and immobility of the pupils, but also marked disturb- ances of locomotion and equilibrium. The same results were obtained in a monkey when the anterior tubercles were destroyed by cautery. Ferrier sums up as follows : " The most prominent effects, therefore, of destructive lesions of the optic lobes, or corpora quadrigemina, in the various animals experimented upon, seem to be blind- ness, paralysis of irido-motor and some oculo motor re- actions, disorders of equilibrium and locomotion, and in frogs, and apparently in other animals, annihilation of certain forms of emotional expression." On the other hand, irritation of the surface of an an- terior tubercle in the monkey causes dilatation of the op- posite pupil, followed by dilatation of the pupil of the same side. The eyeballs are directed upward and to the opposite side, and the head is turned in the same direc- tion. If the irritation be continued, a tetanic condition of the muscles is gradually produced, and finally, opis- thotonus. Irritation of the posterior tubercles produces the same effect, but with the addition of a cry. In man the lesions of the corpora quadrigemina may be divided into two classes : 1, those-resulting from path- ological changes in the blood-vessels, or interruption of the blood-current, haemorrhage, thrombosis, or embolism, and, 2, tumors. Haemorrhages, or areas of softening limited to the corpora quadrigemina, are extremely rare. Reynolds's case,- referred to by Bastian, who, however, says "other cases of the kind are on record," seems to be the only one of any value up to the present time, and this is so scantily reported that no satisfactory conclu- sions can be drawn from it. In it blindness was a prom- inent symptom. Tumors of the corpora quadrigemina are more com- mon. Bernhardt has collected eleven cases. Nothnagel describes seven at length. As is evident, however, con- clusions arrived at from the study of these can only be accepted as hypothetical, or as probabilities at the best. The tumors are rarely so limited as not to extend beyond the boundaries of these organs, and even when they are so, they frequently exert pressure, and act as disturbing influences upon the neighboring parts. Again, when these organs become the seat of new growths we cannot always be sure, without the most careful micro- scopical examination, how far their working tissue is it- self destroyed, and how far it is merely pushed aside. In spite of these difficulties the following conclusions may be considered probable. The symptoms dependent on lesions of the corpora quadrigemina vary according as these are situated in the anterior or posterior pair. Disease of the anterior pair is almost always accopipanied by diminution of sight or blindness, and in these cases the blindness often precedes the development of an optic neuritis. The diagnostic value of amaurosis can only be formulated as follows: If, together with an acute amaurosis (and loss of pupillar reaction), other symptoms of a limited cerebral disease exist, and at the same time the ophthalmoscopic exami- nation is negative, we may assume the participation of the anterior corpora quadrigemina (Nothnagel). In lesions of the posterior pair we may have paralysis or paresis of the oculo-motor nerve, usually limited to a CORPORA QUADRIGEMINA, LESIONS OF. In dis- cussing the lesions of the corpora quadrigemina in man our material is so scanty, and it is so often impossible to distinguish between the results due to injury of one por- tion of the brain from those due to the destruction or ir- ritation of neighboring parts, that we are forced, for the sake of a clearer understanding of our subject, to .pay more attention than is ordinarily justifiable to the results of experimental research upon the lower animals. That the facts tiius obtained can only be applied to man with great reserve, and that they can only serve to support de- ductions derived from actual clinical observation, is plain. They may, however, aid in directing our observation in special directions and in giving a greater weight of prob- ability to certain conclusions. The corpora quadrigemina of mammals correspond in 304 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Coroner. Corpus Striatum. few branches only. This need not occur, and its exist- ence is of no diagnostic value. If, however, we have a bilateral lesion of single homologous branches of the oculi motores, especially if no alternating paralysis of the extremities exists, we are justified in localizing the lesion as in all probability in the corpora quadrigemina. It is, moreover, probable that a lesion of one of these bodies alone is sufficient to produce an affection of both eyes ; hence Nothnagel has formulated provisionally the follow- ing proposition : If the symptoms of a limited unilateral lesion exist, and at the same time a paralysis of one or several homologous branches of the oculo-motor in both eyes, we can diagnosticate an affection of the posterior corpus quadrigeminum. In regard to the condition of the pupils, nothing exact can yet be stated. They are described as in different con- ditions in the different cases-in some dilated, in some contracted, in others of medium size. In lesions of the anterior pair their reaction seems to be lost. There is little doubt but that lesions of the corpora quadrigemina readily produce disturbances of the equilib- rium and of co-ordination in man , but as yet we are not in a position to determine definitely whether these are actu- ally due to injury of these organs themselves, or whether they are not rather produced by coincident affections of the cerebellum. The latter view is favored by the fact that these disturbances calnnot be distinguished from those caused by cerebellar lesions, and by Bernhardt's statement that the reeling gait is absent when the pressure of the tumor is exerted anteriorly only; but that it occurs when the growth extends backward to the fourth ven- tricle and the middle region of the cerebellum. Other symptoms have been referred by certain authors to injury of these bodies, but the weight of evidence is in favor of another cause for their existence. ities, but in the remaining part they are more or less widely separated from one another. We cannot finish the description of the corpus striatum without adding that of a very important band of white fibres, very closely related with it, the internal capsule. This is really the base of the corona radiata, where its fibres, pressed together in compact form, are passing to- ward the crus cerebri. The internal capsule is usually described as consisting of two parts-an anterior, lying between the anterior part of the lenticular nucleus and the nucleus caudatus,' and a posterior, between the optic thalamus and lenticular nucleus. The latter is much the larger division. The two unite with one another at an obtuse angle, which point of union is termed the knee of the internal capsule. Physiology.-Meynert describes the corpora striata as internodes in the projection system, as receiving fibres from the cortex of the hemispheres, and sending fibres into the internal capsule. But Wernicke believes that fibres of the corona radiata do not become united with the corpora striata; that the third, or outer and largest division of the nucleus lenticularis and the nucleus cau- datus are, just as the cortex, primary centres, sending out fibres which enter into or pass through the inner divisions of the nucleus lenticularis, and finally enter the internal capsule. It cannot be doubted that the corpora striata have in- timate relations with the motor tract, and they are deemed to be motor ganglia. Nevertheless we do not know their exact functions, their direct relationship to motor mani- festations. Observations on man have shown that par- tial destruction of these ganglia may occur without any manifest symptoms. Their extensive injury is always attended by motor paralysis, but where there is extensive injury the internal capsule is always likewise affected. Indeed, the careful analysis of a large number of obser- vations leads to the conclusion that lesions in this part only produce permanent paralysis when fibres of the in- ternal capsule are involved. The cortico-muscular tract, or the fibres conducting voluntary impulses, pass through the internal capsule. Flechsig, by means of his studies of the development of the nervous strands in the central nervous system, has localized this tract in the middle third of the posterior di- vision of the internal capsule. But Charcot, from patho- logical observations, believes that the tract occupies the anterior two-thirds of the posterior division. It is prob- able that the fibres conducting voluntary impulses to the muscles of the face and head pass through the knee of the internal capsule, or its anterior division. The pos- terior third of the posterior division contains sensory nerve- fibres. Pathology.-The corpora striata are frequently the seat of haemorrhage or softening, and occasionally, though rarely, tumors are found in this part. The larger number of cerebral haemorrhages of spon- taneous origin, or so-called apoplexies, occur in these ganglia or their immediate neighborhood. Spontaneous rupture of blood-vessels of the brain is due to the presence of miliary aneurisms, and these are found most frequently in the arteries entering the anterior perforate space, that is, the arteries supplying the large ganglia. For this reason, and on account of the height of the blood-press- ure in these vessels, haemorrhage occurs so frequently in this part. One of these arteries, of large size, supplying the anterior part of the corpus striatum and internal cap- sule with nutrient fluid, is so frequently the source of haemorrhage that it has been termed by Charcot the artery of cerebral haemorrhage. The haemorrhagic effusion is sometimes slight, some- times quite extensive, even leading to a perforation of the ventricles. The gray matter, being of softer consis- tency, is usually injured to a much greater extent than the white matter, and it is probably due to the fact that the latter escapes extensive injury, that haemorrhage in this locality often causes no permanent symptoms. Embolism or thrombosis in the arteries of the corpus striatum is not uncommon, though less frequent than hae- morrhage. These arteries are so-called terminal or end Bibliography. Bastian : Lancet, July 25. 1874. Bernhardt: Beitriige zur Symptome u. Diagnostik der Hirngeschwulste. Berlin, 1881. Ferrier : The Functions of the Brain. London, 1876. Ferrier : Glioma of the Right Optic Thalamus and the Corpora Quadri- gemina. Brain, 1882, V. 123. Nothnagel: Topische Diagnostik der Gehirnkrankheiten. Berlin, 1879. Putzel: In Supplement to Ziemssen's Cyclopaedia. New York, 1881. Ross: Diseases of the Nervous System. New York, 1883. William N. Bullard. CORPUS STRIATUM. Anatomy.-The corpora stri- ata are the most anterior of the large ganglia, or masses of gray matter at the base of the brain. They lie for the greater part in front and on the outer side of the optic thalami. Each corpus striatum is composed of two parts, the nucleus caudatus, or intra-ventricular nucleus, and the nucleus lenticularis, or extra-ventricular nucleus. The nucleus caudatus, a large part of whose surface is exposed on opening the lateral ventricle, consists of a large anterior extremity, the head, and an attenuated posterior, the caudate extremity. The anterior extremity borders on the median line, its under surface correspond- ing to the anterior perforate space, while the posterior extremity is farther from the median line, being external to the optic thalamus. The whole is in the form of an arch, nearly corresponding to the arch of the hemisphere, and encircles, as it were, the internal capsule. The len- ticular nucleus lies external to the caudate nucleus, and is of a larger size. Its form is somewhat like that of a wedge, its edge lying internally, its base externally, and the latter almost corresponding in size with the island of Reil, from whose cortical layer it is separated by the ex- ternal capsule. It is divided into three parts by bands of white fibres which run parallel with its external surface, the stria medullares. These parts are named from within outwardly, the first, second, and third divisions. The inner divisions are lighter colored than the outer, partly from some difference in the structure of the gray matter, but chiefly from the number of fibres passing through them to the internal capsule. The nucleus caudatus and nucleus lenticularis are blended together in their anterior and posterior extrem- 305 Corpus Striatum. Cosmetics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. arteries ; they do not anastomose with other vessels. Their occlusion, therefore, causes softening of the area supplied by them. Symptoms.-In some cases lesions of the corpus stri- atum produce no symptoms. In others there is very slight paralysis, very limited in extent, its exact character depending on the locality of the lesion. In such instances the symptoms are the direct expression of the damage which has been done, and may, therefore, be termed direct symptoms. They indicate that certain functions are lost, either because their centres were destroyed, or because the nerve-fibres connected with those centres were severed. But we often find other and much more marked symp- toms attending lesions of the corpus striatum, symptoms not caused by the local damage of the nervous tissue, but due to distant effects of the lesion. Such symptoms we may term indirect symptoms. They are especially severe in cases of haemorrhage at the time of its onset. This is because the sudden escape of blood into the tis- sues, with a force almost equalling the blood-pressure within the artery at the point of rupture, produces an effect like that of a blow on the entire brain, or, at least, on a large part of it in the neighborhood of the haemor- rhage, and thereby robs that part temporarily of its functions. Indirect symptoms are more or less pro- nounced according to the size of the lesion, and, especi- ally, according to the intensity of the onset. As the parts are only temporarily deprived of their functions, such symptoms are transitory. They pass away quickly if they are dependent on the involvement of parts quite dis- tant from the lesion. They pass away slowly if the part, by whose indirect involvement they are produced, is very near the lesion. In describing symptoms we must, therefore, speak of early and late symptoms. Of the former some disappear much sooner than others. Of most of those which do disappear we may confidently aver that they are not directly due to injury of the corpus striatum. On the other hand, the late or permanent symptoms are, for the greater part, directly due to the local damage, and are, therefore, indicative of the functions of these parts. The symptoms of haemorrhage into the corpus striatum are those usually found with cerebral haemorrhage. In the most severe forms there is, in addition to complete unconsciousness, a flaccidity of all voluntary muscles. When the attack is not quite so severe, only one-half of the body is paralyzed, the half opposite to the seat of le- sion ; in other words, there is hemiplegia. There is often at the same time conjugate deviation of the head and eyes toward the unparalyzed side. In severe cases there are also frequently present irregular or difficult breath- ing, great changes in the temperature and pulse, and al- terations in the urine-increased quantity, with dimin- ished specific gravity, and sometimes the presence of sugar and albumen. These symptoms are mostly indirect, and, therefore, transitory. The last mentioned, changes in temperature, urine, pulse, and breathing, are probably dependent on the indirect involvement of the medulla oblongata, and are, usually, of short duration. The paralysis of the muscles on the same side as the haemorrhage is due to in- direct involvement of the opposite hemisphere, and is of but a few hours' or days' duration. The conjugate de- viation of the head and eyes cannot be so easily ex- plained, but is also a very transitory symptom. These symptoms are of special significance in prognosis, as they indicate the existence of a severe haemorrhage, and, therefore, that life itself is in immediate danger, or, at least, if the patient live, that a high degree of paralysis will remain. When consciousness returns-which usually occurs, if at all, within a few hours or days-other symptoms are observed. The most prominent are, loss of sensibility on the paralyzed side, hemianaesthesia, impaired vision in one-half of the field, the paralyzed side, which is of very short duration, and difficulties of speech. The hemianaesthesia is usually an indirect symptom, due to indirect involvement of the posterior part of the internal capsule. But, inasmuch as the latter is in close proximity to the seat of the lesion and is, therefore, more decidedly affected than the distant parts, the hemianaes- thesia is usually of much longer duration than the other indirect symptoms which have been mentioned. In some, but less common, instances the lesion, being in the posterior part of the corpus striatum, may directly implicate the most posterior segment of the internal cap- sule. In such case the hemianaesthesia would be a direct symptom, and, to a greater or less degree, durable. It may also be accompanied by impairment of the special senses, these being affected on the anaesthetic side. Very frequently, after the restoration of consciousness a loss of speech, aphasia, is observed. If only the corpus striatum has been injured, the aphasia is an indirect and, therefore, a transitory symptom. The seat of speech in right-handed persons is in the left hemisphere, and speech is, therefore, far more frequently lost with lesions of the left than with those of the right hemisphere. But a se- vere haemorrhage on the right side (in right-handed per- sons) may produce indirect aphasia. In this case, if the patient recover, the aphasia is of very short duration. Articulatory disturbances from paresis of the tongue, etc., are far more common than aphasia. Even in this respect lesions of the left hemisphere seem to produce more marked disturbances than those of the right. Ar- ticulatory disturbances also usually disappear at an early date, but in some instances some indistinctness of speech remains permanently. When the haemorrhage is only a small one there may be only motor symptoms, symptoms like those which, after a more extensive lesion, are likely to remain permanently. The late or permanent symptoms are mainly motor symptoms, those of hemiplegia. In the beginning, often all the voluntary muscles of one side of the body are affected, those of the trunk as well as of the face and extremities. But the muscles of the trunk soon regain their power. Of the facial muscles, those supplied by the upper branches of the seventh nerve, the orbicu- laris palpebrarum, etc., are very slightly affected. There may be a condition of paresis in the beginning, but even this passes off in a few days. Paralysis of the muscles supplied by the lower branches of the seventh nerve is often permanent. The face is drawn to one side, or, if not so well marked, the angle of the mouth on the paralyzed side hangs lower than the other. When the paralysis of the muscles is very slight it becomes mani- fest when the patient smiles, tries to whistle, etc. In the beginning the tongue is usually affected. When protruded, the tip deflects from the median line toward the paralyzed side. This paralysis often disappears in a short time. The upper extremity is generally more profoundly par- alyzed than the lower, and, in case of recovery, is slowest to improve. The movements of the hand are more impaired than those of elbow and shoulder ; those of the foot more than those of knee and hip. In fact, we gen- erally find that the most complex movements, those most completely under voluntary control, are most af- fected. Perhaps in the simpler movements, those of the chest in breathing, of the eyelids, etc., each cerebral hemi- sphere has a certain control over the muscles of both sides, and, therefore, paralysis of those muscles after a one-sided lesion soon disappears. At least this must be true of the muscles which control the movement of the eyeballs, the act of swallowing, etc., for only in the rarest instances does a one-sided lesion produce disturbances in these parts. In cases of incurable paralysis we often find what is termed late rigidity in the paralyzed parts. The muscles are contracted and rigid, and, when the condition is ex- cessive, maintain the limbs constantly in a fixed position. Often the condition is not so marked, especially at an early period; it is then most noticeable with voluntary efforts, or in states of excitement, while it may be en- tirely absent during sleep. It is generally more marked in the arm than in the leg, and, though the position va- ries, we most commonly find the upper extremity flexed, the lower extended. Late rigidity is always an unfavorable symptom. It 306 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Corpus Striatum. Cosmetics. tells us that the paralysis, at least to some extent, will re- main permanently. Post-mortem examinations in such cases reveal descending degeneration of the pyramidal tracts, that is, the tracts of nerve-fibres conveying im- pulses to the voluntary muscles. This degeneration can be traced through the crus cerebri, medulla oblongata, and spinal cord. It is probable that the muscular rigidity is produced through the degenerative changes, causing secondarily a condition of irritation in the ganglion-cells of the anterior cornua of the cord. Secondary degeneration of the pyramidal tract, and probably late rigidity, have only been found where the internal capsule was injured. Lesions limited to the gray matter of the corpus striatum do not produce this change. With the late rigidity there is always associated ex- cessive tendon reflexes ; the patellar reflex is in excess, the foot clonus is present, etc. The heightened reflexes usually precede the development of late rigidity; they may be present a few days after the occurrence of the 16sion, while the muscular rigidity does not become mani- fest for weeks or months. For this reason the state of the tendon reflexes is often of much prognostic signifi- cance. It may at a very early period lead us to make an unfavorable prognosis, which the later appearance of muscular rigidity will verify. In very rare instances a monoplegia seems to result from a lesion in the corpus striatum ; the face, or the ex- tremities have alone been paralyzed. Not a sufficient number of exact observations of this kind have been made to enable us to make exact diagnoses. But it is probable that lesions limited to the knee,.or, possibly, the anterior division of the internal capsule, produce facial paralysis ; those limited to the anterior two-thirds of the posterior division produce paralysis of the extremities. Cases have been reported in which the hemiplegia oc- curred on the same side as the lesion. But until we have further evidence on this point, such reports must be looked upon with distrust. Other symptoms-hemichorea, paralysis of the vaso- motor nerves, etc.-are found with one-sided lesions. Their cause is not yet well understood, but it is not prob- able that they have any direct relation to lesions of the corpus striatum. Some symptoms which occur at an early period, after severe cerebral lesions, malignant de- cubitus, and inflammation of joints, are also little under- stood. They are evidently dependent on the brain lesion. But they have for us as yet no local significance. The symptoms of softening of the corpus striatum are usually less severe than those of haemorrhage. The oc- clusion of arteries the size of those entering the anterior perforate space does not generally cause an apoplectic stroke-in other words, does not materially affect distant parts of the brain. The symptoms are, therefore, only the expression of the local injury. The symptoms of tumors, when limited to the corpus striatum, are often vague. On account of their slow growth the tissues may be crowded aside rather than de- stroyed by them, and thus no decided local symptoms be produced. They often cause the common symptoms of brain tumors-headache, vomiting, and double optic neuritis. Treatment.-Little need be added on this subject, as the treatment of the lesions of the corpus striatum is like that of cerebral haemorrhage, softening, or tumors in general. To ward off threatened apoplectic attacks, the avoidance of stimulants and all excitement, rest, keeping the bowels freely open, and sometimes general or local blood-letting, are the most valuable measures. Specific medication is demanded if the danger be from syphilitic endarteritis. When an apoplectic attack has already oc- curred, the same measures, especially absolute rest with the head elevated, cold applications to the head if hot, and often cathartic medication, are indicated. In the treatment of the hemiplegia faradization is often valuable in restoring the power of the paralyzed muscles. In the treatment of brain tumors, iodide of potassium promises the most benefit. Even when the neoplasm is not of a syphilitic character, marked improvement often folio ws the administration of this remedy. Special symp- toms, headache, vomiting, etc., require their appropriate treatment. Philip Zenner. COSMETICS (Cosmeticos, from kosmeo, I adorn ; Syn., Cosmetica; Ger., Schoenheitsmittel; Fr., Cosmetique). It is not the author's intention to write down all the cosmetic preparations, or to enter into a complete history of those drugs used since the world began to embellish the vari- ous outward defects which human flesh is heir to. Women and men too'have had recourse to them from the earliest times, while many large volumes have been writ- ten about them. It was not a subject beneath the notice of Hippocrates, and the beautiful Queen Cleopatra found time to write a work of several volumes upon them ; so we consider ourselves justified in giving an outline of the subject at least. Under the heading of cosmetics we must place perfumes, preparations to embellish the skin, and hair-dyes. A knowledge of their use and abuse is important to the physician for curative as well as hygienic reasons. There is no prospect of a discontinuance of their use at present, and their abuse may be best remedied by the knowledge which the physician possesses of recommend- ing what is proper. The general statement of physicians, that " all cosmetics are harmful," shows great ignorance. Many skins have been irretrievably ruined by such an idea. It would be more proper to say * ' many cosmetics are useful," and then choose which they are. In the list given in this article, especial attention is alone called to those cosmetics which the author can recommend from experience in their use. Perfumes {Odoramenta ; Fr., Parfum; Ger., Duftmit- tel).-Perfumes are derived from plants, or are made ar- tificially. Some few, however, such as musk from the musk-deer, ambra from the sperm-whale, and civetta or zibeth from the zibet, are animal products. They are used to perfume garments and as a pleasant addition to applications for all parts of the body. The ethereal oils extracted from perfumes are irritating to the skin, and it is on this account that many highly scented preparations used to beautify are injurious. Their perfume depends upon ethereal extracts, and as these are irritating, it necessarily follows that the more highly scented and costly they are, so much the more are they injurious. The women of the demi-monde, who, as a rule, cannot afford the most expensive cosmetics, preserve their com- plexions to an astonishing degree by the use of many simple preparations, although from the necessities of their life they are forced to use them to an excess, and there- fore, notwithstanding the smooothness of their skin, they look unnaturally white or artificial. The finest perfumes are made from flowers, in the form of essences such as essential acacise, dianthi (clove-pink), resedae (mignonette), jasmini, narcissi, heliotropi, tube- rosae, violarum flor, aurantii. There is also the cologne water (aq. seu spiritus Coloniensis), which is, perhaps, the most popular of all. Cologne water serves as an ad- dition to many compound perfumes, and is used as prin- cipal ingredient. Almost all perfumes are compound products, which are named generally after the principal ingredient. For example, essence of musk (tr. musk, 4 parts ; ambrae, 2; spts. ros., 1); essence of patchouly (ol. patchoul., 5 parts; ol. rosar., 1; alcohol, 120); essence of lavender (ol. lavand. angl., 23 parts ; aq. rosar., 55 ; alcohol, 680) ; essence of violet root (rhiz. ireos., 4 parts ; spts. vini cone., 10; aq. rosar., 1), and many others the ingredients of which may be found in books of phar- macy. The aromatic vinegars-acetum cosmcticum seu aro- maticum-are popular and useful perfumes. One of these, the acidum aceticum aromaticum, is officinal. It is used principally for the filling of smelling-bottles, and as a rubefacient upon the skin. Similar to it is the acetum Britannicum, which is, however, much stronger, and con- sists of ac. acet, glac., 600.0 ; camphor, 60.0; ol. cary- ophyl., 2.0; ol. cinnam., 1.0; ol. lavand, 0.5. Then follows the so-called hygienic vinegar (made of ol. cary- 307 Cosmetics. Cosmetics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ophyl. et lavand., aa 4.0 ; ol. marjoram., 2.-0 ; ol. benzoes, 50.0; spts. vini, 500.0; ac. acet, cone., 1000 ; dig. et filtr.), as well as the well-known toilet vinegar-vinaigre de toilette-(consistingof bals. peruv., 2.0 ; vit. Hoffman, 30.0 ; tr. benz., 10.0 ; aq. Colon., 25.0 ; alcohol, 100.0 ; ac. acet., 20.0 ; aq. dest., 40.0). A simpler form, called Bully's toilet vinegar, consists of tr. benz., 1.0 ; ac. acet., 4.0 ; aq. Colon., 100.0 ; and while being less complex, is just as useful. Rose vinegar is a pleasant preparation, and is made by mixing one part of oil of roses in fifteen parts of concentrated acetic acid. The strength of some of these preparations must be remembered in using them, for otherwise too free an application produces a correspond- ingly intense result. Under the head of smelling-salts-sal volatile odoratum -are many preparations which are generally used in a solid or fluid state, in bottles or boxes. These should close tightly, as their contents soon lose their strength by evaporation. A certain amount of caution should be exhibited in their application, as cases of acute and chronic inflammation of the mucous membrane of the nose and eyes are on record from the too frequent or too prolonged use of a strongly loaded smelling-bottle. A gradual and lasting evolution of ammonia, which is the basis of most smelling-salts, is made by the mixture of equal parts of muriate of ammonia and slaked lime, scented with one of the perfumes. The celebrated so-called Preston, or English, smelling- salts consist of carbonate of ammonia impregnated with ethereal oils, such as oils of lavender or bergamot. Perfumes in the form of powder are now principally used to scent the clothes with. They are made up of aromatic substances, such as vanilla, tonka bean, orris, and vetiver root. The addition to them of the ethereal oils of other perfumes renders them much more odor- iferous, viz., ol. flor, aurant., ol. cort. aurant., rosar., amygdal. amar., aether., santali, patchouli, thymi, etc. They are put into small sacks, bags, or papers, and laid between the clothes. In past generations they were very much used by the beaus and ladies of fashion-at a time of our civilization when bathing was less often resorted to, and when bodily emanations were consequently less pleasant. Thus we read in Shakspeare : ative. Powdered almonds (mandelkleie), or almond meal, is a delightful preparation. It is the dried residue after the oil has been expressed. This powder or meal is either put into small tine muslin bags which are dipped into warm water and then applied to the skin, or it may be applied with the powder puff while the face is slightly moist after washing. For most skins it is beneficial, but in some cases it is too drying, the result being that the skin feels drawn and becomes scaly. This effect is, how- ever, rarely seen, for there are very few skins which are not rendered white, soft, and less sensitive by this prep- aration. Eau de cosmetique de Vienne is a pleasant and useful article, consisting of amygdal., 15.0, which are to be crushed and then mixed with aq. flor, aurant. et aq. rosar., aa 60. This mixture must be strained through muslin, pressed out, and to it added borax, 1.0 ; tinct. benz., 2.00. Mix one or two parts with water and use in washing. 2. Glycerine.-Glycerine is used very generally, either alone or as the basis of many cosmetics. It must be employed with some degree of caution, since its ap- plication to many skins is irritating. As a rule, when applied to mucous membranes, e.g., the lips, it is not beneficial. It may soothe for a w'hile, but it is not cura- tive. Upon some skins it burns like a blister. It is bet- ter to use it diluted, since in this way it is rendered less stimulating-a property it certainly possesses to a high de- gree. 3. Spirituous and Stimulating Washes.-Highly scented spirits of wine, under many impressive names, are advertised and used to preserve the complexion. A little whiskey or plain spirits of wine in three or four times as much water is just as useful. Cologne water diluted is very popular for keeping off or removing freckles, and in some instances is beneficial. It is, however, generally used in combinations, some of which will be mentioned further on. 4. Resins and Balsams. - Balsam of Peru, liquid storax, benzoin, and balsam of Tolu, serve a purpose among the cosmetics. The resinous tinctures form a milky fluid when mixed with w'ater. The most im- portant of this group is the well-known princess water (eau de princesse), modified by Hebra, and which is used in almost every household in Vienna. It is a most ex- cellent preparation and one which can be used without fear. Its especial efficacy lies in its -whitening qualities, in the prevention of sunburn, in the gradual removal of freckles, and stimulant action to the glands of the skin after a severe attack of acne, by which immunity from relapse is more surely established. There are two combinations known as princess water, one with and one without any metal. The reason for modifying one for- mula so that it contains no metal is obvious, since sulphur, which is so universal an application in skin troubles, forms with metals a black precipitate which peppers the skin black and renders it very unsightly. The two formulae are : (a) Talc. Venet. et magnes. carb., aa 15.00 ; tr. benz, et aq. Colon., aa 5.00 ; aq. rosar., 300.00. (6) Bismuth magist., 10.00 ; talc. Venet., 20.00 ; aq. rosar., 70 ; spts. Colon., 3.00. To this last formula may be added a small amount of white precipitate or bichloride of mercury, but a better combination of mercury is known as aqua cosmetica orientalis, consisting of aq. dest., 6000.00; hydrarg. bi- chlor., 35.00 ; album, ovarum num. 24 ; succi citri fruct. num., 8; sach. alb., 300.00. Aq. cosmet. orient, is use- ful in removing freckles. It is applied by wetting linen cloths with it and placing them upon the face. They must be kept wet. If a slow and less irritating action is desired it should be diluted thus: Aq. cosmet. orient., 5.00; aq. rosar., 100.00. 5. Alkalies.-The alkaline spirit of soap is the most important preparation of this group. Spiritus saponis kalinus is composed of sapo viridis, 30.00; spts. vini cone., 60.00; solut. filtr. adm. spts. lavand., 5.00. It is used for removing the epidermis when a stimulating ap- plication is desired. Vide books on skin diseases. "He was perfumed like a milliner, And 'twixt his finger and his thumb he held A pouncet-box, which ever and anon He gave his nose, and took't away again ; . . . for he made me mad, To see him shine so brisk and smell so sweet." Some of the compound powTders, besides perfuming, are useful in keeping moths from woollens and furs. Such a one is known as vetiver powder, or perfume, and consists of pulv. rad. vetiver, 500.0; lign. santal., 250.0; ol. thymi et rosar., aa 0.5. Sachet d'iris is a pleasant perfume, and consists of equal parts of powdered orris root and acacia flowers. But let us now turn to those preparations which are cosmetics in the ordinary sense-those which are used to beautify or correct defects of the skin. As has been done in other articles of this nature, it has been consid- ered best to divide them under different heads, so that an easy reference may be possible. It is needless to say that their number is legion, but it is the author's plan to choose the representatives of each class rather than to enumerate all. 1. Emollients (Emollientia).-First in this list comes the officinal ung. emolliens, known as cold cream or creme celeste, which may be scented with any of the ethereal oils extracted from roses, violets, jasmin, etc. The sim- ple cream without perfume is the best, and for some skins nothing can take its place when they become rough and chapped. Cacao cream and vaseline are pleasant appli- cations, but the latter is not always useful, since upon some skins it produces an acne or an irritation which is unpleasant to a high degree. A popular dermo-cosmetic in Europe-more especially in Vienna-is made of al- monds. They are used in powrder, paste, or emulsion, and are for many skins very soothing, softening, and palli- 308 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cosmetics. Cosmetics. Many of the highly scented toilet soaps are irritating to the skin, for the reasons already given. Highly colored soaps are colored red with cinnabar, blue with smalt or ultramarine, brown with caramel or very finely ground cacao. The pure solid and fluid glycerine soaps are ex- cellent, and generally suit the skin better than any other. A pleasant soap-like toilet preparation, known as Eau Athenienne, is composed of tr. quillaiae, 5.00 ; glycer., 30.00 ; bals. vitae Hoffman et aq. Colon, et tr. ireas. aS 40.00., to which may be added, if desired, essent. musk c. ambr., 0.20. This preparation is used for the re- moval of freckles, dandruff, and for cleaning the hair. Borax possesses antiseptic properties and enters into many cosmetics. Lotio cosmetica is composed of borax, 2.00 to 4.00 ; aq. rosar., 100.00 ; tr. benz., 1.00 ; and, when applied constantly to the face for some time, is recommended for removing freckles. 6. Sulphur.-Sulphur is used in almost all patent prep- arations for the skin. It is very useful in most forms of acne, either in combination with other drugs or alone in powder ; but no metals, especially lead, should be com- bined with it or used separately at the same time, on ac- count of the chemical combination which takes place as before mentioned. 7. Acids.-Organic acids, such as acetic and citric acids, are used for the removal of extravasations, black and blue spots, pigment spots, and other discolorations of the skin. They are mixed with spirituous or ethereal oil extracts, and are applied on linen or with a brush. Sali- cylic acid dusted under the arms and upon the feet is re- commended to correct the disagreeable odors which aff ect those parts in some people. It should, however, generally be diluted with some inert powder. Concentrated acids are used to remove warts from the hands and other parts. Fluid carbolic acid is considered the best for this purpose. 8. Iodine.-Preparations of iodine, tincture of iodine, iodine-glycerine, iodine collodion, are used to remove freckles and various pigment spots of the skin. They must be applied until the upper layer of the epidermis falls off. 9. Chlorine.-Preparations of chlorine, chlorinated lime and liq. natri. chlorati, are useful to correct the odor of the feet and axillae. The last preparation should be diluted with ten parts of water. 10. Alum.-Alum, 1 to 20 parts in aqua dest., 50, or alumacetat., 2 to 5 parts in aq., 100, are recommended for disagreeable odors, for red spots, for enlarged capillaries of the skin, and for red noses when caused by exposure to cold. Mixtures of alum and borax, alum, et borac., aa 2.00 ; aq. rosar., 150.00 ; tr. benz., 5.00, are also used and found beneficial in the troubles just mentioned. Finely powdered alum is also used by itself. 11. Zinc and Bismuth.-Preparations of these drugs -the oxide of zinc and subnitrate of bismuth-are useful for curing red spots and irritating eruptions. The sul- pho-carbolate of zinc has been found to remove freckles and other pigmentations. It is used in solution: zinci sulpho-carbol., 2.00 ; glycerin., 20.00 ; aq. rosar., 3.00 ; aq. Colon., 5.00 ; and also with collodium : zinci sulph. car- bol., 1.00 ; alcohol, 5.00 ; solut. adm. collod. dupl., 75.00 ; ol. citri, 5.00. This latter combination is called collo- dium anti-ephilidicum. It should be applied every night. 12. Mercury.-Mercurial preparations belong to the most efficacious ones we possess for the removal of spots, freckles, indurations, etc. They are, however, when used in too large quantities, or in too concentrated a form, in- jurious. They serve to remove pigment spots which are deeply seated in the cutaneous tissue, and on this account many patent medicines which are advertised for this pur- pose contain principally some preparation of mercury. The celebrated cosmetic wash of Gowland-liquor seu lotio Gowlandi-is composed of amygdal. amar., 10.00; ft. emuls. adm. solut. e hydrarg. bichlor., 0.10; amm. chlor., 0.20 in spts. vini et aq. laurocer., 1.50. It is ap- plied to the face and hands to whiten them. The aqua orientalis (Hebra), composed of hydrarg. bichlor., 0.05; emuls. amygd. amar., 300.0; tr. benz., 1.50, is a useful preparation, and is applied at night upon linen cloths. White precipitate, either alone (hydrarg. amm., 1.00; ung. cerci, 8.00) or combined with bismuth (hydrarg. amm. et bismuth subnit. aS 1.00; ung. simpl., 4.00), serves the same purpose and is used upon linen in the same way. The action of the salves is slower, but just as effective. Unna's ready-made white precipitate and gray plasters are pleasant preparations and supply the place of ointments, while they are much more agreeable to the patient. 13. Paints (blanc et rouge).-To render the skin white almond meal, corn meal, rice powder, starch, Venetian chalk, carbonate of magnesia, precipitated chalk, sulphate of baryta, oxide of zinc, bismuth, and carbonate of lead, are used. The meals, chalks, and magnesia are, as a rule, beneficial and grateful to the skin if they be applied after washing, and in moderate quantities. The other powders must be used with more care. Bismuth renders the skin white and smooth if sulphur be not used at the same time. It gives the skin an artificial slate color if used immoderately. Rouge-red paint-is made out of carmine, safflower (carthamus), or madder-root (rubia tinctorum). These drugs in themselves, when mixed with inert salves or powders, seem to be harmless; but their constant use, and the gradual increase in the quantities necessary to effect their purpose, render the skin un- naturally dry and rough. Berlin and indigo blue, mixed with talcum Venetum, are used to paint false veins or blood-vessels upon the face and other parts of the body. We come now to that subdivision of cosmetics in which are included those preparations used to embellish the hair and scalp. It is best to separate them into groups according to the purpose -which they serve. 1. Remedies for Dry and Split Hair.-Hair-oils and pomades are used for such troubles, and are made either of odorless oils scented with one of the perfumes, or of simple ointments treated in the same way. 2. Preparations for Rendering the Hair Pli- able (Fixateur des cheveux) are composed of a thin solu- tion of gum with the addition of borax or any of the alkalies, and are advertised to curl or crimp the hair without the hot iron. One of these compounds is com- posed of borax, 6.00 ; gummiarab., 1.00 ; aq. odor., 100.00; spts. camph., 30.00 ; another of gummi arab. et sach. alb., 1.50 ; aq. rosar., 100.00 ; aq. Colon., 10.00. The hair, when treated with these preparations, becomes sticky and can be put into almost any shape, but its natural lustre and gloss are gone. There are also many wax pomades for tlie hair, moustache, and beard. The fascinating spit-curl of former days is an example of what use they were put to. 3. Remedies for too Oily or Greasy Hair.-Such hair should be washed frequently with soap. It may be rendered very dry by powdering it at night, and combing the powder out in the morning. 4. Preparations for the Cure of Dandruff.- When there is much dandruff, there is always some trouble in the proper nutrition of the scalp which must be attended to. Certain drugs are beneficial if the trouble be local and not systemic. Borax, soda, spts. of soap, quinine, salicylic acid, tannic and gallic acids, sweet oil, castor-oil, various pomades made of simple cerate, vase- line, cacao butter, are a part of the many hair tonics re- commended by hairdressers. As they are usually or- dered indiscriminately, they are as likely to be injurious as otherwise. That they may serve a purpose when properly applied, cannot be doubted. 5. Superfluous Hair.-This may be removed tem- porarily by the use of the pincette, or by the application of certain caustics. The best of the latter class is composed of equal parts of caustic lime and golden pigment made into a thick paste with water. It should be left upon the skin until it begins to burn, and then removed. Elec- trolysis, which means the piercing the hair-follicle with a fine needle, and then connecting it with a galvano electric current, is the best method of permanently removing the hair. 6. Hair-Dyes.-It is not necessary to enter deeply into this subject. Most hair-dyes contain lead or nitrate of silver. The latter is not supposed to be injurious, since no cases have been reported of systemic poisoning 309 Cosmetics. Cotton. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from its use upon the hair. The former is very injuri- ous. The juice of green walnuts, pyrogallic acid, chlo- ride of iron, chloride of copper, preparations of bismuth mixed with sulphur, sulphate of copper in combination with nitrate of silver, permanganate of potash, tincture of the acetate of iron in combination with the tincture of galls, the tincture of chloride of iron with pyrogallic acid, and the many preparations of lead, are some of the numer- ous compounds used as hair-dyes. Peroxide of hydrogen has been used to render red hair blond, and is the prin- cipal ingredient of the well-known Golden Hair-Wash and Eau Fontaine de Jouvence. Its action is to remove rather than to add color. It is not, however, advisable to try to change the color which nature has provided, since it is better to keep what hair one has in its original hue, than to run the risk of losing it altogether by unhealthy applications. From ancient times internal remedies have also been tried for this purpose, but with no degree of success. It is a well- known fact, however, that hair changes color in a re- markable fashion in some cases. Thus black hair be- comes gray or white almost immediately, and, vice versa, gray hair may again recover its natural color. On some heads no two hairs are of the same shade, and each hair may vary at different points ; while at times it has been said to change regularly every month. But as we cannot explain how or why these changes take place, it is best to leave the facts for future investigators to unravel. Robert B. Morison. charges of chronic diarrhoea, the diarrhoeas of children, of phthisis, etc., and chronic dysentery. It does not appear to be poisonous, or, in the usual doses, to affect the circu- lation or nervous system. It promotes rather than hinders digestion and increases the appetite. It is eliminated by the kidneys. Administration.-Although not officinal, a tincture or fluid extract can be made if desired, but as cotoin it- self represents the best qualities of the bark, it is to be preferred to either, and may be given in powder, pill, or emulsion, to the extent of five or ten centigrams (0.05 to 0.1 Gm. = gr. j. ad jss.). If given in powder or pill, it may be mixed with liquorice, sugar of milk, or some in- different substance, to increase its bulk to convenient size. As it is soluble in alcohol, this vehicle may be used where stimulants are also needed. It has even been given subcutaneously in ethereal solution. The dose of Coto bark may be stated as half a gram or less. Allied Plants.-There can be little doubt that the variety of coto known as Paracoto (Para Coto), which is also imported from South America, is the product of a closely related tree, although its source is also unknown. This, like the other, is a hard, coarse-looking, reddish- brown bark, occurring in large, thick, heavy pieces, with a brittle, splintery fracture, and an aromatic odor and spicy taste. It is coarser and thicker even than Coto, but its odor is fainter and more agreeable, something like that of nutmegs; taste similar to that of Coto, but milder. It is a more abundant and cheaper product than genuine Coto, and often sold for it. The two drugs ap- pear not to be well distinguished from each other in the American market. The constituents of Paracoto correspond to those of Coto, but are not exactly the same: an essential oil of complex nature, separable into numerous portions by fractional distillation ; the neutral substance, paracotoin, resembling cotoin in most particulars and similar in ac- tion, but requiring about twice the dose for the same effect; leucotin, oxyleucotin, dibenzolhydrocotin, etc.; the latter substances are only known as curiosities. Paracotoin is prepared for medicinal use, and may be given for the same conditions as cotoin. This bark and its active prin- ciple are more abundant and cheaper than Coto and Co- toin. Allied Drugs.-The mode of action of Coto and Pa- racoto appears to be quite different from the other medi- cines which are given for diarrhoeas. These generally, either, like opium, quiet peristalsis and reduce secretion by action upon the nervous system ; like the astringents, reduce secretion by their local effects upon the mucous surface ; like bismuth, quiet the inflamed surface by sup- plying a protective unirritating coating; like alkalies, correct abnormal and irritating acidity; or, like the milder laxatives, sometimes remove the cause when it is undigested or altered food, etc. Coto is less useful in acute and inflammatory cases, and in those caused by in- digestion, than in long-continued non-infiammatory ones. IK. P. Bolles. COTO. A bark, imported from Bolivia, of an un- known tree, generally thought to belong to the Laurel family. It had occasionally appeared before, confounded with cinchona, but first attracted attention for itself in London about a dozen years ago, and has been in very limited use ever since. It appears to be the trunk-bark of a good-sized tree, and comes in straight, flatfish pieces, from ten to fifty centimetres long (four to twenty inches), from five to ten in width, and bne or more in thickness. It is either freed from its outer portion, and ragged and pitted on the outer surface ; or, if the entire bark is pres- ent, it is rough externally, with a whitish-gray or brown, longitudinally furrowed and transversely cracked sur- face. It is a ponderous and hard bark, of a deep reddish- brown color and very coarse texture. Its inner surface is coarsely striated, often wrinkled and splintery. The fracture is transverse and cellular in the outer third ; fibrous, with coarse, brittle liber bundles in the inner two-thirds. Odor spicy, something between that of cin- namon and of camphor ; taste pungent and sharp, like that of cascarilla. Composition.-Its odor is due to a pale-yellow essential oil. Besides this, it contains several well-defined, peculiar constituents, which were carefully studied by Jobst and Hesse a few years ago. The most important of these is a neutral, crystallized glucoside, named cotoin. It is pre- pared by exhausting the drug by means of ether, treating the solution with petroleum-spirit, which separates a quantity of insoluble resin, and evaporating the clear liquid until the crude cotoin crystallizes out. The resin also contains a further quantity, wrhich is obtained by boiling it with lime-water and precipitating with acid. Both products are then purified by recrystallization from animal charcoal, etc. Cotoin is in pale-yellow, curved or straight prismatic crystals, freely soluble in alcohol, chlo- roform, hot water, etc., and sparingly so in cold water. It has a sharp, biting taste and a neutral reaction. It is present to the extent of one and a half per cent. Dicotoin, a derivative of cotoin, and capable of being converted into it, is also present in the bark, as well as piperonylic acid. Of these constituents the first appears to represent the principal medical value of the crude drug ; the action of the others is similar, but weaker. Action and Use.-Coto is said to promote absorption from the intestinal canal, and in this way reduce the number and amount of discharges. It is also said to pre- vent certain kinds of decomposition (milk, pancreas, etc.), and so to act as an antiseptic. Its medical use depends upon its undoubted power to control to some extent the dis- COTTON {Gossypium, U. S. Ph., Br. Ph. ; Gossy- pium depuratum, Ph. G. ; Coton, Codex Med.). Cotton-root Bark {Gossypii Radicis Cortex, U. S. Ph.). Cotton-seed Oil {Oleum Gossypii Seminis, U. S. Ph.) The cotton plants {Gossypium herbaceum Linn., and other species of Gossypium, U. S. Ph. ; G. barbadense Linn., etc., Br. Ph. ; G. barbadense, G. arborcum, etc., Ph. G., etc.) are herbs or shrubs with alternate, stipu- late, usually lobed leaves, and large, handsome, holly- hock-like, yellow, white, or roseate flowers. These are supported by a three-leaved involucre of broad, cordate, usually laciniated bracts, and consist of a small, five-lobed calyx, a large and handsome five-petaled corolla, convo- lute in the bud, the numerous stamens united in a column by their filaments, which are characteristic of the order, and a three- or five-celled, many-seeded ovary. The fruit is a large ovoid capsule, bursting at maturity into three or four lobes. Seeds numerous, of various shapes and colors, completely hidden in the long white hairs developed from the testa which constitute cotton. The number of 310 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cosmetics. Cotton. species of this genus has been variously estimated from five, to six or eight times as many ; they are very varia- ble and confusing, and susceptible to change by differ- ences of climate and culture. The following are the most important from an economic point of view : Gossypium barbadense Linn., a shrub, or in the United States generally a large herb from one to three metres high (3 to 10 feet), with a branching, smoothish, cylin- drical stem covered with fine black dots, numerous long-petioled, broadly heart-shaped, from three to five- cleft, spreading leaves (the lower ones simpler or even entire), and bright sulphur-yellow (sometimes pinkish) flowers, with a dark spot at the base of each petal. Fruit large, seeds dark brown, cot- ton fine, very white and long, leaving the seeds comparatively clean and smooth when it is removed. Supposed to be a native of the West Indies, where it is cul- tivated ; also cultivated in Central and South America, the Southern Atlantic States, South- ern Europe, and India. It is the source of our "Sea Island" and other long-staple cottons, of some of the Georgia cottons, etc. ; its product is unsurpassed. G. herbaceum Linn, is a smaller and simpler annual, with less divided (three-lobed), leaves and bracts, whitish flowers, smaller pods and fewer seeds. These latter are distinguished by having a short-haired, dense, woolly covering, which re- mains on them after the longer staple has been separated ; this also is shorter and less valuable than that of G. barbadense. It supplies the most of the Indian and other Eastern cottons, and is probably the parent (in part at least) of the "upland cottons" of the Southern Gulf States (G. hirsutium Linn., etc.). G. arboreum, a larger, and still more tropical species, yields a short-stapled pro- duct of no very great value. Nankin cotton is a tawny- haired variety of G. herbaceum. In spite of the wide distribution of cotton plants, and the fact that cotton manufacture was known in Asia since before the Christian era, the enormous use which is made of this product is of comparatively recent date- since the general settlement of America. The greater part of the cotton of the world is produced on this continent. It is separated from the seeds, to which it is firmly adherent, by means of ma- chines called gins, which, either by a series of circular saws revolving between the teeth of a comb-like guard, or by cylinders which catch the cotton between them, pull, or tear it away from them. It is then compressed in large bales and so exported. It consists entirely of long, thick-walled, collapsed and spirally twisted tubes of glistening clearness, and high refractory power as seen under the microscope. It is nearly pure cellulose, with one or two per cent, of min- eral matter, and has also a small amount of oily and res- inous substances upon its surface-enough to make it re- pellant to water. For medical and surgical uses it is now beautifully purified from most of these impurities, and consists of more than ninety-nine per cent, of pure cellulose C6Hio06. The officinal purified cotton is thus characterized : " White, soft, fine filaments ; under the microscope appearing as flattened, hollow, and twisted bands, spirally striate and slightly thickened at the edges; inodorous, tasteless, insoluble in water, alcohol, or ether ; soluble in an ammoniacal solution of sulphate of copper. " Cotton should be perfectly free from all perceptible im- purities, and on combustion should not leave more than 0.8 per cent, of ash. When thrown upon water it should immediately absorb the latter and sink, and the water should not acquire either an acid or an alkaline reaction. " The quality of readily absorbing water is gained by removing the oil and waxy substances upon the fibres by means of various solvents. Benzine and bisulphide of carbon will do it, but it is probably more frequently done by a series of boilings and washings in diluted al- kalies, acids, and bleaching solutions. Mr. Frank L. Slocum recommends the following: Boil first in a five per cent, solution of caustic soda to saponify all the oily matter, then rinse thoroughly and immerse in a five per cent, solution of chlorinated lime for fifteen minutes, then wash again and dip into acidulated water (hydrochloric), wash the acid out thoroughly, and then boil again in a fresh potash solution ; wash again in clear water, dip again into diluted acid, and finally wash repeatedly with pure water, and dry thoroughly ("Proc. Am. Pharm. Ass.," 1881, p. 108). The loss in weight will be about ten per cent. Pharmaceutical and Medical Uses of Cotton.- Purified cotton is daily employed by the apothecary as a rapid filter or strainer for turbid solutions ; it is also em- ployed in the laboratory of the bacteriologist as a stop- per for the tubes in which his " cultures" are made ; but for this purpose it has to be specially "sterilized" by heat or other means. It is also used in the preparation of the aromatic Aquae" to distribute the essential oils over, in order to ensure their most complete solution. It is also very extensively used, either with or without medication, as a surgical dressing. Dried from a solu- tion of boric acid, yi; corrosive sublimate, tiAto ; or carbolic acid, ; or impregnated with powdered iodo- form, it can be rendered antiseptic ; but such preparations need to be recently made, especially that with the car- bolic acid. Exposed to a heat of something more than 100° C. (212° F.), for say half an hour, renders it practic- ally aseptic, and in this condition it is used at some hos- pitals as a dressing in antiseptic surgery. Nearly all sur- gical bandages, compresses, and gauze materials in this country are made from cotton. Preparation of Cotton.-Pyroxylin (Pyroxylinwm, U. S. Ph.), dinitro-cellulose, one of the explosive com- pounds which cellulose in all its forms makes with nitro- gen, is prepared as the basis of collodion. It is made by mac- erating one part of purified cotton in a mixture of ten parts of nitric acid and twelve of sulphuric acid, for ten hours or more ; then taking it out and washing and drying very thoroughly. After this operation, the cotton has become harsher and heavier than before, it has taken a portion of nitrogen into composition, and is very explosive, although not so much so as trinitro-cellulose or gun-cotton, which is also made in a somewhat similar way. Pyroxylin owes all its usefulness in medicine to the fact that it can be dissolved by a mixture of alcohol and ether, and forms with it an adhesive varnish which dries to a waterproof film or coating, that can be made to cover and protect or hold injured surfaces, or be used as a vehicle for certain medicaments. The following is the formula for Collo- dion {Coilodium, U. S. Ph.): Pyroxylin 4 parts. Stronger ether 70 " Alcohol 26 " Dissolve and decant. The film produced by this collodion as it dries contracts with considerable force, and is sometimes useful where a local compression is desirable; but for most purposes this quality is an objection, and it is partially overcome in the next preparation, Flexible Collodion (Coilodium, Flexile, U. S. Ph.): Collodion 92 parts. Canada turpentine 5 " Castor-oil 3 " Mix. Fig. 751.-Cotton Boll, one-half natural size. (Baillon.) Fig. 752.-Fibres of Cotton, mag- nified. 311 Cotton. Cough. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Styptic Collodion is a preparation of tannic acid, and Cantharidal Collodion of Spanish flies, to which the reader is referred. An Iodoform Collodion is used as an antiseptic coating in minor surgery. Cotton Root Bark {Gossypii Radicis Cortex, U. S. Ph.). This product has some medical employment in the South- ern States, and a very little at the North. It is the bark of the root of the above cultivated species of Gossypium peeled off and dried. The officinal description is as follows : "In thin flexible bands or quilled pieces ; outer surface brownish-yellow, with slight longitudinal ridges or meshes, small, black, circular dots, or short transverse lines, and dull, brownish-orange patches, from the abra- sion of the thin cork ; inner surface whitish, of a silky lustre, finely striate ; bast fibres long, tough, and separ- able into papery layers ; inodorous; taste very slightly acrid and faintly astringent." Of this a Fluid Extract {Extractum Gossypii Radicis Fluidum, U. S. Ph.) is pre- pared. Dose two to four cubic centimetres (2 to 4 c.c. = 3 ss. ad j.), as an emmenagogue. Value very doubtful. Cotton Seed Oil {Oleum Gossypii Seminis) is expressed from the seeds. These, which have been a bye-product of the cotton production only recently fully utilized, are round, oval, pointed, or variously shaped seeds about a centimetre long, covered with short woolly hairs, or, in some varieties, nearly smooth ; the kernel is mostly com- posed of a large oily embryo, and a moderate amount of albumen. The oil, of which they contain from twenty to forty per cent., is extracted by grinding, warmth, and pressure, like other fatty oils ; it is a yellow liquid, con- sisting mostly of olein and palmitin. It has a bland, slightly nutty taste, and little or no odor. Specific grav- ity 9.20 to 9.30; "sulphuric acid instantly renders it dark reddish-brown," otherwise it has the sensible prop- erties of the other edible oils. Until recently, cotton seed oil was generally sold under false colors in Castile soaps, as olive oils, etc. It is, at present, to be had under its own name for culinary purposes, and in the last edi- tion of the Pharmacopoeia it is extensively directed as a basis of liniments (Ammonia, Lime, Camphor, Subace- tate of Lead). Allied Plants.-See Marshmallow. Allied Drugs.-To Cotton, see Linseed, for lint, tow, oakum, etc. ; to Cotton Root Bark, see Ergot ; to Cotton Seed Oil, see Olive Oil. IK P. Bolles. essential oils and resins-have been explained with some plausibility as antiseptic : but still there remain a large number of whose action no explanation can be given, but whose reputation depends entirely upon clinical experi- ence. Such are the mucilaginous herbs and seeds, and the mild ' ' herby " substances like cleavers and the pres- ent article, which appear to be simply sedative to the mucous membrane. The following list contains some of the more commonly used articles of these classes : Cleavers ; Corn-silk ; Hy- drastis ; Pareira Brava ; Sarsaparilla ; Bear-berry ; Pip- sissewa; Buchu ; Oil of Fleabane ; Copaiba ; Gurjun Balsam ; Cubebs ; Oil of Sandal; Benzoic Acid ; Borate, of Soda ; Slippery Elm, etc. IK. P. Bolles. COUGH (Lat., tussis ; Fr., la toux ; Ger., der Husten\ The English word cough is of Anglo-Saxon origin, and comes from the Dutch, Kuch ; M. H. Ger., Kuchen, to breathe; Provincial Ger., Kuchen or Kogen, to cough; N. H. Ger., Keuchen, to breathe, or pant (Webster), whence the German term Keuch-husten, for whooping- cough. Cough is a quick and forcible expiratory effort, or a succession of such efforts, accompanied by a partial closure of the glottis, and preceded by a more or less deep inspiration. It is, essentially, an expulsive effort, having for its ob- ject the removal of some obstructing or irritating sub- stance from the air-passages. It is analogous, physiolog- ically, to the action of the hollow viscera of the abdomen and pelvis, in extruding their contents ; and, like the ac- tion of these organs, may be induced by any irritation of the afferent nerves, and be most violent when there is no obstruction to be removed. The reflex mechanism acts without intelligence, and these actions, which are normally conservative in charac- ter, may, under abnormal conditions, become annoying, or even dangerous to life. The mechanism of cough is as follows: When a for- eign body or other irritant comes in contact with the peripheral expansion of the pneumogastric nerve (or of those with which it is intimately connected), impulses are generated which, travelling along the afferent fibres, are conducted to the respiratory centre in the medulla oblongata. In the ganglion-cells of this centre the im- pulses are translated into others, which are conducted through the efferent fibres of certain cerebral and spinal nerves to the muscles of respiration, whose force they liberate. A study of the muscular relations of the thoracic walls shows that, while the muscles of inspiration-with the ex- ception of the diaphragm and some small ones, e.g., the levatores costarum-are attached to, and act upon the up- per ribs, the expiratory group make their principal trac- tion upon the lower portions of the thorax. This is par- ticularly the case with those auxiliary muscles which are brought into play in forced respiration. The expiratory group, in which we are especially interested, are, ante- riorly and laterally, the triangulares sterni above, and the recti, obliqui, and transversales abdominis below. The action of the triangularis is simple, and does not require special notice. Arising from the sternum and xiphoid appendix, its fibres pass upward and out- ward, to be inserted into three or four of the costal car- tilages. It reinforces the natural resilience of the carti- lages, helping to restore them to the expiratory position. It may also have some effect in counteracting the displac- ing force of the muscles on the exterior of the chest, e.g., the pectoralis minor. The action of the rectus is equally simple. Its sole influence over the respiratory move- ments is to draw the sternum downward, and so to di- minish the size of the anterior wall of the abdominal cav- ity. The action of the obliqui is more complicated. In the first place their posterior portions, which pass directly from the crest of the ilium to the ribs, exert an immediate and powerful downward traction upon the thoracic walls, not only diminishing the size of the lateral walls of the abdomen, but acting as adductors to the ribs, which have been put in the position of abduction during inspiration. In the second place, the more anterior portions have a COUCH GRASS {Triticum, U. S. Ph.; Rhizoma Gram- inis, Ph. G.; C hiende nt officinal ou petit Ckiendent, Codex Med. ; Durfey Grass). Triticum repens Linn., Order Graminece, whose rhizome is the subject of this article, is one of the most troublesome weeds of New England, where it was introduced from the Old World. It is a perennial grass with a straggling, zigzag stem, and a two- rowed ear of pointed spikelets. It spreads principally by means of long subterranean, horizontal rhizomes of most remarkable vitality and persistence of growth. These dug up and dried, constitute the drug. The dried rhizome is generally cut in short pieces (one centimetre or so long), about two millimetres in diameter ; it is hol- low excepting at the joints, dull-yellow, and odorless, or having a slight mixed smell of hay and earth ; taste sweetish, not remarkable. There is nothing notable in its composition or medical qualities, still it has some rep- utation in chronic inflammation of the bladder and kin- dred disorders. It can be given as a fluid extract {Ex- tractum Tritici Fluidum, U. S. Ph.) or in decoction, the latter ad libitum. Allied Plants.-Triticum Sativum, wheat belongs to the same genus ; for the order Graminece, see Starch. Allied Drugs.-The number of bland substances of this kind which have been employed and are still used in chronic cystitis, the irritable bladder of enlarged pros- tate, chronic urethral catarrhs, is very great. Excluding diuretics properly so-called, which increase either the whole urine or its water, and the chemicals, like alkalies and acids, whose corrigent effects are distinct and well appreciated, the mode of action of these drugs is very obscure. A few of them-especially those which have been found to contain benzoic acid, arbutin and the 312 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cotton. Cough. crossed action, and make diagonal traction across the ab- domen. This has been well described by Henle. It will be seen by reference to Fig. 753, that the upper portion of the external, and the middle portion of the internal oblique muscles of opposite sides, attached, as they both are, to the intervening sheath of the rectus, are equiva- lent to one long diagonal muscle, which passes from the ribs on one side to the iliac crest on the other, and is ca- pable, by its contraction, of drawing the ribs downward and inward, so as to contribute much toward the expira- tory diminution of the thoracic cavity. It acts upon the abdomen as well. The function of the transversalis is equally important. Its middle portion is attached by a strong fascia to the trans- verse processes of the lumbar vertebra?; while the fibres below arise from the iliac crest and outer half of Poupart's liga- ment. Above, it arises from the inner sur- faces of the costal cartilages. The fibres of this part of the muscle pass horizontally across the abdomen, and, by the mutual attachment of those from the opposite sides at the lineaalba, one continuous mus- cle is formed, the contractions of ■which strongly adduct the lower costal cartilages and thus di- minish the epigastric angle. The middle portion of the transversalis acts directly upon the abdominal wall. This is best illustrated in a horizontal section of the trunk just above the level of the umbilicus (see Fig. 754). In its contraction the transversalis acts from the outer border of the quadratus lumborum, as that muscle fixes its tendon in the lumbar region. It tends, first, to draw the tinea alba toward the fixed point; but the antago- nism of the muscles of the opposite sides prevents lateral displacement, and simply allows the anterior abdominal wall to approach the vertebral bodies, shortening the antero posterior diameter. The muscular fibres interme- diate between the anterior and posterior attachments, w h i c h, during distention of the abdomen, are sharply curved, become straight- ened during con- traction and make strong lateral compression. The lower fibres of this muscle, when they con- tract, tighten the line across the in- ferior abdominal regions, and com- press the intes- tines. The trans- versatis, then, by its contraction, first, assists in diminish- ing the size of the thorax ; second, it contributes, more than any other muscle, toward the diminution of the ab- dominal cavity ; and, third, it acts in a manner analogous to that of the lower portions of the oblique muscles. Posteriorly, the most important muscles of forced ex- piration are the erectores spince, serrati postici, and quad- ratus lumborum. The erector spince is easily divisible into an outer and an inner portion (see Fig. 755), viz. : the ileo-costalis, and longissimns dorsi. The former is connected below, by means of the lumbar aponeurosis, to the iliac bone; above, to the angles of the six or seven lowest ribs. The longissimus is more complex, but the only part of it which is prominently concerned in the respiratory func- tion consists of a number of digitations running from the lumbar aponeurosis below, to eight or ten ribs above. When the erector spines contracts, it draws the ribs for- cibly downward toward the pelvis, lessens the transverse and antero- posterior diameters of the thorax, and at the same time tends to shorten the perpendicular axis of the abdomen. Those accessory mus- cles which reinforce the divisions of the erector spines above, act upon the upper ribs, but their strength is far inferior to that of the ileo-costa- Lis, and longissimus dorsi. The ac- tion of the serratus inferior and quadratus lumborum is sufficiently illustrated by Fig. 756. When these powerful muscles of expiration are spasmodically con- tracted in the act of coughing, their first effect is to adduct and depress the ribs, and by so doing diminish the size of the thorax in all its di- ameters. The adduction shortens the transverse diameter. The de- pression of the ribs and sternum shortens the antero-posterior diam- eter, and lessens the longitudinal axis of the general body cavity. But, as the abdominal walls only yield in the upward direction, and as the contents of the abdominal cavity are practically incompressible, its roof, the diaphragm, which is relaxed during expiration, must ascend and encroach upon the thoracic cavity, from which enough air escapes to com- pensate for the diminution in its size. The second effect of the expiratory contraction is to lessen the circumfer- ence of the abdomen. As the contents are incompressible, and as the sphincter muscles, by their contraction, pre- vent the escape of anything from the hollow viscera, the decrease in the transverse and antero-posterior dimensions of the abdomen must be com- pensated for by an increase in its long diameter-another fac- tor in the production of the as- cent of the diaphragm. This study of the action of the muscles during forced ex- piration will make plain the effects of coughing upon the lungs and other viscera. As has been already stated, the for- cible expiration is preceded by a more or less deep inspiration, by which a large quantity of air is obtained for use in expelling the offending substance. The glottis is then partially closed, so as to narrow the route of exit and increase the friction of the escaping air against the mu- cous membrane of the larynx, trachea, etc. This is accom- panied by the sudden and strong expiratory effort, during which the lower ribs are drawn quickly downward and inward, lessen ing the capacity of the lower portion of the thorax. The pressure upon the abdominal viscera drives them against the diaphragm, and pushes the floor of the thorax upward against the bases of the lungs. The lower lobes are then suddenly and violently pressed upon from all sides, and their contents driven in the direction of least resistance, viz., upward toward the trachea. If the Fig. 753. Fig. 755. Fig. 754. Fig. 756. 313 Cough. Cough. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. displacement of the air is so sudden that the pressure in the trachea is greater than in the bronchial tubes of the upper lobes, the current will be reversed in the latter, and the superior and anterior parts of the lungs will be in- flated ; for the apices and anterior borders of the lungs are very little subject to the expiratory force, and only expel their tidal and supplementary air properly when the movements of the thorax are sufficiently deliberate to allow of an adjustment of pressure throughout. The forcible distention of the apices is seen in those suffering from violent spasmodic cough, as in bronchitis, phthisis, and pertussis. During the paroxysms, the supra-clavicu- lar spaces are seen to bulge, sometimes to a very remark- able degree, partly from swelling of the large veins in those regions, but partly also from distention of the apices. The same thing" can frequently be seen in the upper intercostal spaces, near the sternum. In acute bronchitis we find, as a result of increased ex- piratory efforts, both in breathing and coughing, a tem- porary distention of the alveoli of the superior and ante- rior parts of the lungs, manifested by prominence, and increased resonance on percussion. It is a temporary functional emphysema which subsides as the attack passes away. . The act of coughing produces a very considerable dis- turbance in the circulatory apparatus, mainly on the venous side. In ordinary breathing, the pressure, inside the thorax, becomes slightly positive during the expiration ; but in forced expiration, particularly when it is sudden in its oc- currence, the pressure rises to a high degree. This not only arrests the current of blood in the large veins of the chest, neck, and abdomen, but, no doubt, even reverses it, so that the blood already in the right auricle and venae cavae is repelled upon that which is advancing toward the heart, and great distention of the veins is the result. In the pelvis, the inferior haemorrhoidal veins, and those of the uterus, vagina, and bladder, are sometimes so turgid that slight ruptures and haemorrhages occur, particularly from the uterus, causing a bloody serous discharge from the vagina during the paroxysms of cough. Involuntary urination, also, sometimes results from the sudden down- ward pressure, especially in women. In spasmodic cough the paroxysms are frequently ter- minated by vomiting. This is so common in whooping- cough as to be one of the diagnostic signs of the disease. It is observed in acute bronchitis, and is very characteris- tic of phthisis. It is probably due, mainly, to the intense hyperaemia and irritation of the pharynx, resulting from the long spells of coughing, with the presence of viscid mucus as the direct irritant. The pulmonary circula- tion and left heart are not greatly affected, though, in acute bronchitis, ruptures of the superficial capillaries of the bronchial mucous membrane may be produced, with slight haemorrhage. The intracranial veins are distended. Any irritation of the pneumogastrics, or of the nerves associated with them, may give rise to cough. Irritation of the external auditory meatus, the tym- panum, or Eustachian tube, may cause it. The posterior portions of the nasal chambers are sometimes the seat of irritation, which excites a reflex cough. The same may be said of the pharynx, the palate, and the mucous mem- brane about the base of the tongue, and superior opening of the larynx. Irritation of the superior compartment of the larynx, excepting posteriorly, in the neighborhood of the aryte- noid cartilages, is not followed by as severe paroxysms of cough as might be expected ; indeed, in the ordinary catarrhal affections of the larynx, cough is not at all a prominent symptom, and only becomes so when the lower compartment of the larynx and trachea are affected. The penetration of any foreign substance beyond the vocal bands excites the most active cough. Affections of the mucous membranes of the trachea and larger bronchi are particularly prone to be manifested by cough, but the reflex from the smaller tubes is not nearly so well marked. The pulmonary parenchyma is still less sensitive. The cough of pneumonia is not as violent as that of bronchitis ; indeed, it may be said to be proportionate to the extent and intensity of the bronchitis by which the pneumonia is complicated. In the early stages of phthisis, when the disease is confined to the parenchymal structure, the cough is usually slight and hacking in character. The more violent cough appears when the disease is more advanced and the bronchitis very active. It is not intended to imply that the existence of bronchitis as a complication is necessary to the production of cough, in diseases of the pulmonary parenchyma, but only to em- phasize the fact that bronchitis is the prominent cause-a fact of considerable importance from a clinical, and par- ticularly from a therapeutical point of view. There is, as far as the writer is aware, no evidence that irritations of the pleura can excite cough. Those branches of the vagi which are distributed to the organs below the diaphragm, and their associated nerves, may also convey impulses to the medulla, which are there translated into the motor phenomena of cough. Dis- orders of the abdominal and pelvic viscera are not, how- ever, very often signalized by this symptom ; and the number of cases in which we can say that there is a " stomach cough," or a "liver cough," is constantly di- minishing as other reflex causes, particularly in the upper portion of the respiratory tract, are discovered. Finally, a cough may be of purely central origin, as is sometimes observed in neurotic subjects, and such coughs may even be contagious. Dr. J. Solis-Cohen relates an instance of a school for young ladies, in which a nervous cough be- came epidemic, and caused so much disturbance that it was necessary to disband the scholars in order to break it up. Many terms are used to indicate the different varieties of cough. The following are the only ones that need claim our attention : A hard cough is one which is vio- lent and accompanied by little or no expectoration. It is most common in the dry stage of acute bronchitis, and in chronic bronchitis or phthisis, when, from any cause, the secretion is arrested. It sometimes has a metallic resonance, when it is called " brassy " or " ringing." The term spasmodic is applied to a cough when it occurs in paroxysms of great violence, many expiratory efforts suc- ceeding each other very rapidly, to be followed by a deep and loud inspiration. The cough of pertussis is typically spasmodic, but has the peculiarity that, during the in- spiration, there is a spasm of the glottis and a consequent crow, similar to that of spasmodic croup. Spasmodic cough is an occasional symptom of irritation of the trunk of the vagus by enlarged bronchial glands, mediastinal tumors, or aneurisms. The hard cough of acute bron- chitis is often spasmodic in character. Trickling of fluids, or penetration of other bodies below the vocal bands, sometimes excite the most violent cough. It is character- istic of the spasmodic cough, that its violence is out of all proportion to the quantity of mucus, or other matter, to be expelled. An irritative cough is one which constantly recurs, without any apparent necessity or result. It is common in the early stages of phthisis. The sufferer has a fre- quent, short, hacking cough, which annoys him con- stantly, but is accompanied by very little expectoration. This form is observed in some cases of catarrh of the upper air-passages, and where an elongated uvula irritates, or is irritated by, the epiglottis and the base of the tongue. Reflex cough is that which is not due to disease of the respiratory apparatus. Under this head are included those cases in which the cough results from digestive, uterine and ovarian disturbances, from irritation of the ear, and from diseased conditions of the nasal passages ; though the latter are really a part of the respiratory tract. This form of cough is sometimes called sympathetic. A suppressed cough is one which is so painful or dis- tressing to the patient that he seeks, by a voluntary effort, to prevent its occurrence, or to moderate its intensity. This occurs most frequently in pleurisy, in which disease the movements of the thorax are so exceedingly painful that any increase of them is greatly dreaded. It is also met with as a symptom of pleurodynia, accompanied by bronchitis. A cough is said to be muflled when, though the mus- 314 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cough* Cough. cular effort may be strong, the sound has not the usual vocal ring due to vibration of the vocal chords. It is an exaggeration of a hoarse cough, and has the same relation to the latter that aphonia has to huskiness or hoarseness of the voice. It is of the gravest import, for it indicates a condition of the larynx in which the vocal bands are so diseased as to have lost their capacity for being thrown into sonorous vibrations. It is the typical cough of laryn- geal croup and diphtheria. It is also heard in phthisis of the larynx, and in paralysis of the muscles of phona- tion. The adjectives tight, loose, soft, short, etc., asap- plied to cough, require no explanation. The sputum, or expectoration, is of interest from a diag- nostic point of view. The substances expectorated are mucus, epithelium, pus, blood, portions of disintegrated tissue, ichorous serum, croupous and diphtheritic mem- branes, and the histological elements of neoplasms. These substances do not often appear singly, but are mixed in varying proportions. Mucus, containing some epithe- lium, forms the expectoration in many cases of catar- rhal laryngitis and the milder forms of bronchitis, in the first stage of acute bronchitis, in the early stages of phthisis pulmonalis, and in the spasmodic and reflex coughs, including pertussis. Tenacious mucus forms the sputum of spasmodic asthma during the height of the attack, but as the paroxysm subsides it becomes more fluid. In diphtheria, croup, and fibrinous bronchitis, false membranes and casts of the air-passages are expectorated. In the secretory stage of acute bronchitis, pus-cells make their appearance, and when they are sufficiently abundant to give a yellow color to the sputum, it is called muco-purulent. This is the character of the expectora- tion in chronic bronchitis, in laryngeal catarrh, and in phthisis before the formation of vomicae. In aggravated bronchitis, bronchiectasis, pulmonary abscess, and perfo- rating empyema, pure pus is discharged. The amount of pus in a sputum may be roughly es- timated by its specific gravity. Mucus is very light, frothy, or like the albumen of eggs, usually somewhat tenacious, and generally floats lightly in water. In pro- portion as it becomes purulent it is less tenacious and heavier. Purulent sputa sink in water. The sputa of the first and second stages of pneumonia are mucous in character, extremely tenacious, so that they cling to the mouth and are with difficulty spat out; and, from the presence of blood intimately mingled with the mass, have a color varying from a light pink or brownish tinge, to bright red. This is known as the rusty sputum. In asthenic pneumonias, in which the congestion is intense and a tendency to oedema exists, the presence of serum renders the expectorated matter fluid. This dark-red matter is known as the prune-juice expec- toration. It is a very grave prognostic omen. The ex- pectoration of acute pneumonia contains a micrococcus, known as the pneumo-coccus of Friedlander (Micrococ- cus Pasteufi, Sternberg). In the later stages of pneu- monia the expectoration becomes muco-purulent. The stage of excavation in phthisis is characterized by the so-called nummular sputum. This consists of a serous or sanious fluid, suspended in which is a more or less globular mass, made up of caseous matter, shreds of disintegrated lung tissue, and epithelial cells. There are also flakes of epithelium and fungoid growths, viz., bac- terium lineola, leptothrix, etc. In addition to these, the sputa, from the very earliest stages, contain the bacillus tuberculosis of Koch. It is claimed by competent ob- servers that these tubercle bacilli disappear from the ex- pectoration in cases in which the disease becomes, for a time, latent. The pathological significance of this phe- nomenon is not known. In pulmonary oedema the sputum usually consists of bloody serum, though this may be modified by co-exist- ing diseases. Treatment.-It may be said, in general terms, that the best way to treat a cough is to remove the cause of it; nevertheless, there are many instances in which treatment must be directed to the symptom itself. The disease which it accompanies may be incurable, in which case we should seek, by judicious management, to ameliorate the sufferings of the patient. In other cases, e.g., in spasmodic cough, the irritation resulting from it may actually aggravate the disease. This is particularly true of the cough of thoracic aneurism. In pertussis not only may the respiratory organs be seriously damaged by the violent agitation of the cough, but the central nervous system may suffer from the repeated and intense venous engorgement. The cough of phthisis is usually unnecessarily severe, and proper attention to it may materially benefit the pa- tient, by preventing the fatigue which it causes, and by saving the digestive apparatus from the succussive vio- lence to which it is subjected during the paroxysms. The best results are to be attained by giving some seda- tive at night to secure rest for the sufferer, and by for- bidding the use of the cough mixture during the day, unless the paroxysms are unusually severe. Great pains should be taken to avoid damaging the stomach, and to this end nauseating syrups should always be avoided. The simplest and most universally useful mixture is a teaspoonful of the syrup of wild cherry with gr. of the muriate or sulphate of morphia, to be taken at bedtime, and repeated once or twice in the night if necessary- which it seldom will be, in the earlier stages of the dis- ease. Morphia, given in this way, will seldom or never produce nausea. If the paroxysms are violent, a small dose of atropia, or the fluid extract of belladonna,may be combined with it; and if the cough is very dry, gr. v. of the iodide of sodium or potassium may be added to each dose. The last will seldom be necessary, as the simple sedative, by allaying the irritation, and giving time for some secretion to accumulate between the paroxysms, will generally change the cough from a dry to a comfort- ably moist one. Another excellent combination is, TTtij.- iij. of dilute hydrocyanic acid with gr. £ of codia, to which spirits of chloroform and syrup of tolu, or glycerine, may be added. When the stomach is irritable, and the cough- ing provokes emesis, a powder containing a small dose of the acetate or muriate of morphia (gr. - iV), with the oxalate of cerium and bicarbonate of sodium (gr. v.), will answer admirably. It may be given at intervals of two or three hours for a day, and then after meals and at bed- time. A small dose, gr. of calomel may be added to it, temporarily, if it is desirable to secure some activity of the mucous glands. In treating the cough of phthisis, we should not for- get that it may be, and frequently is, aggravated by a pharyngeal or naso-pharyngeal catarrh. The writer has. sometimes seen the following gargle give more relief than any cough mixture: IJ. Acid, carbol, cryst., Bij.; sodii bibor., sodii phosphat., aa 3 ij.; acid, tannic., 3 ij.- 3 iij.; glycerina?, 3 ss. ; aqua?, § jss. Misce. S. Two teaspoonfuls to a glass of water. The carbolic acid and sodium salts clean the pharynx, while the tannin coagulates and assists in the expulsion of collections of muco-pus, which, in such cases, may be seen clinging to the posterior wall of the pharynx, or descending from the naso-pharyngeal recess. The local treatment of ca- tarrh of the upper air-passages and trachea should never be omitted where it is practicable, as it affords great relief, and certainly prolongs life. Though it is customary for many writers to decry the use of opiates in phthisis, before the final stage, we are confident that, when properly employed and watched, they may be of the greatest service to the patients. They should only be used to mitigate the cough, as indicated above, never to stop it. The aim of our treatment should be to arrest so much of the cough as seems unnecessary, and therefore injurious. In the latter stages of consump- tion, the opium in the cough mixture sometimes increases the sweating. Atropia may then be combined with it, or a pill containing some anti-sudorific drug may be given at bedtime. A mixture of equal parts of paregoric and glycerine with two parts of mint-water relieves the cough, without having much tendency to produce diaphoresis ; but some stomachs do not bear the paregoric. When the morning cough is very exhausting, a more stimulating mixture may be given for use at that time : IJ. Spts. 315 Cou^li. Counter-Irritants. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ammon. arom., spts. chloroformi, aa § ss.; tr. opii deod., 3 ij.- 3 iij,; glycerinae, § j.; aquae menth. ad § iij. Misce. This may be kept at" the bedside, and, when the patient is first aroused by the onset of the morning cough, he may take a teaspoonful of it at once, and repeat it two or three times, at intervals of half an hour, if necessary. It must, of course, be taken in a little water. In many cases a drink of whiskey or rum, at bedtime, will secure several hours of sleep. If it causes sweating, a small dose of caffeine may be taken with it, or it may be given in a small cup of black coffee. The spasmodic cough of pertussis is to be relieved by atropia, in doses sufficiently large to get a slight consti- tutional effect; or by chloral, given at bedtime to induce sleep. If chloral is used, we should not be timid about the dose, and it should be remembered that, in infancy and childhood, the tolerance of it is greater than in adult life. The inhalation of the vapor from tar or pyrolig- neous acid is very useful. The coal or wood tar, or py- roligneous acid, is put into a little cup, with a lamp under it, and placed in the sleeping-room of the affected child. Apparatus suitable for the purpose are for sale in the shops. Whether the beneficial effects obtained by taking children to the gas-works are due to the inhalation of the carbonaceous gases, or to the creasote and allied com- pounds, wre cannot say, but probably the latter are the effective agents. The spasmodic cough of aneurism, and other diseases in which there is pressure upon the pneumogastric nerves, is best relieved by the iodide of potassium or of sodium, in large doses, 3 j. to 3 iv. per diem. It may be com- bined with the bromide. If the cough is very violent, opium must be employed until the iodide and bromide have time to act. Other antispasmodics may be used, but are not at all comparable to those mentioned, with the exception of chloral, which is too depressing an agent to be introduced into the treatment of a chronic affection, except, sometimes, as a temporary expedient. The hard, dry cough of acute bronchitis, etc., yields most readily to the influence of such means as will excite the secretion of the mucous glands and allay the exces- sive irritability of the respiratory passages. Inhalation of steam will fulfil the latter indication to some extent. The addition of the vapor of benzoin, obtained by pouring hot water upon the compound tincture, usually increases the soothing effect, but, in some instances, makes the cough still tighter. Tartar emetic, calomel, and the iodides of sodium and potassium are the most valuable internal remedies. They may be supplemented by alkaline (sodium or potassium) salts, as the bicarbon- ates and salicylates. Ipecacuanha, lobelia, and the other nauseating ex- pectorants may be employed. One of the most valu- able combinations handed down to us from the olden times is the pill of antimony, calomel, and opium, or Dover's powder. Its ingredients may be modified to suit the particular case. It is better to make the quantities small and repeat them frequently-say, tartar emetic, gr. ; calomel, gr. ; and pulv. opii, gr. | to re- peated every hour until some effect is observed, when the intervals may be lengthened. Hyoscyamus can be added, but is not usually required. The following is a very agreeable substitute for the above : B • Antim. et pot. tart., gr. j. to jss. ; codiae, gr. iij.; syr. tolut., 3 j.; aquae, 3 ij. Misce. S. A teaspoonful every hour. To this basis we may, if necessary, add dilute hydro- cyanic acid, or, in the case of children, when much fever prevails, antipyrin. For children the dose needs simply to be reduced. A very excellent cough mixture for a child with acute bronchitis is this: ly. Antim. et potass, tart., gr. |; sodii iodidi, gr. xvj. ; tr. opii camph., 3 j. - 3 ij. ; glycerinae, vel syr. tolut., | ss. ; aquae menth. ad § ij. Misce. S. A teaspoonful every two hours. Antipyrin may also be added to this mixture, if it is thought necessary. With adults, as with children, if an iodide is to be used, the sodium compound is the best, if there is any irritability of the stomach. The reflex or sympathetic coughs are to be treated by relieving the nervous erythism which is usually present. The continued use of the bromides, combined with such neuro-tonics as quinine, strychnia, arsenic, and iron, will usually accomplish this; attention, of course, being given to any abnormal condition of other organs which may be the exciting cause. A short, dry, hacking cough is sometimes associated with naso pharyngeal catarrh of gouty or lithaemic origin, and will never yield to any form of treatment until the diathetic condition is attended to. The cough of pleurisy should always be ameliorated ; but this is usually accomplished by the means used to overcome the pain attendant upon that disease, viz., morphia hypodermically. The use of respirators, sprays, and the various plans of inhalation treatment will be considered under the dis- eases to which they are applicable. There are conditions in which the cough, instead of being excessive, is deficient in frequency or force. This occurs in asthenic diseases, snch as pulmonary oedema, hypostatic pneumonia, and the capillary bronchitis of old and debilitated persons. In such cases, opiates and other narcotizing substances should be sedulously avoided, or, if used, guarded in their action by combination with other drugs. They should, in general, be replaced by such agents as turpentine, strychnia, digitalis, ammonia, and the like. Turpentine, both internally and externally, is particularly valuable. Quinine is also applicable in the asthenic respiratory diseases. It should be said further, that in the treatment of cough generally, the prime indication is to reduce, or increase it to the normal physiological degree, remem- bering that, as stated at the beginning of this article, it is essentially a conservative action, and useful when kept within proper limits. B. F. Westbrook. COUNTER-IRRITANTS have been defined by Dr. James Risdon Bennett (Practitioner, June, 1869), as ' ' agents which by their irritant action determine an in- creased attraction or flow of blood to one part of the body, and thus influence morbid action in some other part." They cause, first, congestion, and subsequently in- flammation of the part to which they are applied, and are employed with the object of relieving similar states of congestion and inflammation in internal organs. That they accomplish this is abundantly confirmed by clinical experience, although their modus operandi is the subject of considerable controversy. The application of an irri- tant to the surface causes dilatation of the vessels to which its influence extends, and indirectly, through re- flex nervous action, contraction of other parts of the arterial system. Ludwig has found the irritation of a sensory nerve to produce the following effects : (1) " It causes the vessels of the part to which it is distributed to dilate. (2) It causes the vessels in other parts of the body to contract, so that the general blood-pressure is raised, and the blood driven into those vessels which are relaxed. The part supplied by the irritated nerve consequently gets its sup- ply of blood doubly increased by the dilatation of its own vessels and the contraction of those in other parts of the body " (T. Lauder Brunton, M.D., " St. Bart. Hosp. Rep., 1875 "). As irritation of the skin of an animal will produce definite reflex movements of the voluntary muscles, so also it will produce contraction of the muscular coat in definite vascular districts, and may thus be made to in- fluence morbid processes at a distance. Counter-irritants are most efficacious when the part to which they are ap- plied is in vascular connection with the part diseased. Thus, " a blister over a distended knee-joint will fill at the expense of that cavity ; the skin and the synovial membrane being supplied by the same or intimately anas- tomosing vessels. The same rule applies to many other joints, and in a less degree to some of the larger serous cavities, the pericardium in particular." Dr. W. II. Dickinson (" St. George's Hosp. Rep., 1868") strongly op- poses the practice of applying counter-irritants with the object of modifying a disease process in a part which has neither continuity of structure nor vascular or nervous 316 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. counter-irritants. communication with the suffering cuticle, and says that the " custom may be likened to a practice said to prevail at an eastern court, where the children of the royal house- hold are not punished in their own persons for any faults they may have committed, but the stripes are inflicted vicariously upon a boy unconnected with the royal line- age, who is kept for such uses." A sufficient reply to this criticism would be that if the practice of punishing the scapegoat has the effect of improving the conduct of the royal children, it is attended with a certain amount of good. Counter-irritants are of benefit although there be no direct vascular or nervous connection between the diseased part and that to which they are applied. The course of a pleurisy, for example, may be favorably modified in any of its stages by the judicious application of counter-irritants to the chest-wall. This is the experi- ence of all clinicians, and is confirmed by physiological experiment. Zuelzer found that blistering the back of the rabbit for a number of days produced, in addition to hyperaemia of the cutaneous and subcutaneous vessels and of the superficial muscles, an anaemic state of the deeper muscles, and even of the lung itself; so also a seton introduced over the knee-joint produced anaemia of the vessels around the joint and of the joint itself. Counter-irritants may be divided into rubefacients, vesi- cants, suppurants, and actual cauterants. This division is entirely arbitrary, for the application of a so-called rube- facient, if long continued, will cause vesication and even sloughing, and, on the other hand, the action of a vesi- cant, or even of the actual cautery, may be limited to the stage of rubefaction. The principal rubefacients are mustard, ammonia, turpentine, capsicum, and Burgundy and Canada pitch. The effect of mustard should never be allowed to proceed beyond the stage of rubefaction, because the vesication which it produces is attended with very little discharge, is exceedingly painful, and slow to heal. A sinapism, composed of equal parts of mustard and wheat flour, may be left upon the skin of most indi- viduals for half an hour, without danger of vesication. For children the proportion of mustard should be still smaller, and in the case of infants it may be added in amounts varying from one to three teaspoonfuls to an or- dinary flax-seed poultice. Where an immediate revulsive effect is required ammonia is to be preferred as a rube- facient. A handkerchief folded, or better still, a piece of lint, may be dipped in the stronger solution (Aqua Am- moniae Fortior, U. S. P.) and laid upon the skin of the patient. Such an application to the nape of the neck will often rouse a patient from a profound state of toma de- pendent upon acute cerebral congestion. The effect is often magical. It may also be employed in the same manner in cases of opium-poisoning. Turpentine may enter into the composition of various liniments, and is frequently employed as a stupe, which is made by immers- ing a cloth in hot water, wringing it as dry as possible, and subsequently dipping it in warm turpentine. The cloth is again squeezed, and then laid upon the surface. It is most frequently applied to the abdomen, and is used with apparent benefit by many practitioners in cases of peritonitis, and also in the painful tympanitic distention of typhoid fever. It may remain applied for from a quarter to half an hour. Capsicum as a counter-irri- tant is mostly employed as a domestic remedy in the form of a spice plaster, mixed with ginger, cloves, and cinna- mon. The powdered capsicum should not constitute more than one-fourth part of the above ingredients. Proper consistence may be given to the plaster by the admixture of honey. The pitch plaster, Emplastrum Picis Burgundicae, and Emplastrum Picis Canadensis, is mostly employed in cases of chronic bronchitis and in mus- cular rheumatism, especially of the spine. The effect is that of a mild, continuous rubefacient. The vesicant par excellence is cantharides. Properly employed it is one of the most valuable agents in the materia medica. The moxa, the seton, the issue, and even the actual cau- tery, are in a manner obsolete, but the cantharidal plaster is constantly employed in the practice of the most experi- enced physicians of the present day. The principal affec- tions in which it is employed are neuralgia, rheumatism, sciatica, phlebitis, pleuritis, pericarditis, and pleurodynia. In those cases of pleurisy in which it appears to abort the disease it is probable that the costal pleura is chiefly af- fected. Its benefit in neuralgia is universally acknowl- edged, and in the opinion of so well-known an authority as Dr. T. Lauder Brunton, it may even abort an attack of pericarditis, for proof of which the reader is referred to " St. Bartholomew's Hospital Reports," vol. xi. Nothing more need be said upon this subject, since it has already been treated in an earlier portion of this work. Although the practice of medicine offers a wide field for the employment of counter-irritants, the most signal success attends their use in surgical cases. Mr. Furneaux Jordan, in a work entitled "The Treatment of Surgical Inflammations," has reported one hundred and thirty- three cases of inflammatory disease, all of which were treated with remarkable success by counter-irritation. He reports cases of incipient whitlow, palmar, axillary, and other abscesses, which were apparently aborted by coun- ter-irritation. For this purpose he employs the iodine liniment of the British Pharmacopoeia, and a preparation which he calls iodine paint, composed of four-fifths of the tincture and one-fifth of the liniment of iodine. In cases of whitlow he applies the paint to all of the sound fingers, the hand, and part of the forearm. In abscess in other situations he surrounds the tumefaction with the paint in the form of a circle or horseshoe. " With many surgeons," he says, " the main question in the treatment of the more acute abscesses is, When shall they be opened ? When the treatment now described is carefully carried out the question is a very secondary and unimportant one. With this treatment, as a general rule, it is not neces- sary to open abscesses. No advantage is gained by open- ing them. The ill results which, in the ordinary treat- ment of abscess, are avoided by the knife . . . are best avoided by a circumscribing belt of counter-irritation assisted by the other remedies referred to. . . . In a large proportion it is possible to obtain the absorption of pus. In others, spontaneous opening quickly and readily occurs. In a small proportion, however, where, notwith- standing the removal of inflammation, there is no marked tendency to spontaneous opening, an incision may be made in the usual way." Mr. Jordan has also made use of counter-irritants in a series of cases of synovitis, ostitis, and bursitis, employ- ing with success iodine, strong solutions of nitrate of sil- ver, blisters, and the actual cautery. The reader is re- ferred to his work for further detail. While the evidence in support of the great therapeutic value of counter-irritants is overwhelming, there is no doubt that the more powerful of these agents have fallen into discredit and consequent disuse, on account of the injudicious manner in which they have been employed. For example, the custom of passing a blister from the base of the chest behind, over the shoulder like a sus- pender, and downward over the anterior chest-wall, merits unqualified condemnation. The application of ir- ritating ointments to the raw surface left by a blister, with the object of prolonging its action, is also of doubt- ful utility. The chief object of a counter-irritant is to produce derivation of blood at the least expense to the system, and this is best accomplished in the great ma- jority of cases by continuous rubefaction. A great desideratum in the employment of counter- irritants is the possession of some definite rule or rules to determine in all cases the locality to which they should be applied. It is generally agreed that the counter-irritant should be applied over a vascular district collateral with that of the inflamed part. In accordance with this prin- ciple Mr. Jordan (loc. cit., p. 16) suggests that in inflam- mations of the thoracic wall, including pleurisy, abscess, carbuncle, erysipelas, and mammary inflammation, the counter-irritant should be applied over the brachial artery, and that in inflammations of the abdomen and pelvis it should be applied over the femorals. In intra-cranial disease the cervical region, supplied by the external caro- tid, should be the site of the counter-irritation. On the other hand, if inflammation attack the upper extremity or thigh, counter-irritation should be made over the thorax 317 Counter-Irritants. Cramps. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and abdomen, respectively. An acquaintance with the anatomy of the vascular system is, therefore, requisite for a scientific use of counter-irritants, and since inflamma- tion is liable to attack any organ or tissue of the body, there is wide room for the exercise of individual judg- ment in their application. Frederick P. Uenry. and by the fourteenth or fifteenth day crusts of a dark mahogany color are fully formed. These fall off about ten days later, and whitish scars, more or less deeply pitted, mark the site of the vesicles. The lymph and crust may be used in inoculating other heifers or in human vaccination ; but the former, col- lected when the vesicles are from seven to nine days old, is, for obvious reasons, greatly to be preferred. Vaccinia may be produced in the cow by inoculation with lymph from animals affected with the disease, with humanized virus, and with the lymph of variola. The essential features are the same by whatever method produced, but vary in intensity. At one time retrovaccination, or the. inoculation of heifers with humanized lymph, was extensively prac- tised, especially in Italy, in the belief that the supposed deterioration of human vaccine virus could in this way be prevented and all contaminations removed. The prac- tice is now justly abandoned. The true nature of cow-pox has given rise to much dis- cussion in professional circles. It is highly questionable whether it ever originates spontaneously. The weight of opinion tends strongly to support the view originally advanced by Jenner, that the vaccine disease is variola modified by transmission through the system of the cow. It is, however, very difficult to produce the disease by inoculation with small-pox virus. But few of the many experimenters have succeeded, and, at times, very lament- able results have followed the attempt. In several in- stances widespread and fatal epidemics of genuine small- pox have been kindled by the use of virus obtained from bovine variolation. In determining questions of this kind, one successful experiment rebuts the negative tes- timony of many failures. Mr. Ceely, of England, than whom there is no higher authority, and a few others un- questionably succeeded in cultivating a stock of virus which afforded perfect protection from subsequent inocu- lations of variolous matter. It may be stated, then, in sum- ming up our present knowledge, that while vaccinia is very probably variola modified in some mysterious manner by its passage through the system of the cow, the difficulties of inoculation and the sad results which attend the use of spurious virus render bovine variolation impracticable as a source of vaccine supply. It is but right to add, how- ever, that some recent experiments of Dr. Voigt,- Super- intendent of the Vaccine Institute of Hamburg, if con- firmed, will lead to a different conclusion. He claims to have experimentally demonstrated that where bovine variolation is practised the product of the first inocula- tion retains nearly all of the virulence of the original seed, but by successive transmissions from one animal to another it is so modified and reduced in activity as to cor- respond perfectly in its effects upon the human economy with lymph obtained from spontaneous cow-pox. Ac- cording to Voigt, true small-pox virus must be passed through not less than six heifers before it becomes prop- erly transmuted and safe for human vaccination. The undue violence, both local and constitutional, induced not only by original cow-pox virus, but by the earlier human removes from it, seems to offer some confirmation to the above statement. IE J. Conklin. 1 The Medical News, vol. xl., p. 498. 3 The Medical Times and Gazette, September, 1882. COURMAYEUR is a beautiful little town in northwest- ern Italy, at the foot of Mont Blanc, in the valley of Aosta, nearly four thousand feet above the sea. On ac- count of the elevation the climate is somewhat variable, and exhibits rather marked changes of temperature be- tween the day and the night. There are two medicinal springs at Courmayeur, which are known as the Sainte Marguerite and the Victoire. The waters are used only internally, and are taken in the morning, fasting, in doses of from three to ten glasses at fifteen-minute intervals. The regular course of treatment lasts about a month. The following is the composition of the Victoire spring as analyzed by Picco. One litre contains : Grammes. Calcium carbonate 1.3356 Magnesium carbonate 0.2792 Potassium sulphate 0.0748 Sodium sulphate 0.2171 Magnesium sulphate 0.6071 Aluminium sulphate 0.0183 Calcium chloride 0.0262 Magnesium chloride 0.0446 Silica 0.0345 Aluminium 0.0101 There is a considerable amount of free carbonic acid gas. The waters are recommended in anaemia and chlo- rosis, chronic diarrhoea, chorea, and in the cachexia fol- lowing malarial fever and other debilitating diseases. T. L. S. Total solids 2.6475 COW-POX (Syn. : Vaccinia, Vaccine Disease, Kine- pock). Cow-pox is a specific contagious disease, occur- ring in the cow, horse, and possibly in other domesticated animals, characterized by an eruption which closely re- sembles in anatomical structure and successive stages of development the eruption of variola. The disease known as grease in the horse is believed to be identical with, and capable of producing, by inocula- tion, vaccinia in the cow. Vaccinia chiefly affects young cows, and the eruption is nearly alwrays limited to the udder and teats. It rarely, if ever, occurs more than once in the same individual. Cow-pox occurs sporadically and as an epidemic. It is susceptible of propagation by inoculation, but is con- tagious in no other way. The disease prevails more extensively in the herds of Europe than in this country, but is far from common anywhere; in fact, previous to the discovery of the Co- hasset stock in 1881, no perfectly authenticated case of natural cow-pox had ever occurred in America.1 The constitutional symptoms are mild, and the malady would possess little practical importance, were it not that, reproduced in man, it either confers absolute im- munity from small-pox, or greatly modifies its course and mortality. After a period of incubation lasting from five to eight days, the udder becomes hot, tender, slightly swollen, and small, red papules appear upon the udder and teats. The papules, about five days after their ap- pearance, are changed into vesicles, distinctly umbili- cated, and tilled with transparent, amber-colored lymph. When not influenced by location or surroundings, the vesicles are circular in form, and vary in size from one line to five lines. They are encircled with a rose-red are- ola, and a well-marked zone of induration. On section each vesicle is seen to be multilocular; its interior is divided into several distinct chambers contain- ing lymph, and separated from one another by delicate partitions. The transformation into pustules is fully completed by the eleventh or twelfth day, the central depression dis- appears, and the external contour is conoidal. The local inflammation soon abates. Desiccation advances rapidly, COYNER'S WHITE AND BLACK SULPHUR SPRINGS. Location, Botetourt County, Va. ; Post-office, Bousacks, Roanoke County, Va. Access.-By Norfolk & Western Railroad to station at the springs. During the season, from June 1st to No- vember 1st, all passenger trains stop at the station plat- form, two hundred yards from the hotel. The waters have never been analyzed. There are five springs: two white, two black, and one blue sulphur. They all issue from crevices in solid rock at the base of a high hill. Therapeutic Properties.-The designations of the different members of this group of springs is dependent upon the color of their respective deposits. Although never quantitatively analyzed, the waters are known as 318 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Counter-Irritants. Cramps. valuable ones of their class. Situated among the hills of the Blue Ridge range, the climate is cool, the atmosphere invigorating, and the scenery picturesque. The accommodations for visitors are supplied by the Coyner's Springs Hotel, a four-story building, one hun- dred and five by fifty feet, supplemented by cottages, situated on either side of a shaded lawn through which runs a stream of water. There are churches and the ordinary public schools in the neighborhood. At Roanoke City, about seven miles distant, are churches of all denominations and first-class educational establishments. There are many points of interest in the neighborhood accessible by good roads. Geo. B. Fowler. the voluntary muscles are strictly analogous, therefore, to colic of the involuntary muscles. The further relations of cramps to the other hyperkin- eses are shown in the article on Convulsions. In this de- scription of cramps we shall limit the application of the term, as is usually done, to the voluntary muscles. Clinical History.-The voluntary muscles oftenest affected by cramps are those of the extremities, and espe- cially those of the lower extremities. The muscles most susceptible are the gastrocnemii and plantar muscles. The psoas muscle, andfiexors of the thigh upon the abdo- men, are also at times affected. In the upper extremities it is the muscles of the fingers that are most often attacked. In the special neurosis of which writer's cramp is a type, the muscles of the whole arm may also be involved. Of the trunk muscles, those forming the soft wall of the ab- domen are not infrequently affected with slight cramps. After a violent sneeze, for example, part of the rectus may become knotted up in a cramp. In cholera the abdominal muscles are all involved. A sudden "stitch in the side," is due to a cramp of some of the inter- costal muscles. A crampy condition of the sterno- cleido-mastoid and of part of the trapezius is observed in the clonic forms of wry-neck. The muscles of the face, of the eye, and of mastication, are not subject to cramps, except in very rare cases. When the term cramp is used, without further special designation, it refers to painful spasms in the extremities, especially the lower extremities. Attacks of such spasms come on generally at night, or after some violent exertion, such especially as swimming, when the circulation in the extremities is disturbed by the cold water. The pain and contraction comes on suddenly, as a rule, though sometimes slight premonitory twinges are felt. The muscle is con- tracted, and feels hard and knotty, the limb is drawn up, and attempts to straighten it or to relax the muscle give great pain. The patient often feels a sensation of nausea, depression, and even of faintness. Pressure on the affected part gives relief, and forcible rubbing or sudden exten- sion of the muscle will often relax the spasm. No es- pecial change in the electrical relations has been observed. The attack lasts only a few seconds or minutes, as a rule, but it may continue for hours. After one attack has gone, a second and third may succeed. A patient may have to get up half a dozen times a night on account of his seizures. When the spasms have disappeared, the muscle is left sore and tender to the touch, owing to stretching of the muscle, and the irritation and injury to the sensory nerves. Etiology.-Cramps in the extremities occur as the re- sult of organic disease of the brain and spinal cord, and as the result of certain functional morbid conditions. Pressure on, or irritation of, nerve-trunks sometimes causes cramps. The cramps of organic disease I do not propose to consider here. The causes of the functional cramps are various. In some persons there is an inherited or connate tendency to this trouble. Cramps occur more frequently in the aged and in growing children than at the middle pe- riod of life. Gouty and rheumatic conditions, and anaemia, predispose persons to them. In disordered states of the stomach and bowels nocturnal attacks of cramp occur. Cramps in the lower extremities are often an annoying disturbance of pregnancy. In the early months the gas- trocnemii and plantar muscles are most affected ; later the thighs are drawn up by painful contractions of the psoas and other flexors. These cramps of pregnancy are proba- bly at first reflex in character ; later they are due to the pressure of the gravid womb on the nerves which supply the lower limbs. Cramps of a distressing character occur in Asiatic chol- era and cholera nostras. They are also observed in per- sons of intemperate habits. Cramps form part of the clinical course of paralysis agitans and of diabetes. Probably the most frequent of all the exciting causes of ordinary forms of cramps in the extremities is violent exercise, such as swimming, dancing, walking, running, and jumping. Pathology.-In the ordinary type of cramps the CRABS' EYES (Ecrevisse, Codex Med., Crabstones, Lapilli Cancrorum). Small hemispherical calcareous concretions found in the European Crawfish, Astacus fluviaiilis Fabr., and collected by cracking the shells of the crustaceans and piling their bodies in heaps to pu- trefy. These bits are then collected and cleansed. They are from one-half to one centimetre in diameter, plano- convex, with rounded borders, white in color, tasteless, and odorless. They consist of carbonate and phosphate of lime deposited in an animal basis. Crabstones corre- spond exactly to red coral, oyster shells, cuttle-fish, and several other forms of lime-salts formerly used in medi- cine as antacids, etc., but "whose day is now wholly past. W. P. Bolles. CRAB ORCHARD SPRINGS. Location and Post-office, Crab Orchard, Lincoln County, Kentucky. Access.-By the Knoxville & Bardstown Branch of the Louisville & Nashville Railroad, to Crab Orchard Sta- tion, one hundred and fifteen miles southeast of Louis- ville. Analysis.-There are two springs, about a mile dis- tant from each other, and having the following composi- tion. One pint contains : Foley's or Epsom Spring. (R. Peter, M.D.) Grains. Sowder's Spring. (R. Peter, M.D.) Grains. Carbonate of magnesia... 0.955 2.734 Carbonate of iron trace trace Carbonate of lime .. .. 0.648 3.689 Chloride of sodium 2.216 7.290 Sulphate of potassa .. .. 1.329 2.172 Sulphate of soda 7.384 2.900 Sulphate of magnesia 25.660 21.789 Sulphate of lime .. .. 1.349 11.416 Bromine trace Silica 0.408 0.153 Loss and moisture 4.323 50.182 52.143 Therapeutic Properties.-These are valuable saline cathartic waters, and are deservedly popular. The salts are obtained by evaporation, and have long been on the market as " Crab Apple Salts." In this form they are generally accessible, and are certainly as effective and agreeable as any similar article of foreign origin. Geo. B. Fowler. Carbonic acid gas not estimated. CRAMPS. Cramp is a term applied to denote a painful tonic muscular contraction of some moments' or minutes' duration. As several of these painful contractions gen- erally occur successively, the term "cramps" is used to designate the attack. Cramps belong to the local spas- modic disorders ; cramp is, in fact, technically a local tonic spasm, to which is added the element of pain. It is true that in tetanus there is a general cramp of almost the entire voluntary muscular system, and that in cholera cramps are widely diffused ; nevertheless medical usage assigns the term cramps to the local spasmodic disorders. Properly speaking, cramps may affect both the volun- tary and the involuntary muscles. Writers sometimes speak of cramps of the heart, of the stomach, intestines, bladder, and uterus ; but, as a rule, these cramps of the involuntary muscles are given the term colic. Cramps of 319 Cramps. Cranial Nerves. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. muscle itself is at fault. Through deficient nutritidh or over-use its fibres are irritated, an involuntary contraction results which is painful because it is so abnormally pow- erful that the sensory nerve-fibres are pressed upon. Tonic spasms become painful and crampy in character, therefore, simply because of a quantitative excess in mus- cular contraction. No one can voluntarily knot up his calf-muscles as is done in a cramp. The myopathic char- acter of the contraction is shown by the fact that, by the pressure of bands and tourniquets, which alters the blood- supply to the muscles, the cramps can often be relieved. There are, however, certain forms of cramps, like wry- neck, or writer's cramp, that arc of purely nervous origin. In these, pressure on certain nerve-trunks may check the spasm. Treatment.-The treatment of the ordinary type of leg-cramps must be addressed first to the general condi- tion. Rheumatic, gouty, and anaemic tendencies must be corrected, dyspepsia and constipation relieved. If the attacks are unusually severe and obstinate, the question of diabetes or of some organic disease must be investigated. A number of devices have been recommended for pre- venting the attacks. Among these, one which I have found successful is tying a tape about each thigh just above the knee. This is done just before retiring. Raising the head of the bed by placing one or two bricks under the posts is a measure which I have not found to do any good. A dose of bromide with alkalies at night, or a mixture containing five grains each of lupulin and camphor, may be given. In severe cases, especially in pregnancy, codeia or opium may be added to these. Massage and faradization of the limbs will sometimes ward off attacks, and so will small doses of strychnia continuously administered. When the attack comes on the affected muscles must be vigorously rubbed and kneaded. If the patient jumps up at once and puts the muscles on the stretch, he can often break up the cramp. A little rubbing and exercise will then quiet the muscle. Charles L. Dana. ant, vegetable astringent, and considerably employed in diarrhoea, chronic dysentery, etc., and as a wash, gar- gle, or injection, in catarrhs of the pharynx, vagina, or urethra. A Fluid Extract is officinal (Extractum Geranii Fluidum}, strength, f, and represents it well for internal use. Dose, one or two grams or cubic centimetres ( xv. ad xxx.). For washes and gargles a decoction, -jV, may be made in the usual way. Cranesbill is often selected, when an astringent is needed for a child, on account of its comparatively easy administration. Allied Plants.-One or two other Geraniums are oc- casionally met with in the United States, especially G. Robertianum, " Herb Robert," mostly introduced from Europe, where several are indigenous ; all have similar as- tringency, but some of the others have other disagreeable properties. The order contains upward of three hundred species, mostly herbs with pretty flowers, but none of much importance, excepting some of the Pelargoniums of Southern Africa. They are distinguished from Gera- nium by their shrubby habit and thin, slightly irregular flowers. Several species of this genus are the parents of the so-called Geraniums of the flower-garden and lawn, whose beauty has given them a high place in the estima- tion of flower lovers everywhere. One or two species are cultivated for their essential oil, which is used in per- fumery. Allied Drugs.-See Nutgalls. W. P. Bolles. CRANIAL NERVES are those which arise from the central axis of the nervous system, either wholly or partly within the cavity of the cranium. The earlier writers (Marianus, Galen), enumerated seven pairs of these ; Willis (1664) described ten pairs. His tenth pair, the suboccipital, was shown by Haller to belong to the cervical nerves, and rejecting that, his nomenclature is still used in England ; but since Sbmmering showed that his seventh pair should be separated into two, and An- dersch that his eighth comprised three nerves, the cranial nerves have usually been considered as forming twelve pairs. Figs. 757, 758, 759, and 760, together with the fol- lowing table, shows in a condensed form their origin, exit, general distribution, and function. The nature and primitive condition of the cranial nerves are best understood by reference to the spinal nerves. These arise from the central gray matter of the medullary tube called the spinal cord, by two roots, an anterior, motor, and a posterior, on which is a ganglion, sensory (see Fig. 761). The roots unite to form a single trunk which emerges between contiguous vertebrae, after- ward dividing into a dorsal and a ventral branch. From the latter is derived a visceral branch, which communi- cates with the sympathetic and thereby supplies the ali- mentary canal and its appendages. In foetal life the posterior roots appear first, and are formed by an out- growth from a ridge-like collection of cells, called the neural crest, which lies along the tube at the point where the ectoderm folds in to form it (see Fig. 762). The crest at first connects each root with its fellow across the dor- sal surface of the cord. This origin is not, however, per- manent, for in its outward growth the root, after devel- oping the ganglion which belongs to it, throws out a process which becomes attached to the side of the tube (Balfour, Marshall-see Fig. 763), and the original dor- sal attachment becomes gradually obliterated (Fig. 764). The origin is thus shifted farther toward the ventral sur- face. In the lowest vertebrate (Amphioxus) only pos- terior roots are found, and these are mixed, containing motor, as well as sensory, fibres. The anterior roots originate later as an outgrowth from the anterior column of the cord, soon uniting with the posterior to form a mixed nerve, of which the further de- velopment is not completely known, although the weight of evidence indicates that it is by a centrifugal growth. Heusen believes that there is a simultaneous formation of nervous elements along the nerve-path, and this receives some support from Kleinenberg's discovery that in the hydra each muscular fibre is developed independently in the interior of a narrow prolongation of ectodermic cells. (See A, Fig. 765). He calls these neuro-muscular ele- CRANESBILL (Geranium, U. S. Ph.). The wild Gera- nium, Geranium maculatum Linn., order, Geraniacece, a pretty purple wild-flower of our pastures and woods, is the source of this article. It has an upright, herbaceous, hairy, forking stem, from twenty to fifty centimetres high, with several long-stemmed, palmately parted root- leaves, and one or a few pairs of opposite, short-petioled, stem-leaves at the bifurcations of the stem and at the bases of the flower clusters. Leaves about five-parted, with narrow, wedge-shaped, cleft, gashed, or irregularly serrate lobes. Flowers in terminal umbel-like cymes, about twenty-five millimetres (one inch) across, regular, open, perfect. Calyx five-sepalled, segments pointed, hairy. Petals five, rounded, spreading. Stamens ten, pistil one, of five carpels whose five very long styles unite with a prolongation of the receptacle into a pointed column splitting at the apex into five stigmas. The fruit is pointed, three or four centimetres long (one and a half inch), with the five achenia at its base ; these at matur- ity separate from the receptacle and remain attached by their styles to the central column. Cranesbill is common in most parts of the United States, inhabiting rich pastures and open woods. It blos- soms in the middle and latter part of the summer, and its leaves become spotted and marbled with whitish spots as the season advances. It has been a household remedy in this country for years, and is in moderate demand by a few physicians. The rhizome, which is the part employed, is, when dried, in cylindrical, generally simple, pieces, from four to eight centimetres long (1| to 3 inches), and about one in thickness, dark-brown without, pink-brown within. It is wrinkled, twisted, and tuberculated, and breaks with a short, transverse fracture. Odor, none ; taste as- tringent, not bitter. Besides inert mucilage, resin, coloring matters, etc., Ge- ranium contains about four per cent, of gallic and tannic acids, to which its medicinal value is owing. Its use is explained by its composition; it is a mild, rather pleas- 320 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cramps. Cranial Nerves. ments, and considers them as the most simple motor apparatus. This is supported by the observations of Heitzmann, who holds that the axis cylinder of a nerve-fibre is ordinary connective-tissue modified for the transmission of special impulses, and that such modification may take place at any time, along paths in the general connective tissue of the body, determined by the needs of the individual. It appears to be contradicted by what we know of the development of nerves from the cord, and by the fact that when a nerve is divided its regeneration is effected by a sprouting from the proximal end. The cranial nerves may be di- vided into two classes, those which do, and those which do not origi- nate like the spinal nerves. The olfactory and the optic nerves are generally held to constitute the lat- ter class. The olfactory bulb and tract (often improperly called the olfactory nerve), are an outgrowth from the hemispheres (prosenceph- alon), and have been considered as a secondary cerebral vesicle (rhinencephalon).* In most mammals they are comparatively larger than in man. The optic nerve originates as a vesicular outgrowth from the primary anterior vesicle of the brain (thalamen- cephalon), its bulbous extremity becoming indented to form the retina, while its stalk-like attachment remains * Marshall holds that the bulb is connected with a continuation forward of the neural crest, the olfactory filaments arising therefrom like those of the posterior root of a spinal nerve. Kolliker does not accept this. Fig. 757.-General View of the Cranial Nerves. (Slightly altered from Allen Thomson.) Fig. 758.-The Base of the Brain, showing the Apparent Origin of the Cranial Nerves. After Gegenbaur.) Fig. 759.-The Base of the Skull, showing the Exit of the Cranial Nerves. 321 Cranial Nerves. Cranial Nerves. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Origin. Exit from Cranial Cavity. (See Fig. 759.) General Distribution. (See Fig. 757.) Function. Deep or Real. From Nuclei of Gray Matter. (See Fig. 760.) Apparent. From Surface of Brain. (See Fig. 758.) I. Olfactory. Gray matter of olfactory bulb. Olfactory bulb. Cribriform plate of Schneiderian membrane of Sense of smell. II. Optic. Optic thalami, anterior corpora quadrigemina. Per optic tract from ethmoid bone. Optic foramen. upper half of nasal fossa. Retina of the eye. Sense of sight. occipital lobe of cerebrum, and upper portion of spinal cord. III. Motor Oculi Communis. Upper part of the floor of the Sylvian aqueduct optic thalami and cor- pora quadrigemina. Inner side of crus cere- Sphenoidal fissure. Muscles of eye, except su- perior oblique and exter- nal rectus. Superior oblique muscle of Motor. near the median line. IV. Patheticus (Trochlearis). Floor of Sylvian aqueduct, behind and continu- bri, close to pons. Valve of Vieussens. Sphenoidal fissure. Motor. ous with Nucleus III. V. Trigeminus (Trifacial). Sensory Hoot.-Upper lateral part of floor of Side of the pons nearer 1st Division.- the eye. Sensory.-Face, forehead, Mixed, mainly fourth ventricle, and (ascending root) from anterior than pos- Sphenoidal fissure. eye, nose, ear, mouth, tongue, and teeth. Motor.-To muscles of mas- tication. External rectus muscle of sensory. upper portion of posterior horn of spinal cord and its continuation. Motor Hoot.-Upper part of floor of fourth ven- tricle, internal to sensory nucleus, and (descend- ing root) from scattered nuclei at side of aque- duct. VI. Abducens (Motor oculi externus). Upper part of floor of fourth ventricle near the terior border. Between the anterior 2d Division. -Fora- men rotund um. 3d Division.-Fora- men ovale. Sphenoidal fissure. Motor. median line, under the fasciculus teres. VII. Facial (Portio dura). Deeper, but at same level as Nucleus VI. Its pyramid and the pons. Behind the pons, be- tween olive and the restiform body. Between VII and VIII. Internal auditory me- the eye. Muscles of the middle ear, Motor. fibres loop around this nucleus, and a few are derived from it. (Nervus intermedins Wrisbergii. Detached portion of Nucleus IX, which see. atus, through Fal- lopian canal to stylo- mastoid foramen. Internal auditory face, and palate, the stylo- hyoid and posterior belly of the digastric. Tongue, through chorda- Sense of taste ? ] VIII. Auditory (Portio mollis). 1. Medial.-From acoustic tubercle and striae Just external to VII. meatus. Internal auditory tympani ? Vestibule, semi- circular Sense of hearing medullares (nuclei of opposite side ?), floor of fourth ventricle. 2. Lateral.- Side of fourth ventricle and from roof nucleus of cerebellum. IX. Glosso-pharyngeal. 1. Sensory.-Inferior fovea, floor of fourth ven- Between olive and the meatus. Jugular foramen. canals, and cochlea of in- ternal ear. Tongue, pharynx, middle and of direc- tion of move- ment (?). Mixed, mainly tricle. 2. Motor.-Between olive and ascending root of V. X. Pneumogastric ( Vagus). 1. Sensory.-Ala cinerea floor of fourth ventricle, restiform body, below VII. Just below IX. Jugular foramen. ear, and stylo-pharyngeus muscle. Respiratory passages, heart, sensory. Mixed, mainly continuous with nuclei IX above, and XI below. 2. Motor.-Continuous with motor nucleus IX. XI. Spinal Accessory. 1. Medullary.-Continuous with the two nuclei Just below X, and by Jugular foramen. upper part of alimentary canal and related viscera. Sterno-mastoid and trape- sensory. Mixed, mainly of X. 2. Spinal.-From posterior horn of spinal cord as far down as sixth cervical vertebra. XII. Hypoglossal (Sublingual). Lower part of floor of fourth ventricle, near the separate rootlets from upper portion of cord. Between anterior pyra- Anterior condyloid zius muscles, pharynx, and larynx. Most of the muscles arising motor. Motor. median line. mid and the olive. foramen. from the hyoid bone. Table of the Cranial Nerves. as optic nerve and tract. At first there is no trace of nervous fibres, they appearing later as radiating out- growths from the brain. The remaining nerves show an undoubted resemblance to spinal nerves. They form two tolerably well-defined groups, one anterior to the auditory vesicle, called the trigeminus group, another posterior to the vesicle, called the vagus group. Certain of them, viz., the third, fifth, seventh, eighth, ninth, and tenth arise from a neural crest continuous with that for the spinal nerves, and they shift their position like the posterior roots, the third being re- markably displaced, so that it appears on the surface quite at the ventral portion of the cerebral tract. The fourth, sixth, and twelfth do not arise from the crest but seem to represent anterior roots. It would appear there- fore, that several of the cranial nerves represent that primitive condition in which the posterior roots (not necessarily purely sensory) are separate from the anterior. The nuclei of gray matter from which the nerve-fibres take their deep origin are arranged along the axis tube, in what seems at first to be an irregular manner (see Fig. 760). Successive transverse sections show, however, that the nuclei for the motor nerves are derived from prolonga- tions of the gray matter of the anterior horn of the cord, while the sensitive and mixed nerves arise from masses similarly related to the posterior horn. The principal difficulty in making this clear is the fact that as the col- umns of the cord ascend to form the medulla, they are rearranged, the lateral columns first cutting across and isolating the head of the anterior horn of gray matter (de- cussation of the pyramids), and when this is effected the posterior columns, in like manner, cutting off the head of the posterior horn (superior decussation of Meynert). Each horn is therefore divided into two masses, a base, and a detached head. In the base of the anterior horn there are successively found, from below upward, the nu- clei of the hypoglossal, facial, abducens, patheticus, and motor oculi communis, the tract being traced nearly as far as the third ventricle. To the head of the anterior horn belong, 1st, a small mass of large motor cells, known as the motor nuclei of the mixed nerves (the spinal acces- sory, pneumogastric, and glosso-pharyngeal); 2d, the ac- cessory nucleus of the hypoglossal; 3d, the motor nucleus of the trifacial and its descending root. In the base of the posterior horn we find, from below upward, 1st, the continuous nuclear mass from which arise most of the fibres of the spinal accessory, pneumogastric, and glosso- pharyngeal nerves ; 2d, the internal nucleus of the audi- 322 REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. Cranial Nerves. Cranial Nerves. tory; 3d, the sensory nucleus of the trifacial. To the head of the horn is referred the ascending root of the tri- geminus. On a line with the emergence (apparent origin) of the cranium which represent separate vertebrae, it is clear that it is between separate elements that the principal avenues, of nerve exit are found, viz., the sphenoidal fissure and the jugular foramen (see Fig. 759). The nerves are distrib- uted to the visceral arches and clefts as the spinal nerves are to their segments, forking, however, at the cleft, and supplying contiguous lips of two arches in- stead of going to but one. Thus the motor oculi and the patheticus fork about the lachrymal cleft (be- tween the trabeculae); the trigeminus about the buc- cal cleft, supplying the maxillary and mandibular arches ; the abducens and the facial (primitively) about the spiracular cleft, supplying the mandibular and hyoid arches; the glosso - pharyngeal about the hyoid cleft, supplying the hyoid and branchial arches ; the pneumogastric by successive branches supplying the remaining arches. Gegenbaur holds that the trigeminus has for its dorsal branch the ophthalmic, for ventral the superior and in- ferior maxillary, for visceral the branches to the spheno- palatine ganglion. The abducens he considers a portion of the facial.* The auditory is the dorsal branch of a group of which the facialis ventral, and its great petrosal branch, visceral. The glosso - pha ryngeal is mainly a visceral branch, its motor twigs being ventral. The pneumogas- tric and spinal ac- cessory are main- ly the visceral and ventral branches of a considerable number of posterior roots, the hypoglossal representing a similar complexus of anterior roots. As the nerves emerge they come in contact with the covering membranes of the brain. The pia mater be- comes the perineurium, and the arachnoid and dura form around them tubular sheaths, so that communi- cation exists between perineural spaces and the sub- dural and subarachnoid spaces (see Fig. 768). Because of this, intracranial pressure may cause nervous disturb- ances, and frac- ture of the skull involving the exit of the auditory nerve may cause an effusion of fluid from the ear. Before leaving the skull the third, fourth, fifth, and sixth nerves pass for some distance apparently outside the dura, but real- ly between two sheets of it. In comparison with the area supplied, the nerves of special sense (olfactory, optic, auditory) are the largest; the sensory nerves (fifth, ninth, and tenth), required to convey the complex sensations of surface, form, and weight, are next in size; while the nerves for simple .Third ventricle. Neural crest. .Pineal body. Ectoderm. .Medullary tube. Valve of Vieussens. Peduncle. Muscle plate. Notochord. Locus cceruleus. Eminentia teres Fig. 762.-Cross-section of Embryo of Chick before the Appearance of the Spinal Nerves. (After Marshall.) Neural crest. Secondary attachment. Ala cinerea. Accessorius nucleus. .Ectoderm. Obex.. j M u s cle- ( plate. Clava . Posterior root. Funiculus cuneatus.. , Notochord. Funiculus gracilis . Fig. 763.-The Same, at a later stage. (After Marshall.) Anterior root. Fig. 760.-Medulla Oblongata (enlarged). The Roman numerals (I, II, etc.) indicate the superficial origin of the cranial nerves; the Arabic (1, 2, etc.) their deep origin. (Adapted from Landois.) posterior or sensory roots of the spinal nerves we see (Fig. 758) successively appearing, from below upward, the spinal accessory, pneumogastric, glosso-pharyngeal, auditory, and trigeminus. Ranged with the anterior or motor roots are the hypoglossal and the abducens. The ganglion which characterizes the posterior root of a spinal Anterior root. Spinal cord. Mixed nerve. Dorsal branch. Ectoderm. Ganglion. Posterior root. Ganglion. Sympathetic nerve. Posterior root. Muscle- plate. Visceral branch . Mixed nerve. Notochord. Ventral branch Fig. 764.-The Same, when the Formation of Nerve-roots is Completed. (After Marshall.) Fig. 761.-Diagram of a Spinal Nerve. nerve appears more or less distinctly upon those nerves which are supposed to represent posterior roots. In their distribution the cranial nerves also show con- siderable similarity to spinal nerves. While it is by no means settled what is the number of the segments of the * The outer wall of the orbit is absent in most mammals, making the external rectus a face muscle. 323 Cranial Nerves. Cranial Nerves. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. homologous with other nerves supplying clefts, and the Schneiderian folds answer to gills. II. The Optic.-Its fibres first lie in a flattened band, the optic tract, curving around and closely adherent to the crus cerebri on either side. Directly at the point of apparent origin are interposed two considerable ganglionic masses, the external and internal corpora geniculata. The bands from opposite sides meet, and form the optic com- missure or chiasma (Figs. 758 and 767). A set of fibres runs posteriorly in the commissure from one tract to the other, connecting parts of the brain and not entering the optic nerves. This apparently paradoxical behavior is explained by the fact that the commissure is originally part of the brain substance, becoming separated in the course of development. Anatomical and embryological evidence shows a complete decussation in the commissure, all the fibres from one tract passing to the opposite eye ; but clinical data indicate that not more than half the fibres cross. An injury to one optic tract, as at A, Fig. 767, is followed by loss of vision in the outer half of one eye and the inner half of the other (homonymous hemianopsia). motor impulses are the smallest and finest in texture, but yet larger in proportion than the anterior roots of the spinal nerves. Merkel and Tergast1 found that by act- ual count there were in the limbs from thirty to eighty muscle-fibres for every nerve-fibre, while in the eye- A. Ectoderm cell. B. Ectoderm cell. C. Sensi- tive cell. Sensory nerve. Motor nerve. Gan- glion cell. Motor nerve. Muscle process. Muscle cell. Muscle cell. Fig. 765.-Diagram of the Simplest Forms of a Nervous System. (After Foster). A, an ectoderm cell with its muscular process, as in Hydra, (Kleinenberg); B, an ectoderm cell, connected with a muscle cell by a primary motor nerve, as in Hydractinia (Von Beneden); C, a differen- tiated sensitive cell, connected by a sensory nerve with a central cell, which is again connected by a motor nerve with a muscle cell, as in Beroe and Medusa (Eimer). B muscles the relation is from two to six to each, indicat- ing greater specialization. I. The Olfactory (Fig. 766).-The olfactory bulb and tract were first connected with smell by Theophilus, a.d. 800, but Nicolaus Massa, a.d. 1536, first ranked them as a cranial nerve. In many vertebrate animals the filaments of the bulb are collected, like other nerves, into a compact bundle, which pierces the cranial cavity by an appropriate foramen. In man they are scattered into from twelve to twenty bundles, forming a plexiform net- work in the mucous membrane of the regia olfactoria of the nose, that is, the upper part of the septum, the upper turbinate bone, and part of the middle one. The nerves end in peculiar, spindle-shaped cells with large nuclei, Fibres from right side of brain. Fibres from left side of brain. C Commissu- ral fibres. A Optic tha- lami. OlfactoryBulb Hemi- spheres. Fig. 767.-Diagram of the Supposed Course of the Fibres of the Optic Nerve. 'Spheno-paldtme Ganglion. These are the halves which correspond in ordinary vision. A lesion at B, in front of the chiasma, affects the inner half of both eyes, and, the field of vision being always re- versed, objects on the temporal or outer side of each eye are not perceived (temporal hemianopsia). If at C the outer half of the eye is affected, and objects on the inner or nasal side are not perceived (nasal hemianopsia). The fibres connected with the cortex of the occipital lobe are probably concerned in the hallucinations and visual disturbances of cerebral disease, and those passing to the spinal cord cause reflex dilatation of the pupil, and explain the amblyopia with degeneration of nerve-fibres which may occur in locomotor ataxia. The thick and strong dural sheath of the nerve is con- tinued on to the sclerotic coat of the eye (Fig. 768). The nerve-fibres are separated by trabeculae of connective- tissue, forming lymph spaces among which ramify blood- vessels, the chief of which is the arteria centralis retinae and its accompanying vein, and they pierce the lamina cribrosa of the sclerotic, making small foramina, as do at their exit other nerves of special sense, viz., the olfactory and the auditory. The perineural, subdural, and sub- arachnoid spaces communicate with the interfibral lymph spaces, so that inflammatory products readily penetrate throughout. Intracranial pressure causes many affections Fig 766.-The Kight Olfactory Nerve on the Outer Wall of the Nasal Fossa. (Adapted from Hirschfeld.) which send processes to the free surface of the mucous membrane. As the shape of the inferior turbinate bone is such that it directs air upward in inhalation only, ex- haled particles are not smelt. The connections of the nerve with the cerebral cortex are not certainly known. Ferrier locates the cortical centre in the uncinate gyrus, closely connected with that for taste. The olfactory organ arises in the embryo as a pit or depression, around which the filaments of the nerve are distributed. Marshall suggests that this is the most an- terior visceral cleft, that the olfactory nerve is therefore 324 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cranial Nerves. Cranial Nerves. of vision. [The retinal nerve-endings are described in articles relating to the eye.] Stimulation of the optic nerve causes nothing but sen- sations of sparks, flashes of light, or play of colors. If but few fibres are affected sparks are seen ; if the inflam- mation is more general, disks or spheres of light, colored the image not falling on corresponding spots in the two retinae. 5. Dilatation of pupil, from failure of its sphincter. 6. Inability to accommodate for near objects, from fail- ure of ciliary muscle. Direct irritation of the nerve, either at its nucleus or by basilar meningitis, may occasion spasmodic rolling of the eyes (nystagmus), and reflex stimulation (teething, worms,) may cause internal spasmodic strabismus. The nerve has been torn across at its entrance into the orbit by a fracture involving tile optic foramen, and it has been di- vided by a stab through the upper eyelid, without injury to the globe or fracture of the bone. IV. The Patheticus (Fig. 769) is the smallest cranial nerve, and has the longest course in the cranium. On that account its discoverer, Fallopius, enumerated it as the last of the series. It is purely motor, actuating one muscle only, the superior oblique of the eye, but it re- ceives filaments from the carotid plexus and the ophthal- mic branch of the fifth. Its paralysis occasions a very slight external strabismus, the pupil being directed up- ward and outward by the inferior oblique, and conse- quent double vision, in which the images separate on moving the head toward the affected side, because com- pensatory adjustment is lost, the eye turning with the head. VI. The Abducens (Fig. 769), conveniently consid- ered in connection with the other motor nerves of the eye, lies, while in the cranial cavity, against the carotid artery in the inner wall of the cavernous sinus, receiving, like the others, filaments from the sympathetic (carotid plexus) and ophthalmic nerves. Its nucleus is believed to be connected with that of the third of the opposite side, which may account for the associated action of the two. Its paralysis causes an internal strabismus, from failure of the only muscle it supplies, the external rectus. As the nerves of the orbit lie closely together in the sphenoidal fissure, while farther forward they separate, any growth or injury involving all of them is likely to be situated far back. V. The Trigeminus, the largest of the cranial nerves, bears a strong resemblance to a spinal nerve, as it arises by two roots, one large and sensory, the other much smaller, purely motor. It appears to contain also trophic fibres (derived perhaps from the sympathetic) controlling nutri- tion, for after complete section the mucous membranes ulcerate, smell and taste are lost, and a general ophthalmia destroys the eye. Lesser impairment causes circum- scribed inflammation of the skin (herpes), and affections of the hair, it turning gray and falling out. The two roots pass together through an opening in the dura, where the tentorium spans over from the petrous bone to the clinoid processes, and reach a large ganglion, the Gasserian,* which is formed on the sensory root. The ganglion has not the usual oval form, but is flattened and crescentic, the convexity forward. Filaments from the carotid plexus are said to join it. From it diverge three great trunks (whence the name trigeminus), the ophthalmic, and the superior and inferior maxillary, whose united calibre is greater than that of the original nerve. The central nuclei of the trigeminus appear to connect with those of all the motor nerves except the abducens, which explains its extraordinary reflex relations. It is probable that its fibres convey impulses to widely sepa- rated portions of the cortex. A brief review of the branches follows. A. Ophthalmic (Fig. 769). Purely sensory and the smallest of the three main trunks. Receives sympathetic fibres from the cavernous plexus, then gives branches to Inner layer of the retina Outer layer Choroid. Sclerotic Lamina cribrosa. Arteria centralis retinas Nerve-fibres Pial sheath. Arachnoid sheath Subarachnoid space. Dural sheath. Fig. 768.-Horizontal Section of the Optic Nerve at its Entrance through the Coats of the Eye. Magnified. (After Heitzniann.) rings, etc. These may occur even when the patient is totally blind. III. The Motor Oculi Communis (Fig. 769).-Within the cavity of the cranium, this purely motor nerve lies, together with the fourth and the ophthalmic branch of the fifth, along the outer wall of the cavernous sinus ; re- ceiving there some filaments from the cavernous plexus and from the fifth. It innervates not only the muscles moving the eyeball (except the superior oblique and ex- ternal rectus), but also the sphincter of the pupil and the ciliary muscle (muscle of accommodation), the latter being done through the ciliary ganglion, a small body about as large as a wheat grain, attached to the main trunk of the nerve by a short root. In many vertebrates Supraorbital. Supratrochlear. Infratrochlear. .Lachrymal gland. .Frontal. Lachrymal. .Nasal. Ciliary nerves. Ciliary ganglion. Ophthalmic division. it is found on the trunk of the nerve, like the ganglia on the posterior roots of the spinal nerves. It receives fibres from the carotid plexus of the sympathetic, which antag- onize those from the third in their action on the pupil. The paralysis of the third causes : 1. Drooping of upper lid (ptosis), from failure of leva- tor palpebrse. 2. Immobility of globe, from failure of rotator muscles. 3. Slight protrusion of ball, from unopposed action of superior oblique. 4. External strabismus, pupil directed downward and outward,<from unopposed action of superior oblique and external rectus, and consequent double vision (diplopia), Fig. 769.-The Nerves of the Left Orbit. (Young, reduced.) * Some anatomists (Huxley, Anatomy of Vertebrates; Gray, Human Anatomy) improperly call this the Gasserian ganglion. The works of Casserius, a.d. circa 1600, show that he was unacquainted with it, as he reckoned the ophthalmic division as an independent nerve. Fallopius described the correct division, and Eustachius figured it(Ed" Maxentinus, pls. xvii., xviii.). Meckel recognized a flattened structure which he called tania nervosa, and Vieussens termed it the plexus gangliiformis, but Hirsch (Disquisitio paris quinti, Vindob., 1765, in Sandifort's Dis- sert., vol. iii., 577-500) first distinctly recognized it as a ganglion, and named it ganglion Gasserianum in honor of his master, " clarissimus J. L. Gasser," who by his excellent dissections had demonstrated its true character. 325 Cranial Nerves. Cranial Nerves. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the tentorium, to the patheticus, and the other motor nerves of the orbit, thus giving sensation to the muscles. Before entering the orbit it divides into the following branches: a. Lachrymal. To the lachrymal gland, conjunctiva, and skin over the outer angle of the eye. When injured the secretion of tears ceases. Secretion is believed to be governed by motor nerves, and it is probable that the branches received from the patheticus (or facial, per great petrosal and temporo-malar ?) are the real agents (Hyrtl). b. Frontal. Under roof of orbit, midway divides into a. Supratrochlear, out near the inner angle of the eye to skin of eyelid and forehead. ft. Supraorbital, through supraorbital notch or over edge of orbit (Hyrtl) to eyelid, brow, periosteum, and mucous membrane of the frontal sinus. The periosteal filaments, closely confined by dense structures, are, for this reason, the fir§t to suffer in neuralgia, and " brow ague " or malarial neuralgia is a common affection, char- acterized by a spot over the supraorbital notch painful on pressure. c. Nasal (cilio-nasal). Deep in the orbit, passes over the optic nerve to the inner side, through the anterior ethmoidal foramen into the cranial cavity, then down through the cribriform plate to the nasal fossa, grooving the nasal bone and passing out between it and the carti- lage to supply the tip of the nose. In foetal life the eth- moid is represented by a cartilaginous capsule, to which resisting structures. The malady is characterized by painful points at the infraorbital foramen and over the malar bone. From the great number of filaments of its facial distri- bution, irritants there applied produce a profound ner- vous impression. A small splinter of glass has produced fearful neuralgic pains, and even paralysis, trismus, and a return of epileptic attacks (Johnson). Fracture of the malar and inferior maxillary bones may be followed by anaesthesia over the region supplied by this nerve. Be- sides a recurrent branch to the dura, this nerve has the following : a. Temporo-malar. Through spheno-maxillary fissure into orbit, anastomosing with lachrymal. Filaments pass through malar bone to skin over temple and prominence of cheek. b. Spheno-palatine. Branches to the spheno-palatine ganglion of the sympathetic (Fig. 766, see Sympathetic Nervous System). Not all the fibres enter the ganglion. From them, or from the ganglion, are given off : a. Pharyngeal branches to mucous membrane of phar- ynx. Naso-palatine to septum of nose and through ante- Gasserian ganglion. Sensory root. Ophthalmic div. .Motor root. Temporo-malar. Superior maxillary div. Foramen ovale .... .Otic ganglion. Lesser pe- trosal. Sphenopalatine ganglion. Superior maxillary division. Ophthalmic division. Anterior trunk.... Chorda tympani. Gasserian ganglion. Auriculo - tem- poral. Infraorbital. .Middle menin. art. Inferior dental. Gustatory. Vidian nerve. Carotid artery with plexus. Facial artery. Descending palatine. .Submaxillary ganglion. Mylo-hyoid. Naso- palatine. Fig. 770.-The Superior Maxillary Division of the Fifth. Left side. (Altered from Young.) Dental. Mental foramen. the nerve is distributed. This disappearing, the nerve is exposed in what seems a peculiar course. Its branches .are : a. Sensitive root of ciliary ganglion, from which run the short ciliary nerves of the eyeball. ft. Long ciliary nerves. With the last these give sen- sibility to the eye. Intraocular pressure causes great pain by compressing them between the choroid and the un- yielding sclerotic. /. Spheno-ethmoidal (Luschka). Through posterior ethmoidal foramen to ethmoidal cells and sphenoidal sinus. 8. Infratrochlear, out at inner angle of eye to lachrymal sac and integument over root of nose. e. Internal nasal, to walls and septum of nose. The area of distribution of the ophthalmic nerve is nearly the same as that affected in acute coryza or cold in the head. B. Superior Maxillary (Fig. 770). This purely sensi- tive trunk passes forward through the foramen rotun- dum, across the spheno-maxillary fossa and beneath the orbit, emerging on the face as infraorbital nerve through the foramen of that name. Its terminal branches radi- ate to the eyelid, nose, and lip, forming the " lesser goose- foot " (pes anserinus minor). Like all facial branches of the fifth it unites intimately with the twigs of the facial nerve. Neuralgia of this nerve is the severest form af- fecting a single trunk. This is probably because it lies for so great a part of its course surrounded by firm and Fig. 771. -The Inferior Maxillary Division of the Fifth. Left side. (Young.) rior palatine foramen to mucous membrane of hard palate. 7. Posterior nasal to external wall of nasal fossa behind. d. Descending palatine, three in number, through poste- rior palatine canal to soft and hard palate. They were considered by early anatomists as separate cranial nerves. As they reach the nasal fossa through a comparatively large orifice (spheno-palatine foramen) they are not sub- ject to neuralgia. c. Superior dental. Usually three-posterior, middle, and anterior. Running in special bony canals, they form loops with each other, from whence branches supply the antrum, gums, and pulp of teeth. The canine teeth are connected with branches which proceed vertically up- ward, and pain is conveyed in that direction. Hence probably the term " eye-teeth." C. Inferior Maxillary (Fig. 771).-The largest of the three trunks and of mixed function, the motor root unit- ing with it immediately after it quits the cranium by the foramen ovale. The otic ganglion of the sympathetic (see Sympathetic Nervous System) is here attached to its median surface. After sending a twig to the dura, it gives off two groups of branches. The smaller group re- ceives most of the fibres of the motor root and actuates the muscles of mastication except the buccinator, to which it sends sensory filaments only. Its branches are : a. Masseteric, to masseter and temporo-maxillary ar- ticulation. b. Deep temporal, two in number. 326 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cranial Nerves. Cranial Nerves. c. Buccal, to buccinator, skin, and mucous membrane of cheek. It can be reached through the mouth for ex- tirpation. d. Internal pterygoid, to muscle of that name. Ap- pears to arise from the ganglion. Sends branch to actu- ate the tensor palati. e. External pterygoid, to muscle of that name. f. Tensor tympani, supplies that muscle of the ear and the mucous membrane of the tympanum. Appears to arise from the ganglion. When injured, perception of tone is impaired and inflammatory changes occur in the ear. The larger division splits into three main branches : g. Auriculo-temporal, arises by two roots embracing the middle meningeal artery, runs between the ear and the temporo-maxillary articulation under the parotid and supplies the concha and the temporal region. h. Lingual or gustatory. Receives soon after its ori- gin the chorda tympani from the facial, and taking a cur- vilinear course passes internally to the ramus of the jaw, to the mucous membrane of the mouth, and the papillae of the anterior two-thirds of the tongue. It shares with the glosso-pharyngeal the function of taste. It gives fila- ments to the submaxillary ganglion of the sympathetic (see Sympathetic Nervous System). When the lingual is paralyzed, morsels of food pushed over to the affected side seem tq have escaped from the mouth. i. Inferior dental. The. largest branch. Supplies the ferred to the nasal or frontal region or even extending to the branches of the second division. Inflammation of the region supplied by the nasal nerve is likely to be fol- lowed by conjunctivitis ; strong sunlight on the eyes may cause sneezing. Carious teeth are associated with a va- riety of ailments, such as gray hair over the distribution of the auriculo-temporal nerve (Hilton), ear-ache, and in- flammation of the middle ear. Repeated yawning and sneezing are also noted in connection with ear ailments. Richet reports that certain quacks in Paris gained repu- tation for the cure of dental neuralgia by dividing the auriculo-temporal nerve in front of the ear. Paralysis of the trigeminus causes anaesthesia over the region shown in Fig. 772. The areas delineated as be- longing to the different branches are approximate only and shade into each other. The mucous membrane of the nasal passages, mouth, anterior part of the tongue, and part of the pharynx, are also rendered insensible, and the patient, in drinking, feels as if part of the glass applied to the lips were cut away. The muscles of mas- tication on the affected side are disabled, and as those of the sound side crowd the jaw over, the mucous mem- brane becomes chafed by the teeth. The motor branches are much less liable to be affected than are other portions of the nerve, following the law which is so apparent throughout the body, that the apparatus essential to the functions of organic life is much less likely to be affected Lesser petrosal. Great petrosal. External petrosal. Great \ Occipitdl\ Geniculate ganglion. Chorda tympani. Stylo-mastoid foramen. Otic ganglion. Middle menin- geal artery. Posterior auricular. Stylo-hyoid and digastric. Gustatory. Great ^uri/ular! Superficial Cervical Temporo-facial. .Cervico-facial. Fig. 773.-Left Facial Nerve, seen from the median side. (Adapted from z Young.) Fig. 772.-Cutaneous Distribution of the Nerves of the Head. by slight causes than the subsidiary parts of later devel- opment. Regarding the trigeminus as a sentry nerve whose duty it is to give notice of approach from without, it may be noted that each orifice for special sense (eye, nose, mouth, ear), is guarded by branches from more than one trunk, so that injury of a single trunk does not completely de- prive the orifice of sensation. This is due to the fact that the sense orifices are always interposed at visceral clefts. VII. The Facial (Fig. 773), chief motor nerve of the face, was called by the old anatomists the portio dura, from its firm consistence as contrasted with its compan- ion, the auditory nerve, which was called the portio mollis. They supposed it to be a mixed nerve ; misled by the filaments it receives from sensory nerves, especially the fifth. Believing it to be the principal nerve affected in neuralgia, section of it was practised for the cure of that malady ; but, as naively admitted by Blandin, " presque toujours sans succes." In animals below man the facial rapidly reduces in size and importance as we de- scend, owing to the great reduction in the number and complexity of the facial muscles. Below reptiles it seems to be merged with the trigeminus, and being distributed mylo-hyoid muscle and anterior belly of the digastric, then passes through inferior dental canal in lower jaw to mental foramen, where it divides, one branch emerg- ing as mental nerve, the other continuing on to supply the incisor teeth. Within the canal it supplies the pulp of lower teeth by filaments from anastomotic loops. It can be divided at its entrance (to relieve the pain of neu- ralgia and cancer) by an incision behind the last molar, and at its exit by turning back the lower lip. Stimulation of the motor fibres of the fifth causes a spasmodic clenching of the jaws (trismus). They are lia- ble to affection in disorders of the central nervous sys- tem, as in lockjaw, strychnine-poisoning, and the chat- tering of an ague fit. Reflex causes may affect them ; grinding of the teeth occurs from slight disturbances of the alimentary canal, and trismus may arise from worms or from dentition. The branches of the trigeminus are liable to be affected by what may be called the law of as- sociative action, an affection of one branch causing pain or actual inflammation within the area supplied by an- other. Thus affections of one eye are frequently fol- lowed by similar changes in the other, also by pain re- 327 Cranial Nerves. Cranial Nerves. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to the muscles of the gill-cover, is a truly respiratory nerve. Bell recognized this function of the facial in man, and made it a basis of classification. Considering its phylogenetic history, it is not surprising that there is connected with the facial a lately developed area of brain the internal auditory meatus, the facial and the inter- medins entering the Fallopian canal (Fig, 775). The latter nerve, having given some filaments to the auditory, loses itself in the facial at the point where the canal turns sharply, and a small ganglion (geniculate) is formed. Following the original direction of the canal, and there- fore passing out of the bone by the hiatus Fallopii, a small nerve is given off, the greater superficial petrosal. It goes to the spheno-palatine ganglion, and, after being joined by a branch from the carotid plexus, is known as the Vidian nerve. It supplies the levator palati and azygos uvulae (muscles of the spiracular cleft). There is reason to believe that this represents the primitive trunk, as the hiatus is, at an early period, the external opening of the Fallopian canal, the tortuous course beyond it be- ing at first an outside groove, and covered in by a sub- sequent growth. Other branches given off in the canal are filaments to the lesser superficial petrosal (to otic ganglion), to the carotid plexus, to the stapedius muscle, to the auricular branch of the pncumogastric and finally a branch, named from its peculiar course, the chorda tympani. The latter is given off just before the facial emerges at the stylo-mastoid foramen, takes a recurrent course like a nerve foreign to the main trunk (see Fig. 773), passes into the middle ear through a special canal, stretches above the drum among the ossicles, emerges at the canal of Huguier and joins the gustatory. Its fibres can be traced (by the method of degeneration after section) to the submaxillary ganglion and the tongue. Section of it abolishes taste in the anterior portion of the tongue. As this would indicate that it contains afferent fibres, attempts have been made to trace it to an afferent nerve like the fifth, through filaments to the otic ganglion or the great auricular, or through the great petrosal. Duval and others think it is connected with the inter- mediary nerve, and Sapolini by very careful dissection believes that he has demonstrated this.2 The nucleus for the intermediary is apparently a detached portion of that for the glosso-pharyngeal, undoubtedly a nerve of taste. The latter nerve may also send fibres to the chorda by its anastomoses with the facial (see Fig. 777). The long course of the facial through the skull is com- parable to that of the infraorbital, and, as in that nerve, the unyielding character of the bony wall is a source of injury. Paralysis is more common than in any other motor nerve. After leaving the skull the facial gives a branch to the stylo-hyoid and the posterior belly of the digastric, but the main area of its distribution is to the superficial sheet of muscles of the face (the platysma and its derivatives), which preside over expression. One branch goes to a muscle behind the ear (posterior auricu- lar), the others split into two main trunks, the temporo- and cervico-facial. These branch and divide with many in- terlacements, caused by the differentiation of the primi- tive muscle-sheet into many specialized muscles (Gegen- baur). This branching, called the greater goose-foot (pes anserinus major), begins deep in the substance of the parotid gland, which cannot be extirpated without de- stroying the nerves. The course of the nerve here is forward and a little downward from the point where the anterior border of the mastoid process meets the ear. In- cision for abscess should be parallel to that direction to avoid injury to the pes. Lesions of the nerve may be diagnosed by recalling its anatomical relations. On the face its superficial position makes it liable to be affected by cold (causing an effu- sion into the nerve-sheath), or by pressure on the pes by tumors, abscesses of the parotid, enlarged lymphatics, or the obstetric forceps. In the canal it may be affected by syphilitic or other growths, by disease of the ear or of the bone, and by rupture of the stylo-mastoid artery. In the encranial portion, pressure within the arachnoid sheath, tumors, aneurism of the vertebral artery, and embolism of the basilar artery (cutting off supply of blood to the nucleus), all cause disturbance. The connecting fibres between the nucleus and the cortex may be interfered with by blood-clots, tumors, or degenerative changes. If the lesion is in the pons (as at B, Fig. 774), the facial pa- ralysis is accompanied by paralysis of the opposite side of .Facial. . Spinal nerves. Cortical centres. To muscles of face, left side. Right side. To muscles of limbs. Left side. Fig. 774.-Decussation of the Fibres of the Facial, as deduced from the phenomena of crossed and unilateral paralysis. cortex, viz., the operculum or convolutions covering the island of Reil. It is probable that, as in spinal nerves, some fibres run directly from the cortical area to the nerve without interruption by ganglionic masses. Clinical evi- dence shows that the fibres completely decussate, and that this occurs somewhere in the neighborhood of the pons (see Fig. 774). As the nerve emerges from the brain, the auditory lies . Falciform crest. .Canal of Fallopius. For utricular branch. For saccular branch. Fig. 775.-Inner End of the Internal Auditory Meatus. (X 6). The cochlea is seen in reverse. (After Beau.) Series of foramina for cochlear branch. at its outer side, and between the two is usually a slender fasciculus, called the intermediary nerve of Wrisberg. These pass forward, the facial being partially ensheathed by the larger auditory. They separate at the bottom of 328 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cranial Nerves. Cranial Nerves. the body ; if anterior (as at A), the face and body are paralyzed on the same side. The seat of the lesion can usually be ascertained with considerable precision by referring the symptoms to the different branches and connections of the nerve. If it be external to the Fallopian canal, only the muscles of the face are involved ; slightly higher, the muscles of the external ear also (posterior auricular branch); next is added partial abolition of taste and diminution of salivary secre- tion (chorda tympani), then abnormal sensitiveness of hearing (branch to stapedius), then inaction of the levator palati and azygos uvulae (great petrosal). If above the geniculate ganglion, the auditory nerve is frequently in- volved also. Lesion of the nucleus causes complete paral- ysis of all muscular branches, but is not necessarily ac- companied with loss of taste. This is also present when the lesion affects the communicating fibres between the nucleus and the cortex. A cortical lesion of one side has been known to produce bilateral paralysis. V III. The Auditory (Fig. 776), which accompanies the facial for the first part of its course, divides in the meatus into two main branches, the cochlear and the ves- tibular. The first or lower division passes through a series of small foramina at the bottom of the meatus (see Fig. 775) into the cochlea; the second, or higher, is dis- tributed through another series of small orifices to the ampullae and semicircular canals. (For the terminal endings consult articles on the Ear.) The latter branch is the older in development, and the only one found in lar and the petrous, which should be considered as sepa- rated portions of a single one. Although associated, in its exit from the cranium, with the pneumogastric, it has a separate sheath of dura mater. Its course is deep between the carotid artery and the jugular vein, then forward over the artery to be distributed to the root of the tongue. The nerve has connections with the seventh and tenth, and with the sympathetic. Its principal branches are the tympanic or Jacobson's nerve, which passes into the middle ear and ramifies on the mucous membrane of the promontory, corrimunicates with the carotid plexus, the otic, and the spheno-palatine ganglia, and supplies the Eustachian tube and the mastoid cells ; the tonsillar, to the tonsils ; the pharyngeal, to the pharyngeal plexus ; muscular, to muscles of pharynx, and lingual. Stimula- tion of the sensory branches causes reflex movements of deglutition. Hilton noticed, during an attack of tonsil- litis, a furring of the tongue confined to the posterior Great petrosal. Lesser petrosal. Carotid artery [ Fenestra | ovalis. i Fenestra l rotunda. Spheno- palatine ganglion. Tympanic Otic ganglion. Cochlear branch. .Cochlea. Sup. semi- circular canal. Audi- tory nerve. Superior cervical ganglion Jugular ganglion. Petrous ganglion. Vestibular branch. Pharyngeal. Saccule . Utricle . Post, semicircular canal Ext. semicircular canal. Muscular branches. Fig. 776.-Section through the Internal Ear, showing the Distribution of the Auditory Nerve. lowest animals. There is reason to believe that it con- tains fibres which can be traced as far as the so-called roof-nucleus (nucleus fastigii) of the cerebellum, and that these convey impressions received from the semicircular canals, which give notions of the direction of movement, or change of position of the body in space. The canals lie perpendicularly to each other in the three dimensions of space, and any change of position necessarily sets in motion the fluid they contain. If this continues for some time vertigo occurs. This is believed to be one of the causes of sea-sickness. In diseased conditions of the canals (Meniere's disease) vertigo is a prominent symp- tom. Hyrtl found the acoustic striae on the floor of the fourth ventricle wanting in a deaf-mute. The connections of the auditory nuclei with cortical areas cannot be demonstrated anatomically, but injury to the first convolution of the temporo-sphenoidal lobe is followed by deafness. If slight it may occasion only the so-called word-deafness, in which the patient hears but does not understand words, although he reads them un- derstandingly and repeats them perfectly. The fibres probably run in the posterior third of the internal cap- sule. IX.-The Glosso pharyngeal (Fig. 777) is a mixed nerve, supplying sensory filaments to the tongue, fauces, and upper part of the pharynx, motor fibres to the stylo- pharyngeus and middle constrictor (Volkmann), being also the nerve of taste for the posterior third of the tongue. Upon its trunk are found two ganglia, the jugu- Tonsillar. Lingual Fig. 777.-The Left Glosso-pharyngeal Nerve. (After Young.) third, which he ascribed to associative action of the glosso- pharyngeal. X. The Pneumogastric or Vagus (Fig. 778), so called from its extensive distribution, is the only cranial nerve absolutely essential to life, its section on both sides being followed by death within a few hours. This is because of its functions in connection with important viscera, among which are the heart and the lungs. It is essentially a visceral nerve and closely connected with the sympathetic, taking its place, indeed, in some low verte- brates. It is of mixed function, containing both sensory and motor fibres for the alimentary canal and respiratory passages, and also governing their nutrition (trophic fibres ?). It also transmits fibres (inhibitory) which, con- veying impulses centrifugally, slow the action of the heart, as well as others (depressor) which, operating cen- tripetally, cause a slowing of the heart by reflex action. Most of its motor filaments are derived from an anasto- mosis with the spinal accessory, which takes place im- mediately after it quits the cranium in the same sheath with that nerve. Before the junction two ganglia are 329 Cranial Nerves. Craniotabes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. formed, the first called the ganglion of the root (jugular), the second (a plexiform arrangement with interspersed ganglionic cells) the ganglion of the trunk (plexus gang- liiformis). The nerve descends in close relation with the jugular vein, and the carotid arteries (first the internal, then the common), lying in the same sheath with them ; farther back, passing behind the right innominate vein and the oesophagus to the posterior surface of the stomach, the splenic, and left renal plexuses, the pancreas, spleen, and small intestine. This unsymmetrical behavior is caused by the development of the alimentary canal, which is at first perfectly symmetrical, the nerves descending on either side. As it grows, some parts increase more rapidly than others, and this causes the stomach to turn over to the right, bringing the left nerve in front. The vagus is liable to be involved by injuries of the important organs lying in its course. Gunshot wounds may sever it, or if the ball lodge near, great dyspnoea and acceleration of the heart may ensue from its compression. In operating on tumors of the neck it has been severed with fatal result. Aneurism of the carotids and enlarged lymphatics are likely to affect it, or some of its branches. Slowly growing mediastinal tumors are sometimes de- tected by the quickening of the pulse which their press- ure causes. The vagus anastomoses with neighboring nerves im- mediately after its exit. Besides its intimate union with the spinal accessory, it has branches of communication with the superior cervical ganglion of the sympathetic, with the glosso-pharyngeal, and with the hypoglossal. Like the trigeminus trunks, it sends a recurrent branch to the dura mater. The other branches are as follows : A. Auricular, or Arnold's nerve, arises from the upper ganglion, passes through the temporal bone to the Fallo- pian canal (anastomosing with facial), emerges behind the ear and divides into two branches, one of which joins the posterior auricular nerve, the other supplying the skin back of the concha, and the lower and back part of the auditory meatus. This is interesting from its being the remains of a large posterior branch which supplies the sides along the whole length of the body in low ver- tebrates. Its irritation may set up associative disturb- ances. Reflex cough and vomiting have been caused by the pressure of a foreign body in the meatus, and ex- perienced diners are said to stimulate digestion by touch- ing the back of the ear with a moistened napkin (Treves). Hence it has been called the " alderman's nerve." B. Pharyngeal.-Several offsets, many of their fibres derived from the spinal accessory, join with filaments from the sympathetic and glosso-pharyngeal to form the pharyngeal plexus. Vagal fibres from this plexus supply sensation to the entire mucous membrane of the pharynx and motor fibres to the constrictors. Deglutition is, per- formed by their reflex action, and is set up as well by a foreign body, or a pathological growth, as by a bolus of food. Constant effort at swallowing is a source of annoyance in cases of enlarged tonsils or pharyngeal polypus. Central disturbances may cause cramp of the constrictors through these fibres. Such are usual in hydrophobia and hysteria (globus hystericus). Partial paralysis may occur after diphtheria or from syphilitic growths, and is often present in the last stage of severe disorders and during a prolonged death agony. C. Superior laryngeal.-From ganglion of the trunk along inner side of internal carotid, dividing into two branches : a. External laryngeal. To crico-thyroid muscle and inferior constrictor. h. Internal laryngeal. Through thyro hyoid mem- brane with laryngeal artery to mucous membrane of larynx, anastomosing with inferior laryngeal nerve. Slight irritation of the terminal filaments causes cough- ing ; stronger, like inhalation of irritating substances, causes arrest of respiration and closure of the glottis. D. Inferior laryngeal, also named recurrent, from its peculiar course, arises on the right side at the root of the neck and turns backward around the subclavian artery, on the left arises in the thorax, and turns around the arch of the aorta. The two nerves then ascend symmet- rically along the trachea, enter the larynx from below, and supply all the intrinsic muscles except the crico-thy- roid. In early foetal life there is no neck, and the heart lies in front of the first cervical vertebra. The nerves then pass directly down to the larynx ; the aorta and subclavian arching over them from the base of the heart. .Auricular. .Medullary root. Superior cervical ganglion. , Spinal root. To 1 pharyn- i geal plexus. . Superior laryngeal. Internal laryngeal. Inferior laryngeal. (Esophageal. To cardiac plexuses. To pulmonary plexuses. Fig. 778.-The Pneumogastric and Spinal Accessory Nerves of the Left Side. (After Young.) Hepatic. Gastric. Splenic. and inexperienced operators have sometimes included it in a ligature of one of these vessels. The nerve of the right side enters the thorax behind the left innominate vein, then descends in front of the arch of the aorta and the oesophagus to the anterior surface of the stomach, the hepatic plexus, and the liver; that of the left side lies 330 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cranial Nerves. Craniotabes. The body wall grows faster than the interior, thus form- ing the neck and causing the heart to apparently descend into the thorax. This displacement loops the nerves around the vessels. They appear to derive nearly all their motor fibres from the spinal accessory, as, when the medul- lary origin of that nerve is extirpated, all the muscles of the larynx are paralyzed, except the crico-arytenoideus posticus. The long course of the recurrent nerve makes it liable to injury. It may be compressed by aneurism, goitre, tumors, enlarged bronchial glands, or pleuritic ad- hesions, causing paralysis of the vocal cords of the af- fected side and consequent aphonia. This also occurs from central causes, as in arsenic- or lead-poisoning, and in hysteria or diphtheria. Spasm of the muscles from excitation of the nerve may be occasioned not only from irritating vapors and particles, as mentioned above, but also by hysteria and epilepsy (Ross), in which spasm oc- curs with a loud crowing inspiration. Reflex irritation, either of another branch of the vagus or some other nerve (worms in alimentary canal, teething, uterine dis- orders), may also cause spasms. E. Cardiac branches are given off both in the neck and thorax. From the researches of Cyon and Ludwig, it appears that they carry both inhibitory and depressor fibres. They form, with branches from the sympathetic, the cardiac plexuses. Interference with these is probably one of the factors in the causation of angina pectoris. F. Pulmonary branches form, with sympathetic fila- ments, the pulmonary plexuses. Ramifying from these on the bronchi, terminal offsets probably reach the air- cells. Asthma is believed to be connected with a disor- der of these branches or their ramifications (Salter). When they are permanently injured, pneumonia ensues. G. (Esophageal.-Connecting cords from the right and left nerves form the oesophageal plexus, which gives movement and sensation of a low order to the oesoph- agus. H. Gastric.-These (referred to above) appear to be mainly trophic, not conveying ordinary sensation and but slight motor impressions. Their irritation may cause symptoms referred to other branches. The " stomach cough" and cardiac symptoms of dyspepsia are well known. I. Abdominal.-These are distributed from the sympa- thetic plexuses of the abdomen. They appear to convey some motor impulses and to be concerned in secretion. Action of purgatives is retarded when the vagus is in- jured (H. C. Wood). The great variety of reflex effects produced on the ali- mentary canal and associated organs by stimulation of the pneumogastric, is more appropriately treated in phys- iological articles. XI. The Spinal Accessory, or Nervus Accessorius of Willis (Fig. 778), is so closely allied to the pneumogastric that it is doubtful whether it is entitled to rank as a separate cranial nerve. It is composed of two quite dis- tinct portions (see Table), an internal or medullary, formed by single bundles emerging just below the vagus roots, and an external or spinal, arising from the respiratory tract of the spinal cord by live to seven filaments, which unite and pass up between the anterior and posterior roots of the spinal nerves through the foramen magnum, and unite with the medullary portion in the jugular foramen. They soon separate without having exchanged fibres, the internal branch joining the vagus, and the external, pass- ing backward over the jugular vein, to supply the sterno- mastoid and trapezius muscles. Extirpation of the medul- lary portion paralyzes the motor branches of the vagus, as before stated, and suspends its inhibitory action on the heart. The outer branch, when irritated, causes wry-neck (torticollis), by tonic contraction of the trapezius and sterno-mastoid. As those muscles are mainly supplied by the cervical nerves, Bernard thinks that the function of the spinal accessory is only to correlate them with pro- longed acts of phonation, such as singing and shouting. The nerve is usually considered as purely motor, but since a small ganglion is sometimes found in the medul- lary portion, the question of its function is not entirely settled (Hyrtl, Remak). XII. The Hypoglossal (Fig. 779) is so much like the anterior root of a spinal nerve that it is ranked among the cranial nerves with some hesitation. A careful study of lower vertebrates shows that it does not represent the anterior roots of the vagus, but is a coalescence of several spinal nerves, probably three (Froriep, McMurrich). In some mammalia and in the embryos it has a posterior root with a ganglion. This has also been seen in adult man (Mayer), though the nerve is believed to be purely motor. As the filaments emerge from the medulla, they form two bundles which pierce the dura separately, and are then united. Passing down the neck deeply, it winds around the occipital artery, crosses the external carotid to the under part of tongue, lying on the hyo-glossus. Here it answers for a guide for finding the lingual artery, which passes on the other side of the muscle. It then sends fil- Branches from cervical ' nerves. Communicating Superior cervical ganglion .Communicans ncni. Descendens noni, Lingual of V. Muscular. Thyro-hyoid. Terminal muscular. Fig. 779.-The Left Hypoglossal. (After Young.) aments to the lingual branch of the fifth and is distrib- uted to the stylo-glossus, hyo-glossus, and the intrinsic muscles of the tongue. Near its exit it communicates with the sympathetic, the vagus, and the first two cervi- cal nerves. From the latter pass strands which, although united with the main trunk, do not exchange fibres with it. They supply the genio-hyoid and thyro hyoid mus- cles, and form a descending branch (descendens noni), which passes down on the carotid sheath (sometimes within it), and joins a loop from the second and third cervical nerves (communicans noni). From this loop fila- ments pass to the omo-hyoid and sterno-hyoid muscles. The nerve has been divided in the neck by stabs and gunshot wounds, and in opening abscesses. The tongue then loses muscular power, and atrophies on the affected side. Frank Baker. 1 Archiv fiir Mikroskop. Anat., ix., 36. 2 Journal de Medecine, etc., 1883, vol. Ixxvii. pp. 337, 460, 570. Brux, elles. CRANIOTABES. A peculiar condition of the bones of the cranium in which there are numerous soft spots, occasioned by thinness or even complete absence of bone. The affection occurs in infancy and early childhood, and is usually associated with syphilis or rickets. In the for- 331 Craniotabes. Cremation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mer case the parietal bones are chiefly affected, in the latter the occipital bone. Laryngismus stridulus has been supposed by some to be caused by pressure upon the brain from the weight of the head resting upon the soft- ened occipital bone, but the relation between the two is at best somewhat doubtful. No treatment is usually re- quired, as the spots disappear spontaneously with the subsidence of the cortstitutional disease. If serious symp- toms appear to be caused by pressure, this may be ob- viated by fitting a cap of hard rubber over the affected bone. The shield should be worn only while the child is lying down, and should be removed during the day when it is sitting up or running about. Thomas L. Stedman. Pharmacopoeia under the title Creasotum, Creasote, and is thus described : " An almost colorless, or yellowish, strongly refractive, oily liquid, turning to reddish-yellow or brown by exposure to light, having a penetrating, smoky odor, a burning, caustic taste, and a neutral reac- tion. Sp. gr. 1.035 to 1.085. It begins to boil near 200° C. (392° F.), and most of it distils over between 205° and 220° C. (401° to 428° F.). When cooled to -20° C. (-4° F.) it becomes thick, but does not solidify. It is inflammable, burning with a luminous, smoky flame. Creasote is soluble in about 80 parts of water at 15° C. (59° F.) to a somewhat turbid liquid, and in 12 parts of boiling water; it dissolves, in all proportions, in absolute alcohol, ether, chloroform, benzin, disulphide of carbon, or acetic acid. When applied to the skin it produces a white stain. Creasote does not coagulate albumen or collodion (difference from carbolic acid). If 1 volume of creasote be mixed -with 1 volume of glycerin, a nearly clear mixture will result, from which the creasote will be separated by the addition of 1 or more volumes of water " (U. S. Ph.). Creasote is chemically a mixture in varying propor- tions of phenols, of which the principal ones are creasol, methyl creasol, phlorol, guaiacol, methyl guaiacol, and phenol proper (carbolic acid). These bodies belong to that chemical group of which carbolic acid is a mem- ber, and their association in creasote gives this sub- stance almost identical properties, in respect of action upon living things, with carbolic acid. Physiologically, toxicologically, and therapeutically, therefore, creasote is practically a twin with carbolic acid, to the article upon which the reader may be referred. The U. S. Pharmacopoeia makes officinal Aqua Creasoti, Creasote Water, a simple one per cent, solution of crea- sote in distilled water. Edward Curtis. CRANSAC is a hamlet of about one thousand inhab- itants in the department of Aveyron, France, lying at an elevation of about nine hundred feet above the level of the sea. There are several medicinal springs in the place, three only of which are of any importance. These are known as the Basse Bezelgues, Basse Richard, and Galtier, the two last-named being those chiefly used in- ternally. The following are the analyses of the three springs, as given by M. Rotureau in " Dechambre's Dic- tionnaire Encyclopedique." Basse Bezelgues. Basse Richard. Galtier. Calcium sulphate .... 1.21 2.413 1.319 Sodium sulphate 0.011 Magnesium sulphate ... 1.12 2.291 1.567 Potassium sulphate 0.021 Ammonium sulphate 0.023 Aluminium sulphate .... 0.95 2.079 0.083 Ferric sulphate 0.056 Manganese sulphate .... 0.41 0.101 Sodium chloride 0.062 Potassium chloride 0.012 Sodium iodide trace Calcium nitrate trace Ferric arseniate.. trace Salicic acid 0.005 0.035 Arsenicum sulphide trace Ammonium hydrochlorate.. 0.012 Ammonium hydriodate.... 0.009 Organic matters trace Total solids .... 3.69 6.841 3.258 CREMATION. The subject of cremation is one of very- great importance, and it is rather surprising that it has so far received but little attention from our local sani- tarians. While great efforts are being made in Europe and in a few of our States to introduce or generalize the practice of cremation, there generally exists in our midst a strong opposition to this most essential sanitary meas- ure. Our people are prejudiced against this beneficial hygienic reform, the great advantages of which are, per- haps, not generally known or sufficiently appreciated. But if the introduction of cremation should meet with some opposition in our midst, we can easily be consoled with the thought that such has been the case, at all times and in every country, with every innovation, however useful or necessary. All important discoveries, all new ideas of science have had their enemies. Time alone, with the assistance of reason, can uproot prejudices and foster new ideas, heretofore condemned or rejected simply because they were not well understood and studied. In this article I shall endeavor to show the dangers of earth and vault burials ; to explain what the system of cremation really is ; in what its hygienic advantages con- sist ; and to demonstrate its superiority over all other methods of final disposition of the human body. I hope that the historical considerations, and the well-observed facts upon which I shall dwell, will convince every in- telligent person of the absolute necessity of a complete reform in our methods of burial, especially in cities and thickly-populated districts. The question of how to dispose of the dead with the least danger to the living has at all times absorbed the at- tention of sanitarians and occupied the public mind. One is greatly surprised, in looking over the literature of the subject, to find that as far back as the year 1539, the question of the different methods of sepulture was dis- cussed and gave rise to the publication of several remark- able works, among which we shall mention those of Gyraldus Ferrarensis, of Ferrara, Italy, "De Sepulchris et vario Sepellendi ritu Libellus ; " of Claude Guichard, published at Lyons, in 1581, entitled " Funerailles et Di- verses Manieres d'ensevelir des Grecs, Romains, et autres nations tant anciennes que modernes." In 1636 there was published in Holland a letter (epistola) in which the cus- There are no gaseous constituents, and the waters are cold. The waters are employed externally, in baths and douches, and internally. They are diuretic and laxative. There are some other springs in Cransac, the waters of which possess such a violent purgative action that they are never employed internally, but are sometimes used externally as an application to ulcers. When used in small quantities, the waters of the three springs above mentioned induce constipation, and are thus useful in chronic diarrhoea and dysentery. In larger doses they are recommended in scrofula, in periodic neuralgia, and other chronic malarial conditions, in hypochondriasis with con- stipation, in rheumatism, and in various skin diseases. Near Cransac there is a hill called le Montet, from which smoke and vapors issue through numerous crevices. Holes are dug in the sides of the hill forming natural ovens, the air of which is very warm and charged with sulphurous vapors. Patients sit in these holes, with the head exposed to the air, and take vapor-baths. The tem- perature of the different ovens varies from 90° to 120° F., but remains at a fairly constant elevation in each. Sub- limated sulphur is deposited about the mouths of these pits, and along the edges of the fissures in the sides of the hill. The season at Cransac is from June to September, and there are often so many guests that the hamlet will not contain them, and they are forced to seek accommo- dations in the neighboring villages. T. L. 8. CREASOTE. The title crcasote belongs to a product of distillation of wood-tar, and much confusion has of late years arisen from its application ; also to certain prod- ucts of distillation of coal-tar, as in the title coal-tar creasote. This confusion, furthermore, has been worse confounded by the too frequent commercial trick of sell- ing the coal-tar product in substitution for the wood-tar creasote proper. True crcasote is recognized by the U. S. 332 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Craniotabcs. Cremation. tom of burying in temples was severely condemned. In 1658, Thomas Brown published, in London, a memoir on " Hydriotophia," or urn burial. In 1729, Groenen wrote his " Dissertatio Inauguralis de Noxis ex Sepultura in Caemeteris ex Urbibus tollendi," Frankfort; and a few years later appeared another thesis by John Godfrey, " De Sepulchrorum salubri translatione extra urbem " (Hall) ; and a " Memoire sur les Dangers des Inhumations dans les Eglises," by Huguenot, from Montpellier (1747); and one year later Panenot wrote " De Sepultura in Urbe et Templis prohibenda," published in Utrecht. From this time were published every year books and memoirs of more or less importance on the dangers of burial in churches and cities. In 1790, Thouretet de Fourcroy published their report, " Sur les Exhumations du Cimetiere et de 1'Eglise des In- nocents" {Bulletin de la Societe Roy ale de Medecine, et An- nates de Chimie, 1790). This report was translated into German, in Crell's Chernik Annalen, in 1792. During the last years of the eighteenth century and the first years of the present one, many publications on the dangers of cemeteries, and the necessity of their removal from large centres, came to light in Germany, among which those of Wurzer, Trommsdorf, Fluegge, Reinhardt, Joannis Pe- trus Frank, and others. One of the greatest of German poets, Goethe, was a strong partisan of cremation. In 1830 Orfila published his " Meriioire sur les Exhumations Juri- diques," and in 1839, another memoir, " Sur les terrains des Cimetieres, sur 1'Arsenic qu'ils peuvent contenir, et sur les consequences medico-legales que 1'on doit tirer de 1'existence possible d'un compose arsenical dans ces ter- rains" {Annates d' Hygiene}. Many cases of poisoning by gases, from tombs or from the soil of cemeteries, were published about that time. In 1843, Chadwick, of Lon- don, made a report " On the results of a special inquiry into the practice of interment in towns." In 1849, Grimm, Moleschott and others, in Germany, began to scientifically discuss and advocate cremation as actually practised. In 1852, Ambroise Tardieu wrote his "Voiries et Cime- tieres." In 1855 was published a work on " Cremation in Japan," by Sagholin. That same year, or the year following, appeared several works on cremation, by Cobb, of London, Collett, of Padua, and Loude, of Paris ; since which time the subject of cremation has been constantly agitated and discussed, all over the world, in medical and scientific publications. ' Connected with this subject, there were frequently pub- lished, in different countries, papers and reports on the dangers of well and spring waters in the environs of graveyards. See Bull, de I'Acad, de Medecine, and An- nales d' Hygiene, 1869, 1870 and 1871. Within the last twenty years an immense number of books, memoirs, and papers on the subject of cremation have been published in every country of Europe, and more recently in the United States. Without, perhaps, a single exception, the habitual method of burial, especially in cities and thickly-peopled countries, has received the universal condemnation of science all over the world, and in its place cremation, or rather incineration, has been everywhere recommended as a perfectly safe, rational, and unobjectionable practice, one which would destroy powerful causes of disease and greatly promote the pub- lic health. Under the Empire, thousands of French sol- diers, who had perished during the disastrous retreat from Moscow, were burned by the Russians ; and in 1814, after the battles around Paris, more than four thousand dead bodies were incinerated at Montfaugon, during the space of fourteen days, to prevent infection. . . . The same was done after the battle of Sedan, in 1870. Since 1876 cremation has been introduced in almost every country in Europe and America. Italy is perhaps the country in which this great sanitary reform has been carried for- ward with most energy and success; this result being due in a great measure to the efforts of Castiglioni, Gorini, Amati, Dell'Acqua, Mantegazzi, Polli, de Cristoforis, Pini, and others. Let us here mention, among the conspicuous men who have taken a leading part in the diffusion of cremation, Professor Brunetti, of Padua, Professor Reclam, of Leipsic, Dr. Siemens, of Berlin, and Sir Henry Thompson, of London, who wrote such remarkable articles in the Contemporary Review in 1874. Among the partisans of cremation in our own country we should not neglect to name Henry Laurens, a military attache and friend of General Washington, the first person whose remains were formally cremated on this side of the Atlantic; Henry Barry, of South Carolina, whose remains were burned in his own garden, accord- ing to his instructions; Rev. Dr. Beugless, of Brooklyn, whose writings have so greatly contributed to the diffu- sion of the knowledge and advantages of cremation among us; and last, but not least. Dr. Julius T. Le Moyne, of Washington, Pa., who, besides much writing and speaking in favor of cremation, had erected at his own expense a crematorium, in which his remains were cremated, and which still stands, an honor to his zeal and earnestness in the cause of cremation. Within the last few months cremation has received the highest and most valuable indorsement from one of America's greatest surgeons and scientists, Professor Samuel D. Gross, of Philadelphia, whose body was, at his own request, incinerated in Dr. Le Moyne's crema- torium. Numerous medical societies have since indorsed cremation as an essential sanitary measure. The Ameri- can Medical Association has given that practice its of- ficial sanction and approval. We see that, at all times and in every country, the cus- tom of earth burial has been strongly condemned by the most enlightened men of the time. We notice that par- ticular objections have been made, as far back as three centuries ago, to burials in churches and in cities. The dangers from such practices have been clearly demon- strated in 1636, and at that remote period strong efforts were already made by physicians and savants to have cemeteries built outside of city limits. Such unanimity of opinion, in all countries and at all times, would by it- self be sufficient to establish beyond a doubt the real and positive danger of earth and intra-mural burials. But to still better convince and satisfy the most incredulous, we beg leave to give here a few striking illustrations of said dangers. It was Sir Henry Thompson who said, in 1874 : " No dead body is ever placed in the soil without polluting the earth, the air, and the water above and around it." This saying has been confirmed by men of science in every country of Europe and America ; and nowadays the fact of the pollution of air, soil, and water by decomposing bodies is as well ascertained and recognized as the poi- sonous qualities of strychnine and arsenic, or the froth of a rabid dog. It is well known that grave-diggers, who are generally of strong constitutions, very seldom live to old age. " In the middle ages, when burial in churches was common, they fell victims by hundreds to their horrible duties," says Wagner-Ercolani, who observes that even now ' ' they are mostly pale of face and seldom healthy." Instances of the sudden death of grave-diggers by foul air-poison- ing in the bottom of vaults are very numerous in the past and are still of frequent occurrence. A few weeks ago three grave-diggers in Paris died suddenly while lowering some coffins in a deep vault. Fetid emanations from de- composing bodies are mortal if breathed in a concentrated state, and when diluted in the atmosphere diminish the vital powers and produce low forms of fever, which are often fatal. Dr. Copeland relates that a gentleman of his acquaintance was poisoned by a rush of foul air from the grated openings at the side of the church steps ; he was seized with a malignant fever which he communicated to his wife. There are well-authenticated cases of sex- tons being infected while shaking and cleaning the mat- tings of church floors, the mats being saturated with the poison of the vaults (Williams on Cremation). We may here mention that the experiments of Drs. Koch, Evart, and Carpenter have shown that the blood of animals dying of splenic fever may be dried and kept for years, and pulverized into dust, and yet the disease germs survive with power to produce infection. We all know of the plague of Modena, breaking out in 1828, in consequence of excavations made in the ground where. 333 Cremation, Cremation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. three hundred years before, victims of the plague had been buried. A similar fact occurred a few years ago in Derbyshire, England, and the terrible violence of the cholera in London, in 1854, was charged to the upturning of the soil wherein the plague-stricken of 1665 were buried. In 1843, the population of Minchinhampton, England, was nearly decimated by a disease manifestly caused by using as fertilizer for their gardens the rich soil of an abandoned graveyard. In 1823, an outbreak of the plague in Egypt was confidently traced to the reopening of a disused graveyard at Kelioab, fourteen miles from Cairo. A few years ago, the villages of Ritondello and Bollita, in Italy, were decimated by a terrible epidemic, the origin of which was unmistakably traced to the cemeteries. More recently, the monumental cemetery at Milan, situ- ated on a hill to the north of the city, was proved to be the cause of a fatal epidemic that prevailed in parts of the city, the wells being the channel of communication and infection (Williams). The investigation and experiments of Professor Petten- kofer, of Munich, have proved conclusively the manner in which graveyards exert their poisonous influence through air and water-G rundiv ft and Grundwasser. The danger of contamination of wells, fountains, and running water in and around burial-grounds is well known. This contamination sometimes extends to quite a distance, as we have seen, and is a source of far greater danger than is generally supposed. These waters pre- sent a sparkling and seductive appearance-due to a large proportion of nitrates and nitrites-which make them still more dangerous. "It is a well-ascertained fact," says the London Lancet, ' ' that the surest carrier and the most deadly, fruitful aider of zymotic contagion is this brilliant, enticing-looking water charged with the prod- ucts of decomposition." There are many examples of transmission of disease, such as typhoid fever, dysentery, by water apparently pure and attractive, running in or around burial-grounds, or in the vicinity of places where the excreta from those diseases had been simply de- posited. In the strata of air lying in a prolonged calm above a cemetery, Professor Selmi, of Bologna, discovered an or- ganic corpuscle (the septo-pneuma) which poisons the at- mosphere to the detriment of the living economy. This substance, says Dr. Pietra Santa, which it is easy to col- lect and isolate, if placed in a solution of glucose, pro- duces the phenomena of putrid fermentation, and gives birth to a considerable quantity of bacteria similar to those which are manifested in butyric fermentation. A few drops of this solution, injected under the skin of an animal, bring on the symptoms of typhic infection, and death supervenes on the third day. Infiltrated into water- courses, this substance has doubtless carried infection and death into important towns. It was Professor Selmi who discovered those deadly poisons he called ptomaines or alkaloidi cadaverici. By protracted experiments, he showed, and his results have been confirmed by other investigators, that the common constituents of the human body, as the brain, the blood, fibrin, etc., perfectly innocuous in health, are rapidly con- verted by decomposition, under certain conditions of heat and moisture, into new alkaloids, analogous to those of plants, and equally virulent. He even showed that death does not always precede the change, but when the dis- ease is one that induces internal decomposition of the plasmatical or histological elements, the transformation into ptomaines may take place while the patient is still alive, or immediately after death, before any indication of external putrefaction becomes apparent. A few years ago, in a celebrated trial which took place in Italy, in which a party was accused of poisoning by strychnine, this eminent chemist saved the prisoner from the gallows by proving, to the satisfaction of the tribunal, that the poison found in the dead body was simply an alkaloid formed in the body after death, by the natural process of putrefaction. Dr. Domingo Freire, of Rio Janeiro, asserts that, while investigating the causes of a recent epidemic of yellow fever, he came upon the dreadful fact that the soil of the cemeteries in which the victims of the out- break were buried was positively alive with microbian organisms, exactly identical with those found in the vom- itings and blood of those who had died of yellow fever in the hospital. This characteristic parasite, says Dr. Freire, permeates the soil of cemeteries, even to the very surface. From a foot underground he gathered a sample of the earth overlying the remains of a person who had been buried about a year before ; and though it showed nothing remarkable in appearance or smell, under the microscope it proved to be thickly charged with those yellow-fever germs. The cemeteries, therefore, Dr. Freire pronounces ' ' nurseries of yellow fever, and perennial foci of the disease." It may be proper to mention here, en passant, that according to a recent number of the Gazette Hebdomadaire, of Paris, the same Dr. Freire has positively discovered the microbe of yellow fever. He has, moreover, succeeded, by following strictly Pas- teur's method, in cultivating and attenuating said microbe to the point of rendering it not only innocuous, but pro- phylactic, of making it a vaccine against yellow fever. In fact, quite a number of persons were exposed to the disease after having been inoculated with this new vac- cine, and no one took it. Let us hope that further ex- periments will confirm this remarkable discovery. But whether we admit it or reject it, there can be no doubt but that sooner or later the microbe of yellow fever, if not already discovered, will be discovered like that of phthisis, rabies, charbon, cholera, and other contagious and infectious diseases. The above-given facts, as well as the facts relating to the breaking out of the plague in Modena in 1828, and of cholera in London in 1854, from the opening of trenches in graveyards where, three or four hundred years before, plague or cholera-stricken victims had been buried in the ground, and those that have been observed in New Or- leans during the cholera epidemic of 1832, and in New York in 1806, at the time the Potter's Field was abolished and converted into a public square (Washington Square), all go to demonstrate most positively that soils once satu- rated with products of decomposition may retain for an indefinite period their infective properties, and continue for generations to be a source of danger. This danger exists at all times, but during epidemics becomes threaten- ing indeed. In fact, we have seen that the bodies of those who die of contagious or infectious diseases are a source of alarming danger, not only during life, but long after they have been buried according to prevailing cus- tom. Does not the germ theory of disease, the doctrine now- a-days generally accepted by the scientific world, explain in a perfectly satisfactory manner this pollution of soil, air, and water by decomposing bodies ? Darwin, Pas- teur, Koch, and others have already shown that the im- mediate essential cause of most contagious and infectious diseases is a living animalcule, or microbe, capable of re- producing itself ad infinitum. These germs are possessed of a vitality, of a power of reproduction and resistance, which is really wonderful. It seems that the lower in the animal scale is an organ- ism, the more numerous and prolific are its species, the more clinging its vitality. We have an additional proof of this in the particular, and at one time mysterious, mode of transmission of charbon, first observed by the illustrious Pasteur. A sheep which had died of charbon was buried at the depth of twenty feet in the ground, in a field which, for ten or twelve years after, ceased to be used as a pasture ground. After that length of time some healthy sheep were pastured in that field ; soon after, three sheep were taken sick and died of charbon, at a time when the disease did not exist in that locality or the environs. Upon diligent investigation it was found that the animal affected with charbon, and which had been buried twenty feet deep ten years before, was the cause of this new breaking out of the disease. Pasteur demon- strated that the germs of the disease were brought to the surface by earth-worms. Are not all these facts positively conclusive ? Can any- 334 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cremation. Cremation. one doubt the infective qualities of soil saturated with the poisonous germs of disease ? In the light of the late researches and discoveries of science, it is not difficult to understand how cemeteries may continue for centuries to be the nidus and habitat of the living microbes of viru- lent diseases. From the very moment the vital spark abandons an or- ganized living body, be it man or the lowest animal, pu- trefaction begins its slow and loathsome process; it gradually passes through the different phases of putrid decomposition, too horrible to behold or even to describe, until all the constituting elements of the decomposing body are finally set free by a slow and dangerous pro- cess of combustion. This process has been known to last, according to circumstances-especially according to the nature of the soil in which it takes place-ten, twenty, fifty, and even hundreds of years ! While this slow and horrible process of decomposition is going on, every particle of matter around it is being saturated and in- fected with these germs of disease and death. This pollution of air, soil, and water takes place more readily, and gives rise to special dangers, in certain soils and cli- mates ;-for instance, in lower Louisiana, where the atmo- sphere and soil are saturated with dampness, subsoil-water is found at only a few inches from the surface, and the land is of such a nature as to absorb and retain all sorts of offensive and poisonous matter. With all these un- favorable conditions of climate and soil, they have adopted, in New Orleans, a method of disposing of the dead which is quite peculiar to that locality. With a few excep- tions the dead are not buried in the ground, as is gener- ally the case all over the world, but are deposited in tombs or ovens above-ground, generally badly constructed and exposed to the alternate influences of a burning sun and excessive moisture. No disinfectants are used either in the coffins or in the vaults, and, to make matters worse, most of the cemeteries are overfilled and located in the very heart of the city. This practice constitutes one of the worst unsanitary features of that city, where crema- tion is more needed than anywhere else. We have seen that the ordinary mode of inhumation presents a double danger : first, the contamination of earth, air, and water, which may extend to quite a dis- tance ; second, the reproduction of special contagious and infectious diseases by germs which are buried with the human body, but not destroyed. How are we to destroy these disease-germs ? What is the remedy ? There is but one. That remedy is cremation or incineration. Cre- mation alone will put an end to the pollution of earth, air, and water. It applies not only to the dead human body, but to animals, to garbage, to everything which is offensive or dangerous to health. Cremation alone can completely annihilate the living organisms or germs of contagious and infectious diseases. The ashes from the incinerated bodies of victims of small-pox, plague, yellow fever, or cholera, are as pure, as clean, as innocent as those of the most precious woods or metals. We should by all means prefer cremation to the Potter's Field and all its horrors. The relics of the dissecting- room, of the dead-house, etc., should be properly cre- mated. In epidemics of a contagious or infectious char- acter, the crematory flame should be made, by law, the great purifier. The garbage of cities should be cremated. It is the safest and cheapest manner of disposing of it. It is evident that these germs of disease are not de- stroyed by being simply deposited in any particular lo- cality, however remote from large centres. The stopping of intramural interments only partially remedies the evil. It does not solve the problem ; it only adjourns the ques- tion. The legal obligation to establish cemeteries beyond certain limits, as in the case of the new cemetery of Paris, at Marly-sur-Oise, sixteen miles from the capital, is sim- ply planting the seeds of disease and death a little further off. The cemetery will always be a focus from which death radiates. One shudders at the thought that in all large cities, or in their immediate vicinity, there are con- stantly to be found, in a state of complete putrefaction, as many as forty and fifty thousand corpses. Sanitary reasons should alone influence and determine the scientist and the physician in all questions of science, especially in all questions which concern the public health. Having said this much in favor of cremation, in a sani- tary point of view, I might here put an end to this article by giving a short description of the most approved pro- cesses of incineration. But the subject would be incom- plete without a few considerations on the religious, senti- mental, and utilitarian aspects of the question, more especially as the greatest objections to the generalization of cremation come fropi the want of proper understand- ing of these questions. For my part, I do not see why the religious question should enter into the subject of cremation. Religion has nothing whatever to do with this great sanitary reform, not more than it has in questions of drainage, sewerage, water-closets, or any other sanitary measure. Cremation is nothing else but a very simple method of reducing the human body to its constituent elements with- out injurious consequences to the living. It is in strict conformity with the laws of nature, and merely accom- plishes in a few minutes that which putrefaction would take months and years to accomplish. It is nature's remedy, combustion, facilitated, hastened, and purified, and rendered innocuous by the application of the laws of modern science. Why should it be called a barbarous custom, a relic of paganism ? Was not inhumation prac- tised by antiquity as well as cremation ? Yet the custom of burying the dead, which we owe to antiquity as well as many other customs, such as baths, festivals, etc., has never been called a barbarous or pagan custom. And how can ignorance and fanaticism base their objections to the system of cremation on the religious idea of resur- rection ? Does an omnipotent God need the assistance of man to accomplish His great work ? Is the void of the tomb more favorable to resurrection than the ashes of the urn ? That power which can recall to life every part and parcel of the human body, whether devoured by ferocious beasts or burnt at the stake, like the martyrs and saints, thousands of years ago, or dissolved in the waters of the seas, or which have turned to clay on many a battle-field, can certainly resuscitate the ashes of the funereal urn in the hands of friends. In all countries where cremation has been adopted, it is only after all religious rites and church ceremonies have been performed that the corpse is taken to the cremato- rium. The process of cremation is no more incompatible with the idea of religious services to the dead than our present method of inhumation in a tomb or in the bowels of the earth. The religious rites could be performed in church or at the crematorium, in a room especially consecrated to that purpose. We are happy to notice that of late the opposition to cremation, on religious considerations, has considerably diminished. Some of its most enthusiastic advocates in our country are either clergymen or zealous members of the church. In Italy, the opposition of the Catholic clergy has apparently entirely ceased, and in Rome it- self a splendid crematorium has been built, and crema- tion is steadily on the increase-forty bodies have been cremated there during the last four months. By degrees, all objections based on considerations of a religious char- acter will disappear, and I do not believe that at the pres- ent day an intelligent and enlightened member of the clergy, of whatsoever sect or creed, could be found to honestly oppose cremation on religious grounds. Igno- rant and bigoted persons may, willingly or not, con- found the two questions ; not the intelligent and philan- thropic. In this utilitarian age the question of economy is not to be despised. Statistics show that the sums annually ex- pended in the United States as funeral expenses exceed the value of the annual produce of all our gold and silver mines, and equal the amount of all the failures of our business houses of the country (Beugless). A decent bur- ial costs not less than $100, exclusive of the price of the tomb or vault. How many families are daily impover- ished by the excessive cost of interment incurred through false pride ! How often expensive burials are given to 335 Cremation. Cremation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. those who in their lifetime lack all the necessaries of life ! The whole cost of cremation would not reach one-twen- tieth part of the price of an ordinary tomb and interment. As practised at present in Milan, the cost for cremating one body is only eight francs ! But, from a general point of view, the great economy would be that of l$nd and space occupied. The practice of cremation would eventually restore to the State or community vast amounts of valu- able land now used as graveyards, and which are lost to agriculture and industry. Under the present general sys- tem of interment the dead are gradually crowding out the living. Take, for instance, the city of London, with an annual death-rate of only twenty-one per thousand; the number of deaths is about eighty-one thousand per annum. Have you calculated how much space is re- quired for the annual burial of eighty-one thousand persons? At the limited rate of two feet by six per person, or twelve square feet per each grave, you can bury three thousand six hundred and thirty bodies to the acre ; but this allows nothing for walks, roads, gardens, monuments, etc. On this crowded theory of three thousand six hundred and thirty graves to the acre, London's annual deaths will fill twenty-two and one-third acres. Of course, it practically requires four times as much space. Cremationists do not ad- vocate the abolition of cemeteries now existing, but they claim that, through the process of cremation, cemeteries would cease to be nuisances and would become amply sufficient for all time to come. On the smallest lot of ground, an edifice in the shape of a columbarium, divided into compartments, would serve the same family for ages. It has been calcu- lated that six millions of urns, each containing the ashes of one person, and placed in separate compart- ments, would not require twenty acres of land, in- cluding the flower-beds, walks, etc. Greenwood Cemetery alone could receive no less than twenty million urns. Owners of lots in grave-yards would not be slow to perceive the increased value of their property, since the space for an ordinary vault, twenty by twenty feet, could receive four hundred urns. The sale of a compartment or vault would yield greater profit than the sale of a whole lot could possibly now give, and cemeteries would never be full. Each and every church or temple could accom- modate four thousand urns containing the ashes of as many persons, without any resulting injury, thus serving a religious purpose while being a legitimate source of income to the church (Beugless). The generalization of cremation would render im- possible the desecration of tombs and the theft of dead bodies, examples of which have been quite fre- quent, of late, in our country. Be it sufficient to re- call the theft of the body of the late millionaire, A. T. Stewart, of New York, and the attempts made to steal the bodies of Presidents Lincoln and Garfield, without mentioning the many instances of body- snatching for the purpose of dissection, etc. With that system in vogue the danger of being buried alive will no longer prey on our imagination. This danger is not chimerical. In a recent work published in Italy on the dangers of premature in- humation, no less than sixty-five well-authenticated cases of burial of living persons are related. Again, cremation offers the advantage, the consolation, of being able to preserve and transport the ashes of those whom we have loved. Many of us will heartily join Rev. Burke Lambert, of England, in his opinion when he said, recently : "I have lost three very dear kinsfolk in remote quarters of the earth, and I would give everything I could command if I could receive their ashes and keep them by me in a vase." Why should not the purification of human remains be intrusted to this rapid method, which frees the sepulchre of its horrible mysteries, and which in its comeliness re- tains a certain degree of poetry? For, "Cremation," says Professor Gross, "is truly a beautiful method of dis- posing of the dead." The process of cremation does not consist, as is erro- neously believed, in the burning of a corpse. It is a mere incineration or reduction of the body to ashes by means of dry heat, reaching as high as 1,500° and 2,000° F. Neither fire nor flames ever come in contact with the corpse.. All the smoke and volatile substances resulting from combustion pass through a heated absorbing retort and are immediately destroyed. The process has been described by ocular witnesses to be as follows : The body is borne into the chapel and placed on a catafalque, which stands in front of the altar. The section of the chapel floor upon which the body rests constitutes the floor of a lift or elevator. As the funeral service proceeds, the ele- vator invisibly and noiselessly descends, bearing the body to the basement in front of the incinerator, which by Fig. 780.-Cinerarium ; beautiful edifice connected with the Crematorium (Milan). means of superheated air has been raised to a white heat within, at a temperature of about 1,500° F. As the door of the incinerator is opened to receive the body, the in- rushing cold air causes the temperature to fall a little, and gives to the interior a beautiful rose-tinge. The corpse, wrapped up in a sheet saturated with alum or asbestos, and placed on a metallic bed, passes over rollers into a bath of rosy light. The sheet delineates the form of the human body until incineration is complete, and the bones crumble into ashes under the mystic touch, as it were, of an invisible agent. This process may be called the etherealization or spiritualization of the human body. It requires about an hour per one hundred pounds of the original weight. A few pounds of clean, white ashes are 336 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cremation. Cremation. dropped by means of a lever into the ash-chamber below, and are drawn thence into an urn of terra-cotta, marble, alabaster, or other suitable material, and returned by means of the elevator to the catafalque. The service or ceremony being now over, the friends of the deceased find the ashes just where they had last seen the body of the departed, and may bear them thence to the columbarium or mortuary chapel, or set them on the border and plant violets, hearts- ease, and forget-me- nots in them from year to year. Each urn contains the ashes of but one person, as a rule, and has an ap- propriate inscription. The process is accom- panied with no percep- tible sound, smell, or smoke, and presents absolutely nothing that can offend the suscep- tibilities of the most fastidious. Scarcely an instance, says Beugless, is known of anyone hav- ing witnessed the pro- cess as thus conducted who has not at once become a pronounced convert to cremation, whatever may have been his pre-existing pre- judice. Connected with the crematorium are rooms for post- mortem examinations and medico-legal researches, when deemed necessary. Crematory temples, in many large cities of Europe, are of beautiful monumental architecture. Italy alone boasts of thirteen such temples. Milan has two. Those of the latter city and the one of Rome are of the grandest proportions. There exist to-day cremation societies in all countries of the world. There are not less than thirty- seven in Italy alone. The most important and most organizations. Among their members are to be found some of our most distinguished citizens. The greatest practical objection to the generalization of cremation was, until recently, the want of a proper Fig. 781.-Crematorium of Milan (1883). apparatus for the rapid and complete incineration of bodies. That objection exists no longer-the problem is now solved by the late experiments made in Europe and in our own country. Great progress has been made in the different apparatuses. Venini's, which is used in Fig. 783.-Vertical Section of Siemens' Apparatus. It can be placed under the floor of a crematorium, entirely out of sight. When prop- erly heated, it will completely incinerate a body in sixty minutes. Milan, Padua, Brescia, and Udine (Italy), seems, so far, to be the most perfect. It is represented in Fig. 785. It destroys most thoroughly all animal gases, is fumivor- ous (smoke-destroying), emits no smell, and its action is continuous. It is heated by gas, with variable oxidation, Fig. 782.-Plan of Crematorium of Milan. A, room for funeral cere- monies ; B, cremation room ; C, room for relatives (waiting room); D, mortuary room (dead-house); E, cinerarium, with a, b, c, columba- rium ; F, cremation apparatus. active is in Milan, which city is also the centre of the " Lega Italiana delle Societa di Cremazione. " The Cre- mation Society of Copenhagen numbers two thousand members, that of Holland twelve hundred members, that of Paris six hundred. There are also societies in Berlin, London, Dresden, Rio Janeiro, etc. ; and in the United States there are not less than ten regularly incorporated Fig. 784.-Horizontal Section of the Same. and its jets can be subdivided and concentrated on one point at will. By this apparatus the most rapid and hygienic, and at the same time least expensive, method of cremation has been obtained. As we have said before, 337 Cremation. Croton Oil. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the cost of cremating one body has been reduced in Milan to the sum of 8 francs ($1.60). In Italy they have already built, in addition to their numerous beautiful crematorium temples in cities, large crematory furnaces (forni collettiri) for the cremation of bodies in time of war, especially of those who fall on the battle-fields, and during epidemics for those who die from contagious or infectious diseases. These furnaces have been constructed according to Gorini's plan. It has been estimated that three of these forni crematorii collettivi could incinerate ten thousand bodies in three days. A movable crematorium, on wheels, intended for an army in the field, or for localities in which crematory temples do not exist, has been invented by Captain Rey, of the Italian Army, and has, upon trial, given perfect satisfaction. This apparatus, which can be easily drawn by two horses, does not cost over 3,000 francs ($600). The main object of cremation societies, for some time to come, should be to enlighten public opinion, to remove all prejudices against cremation, and to prove that it can be practised without in the least wounding religious sentiment or susceptibilities. For, with so many power- ful sanitary, philosophical, and economical arguments in CRESSON SPRINGS. Location and Post-office, Cresson, Cambria County, Pa. Access.-By Pennsylvania Railroad-main line. Analysis of the Iron and Alum Springs, by Professor F. A. Genth, 1875. One gallon of 231 cubic inches con- tains : Sulphate of ferric oxide... Iron Spring. Grains. trace Alum Spring. Grains. 33.381170 Sulphate of alumina 1.(10466 21.20498 Sulphate of ferrous oxide 23.47923 16.25273 Sulphate of magnesia.... 22.58007 27.69855 Sulphate of lime . 48.91824 40.20179 Sulphate of lithia trace 0.04693 Sulphate of soda... 1.64331 0.70398 Sulphate of potash 0.32405 0.42622 Chloride of sodium 0.04063 0.02336 Bicarbonate of iron 5.03471 3.74756 Bicarbonate of manganese.... Bicarbonate of lime .....' 3.52946 trace Phosphate of lime .... 0.02914 trace Silicic acid... 1.20832 108.39182 1.86749 146.56374 In addition to the above, Cresson possesses a spring of nearly perfectly pure water, which issues in considerable Fig. 785.-Venini's Apparatus. Longitudinal vertical section. Fig. 786.-Horizontal Section of the same. favor of cremation, why is it that this essentially useful and hygienic measure is not more generally adopted in our country ? Is it not simply on account of the igno- rance, bigotry, and prejudice that surround us ? Is it not the duty and mission of hygienists, philosophers, and sanitarians to attempt to enlighten the people, to advise legislation, to remove prejudice and false ideas, toprepare public opinion for the adoption of one of the greatest sanitary reforms of the age, which is intended to bring sanitary results of incalculable importance ? Let our people understand and appreciate the immense benefit of cremation ; let prejudice and bigotry be conquered. Cremation, once known, will become popular among us, and science will have made one more great step forward. volume from a stratum of sand. Its flow is never much affected in dry seasons, and tlie water maintains a mean temperature of 43° F. Therapeutic Properties.-The waters of the sev- eral medicinal springs, of which there are seven, are said to have different effects on the system. One has an aperient action, another decided tonic properties, and a third a beneficial effect in kidney troubles and catarrhal affections of the bowels. The climate is superb, the thermometer seldom touch- ing 75° F. in the hottest weather. In fact, invalids are benefited as much by the invigorating effects of the air as by the medicinal qualities of the waters. Situated on the summit of the Alleghanies, at an altitude of 2,300 feet, the surrounding country affords mountain scenery of the grandest variety. Excursion trains, with observation cars, are run to the various points of interest along this portion of the Pennsylvania Railroad. The hotel-The Mountain House-is of modern con- struction and ample size. It is located on a plateau, and is surrounded by a park of five hundred acres, adorned with gardens, lawn, and groves of primeval forest trees. George B. Fowler. Cremation Societies Existing in Italy, with Date of their Or- ganization. Milan 1876 Lodi (municipal institution).... 1817 Cremona 1877 Udine 1879 Rome 1879 Varese 1880 Domodossola .... 1880 Como 1881 Bologna 1881 Modena 1881 Pavia 1881 Padua 1881 Codogno 1881 Venice 1882 Plaisance 1882 Leghorn 1882 Novara 1882 Ancona 1882 Genoa 1882 Florence 1882 Brescia 1882 Turin 1882 Parma 1882 Verona 1882 Pisa 1882 Carpi 1882 Asti 1883 Pistoja 1883 Siena 1883 St. Remo 1883 Intra 1884 CRIMINAL IRRESPONSIBILITY. Until near the be- ginning of the present century the definitions of insanity followed by the law-courts were confused, and very little Felix Formento. 338 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cremation. Croton-Oil. effort was made to grade the insane, or distinguish a de- gree of mental disease which should exempt the sufferer from amenability to punishment, as compared with that degree which should invite treatment or affect civil rights (see Insanity, Civil Incapacity). By about the year 1800 medical jurisprudence had advanced so far in Eng- land as to prescribe one rule for determining insanity in cases of crime, which is still respected, viz., if the indi- vidual is incapable, from mental imbecility or disease, of knowing the criminality of an act which he commits, he is not amenable to punishment for it. The decisions in which this rule was formulated at that early date are, of course, chiefly English, as the American courts had then made but little independent progress, but it has been generally adopted and prevails throughout the Union. Perhaps it might have continued the sole criterion for determining the criminal incapacity of the insane, if it were not that members of the medical profession, steadily and rapidly proceeding in the study of insanity, have been constantly calling attention to types previously un- distinguished, and urging that they should receive medi- cal treatment rather than criminal punishment. By such efforts, toward 1850, a new criterion of criminal incapacity became established throughout England and America. Medical men testified that instances were observed in which an individual, although capable of judging sanely of right and wrong if the facts were truly before his mind, yet had his judgment fatally perverted and his consequent action uncontrollably vitiated, by delusions which were the product of disease. The famous trials of Daniel M'Naghten, in England, for shooting Edward Drummond (at the time private secretary of Sir Robert Peel), and of Abner Rogers, in Massachusetts, for shooting Charles Lincoln (warden of the State prison in which Rogers was confined), were those which elicited the rule. Rogers, for example, was the subject of diseased visions and voices warning him of conspiracies against his life, in which the warden was represented as prominent; and it was under the influence and in the belief of these that he committed the homicide. Subsequent cases, involving similar facts, have riveted the rule, though it is now gener- ally stated with the very just qualification that the dis- eased delusions must be of such character that if they had been true they would constitute an excuse for the act charged. During recent years a third criterion of criminal in- capacity has been urged, viz., inability of the will to con- trol the conduct by one's knowledge, briefly called " moral insanity." Some practical observers of the insane have declared that organizations exist in which they find no loss of the power to judge of right and wrong, nor any disturbance as to facts, but find the mind powerless to control con- duct according to its knowledge. The subject of such disease, they say, knows what is right, but cannot choose it ; what is wrong, but cannot shun it. Down to about the commencement of the present decade, the body of med- ical opinion tending to this effect was making a steady and marked impression upon the criminal jurisprudence of the country. The highest courts of nearly a quarter of the States had accepted moral insanity as a tenable defence in cases where it could be clearly proved ; ex- plaining, some of them, that the question what mental incapacity is sufficient to impair responsibility is one of fact on which courts should take the testimony and fol- low the opinions of experts in mental disease, and, when these unite in declaring it a form of incapacity previ- ously unnoticed, courts should recognize it. Upon the other Jiand, the highest courts of five of the States, and one or two subordinate courts of the Union, have repudi- ated this defence, giving as the general reason that the processes and means of inquiry at the command of courts of justice are not adequate for testing so vague and easily pretended a defence as that of uncontrollable morbid im- pulse, and declaring it necessary for the public welfare to adhere to the former tests of criminal incapacity. The trial of Guiteau for the murder of President Garfield, and the very extended and able medical testimony and legal argument on this question which it elicited, unquestiou- ably diminished the disposition of jurists to accept "moral insanity" as a doctrine of the criminal law. The full official report of Guiteau's trial (which may be found in the larger libraries), with the charge of the judge and Mr. Wharton's note (see 10 Fed. Repr., 159, or 3 Crim. L. Mag., 347), and the extended discussion in 1 Wharton and Stille, "Med. Jur.," fourth edition, §§ 531-681, will be found to present the question fully. But it is believed that the criterion of amenability to punishment now most generally approved may well be stated thus: Was the accused, at the time df committing the act charged, dis- abled (either by general impairment of the brain or by morbid delusions adequate, if true, to excuse his act) from knowing that it was criminal. Whether such in- capacity must be affirmatively proved by the defence, or whether to raise grave doubt of the individual's capacity is enough to entitle him to acquittal, is a question on which jurists and courts in different jurisdictions are not agreed. Benjamin Vaughan Abbott. CRONTHAL is a town in Nassau, Germany, not far from Homburg, in which are found several medicinal springs, of which two only, called respectively the Stabl- er Trinkquelle, and the Saiz- or Wilhelmsquelle, are of much importance. The waters are taken internally, and also in baths of various kinds. The dose is from three to six glasses, taken in the morning before breakfast. The duration of a course of treatment of the Cronthal waters is usually from three to four weeks. The following is the composition of the two principal springs, according to an analysis made by Dr. Jung. Each litre contains : Trinkquelle. Salzquelle. Grammes. Grammes. Sodium chloride 2.150 2.150 Magnesium chloride 0.080 0.300 Calcium bicarbonate 0.155 0.285 Magnesium bicarbonate 0.020 0.040 Ferrum bicarbonate 0.100 0.010 Sodium sulphate 0.080 0.060 Aluminium 0.070 0.055 Total solids 2.655 2.900 There is considerable free carbonic-acid gas present in the water as it issues from the springs. The Cronthal waters are useful in various conditions of debility in which tonics are indicated, in anaemia and chlorosis, and in ca- tarrhal affections of the respiratory passages. T. L. S. CROTON-OIL {Oleum Tiglii, U. S. Ph. ; Oleum Cro- tonis, Br. Ph., Ph. G.; Croton tiglium, Graine de Tilly, Graine des Moluqves, Codex Med.). Croton Tiglium Linn., whose seed furnishes the above-named oil, is a small, branching, slender-limbed tree, with smooth, ashy- brown branches, alternate, simple, bright green, ovate acu- minate, obscurely serrulate leaves, and small monoecious flowers in terminal, upright, spike-like racemes. The lower flowers in the raceme are fertile, and have a five-parted calyx, sepals glandular at the base, five petals, a three- celled, three-ovuled ovary, surmounted by three forked styles. The upper (staminate) flowers have also five sepals and five petals, but have from a dozen to twenty stamens, and, of course, no pistil. The fruit is a three- celled, three-seeded capsule. The seeds are about a cen- timetre long, oblong, rounded on the back, slightly flat- tened on the face each side of the median line, where the raised raphe is to be seen running from end to end. Color of seeds brown, testa brittle, black within. Embryo large, albumen oily. In structure and shape they are very much like castor-oil seeds. Taste at first oily, then acrid. The leaves, fruits, and parts of the flower are provided with a thin pubescence of stellate hairs. The plant is a native of Southern Asia, and is common in India, where it is also extensively cultivated. It grows, too, in many of the great Pacific islands (Borneo, Ceylon, Japan, etc.). Both the seeds and oil are imported from Bombay, Cochin, etc. j the oil is also expressed in Great Britain from seeds imported from the East. These were first brought to Europe in 1578, and had some employment during that and the succeeding century, but then, accord- 339 Croton-Oil. Croup. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing to the Pharmacographia, fell into disuse. They were revived again in the beginning of the present century. The seeds have just been described; they are imported into England as a source of the oil, which the British Pharmacopoeia requires shall be expressed in that coun- try. They contain from sixty to seventy per cent, of a complex, liquid, yellow, or brown/aW^ oil, of unpleasant odor, acrid taste, and very irritating and drastic proper- ties. This oil, which is the only officinal product (see title and synonyms), varies in color between yellow and deep sherry ; that made here or in Europe from the dried seeds being the darker. The officinal description and tests are as follows: "A pale-yellow or brownish-yellow, some- what viscid and slightly fluorescent liquid, having a slight, fatty odor, a mild, oily, afterward acrid, burning taste, and a slightly acid reaction. When applied to the skin, it produces rubefaction or a pustular eruption. Spe- cific gravity, 0.940 to 0.955. When fresh, it is soluble in limited to the region to which the application is made, but in extremely susceptible patients a general vesication of nearly the whole body may follow a limited applica- tion. It has been a moderately common mode of coun- ter-irritation in bronchitis and other diseases, but is now only rarely used. As a quick purgative, where the most rapid and complete emptying of the bowels is required, in "congestive" and other apoplexies, in injuries to the head, in uraemic conditions, in short, whenever an intense derivative action to the bowels is required, croton-oil is at the head of the list; its rapidity and the smallness of its dose are great advantages. Administration.-It may be diluted with any bland oil and so given, or mixed with some inert powder and made into pills ; the dose is from two to ten centigrammes (0.02 to 0.10 Gm. = gtt. | ad jss.). Allied Plants.-Cascarilla is from the same genus, but has no medicinal affinity with Croton-oil. The Pulga Seeds or Purging Nuts of Brazil, from Jatropha Gurcas Linn., in the same Order, have similar qualities ; for the Order, Euphorbiacece (see Castor-oil). Allied Drugs.-See Elaterin. IF". P. Bolles. CROUP. Croup is an acute inflammation of the mu- cous membrane of the larynx, characterized by the for- mation of a false membrane. The disease has always been more or less prevalent, and occurs for the most part in children between two and seven years of age, although by no means strictly confined to that period of life. The term is derived from the Scotch, and means strangulation. It will be used in this article to include two varieties, namely, primary or idiopathic croup, and diphtheritic or secondary croup. The profession has always been, and still is, divided upon the question of the identity of these two varieties, one portion claiming that the primary is purely a local, and the secondary, a constitutional affection; while an- other portion, with equal confidence, asserts that they are one and the same disease with different manifesta- tions. As this question is of considerable importance as regards the treatment, and of still more importance in reference to contagion and isolation, a few wrords may be devoted to it. Much of the confusion which exists upon this subject is due to the fact that authorities are not agreed as to what group of symptoms shall constitute either malady. Typical cases of the two varieties of croup under con- sideration are distinct enough, but in localities infected with diphtheria, the clinical history and the anatomical appearances shade into each other so gradually that it is not always easy to determine to which class a given case belongs, especially in the early stage, the time when it is most desirable to make an exact diagnosis. Cases of diphtheritic croup should be isolated, both during life and after death, while no such precautions are necessary, in the idiopathic affection. Dyspnoea, the most prominent and important symptom, is common to both varieties of the disease. Glandular enlargements, nasal discharges, albuminuria, and paraly- sis are the distinguishing features of diphtheria, and cases of croup presenting these symptoms should not be classed as primary, but as secondary croup, and should be treated accordingly. Fatal cases of diphtheria in which the larynx is not involved are common. Primary croup, on the contrary, is usually a laryngeal affection from the first, and causes death by suffocation. In short, the latter is simply croup, and nothing else, while diph- theria, although occasionally complicated with croup, is always something more. Many of the older members of the profession, who had opportunities for studying croup when and where diph- theria was unknown and did not exist, and whose opin- ions are entitled to great respect, recognized the clinical difference between the two affections. They did not look upon the croup of those days as being contagious, nor did they observe any of those constitutional symptoms so prominent in diphtheria, and so characteristic of septi- caemia. From about 1775 to 1850, the cases of pseudo-mem- Fig. 787.-Branch of Croton-oil Plant, about one-half the natural size. (Baillon). about sixty parts of alcohol, the solubility and therapeu- tic activity increasing by age. It is freely soluble in ether, chloroform, or disulphide of carbon." The fatty glycerides and acids composing this oil are : olein, stearin, palmitin, myristin, laurin, together with acetic, isobutyric, isovalerianic, tiglinic, etc., acids. Schlippe discovered an acid, aromatic principle in the oil which he named crotonol, to the extent of four per cent. According to this investigator this is to be re- garded as the vesicant portion of the oil. It is contained in that part of croton-oil which is freely soluble in alco- hol. After the crotonol has been removed, the oil is said to be equally drastic, but not even rubefacient to the skin. It would seem worth while to have commercial prepara- tions of these separated products. Action and Use.-Upon the skin, a drop to each twenty or thirty square inches produces violent irritation, usually an acute eczematous eruption of numerous closely aggregated blisters, becoming, if the result is intense enough, pustular and scabby. The eruption is usually 340 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Croton-Oil. Cro up. branous laryngitis occurring in this country, as well as in Great Britain, were local in their character, the lesions being confined for the most part to the upper air-passages, and causing death by suffocation. Septic symptoms were not observed, nor was the dis- ease contagious. Diphtheria was almost or quite unknown during that period, and many practitioners with large op- portunities for observation, and who were familiar with true croup, never saw a case of the former malady in all their lives. The record of the mortality from croup and diphtheria in Philadelphia during the past forty years is instructive in this connection. From 1846 to 1859, the annual mor- tality from croup varied from 111 to 312. No deaths from diphtheria were recorded during that period. From 1860 to 1879, the annual death-rate from croup ranged from 185 to 455, while that from diphtheria was from 110 to 708.1 It cannot be possible that the 3,078 deaths recorded as due to pseudo-membranous laryngitis during those thir- teen years previous to 1859 were all caused by diphtheria, while not a single fatality from that malady was so re- ported in the city during that time. Had the croup of those days been diphtheritic, surely the other forms of diphtheria must also have existed, and would, in all prob- ability, have been recognized and reported. The history of the advent of diphtheria to the city of New York is equally as striking. Previous to 1858, only three deaths were recorded as being due to diphtheria during the present century, while the deaths from croup had been more or less frequent each year. From this time to 1875 the annual death-rate from croup ranged from 338 to 758, while that from diphtheria varied from 5 to 2,329.2 Dr. Smith makes the following pertinent remarks : " Thus, in the first years after the introduction of diphtheria the deaths assigned to croup so greatly out- numbered those of diphtheria, as in 1858, when five died of diphtheria, and four hundred and seventy-eight of croup, that it is evident that most of the cases of croup in those years were attributable to other causes than diph- theria." These remarks are even more applicable to the numerous instances of croup met with in this country and elsewhere during the many years previous to the appear- ance of diphtheria. It is not reasonable to suppose that for three-quarters of a century an affection so grave as is diphtheria, and having such characteristic symptoms, should have repeatedly occurred in the practice of thou- sands of intelligent physicians, solely as a local lesion of the larynx, without presenting one of its most prominent features, namely, septicaemia. After making due allowance for the unavoidable errors of statistics, the above data furnish strong proof of the correctness of the statement made here, that pseudo- membranous laryngitis is not always due to the diph- theritic poison, but that it may be, and at times is, a simple local inflammation, plus a peculiar exudation. Unless primary and secondary croup are separate and distinct affections, as regards their etiology, or, in other words, unless pseudo-membranous laryngitis under cer- tain circumstances arises from other causes than the con- tagium of diphtheria, it must be admitted that, either the character of the disease has changed very greatly during the past thirty years, of which there is little or no evi- dence, or that the observations of the older practitioners were imperfect and wholly untrustworthy. I cannot think that either supposition is true, but would submit the fol- lowing statements, as being the result of my observation and study: First, there is an acute, non-contagious and non-in- fectious disease of the larynx, local in its nature, confined to the upper air-passages, not epidemic, characterized by the formation of false membrane, which causes the prin- cipal symptom, dyspnoea, and very often destroys life. This is primary croup, and at the present time it is of comparatively rare occurrence. Second, there is an acute, contagious, infectious, and often epidemic affection, presenting a membranous de- posit in the fauces, larynx, and other localities, accom- panied by symptoms of blood-poisoning, such as enlarged glands, nasal discharge, albuminuria, paralysis, debility, and coma. This is diphtheritic or secondary croup. For more than a quarter of a century it has been the pre- vailing type of the affection, and, like the preceding variety, it is very fatal. Anatomical Characters.-The changes observed in the tissues involved in pseudo-membranous laryngitis are similar to those found in acute inflammation of all mucous membranes, plus the exudation of a false membrane. The affected parts are congested and infiltrated to a greater or less degree, and in addition there are patches of a gray- ish or yellowish deposit, of varying extent and thickness, on the tonsils, uvula, soft palate, and adjacent parts. In the primary form of the disease this exudation usually appears as a thin layer upon one or both tonsils; limited in extent, and confined for the most part to the earliest stages of the disease. For these reasons it is not infre- quently overlooked, or it has disappeared before the pa- tient comes under the notice of a physician. Although the faucial exudation is usually much more abundant in the diphtheritic variety, yet the observations of Dr. John Ware, of Boston, and other writers, go to show, that it is almost always present to a slight extent in idiopathic croup. In an admirable monograph published in 1842, long before diphtheria made its reappearance in America, Dr. Ware reports the presence of an exuda- tion in the fauces in seventy-four out of seventy-five cases of croup examined with special reference to that point. The membranous deposit usually begins in the fauces in both varieties of croup, and not infrequently extends to the bronchi and smaller air-tubes, thereby producing bron- chial croup. In some cases the membrane is so loosely adherent to the subjacent tissues that it can be easily peeled off, while in others it so infiltrates the parts that it cannot be re- .moved without doing considerable violence to the mucous and submucous structures. It was thought, at one time, that the former condition of the deposit was peculiar to primary, and the latter to secondary, croup. The distinc- tion, however, is not a practical one, and cannot be re- lied upon in making a diagnosis. Etiology.-In order that this or any other disease may become developed, the system must be in a peculiar, yet unknown condition. While it is in this condition, a cold, wet atmosphere, and great and sudden changes in temperature, act as exciting causes of primary croup. In addition to these, filth, infected water, milk, and perhaps other substances, and the specific contagium of diphtheria, have a similar effect in producing the secondary form of the affection. The latter variety is both contagious and infectious, and often occurs in the form of an epidemic. Croup is more common in the winter and spring than in summer or autumn, although at present it is quite preva- lent throughout the year in America. Some writers think that diphtheritic croup may arise from auto-inoculation, particles of the faucial exudation being carried into the larynx by the act of inspiration. This is probably not a common cause of the laryngeal complication, from the fact that in many cases attended with extensive deposit in the fauces the larynx escapes infection altogether. As a rule, there seems to be no definite relation between the amount of exudation in the fauces, and in the larynx. Furthermore, in some in- stances the membrane has disappeared from the throat several days before the laryngeal symptoms make their appearance. Occasionally the disease begins in the larynx, and no lesions are seen in the throat throughout the pa- tient's illness. Particles of diphtheritic membrane com- ing in contact with the mucous membrane of the mouth, throat, nose, or eyes of a healthy person, or coming in contact with a wound upon any part of the body, may give rise to diphtheria, and hence to croup. Kissing a diphtheritic patient on the lips is particularly dangerous, and the friends should always be cautioned against it. Croup occasionally follows or complicates measles and scarlet fever. Occurring under these circumstances, the type is usually very severe. Heredity is said to exert a marked influence in the production of the primary form of the disease in certain families. Smith gives the causes of true croup in the order of their frequency, as follows : 341 Croup. Croup. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. "diphtheria, ' taking cold,' measles, pertussis, scarlet fe- ver, typhoid fever, irritating inhalations." Symptoms.-Primary croup generally begins with the symptoms of an ordinary cold : cough, hoarseness, and fever. The throat is sore, and the cough has a harsh or clanging sound attended with little or no expectoration. Dyspnoea is usually absent in the earlier stages, but in the majority of cases it is well marked by the second, third, or fourth day. The peculiarity of the dyspnoea is, that instead of abating or yielding to simple remedies within two or three days, it steadily increases. It may, and often does, remit, but it seldom intermits. The voice is weak, hoarse, reduced to a whisper, or entirely absent. The cough is short, painful, and smothered. The dysp- noea is distressing. First the inspiration, and then both inspiration and expiration are impeded, and become la- bored and noisy. Imperfect inflation of the lungs from laryngeal stenosis is indicated by a sinking in, or retraction of the soft parts at the epigastrium, and above the clavicles and sternum during inspiration. This symptom is peculiar to laryn- feal obstruction, and is always present in severe cases, t is regarded by some writers as a signal for tracheotomy -and with good reason, for the narrowing of the glottis must be considerable to give rise to this condition. The case is always an anxious one when it has reached this stage. The course of the affection is often interrupted by se- vere paroxysms of dyspnoea, during which death from suffocation seems imminent. The patient chokes, and breathes with the greatest difficulty ; the face is purple, or cyanotic ; he tosses about, clutches at his throat, and presents the appearance of the most intense suffering. After a time the spasm of the glottis relaxes, a little more air gains entrance to the lungs, respiration becomes easier, and comparative relief follows for a longer or shorter time. As the disease progresses the blood becomes more charged with carbonic acid, and the restlessness grad- ually merges into coma, which finally terminates in death. In some instances the respiration becomes easier toward the last, yet there is no improvement in the gen- eral condition of the patient, the vital powers having be- come too enfeebled to rally. Croup may arise at any time during the course of an attack of diphtheria, or after all local symptoms of the latter affection have disappeared. In this form of the affection the laryngeal symptoms do not, as a rule, ap- pear in the first few days of the illness, the local lesions being confined to the fauces. The prostration is much greater than would be expected from the dyspnoea. The characteristic symptoms of septicaemia-enlarged glands, albuminuria, discharge from nose, etc.-sooner or later make their appearance and determine the nature of the affection. Other cases are also likely to occur in the im- mediate family or vicinity. Inspection of the fauces in the early stages of primary croup reveals little save congestion, and perhaps a thin film of exudation confined for the most part to the ton- sils. Not infrequently the deposit has disappeared when the patient is first seen by the physician, but that such a deposit is almost always present in the first stages of the disease is conclusively shown by the observations of Ware, Meigs and Pepper, and others. Unless the throat, in any given case, has been under close inspection from the first, it is impossible to say that no membrane has ex- isted, for it may have remained but a short time, or it may be so limited in extent as to escape notice. In the diphtheritic variety the exudation in the fauces is seen early, and is more abundant and widespread, of- ten extending to the uvula, soft palate, cheeks, and nares, as well as infecting external wounds. In both forms of croup the deposit not infrequently extends to the trachea, bronchi, and smaller air-tubes, thus producing a most se- rious complication-bronchial croup. Its occurrence is indicated by increased dyspnoea, more frequent respira- tion, and the presence of rales in the chest, which can be readily detected with the stethoscope, if not by the ear alone. The false membrane in croup is loosened by disintegra- tion and ulceration, and is ejected by coughing, either in the form of shreds and small patches, or in that of a more or less complete cast of the trachea and larger bronchi. The time occupied in the formation and ejection of the membrane is usually from four to six days. The result of this process is a marked amelioration of the dyspnoea, and a corresponding rise in the spirits of the patient and his friends. In a majority of instances, however, in which the membrane is thrown off in the form of a cast, a fresh deposit makes its appearance within twenty-four or forty-eight hours, the unfavorable symptoms return, and too often the result is fatal. The duration of the disease, in fatal cases, ranges from two to ten days. In those patients who recover, the course of the affection is more gradual. The membrane is slowly ejected, the cough becomes looser, the breath- ing is easier, and all the symptoms improve. The voice does not regain its natural tone and vigor for some time, but remains weak, and easily becomes hoarse and tired. The general health is often enfeebled for months, par- ticularly after diphtheritic croup. Favorable Symptoms.-The patient is bright, the nerv- ous system is quiet and natural, and he is interested in what is going on about him. The dyspnoea and cough are only of moderate severity; no marked septicaemia. The pulse and temperature have a downward tendency. The secretion from the air-passages consists mainly of a thin, light-colored mucus, which is not tenacious. The patient takes food well, and sleeps without the aid of drugs. The ejection of a membranous cast is not a fa- vorable symptom unless the relief lasts for twenty-four hours or more ; in fact, no change for the better is to be relied upon until that length of time has elapsed. Unfavorable Symptoms.-Stupor and indifference to sur- roundings, restlessness, high pulse and temperature, short, quick and difficult breathing, refusal to take food, pallor and lividity, marked prostration, symptoms of septi- caemia, lung complications, suppression of urine, ab- sence of, or scanty, secretion from the air-passages. If the tracheotomy tube "gums," that is, if the secretion adheres to the canula so firmly that it is removed with difficulty, the patient in the majority of instances will die. A copious, purulent, or bloody discharge from the bronchial tubes or the nares is also indicative of serious results. The condition of the nervous system in this af- fection, as in so many others, is of the utmost signifi- cance, and cannot be observed too carefully. Listless- ness, indifference, and stupor are particularly grave features, as they show a profound disturbance of the vital forces. Diagnosis.-To arrive at a reasonably sure diagnosis, of true croup, the symptoms of the following affections must be taken into consideration: catarrhal laryngitis, tonsillitis, laryngismus stridulus, bronchitis, and pharyn- geal diphtheria. It is to be remembered that the voice is always affected in croup. It is hoarse, weak, and, in the later stages, entirely absent. The voice may be de- stroyed for several days or weeks without there being any difficulty in the breathing. However severe may be the dyspnoea and cough, unless the voice be impaired there can be no croup. This fact is of especial importance in studying cases of acute and capillary bronchitis, as well as affections of the fauces. Hoarseness is the one con- stant and invariable symptom of croup. If it be accom- panied by dyspnoea and a deposit of membrane in the fauces, the disease will almost always prove to be true croup. In other words, a membranous deposit in the fauces attended by hoarseness indicates the presence of a membrane in the larynx, that is, pseudo-membranous la- ryngitis. The exceptions to this rule are too rare to invali- date it. Furthermore, a progressive laryngeal dyspnoea attended with hoarseness, lasting over thirty-six or forty- eight hours, even if not accompanied by any visible exuda- tion in the fauces, indicates, in a great majority of cases, true croup, and should be treated as such. There is no acute disease except laryngitis, either membranous or catarrhal, which gives rise to these symptoms, and what- ever may be the condition of the fauces, or of the lungs, or of the general system, the dyspnoea is the main feature 342 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Croup. Croup, of the case, and demands early and careful attention. No theory as to the nature of the affection should allow the practitioner to lose sight of this fact. The question of relieving the respiration takes precedence of all others for the time being. That catarrhal laryngitis occasionally proves fatal is undoubtedly true, and furnishes an addi- tional reason for placing more reliance upon the condi- tion of the respiration than upon the local appearances in the throat. In cases of severe tonsillitis, the respiration is thick and snoring, and more or less impeded by the swelling of the tonsils, as well as by the restricted action of the mus- cles of the throat. Swallowing is very difficult, and sleep is disturbed or prevented. The test that defines the limit of the affection, and proves the larynx to be free, is the voice. In true croup no effort on the part of the patient will enable him to overcome the hoarseness ; while, if the obstruction be in the fauces, he can almost always make vocal sounds sufficient to show that the larynx is not the seat of the disease. The same symptoms are met with in certain cases of malignant diphtheria, attended by a great amount of exudation in the fauces. In sev- eral instances that have come under my observation the difficulty in breathing has been so great that an opera- tion was seriously considered. Careful watching, for a short time, will convince the physician that the larynx is not involved to any seriods extent, and hence that trach- eotomy is seldom, if ever, necessary under these circum- stances. Faucial dyspnoea presents a marked contrast to the laryngeal form. It is characterized by a choking and snoring quality of the respiration, and, unlike the latter, it is more troublesome during sleep. Upon waking, the patient draws a few full breaths quite easily and natu- rally, and again relapses into his former state of irregular and jerky respiration. The dyspnoea has not that tight, unyielding character of the laryngeal variety, and is more or less relieved by swabbing out the throat. There is no retraction of the parietes at the epigastrium. The cause of the difficult breathing is also plainly visible in the form of swollen tonsils and extensive exudation. Catarrhal laryngitis, or false croup, is a very common affection, and may be distinguished from the disease under consideration by the fact that it occurs suddenly, oftener in the night, is paroxysmal, of short duration, less severe in character, yields readily to simple treatment, or subsides without treatment, and very seldom terminates fatally. The affection is apt to recur for two or three nights, but there is little or no dyspnoea in the meantime, showing that the disease is principally spasmodic in its character. In exceptional cases the catarrhal symptoms are more pro- nounced than the spasmodic, and there may be some dif- ficulty of respiration for two or three days, but it is not severe, nor does it go steadily on from bad to worse, as it usually does in true croup. The walls of the chest do not recede, and of course there is no exudation of false membrane. It is probably a fact that true croup may supervene upon the catarrhal variety, and that the latter may accompany a membranous deposit in the fauces. But both of these conditions are of too rare occurrence to impair the rule previously mentioned. Laryngismus stridulus, or "internal convulsions," is a peculiar convulsive affection of the central nervous sys- tem, and, properly speaking, is not croup at all. It is characterized by a sudden attack of difficult or suspended respiration in an apparently healthy child. The inspira- tions are noisy and crowing, and the patient presents the symptoms of strangulation. The head is thrown back, the eyes are staring, the face is livid, the teeth are set, the fingers are clutched on the thumbs, the toes are flexed, and the whole appearance is one of great suffering, as well as of great danger. After a period of some seconds, or perhaps a minute, the spasm suddenly relaxes, a full inspiration is taken, and the child is soon in its normal condition. Neither cough, hoarseness, nor dyspnoea re- mains to indicate any affection of the larynx. The cough and difficulty in breathing occasionally met with in acute bronchitis in children is strongly suggestive of true croup. The latter disease may be excluded, how- ever, by the fact that the voice is comparatively free and clear, and there is no recession of the walls of the chest during inspiration. Primary and diphtheritic croup often resemble each other in the following particulars : both are of common occurrence in children ; in both there is an exudation of false membrane ; in both there is difficult respiration and impairment of the voice; in both a fatal result is com- mon, and death is not infrequently caused by suffocation. The contrast between the symptoms of typical cases of the two varieties is indicated in the following groups : A local disease. Begins in the larynx. Pharynx slightly affected. Not traceable to local causes. Seldom occurs in adults. Neither contagious nor infectious. Not epidemic. Does not disappear for long periods of time. A sthenic disease. Membrane does not extend to nares. Dysphagia slight or absent. No symptoms of septicaemia. No affection of lymphatics. No albuminuria. Neither attended nor followed by paralysis. Death seldom caused by syncope. Death due to suffocation. Pbimaby Cboup. A constitutional disease. Begins in the fauces. Pharynx extensively affected. Often traceable to bad drainage, etc. Often occurs in adults. Both contagious and infectious be- fore and after death. Often epidemic. Does so disappear. An asthenic disease. Membrane often extends to the nares and other parts. Dysphagia often severe. Septicaemia generally present. Lymphatics usually affected. Albuminuria common. Paralysis not infrequent. Death from syncope not uncommon. Death frequently results from other causes. Diphthebitic Cboup. Prognosis.-Croup is one of the most fatal diseases of childhood. The mortality ranges from fifty to eighty per cent., according to the type of the affection. The younger the patient the more fatal is the result, very few recover- ing under three years of age. Recoveries in adults are not common. As the majority of cases occur between four and seven years of age, so the greatest number of recoveries take place during that period. Croup appearing in the later stages of diphtheria is generally milder in type than when it manifests itself during the first week. Again, the more slowly the croupal symptoms are developed, the better is the prog- nosis. A croup which becomes severe within twenty- four or thirty-six hours of its onset, is not easily controlled by treatment. Recoveries are more common, in my ex- perience, in diphtheritic than in idiopathic croup, al- though other writers state the reverse. The result, how- ever, is determined more by the type than by the variety of the affection. Croup supervening upon the exanthematous diseases is considered especially dangerous, and experience shows that the apprehension is well founded. The vital powers having been more or less depressed by the primary affec- tion, they are unable to resist further encroachments. The extension of the disease to the bronchi and smaller tubes is a serious complication, but it does not necessarily render the case fatal. In a general way it may be said that the most malig- nant cases of pseudo-membranous laryngitis will die in spite of any and all methods of treatment; that the mild- est cases will recover under the simplest treatment or without any ; while the result in a large proportion of the cases of medium severity may be favorably influenced by judicious remedial measures. Treatment.-The treatment of pseudo-membranous laryngitis comprises tracheotomy, inhalations, food, stim- ulants, and drugs. Prompt and decided action in the early stages of this affection is of the utmost importance. While it is often difficult to properly estimate the effects of our remedies, yet the danger is so great, and the re- sults of late efforts are so unfavorable, that it is better to be over-active, if not over-anxious, in the early manage- ment of this malady. Even a needless tracheotomy is preferable to a possible fatality through too great a delay. Whether prompt and judicious measures will prevent a light case from becoming a severe one, is a question which each practitioner must decide for himself. It is to be hoped that something can be done in that direction, and our utmost endeavors are to be directed to that purpose. 343 Croup. Croup. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Two methods of treating croup engage the attention of the profession at the present time, namely, the oper- ative, and the expectant or medicinal. While both have their advocates, the weight of testimony from prac- tical surgeons, who have had the largest experience dur- ing the last ten years, is in favor of the former. My own opinion, based upon a somewhat extensive observation, is, that in a large proportion of the cases the two modes of treatment should be combined, that croup more seldom recovers under the purely medicinal or expectant plan, and that more recover with an operation than without it. Extensive and careful observations upon the results of the treatment of this disease by the medicinal plan alone are much to be desired. In speaking of idiopathic croup, Agnew says : "I am of the opinion that with American practitioners the recoveries without an operation are at least fifty per cent."3 Meigs and Pepper report fifteen spontaneous recoveries out of thirty-five cases of croup, mostly of the secondary variety.4 Dr. J. Lewis Smith had seven recoveries in twenty-one cases without an op- eration.6 On the other hand, thirty out of thirty-three of Dr. Ware's cases of primary croup proved fatal under the medicinal treatment. Steiner has seen only three recov- eries without an operation. Mackenzie places the mor- tality under the expectant treatment at ninety per cent. At the Boston City Hospital upward of five hundred cases of diphtheria have been treated during the past nine years. Between forty and fifty of these patients, suffer- ing from undoubted diphtheritic croup, as indicated by the presence of dyspnoea, membranous exudation, gland- ular enlargements, etc., received medicinal treatment only, and every one died. Not a single case of pseudo- membranous laryngitis has ever recovered in this hospital without an operation.* The experience of the profession throughout New England is to the effect that true croup, treated medicinally, is a very fatal disease, and that the recoveries are comparatively rare. I can explain this great difference of opinion and ex- perience only upon the supposition of a difference in the diagnosis. It would seem probable that cases attended by impairment or loss of voice, without dyspnoea-a con- dition not uncommon in adults affected with this malady- have been taken into consideration by some writers. In comparing the two methods of treatment, the above class of cases should not enter into the question, any more than should cases of false croup, or of faucial dyspnoea, as the operation of tracheotomy would very seldom be required under these circumstances. The statistics of results from the operative treatment of croup are very extensive, and those of late years, in America, are pretty uniform in their character. The formidable array given to the profession by the arduous labors of Mastin, Cohen, and many others, comprising over eleven thousand cases, as collated by Agnew, shows that from one-fourth to one-third of the cases of trache- otomized croup recover. Cohen's success has been re- markable. He reports one hundred and ten recoveries in one hundred and sixty-six selected cases, most of them occurring in private practice. The experience of Jacobi, Cheever, Ripley, and many other American surgeons, while not as favorable as that of Cohen, is yet very satis- factory, about one-third of their cases terminating favor- ably. It has fallen to my lot to perform tracheotomy eighty-six times for croup. Twenty-nine patients recov- ered (33+per cent.). Tracheotomy for croup has been performed two hun- dred and six times at the Boston City Hospital during the past twenty years. The result was favorable in sixty- five cases. One hundred and eighty-five of the operations have been done since January 1,1880, fifty-nine of which recovered. These facts, taken in connection with the unfavorable results from the expectant method, furnish strong evidence in favor of the operative treatment. An early resort to tracheotomy in true croup is advis- able for the following reasons : The disease is always dangerous, and very often fatal. The results obtained from medical treatment alone are extremely unsatisfac- tory. The operation gives more relief, and saves more lives, than any other mode of treatment known to the profes- sion. It seldom hastens death, and still more seldom causes it. And, finally, it affords the friends the great satisfaction of knowing that everything possible has been done to re- lieve, and to save, the patient. The proper time at which to do the operation is when the dyspnoea gets severe enough to tax the patient's strength, as indicated by restlessness, inability to sleep, and retraction of parietes at epigastrium during inspira- tion. The occurrence of paroxysms of severe dyspnoea also calls for an early operation. Moderate dyspnoea, coming on slowly and in the later stages of diphtheria, does not demand so hasty a resort to the operation as it does in the more violent cases. It is possible that in rare instances the laryngitis may be of the simple variety, and hence the mildness of the attack. The cases of probable pseudo-membranous laryngitis, attended with severe and increasing dyspnoea of at least twenty-four hours' duration, and not amenable to simple remedies, are rare in which the patient, whatever may be his complications or his general condition, should be refused the benefit which may result from opening the trachea. It is of the first importance that the mechanical obstruction to free and easy respiration should be removed at the earliest moment possible. Taking into consider- ation the fatal character of the affection, the unsatisfac- tory results of the expectant treatment, and the impossi- bility of determining the cases which would recover spontaneously, a resort to this measure is justifiable in urgent cases, even if the diagnosis is doubtful. Waiting for a clear diagnosis is, in some instances, simply waiting for an autopsy. The advantages of an early tracheotomy are, that the patient is better able to undergo the operation, the strength is. preserved, more nourishment can be taken, and more sleep secured ; time is gained, in which it may be hoped that the disease will run its course ; and, finally, it seems reasonable to suppose, as is claimed by some writers, that it tends to prevent those pulmonary complications which are so common in the later stages of the disease. Other things being equal, early operations will probably give better results than late ones. Tracheotomy will almost always afford temporary re- lief, even in fatal eases, provided the smaller air-tubes are not too extensively involved. If the patient progresses favorably for four days after the operation, in a majority of cases he will recover. A dry tube, with dyspnoea re- turning after twenty-four hours, means an extension of the disease to the smaller bronchi, and usually a fatal ter- mination. Next to tracheotomy, the most successful method of treating this affection is by inhalations. They should al- ways be resorted to early in the disease, whether an oper- ation is performed or not, and they should be con- tinued more or less constantly according to the severity of the illness. The agents used are simply steam, or steam charged wijh lime-water, carbolic acid, and vari- ous other substances. Smith speaks highly of slightly turbid lime-water, containing about one and one-half per cent, of liquor potassse, which is to be used through a steam atomizer. Steam itself is very efficacious, and is best supplied from a steam service, by tapping the pipe and throwing the vapor directly upon the face of the pa- tient, rather than by filling the room. In the latter case, the air soon becomes dead and depressing, as well as over- heated, and hence most uncomfortable for patients and attendants. Outside of hospitals the most convenient method of supplying vapor is by means of a relay of steam atomizers. A good apparatus will furnish sufficient vapor, but it requires constant watching to keep it in order. A spare one should always be at hand, and the larger the atomizers are, the better. At the City Hospital only unmedicated steam has been used in the treatment of these cases for the past three * April, 1885. 344 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Croup. Croup. years, and the results are as satisfactory as they were when medicated vapors were in vogue. The intra-laryngeal method of treating croup by local applications of a strong solution of nitrate of silver, as advocated by Dr. Horace Green in 1852, has probably saved some lives, but the treatment is so harsh and-uncer- tain that it has few advocates at the present time. Tubage of the larynx is not a practical method of re- lief, especially in children, although successful cases are on record. It consists in passing a silver tube, slightly flattened, and about an inch in length, into the larynx by means of a curved handle, and allowing it to remain as long as is necessary. The objections to it are, the diffi- culty of introducing and of retaining it in the proper po- sition, the liability to produce ulceration, and the inabil- ity to clear the trachea and parts below. Few, if any, drugs given internally are excreted freely enough by the mucous membrane of the larynx and trachea to exert either a sudden or marked influence upon cases of severe croup. Emetics have long enjoyed the confidence of a large number in the profession, but they are not now resorted to as much as they were formerly. Their action, aside from relaxing spasm, is chiefly me- chanical, and any benefit is obtained at the expense of more or less of the patient's strength. Hence, their favor- able effects are limited. In the early stages of the affec- tion, before there is any exhaustion, an emetic of ipecac, turpeth mineral, or sulphate of zinc, may be advisable to procure temporary relief, and, perhaps, to aid in es- tablishing the diagnosis. But in cases which are at all severe, emetics soon fail to afford relief, and, if persisted in, they do much harm, by deranging the stomach and increasing the prostration and restlessness. During the past few years the mercurial treatment of croup and diphtheria has attracted unusual attention. Corrosive sublimate, in particular, has been administered in large and frequent doses with varying results. The practice is based upon the theory that the bichloride, be- ing a powerful germicide, is indicated in those affections that are supposed to be caused by the presence of bacte- ria, or other micro-organisms in the blood. The object of treatment is to introduce a sufficient quantity of the drug into the system to " sterilize the blood," or, in other words, to kill the germs. The bichloride is better tolerated by children than by adults, and may be given to the former in doses of one- fortieth to one-fifteenth of a grain every hour or two, for two, three, or even four days, if necessary. As the bene- ficial effects will manifest themselves in that time, if at all, it is not prudent to push the remedy further. Thal- Ion 8 reports the case of a child, sixteen months old, to whom was given one-sixteenth of a grain every hour for eight hours, with apparent benefit. Another child, aged four years, suffering from true croup, took over two grains in one hundred and thirty hours, taking over half a grain in twenty-four hours. The symptoms improved under the treatment, and the child recovered. The poisonous effects of the drug are not often devel- oped in children who are subjected to it. Intestinal irri- tation, and even death, have been known to follow its use, but with care there is little danger attending the careful administration of this remedy. Adults are more liable to suffer from salivation, colic, and diarrhoea. Thus, one-twentieth of a grain of the corrosive sublimate, given hourly to a man, has caused severe intestinal irrita- tion in seven hours. The drug should be given largely diluted, to prevent nausea and vomiting, as in some instances the effects, as well as the taste, are very disagreeable. A good com- bination is that of the bichloride, pepsin, and elixir of bismuth, as recommended by Pepper and Thallon. It may also be given with the muriated tincture of iron largely diluted with water. Both the theory and practice of this mode of treatment are in their infancy, yet it is> regarded with favor by many prominent writers and practitioners, and is worthy of a more thorough trial. My own experience with this agent has been limited, yet the results have been such as to lead me to expect considerable benefit from its further use. Calomel has been used in the treatment of croup from time immemorial, on the theory that it has a tendency to counteract or destroy the plastic character of the exudation. There are good reasons for thinking that it is sometimes beneficial. The drug has been administered in doses ranging from a fraction of a grain to a scruple or more. The best method is probably that of small and repeated doses, as, for example, one grain every two or three hours to a child four or five years of age. The effects of this agent upon the gums and alimentary tract must be care- fully watched, as occasionally a patient is very suscep- tible to its action. In a majority of cases, however, the above dose may be continued for three days with safety, and often with apparent benefit. Any irritation of the bowels caused by the medicine will usually subside in a short time after discontinuing its use. Salivation is less liable to occur than diarrhoea, and calls for the ordinary treatment by chlorate of potash and cleanliness. Aside from the mercurials, the drugs which have been the most extensively used in the management of this dis- ease, in late years, are muriated tincture of iron, chlorate of potash, and quinine. They should be given frequently, and in small doses. Three drops of the iron, and two grains of potash, may be administered separately or to- gether every two hours. Two or three grains of quinine may be given every four hours, or oftener, according to the severity of the prostration. For the extreme restlessness, which is a frequent symp- tom in this affection, bromide of potash, chloral, and opium should be given separately or combined, according to circumstances. In some cases in which the secretions in the air-passages are scanty and tenacious, pilocarpine gives temporary relief by loosening the contents of the air-passages, and quieting the patient. As this drug is a depressant, its effects must be closely watched, and stimu- lants given if necessary. The distressing dyspnoea Caused by the invasion of the smaller air-tubes may be somewhat mitigated by opiates and anaesthetics. Should a resort to the latter agents be necessary, chloroform is preferable to ether, because it is less liable to produce spasm of the glottis, and the consequent shock and exhaustion. Faithful, intelligent, and untiring nursing is of the ut- most importance in the treatment of croup. There should be one nurse for the day, and another, equally efficient, for the night. It is not safe to leave these patients in the care of inexperienced friends while the overtaxed nurse gets her sleep. Lives have been lost for lack of proper care. The better the nursing the better will be the re- sults. The nurse should be trained to take care of the throat and of the tracheotomy tube, and in an emergency to remove and replace the outer cannula, in the meantime keeping the wound open with dilators, and clearing out the trachea with feathers. A cool, strong, faithful, and intelligent nurse is invaluable in the management of these cases, more especially after tracheotomy has been performed. That diphtheria and diphtheritic croup are contagious, will be questioned by few, and hence patients suffering from these affections should be isolated, after as well as before death, particularly from children. In localities in which diphtheria is prevalent, all cases of true croup should be isolated. In all questions of doubt as to the contagiousness of any disease, it is wise to take every precaution against infection. The method usually pursued by myself in the treat- ment of pseudo-membranous laryngitis at the Boston City Hospital is somewhat as follows : The patient is at once placed in the steam-room. A special pipe direct from the boilers furnishes a full and constant supply of warm vapor, which is directed upon the throat and face of the patient, and it is kept up more or less constantly,, accord- ing to the severity of the case, as long as there is any dyspnoea. It is not medicated. If the patient is seen early, before the symptoms be- come very urgent, one or two doses of turpeth mineral, two grains each, are administered, which usually acts promptly upon the stomach and bowels. To a child four or five years of age, a grain of calomel and a grain of quinine are given alternately every two hours, or a for- 345 Croup. Cumin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tieth of a grain of the bichloride every hour. Stimulants are not resorted to until the strength shows signs of fail- ure. Brandy, sherry, and champagne are the favorites. Milk, ice-cream, meat-juices, or any other food that the patient will take, is given freely and frequently. Cold applications, in the form of ice-bags or ice-poul- tices, are made to the throat in some of the sthenic cases, but more commonly hot flaxseed-meal poultices, or some simple liniment, as the soap and opium or camphorated oil and wool wadding, constitute the external treatment. I seldom use chlorate of potash in this affection, nor do I give iron until convalescence is established, and then it is continued until recovery is complete. The reasons for varying the usual method of treatment are, that iron seems to be contraindicated in febrile conditions of the system, and, furthermore, in my experience it has never seemed to do any good. If the fauces and nares are in- volved, iodoform is applied by insufflation every two or three hours or oftener according to the condition. When, in spite of treatment, the dyspnoea has become so severe as to exhaust the strength of the patient, the trachea is opened and a silver tube with a movable shoul- der is introduced. The operation is done under chloro- form, unless the patient is partially stupefied by carbon- semia, when no anaesthetic is used. After dividing the skin the pain is not severe, and with good assistants the operation can usually be done more satisfactorily without ether than with it. With the exception of the local ap- plications to the throat, the same general treatment used previous to the operation is continued. A trained nurse is constantly on duty, regulating the steam, cleaning the tube, throat, and nose, feeding the patient, and taking the pulse and temperature every three hours. From the fifth to the seventh day, should the case pro- gress favorably, the tube is quietly retnoved. No trials are made to see if the patient can breathe through the larynx. If, as the tracheal wound closes, the difficulty in breathing should return, the canula is replaced for a day or two, when another similar attempt is made to get rid of it. The cases are exceptional in which this method of discarding the tube is not satisfactory. The results obtained by myself in the treatment of croup during the past two years are given below. Every case was tracheotomized, and every one is included in the following table. A great majority of the patients had diphtheritic croup, and all were suffering from hoarse- ness or complete loss of voice, as well as from severe and progressive dyspncea, which was exhausting the strength and threatening suffocation. both kinds of flowers. Stamens two ; ovary single, one- celled ; one ovuled. The fruit is a globular one-seeded berry, slightly pointed at the apex, and narrowed below to a fine peduncle-like base nearly as long as the globular portion. Habitat: Java, Sumatra, Borneo ; also cultivated in the coffee plantations of Java and Sumatra, as well as in the West Indies. The drug generally reaches us through the commercial ports of India. It has been known in Europe since the middle ages, having been introduced through the Arabian physicians, and its earliest employment appears to have been as a spice. It was, however, used in genito-urinary troubles by the Arabians centuries ago ; but that employment either never took any hold in European medical practice, or completely died out long ago, and was not revived until the beginning of the present century, when it was rein- troduced by medical officers stationed in India. " Cubeb" consists of the whole fruits dried. They are about five millimetres in diameter (| inch), globular, wrinkled by the shrinking of the juicy mesocarp, slightly pointed at the apex, sometimes flattened at the base, from which the slender brittle stalk above mentioned projects from two to six millimetres. They each contain a round- ish stone within which is a single flatfish seed, or, as the fruits are collected before maturity, frequently an air- No. of Cases. Recovered. 1883 21 10 1884 20 7 1885 (January, February) 14 5 Total 55 22 Fig. 788.-Cubeb Plant in Fruit (Bullion). space. Color, grayish brown or blackish ; odor, strongly aromatic and peculiar ; taste, spicy, but milder than that of pepper. Cubeb contains from six to twelve or more per cent, of a composite essential oil which is officinal {Oleum Cubeba, U. 8. Ph.), a pale yellow or colorless liquid with the cubeb odor and an agreeable warm camphoraceous taste, sp. gr. 0.920, soluble in alcohol. It consists of a light portion, cubebene, and a heavy one. Upon long standing in the cold, crystals of a camphor are deposited. Cubeb also contains about six per cent, of a composite resin composed of cubebic acid, cubebin, nnd an indifferent amor- phous resin, besides some fat and other uninteresting in- gredients. All the above substances combined, extracted by ether and concentrated by evaporating the solvent, compose the so-called " Oleo-resin of Cubeb" {Oleo-resina Cubeba, U. 8. Ph.), of which the yield is from sixteen to twenty per cent, of the cubebs. Action and Use.-Cubeb is mainly an aromatic spice like its near relative, pepper. The odor and flavor are due to its oil, the pungent taste to its amorphous resins ; cubebin is inert. As a local stimulant to digestion, as an ingredient of cough mixtures and gargles, it has a certain value which it shares with others of its class. But nearly all the call for Cubeb is in diseases of the bladder and urethra, especially in gonorrhoea and gleet. It is elimi- The type of the disease in the above cases presented the usual variations, the symptoms in some being ex- tremely unfavorable, and yet the proportion of recoveries was forty per cent. A careful consideration of the dif- ferent methods of treating pseudo-membranous laryn- gitis in vogue at the present time leads me to conclude that more favorable results may be expected from the oper- ative combined with the medicinal treatment than from the latter alone. George W. Gay. 1 Meigs and Pepper : Diseases of Children, seventh edition, p. 90. 2 Dr. J. Lewis Smith: American Journal of the Medical Sciences, April, 1885. 3 Principles and Practice of Surgery, vol. iii., p. 35. 4 Ibid., p. 113. 8 Dr. J. Lewis Smith ; Diseases of Children, fifth edition, p. 291. 8 New York Medical Journal, April, 1884. CUBEB {Cubeba, U. 8. Ph., Br. Ph. ; Cubeba, Ph. G. ; Cubebe ou Poivre d queue, Codex Med. ; Cubebs). Piper Cubeba, L. fils {Cubeba ofiicinalis Miquel), Order, Piperacea, is a climbing plant with perennial, zigzag, smooth, branched stems, and alternate lanceolate, bright green, and shining leaves. The flowers are disecious, ap- parently lateral, but opposite the leaves, and aggregated in close linear catkin-like spikes. Perianth absent in 346 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Croup. Cumin. nated by the kidneys, whose secretion it augments slightly and scents decidedly, and the urine so impregnated soothes the bladder and urethra, through which it passes, and di- minishes the formation of pus-by exactly what process cannot be said. Administration.-It may be given in powder, the dose of which is from four to ten grams (4 to 10 Gm. = 3 i. ad ijss.); the bulk is generally an objection. There are a Fluid Extract (Extractum Cubeba Fluidum, U. 8. Ph., strength }) and a Tincture (Tinctura Cubeba, U. 8. Ph., strength i^-), both good, which may be reduced, if desired, by syrup or mucilage. The Oleo-resin (Oleo-resina Cubeba, U. 8. Ph.) is really an ethereal extract, and represents about six times its weight of Cubeb. Cubebic acid is said to represent the ' ' urethral " value of the drug, but the mixed preparations above mentioned are generally used. From the Oleo-resin are made the Troches of Cu- beb (Trochisci Cubeba, U. 8. Ph.), each containing half a grain (Gm. 0.03), considerably used as a popular " expec- torant " in pharyngitis, etc. Allied Plants.-See Pepper. Allied Drugs.-Copaiba, Sandal Oil, etc., and many other essential oils and resins. IF. P. Bolles. CULVER'S ROOT (Leptandra, U. S. Ph. ; Culver's Physic). Veronica virginica Linn. (Leptandra virginica Nutt.), Order, Scrophulariacea, is a tall perennial herb, with a simple, straight stem from one-half to two metres high (20 inches to 2 yards), and whorled, lanceolate leaves. The flowers are closely aggregated in one or several long ter- minal spikes. They are minute and slightly irregular ; calyx, five-toothed ; corolla, long and trumpet-shaped, five- lobed, white, pink, or purplish ; stamens, two ; ovary, two- celled. Habitat, United States; also occasionally culti- vated in flower-gardens both here and abroad. The rhi- zome and its adherent rootlets are the parts used. The rhizome is "horizontal, from four to six inches (10 to 15 centimetres) long, and about a quarter of an inch (6 milli- metres) thick, somewhat flattened, bent, and branched ; deep blackish brown, with cup-shaped scars on the upper side; hard, of a woody fracture, with a thin, blackish bark ; a hard, yellowish wood, and a large purplish brown, about six-rayed pith; rootlets thin, wrinkled, very frag- ile, inodorous; taste bitter and feebly acrid " (U. 8. The demand for Leptandra is almost entirely American, and largely confined to household and "eclectic" medi- cation. It has, however, been recognized in the Pharma- copoeia since its first edition. Its composition is rather indefinite ; a considerable amount of resin (the principal part of the so-called " leptandrin" of the eclectics) and a crystalline glucoside, discovered by Professor Wayne, which appears to be its active principle, are the most noteworthy; tannin, gum, and extractive matters are also found. The fresh root is said to be a violent emetic and cathar- tic. The dried product is less energetic, but still physics in full doses, and may cause nausea. It is supposed by some to stimulate the liver to action, but its power in this respect cannot be considered as settled. It undoubtedly stimulates and irritates the mucous membrane of the in- testine in full doses. Leptandra is principally recom- mended in dyspepsia, gastro-duodenitis, and hepatic dis- orders. Administration.-It may be given in powder ; dose, two or three grams ; for continued administration a smaller one should be directed. The officinal prepara- tions are an Extract (Extractum Leptandra, U. 8. Ph.), about four or five times as concentrated as the powder, suitable for pills, and a Fluid Extract (Extractum Leptan- dra Fluidum, U. 8. Ph., strength }), both of which rep- resent it well. The so-called " Leptandrin," precipitated from a tincture, is not to be recommended. Allied Plants.-Leptandra differs considerably, both in habit and medical properties, from most others in the great genus Veronica (see Beccabunga) ; for the order Scrophulariacea in general, see Foxglove. Allied Drugs.-Cathartics in general, see Podophyl- lum. Iris versicolor, Taraxacum, and others are reputed to act in some way upon the liver. Compare also Calo- mel. W. P. Bolles. CUCUMBER (Concombre, Codex Med. ; fruit, seed). The common, cultivated cucumber, Cucumis sativus Linn., has had considerable employment as an ingredient in mild soothing ointments, and is still occasionally, although less commonly, used. The French method of preparing the ointment is as follows : first the juice is obtained from the nearly ripe cucumbers, by scraping and then press- ing the pulp ; this is allow'ed to clarify itself by slight fermentation, and filtered ; then a thousand grams of lard, six hundred of veal tallow, two of balsam of Tolu (moistened with a little alcohol), are melted together in a water-bath, and ten grams of rose-water added ; then the mixture is poured off and the cucumber juice added in three portions, with long-continued stirring after each portion; the unincorporated liquid is rejected, and the ointment again melted, skimmed, and put into suitable jars for storing. When dispensed, a portion is slightly warmed but not melted, and beaten with a spatula to a frothy consistence. Allied Plants.-See Colocynth. Allied Drugs.-Cold Cream (Rose-water Ointment) is probably in every way as good as the cucumber prepa- ration. W. P. Bolles. CUDOWA, a village in Silesia, Prussia, is much fre- quented during the season by invalids, who are attracted thither by the reputation of the waters. The village lies at an elevation of about one thousand three hundred feet above the sea, and the air is in consequence fresh and invigorating, though the climate is equable. There are three medicinal springs at Cudowa, known as the Eugen- or Trinkquelle, the Gasquelle, and Oberbrunnen. The waters are taken internally, usually mixed with milk or whey, and are also used in the form of baths of various kinds. According to the analysis of Duflor, the composition of the Eugenquelle is as follows. Each litre contains : CUMIN, Codex Med., the fruit of Cuminum Cyminum Linn., Order, Umbellifera, an annual of the caraway type, probably of Asiatic origin, but extensively cultivated in China, India, and parts of Europe for its aromatic fruits. It is a low plant, with compound umbels of white or lilac, somewhat irregular flowers, and long, pointed, bristly, laterally compressed fruits. Oil-cells, four dorsal and two neutral in each mericarp. The odor and taste are strongly aromatic, but less pleasant than many others in the family, on which account it is scarcely used in this country. Cumin seeds yield about three per cent, of a clear, yel- low essential oil of spicy taste and odor, and having the general medical properties of the innocuous portion of the order (see Anise). The oil is separable into cuminol and cymol. Cumin is used everywhere in the East, and to a less extent in Europe, as a domestic flavor, and is said to be one of the components of curry powder ; also- an ingredient in some European liqueurs. In plasters and liniments, and in veterinary practice, it is also occa- Grammes. Sodium bicarbonate 1.25078 Calcium bicarbonate .. 0.49052 Magnesium bicarbonate 0.15625 Ferrum bicarbonate 0.02565 Manganese bicarbonate 0.00278 Sodium chloride 0.11718 Potassium chloride 0.00445 Sodium sulphate 0.70632 Calcium phosphate 0.00669 Ferrum arseniate 0.00156 Silica 0.09164 Total solids 2.85382 The proportion of free carbonic acid gas is large. Cudowa w'aters enjoy considerable reputation in the treatment of those conditions in which tonics and altera- tives are indicated; in anaemia, neuralgia, atonic, rheu- matic and gouty affections, and in certain diseases of the female sexual organs. T. L. 8. 347 Cumin. Cyanides. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sionally required, but its employment is rare in the United States. Dose similar to that of other carminatives ; from two to eight or ten drops of the oil. Allied Plants, Allied Drugs.-See Anise. W. P. Bolles. kinds of snakes, and some peppers are added to complete the mixture, which is then boiled down to a thick syrup. Dr. Jobert gives the following description of its prepa- ration by the Tecuna Indians in Brazil. The principal plants are : " Urari uva" {Strychnos Castelnaana Wedd.), " Eko" {Cocculus toxiferus?) " taja," a plant of the Arum family " eone," three Piperacea, and "tan ma gere." The barks from the branches of the first two are scraped fine and mixed, and a watery percolate is made from them ; this, boiled with fragments of the stems of " taja eone" for several hours until it thickens, when the scrapings of the Piperacea are added, and it is boiled again. Dr. Jobert found the "urari" and "taja" the most active substances. Besides these are other accounts, all agreeing in including some Strychnos, and varying in the details of the other ingredients and in the ceremonies, often of a half-religious character, with which the making is ac- companied. Curare is imported in small gourds or in little earthen pots. The specimen from which this description is made is contained in a rounded, grayish brown clay vessel, about eight centimetres across and five or six in height (3x2 inches). The neck of this vessel is slightly con- tracted, and its mouth is closed with several thicknesses of some endogenous leaves, probably those of a palm, which are tied over it with a string. The Curare, which about half fills it and was evidently poured into it while soft, is a dry, brownish black, brittle extract, of disagree- able odor when freshly broken, and of very bitter taste. It is only partially soluble in cold, but nearly completely so in boiling, water, to which it gives its taste and odor and a reddish brown color. In alcohol (about 92 per cent.) it is only slightly soluble,in ether not all so. Solutions neu- tral. Curare is a variable substance both in quality and ap- pearance-sometimes it contains the bodies of ants. Other specimens are said to be soft or semi-liquid, but the usual variety in this market is the one described above. The Curares of different tribes are not, at present, distin- guished from each other here. Composition.-The active principle of this poison was first pointed out and prepared in an amorphous state by Roulin and Boussingault in 1830, and named by them curarin. Their observations were confirmed by several chemists afterward, but no special gain was made until Preyer, in 1865, obtained it in a purer and crystalline form. " Curarine crystallizes in colorless, four-sided, very hy- groscopic prisms, of a bitter taste and feeble alkaline reaction. It is freely soluble in water and spirit, but little so in chloroform, and insoluble in ether" (Huse- mann). It is supposed to exist in the drug in the form of a sulphate, and should be about twenty times as active as Curare. Its sulphate, acetate, nitrate, and chloride are also crystalline. The curarine of the market is far from being a reliable product, and may be even less active than crude Curare. According to Sachs, it is only calcic phosphate and carbonate contaminated with Curare. This is the only active and peculiar substance isolated from Curare, but it must be acknowledged that its composition is not yet satisfactorily made out. Action and Use.-Curare is a paralyzing agent of most intense character, affecting, in small doses, espe- cially the peripheral ends of the motor nerves-the trunks of these nerves and the sensory fibres are only later dis- turbed. Large doses paralyze also the vagus, heart, and the spinal cord. Death takes place from the failure of respiration, and may be postponed and even averted after this ceases by artificial means. Internally administered, Curare is much less active than when injected into the tissues or veins, a result partially explained by its very rapid elimination by the kidneys. Medicinal doses in men produce a feeling of weariness, with disinclination to ex- ertion, or even decided paralysis. Increase of perspiration, lachrymation, and salivary secretion are also observed. The principal employment of Curare is in physiologi- cal laboratories, where its paralyzing power makes it in- valuable for a wide range of experiments. As a medicine it is but little used. Its most plausible employment is in tetanus, whose convulsions it antagonizes, although it can scarcely be claimed to reach the cause of the disease. CUNDURANGO {Cortex Cundurango, Ph. G.). Of the different products known in South America by this name, that selected by the German Pharmacopoeia is a bark attributed to Gonolobus Cundurango Tri., Order, Asclepiadacea, of Colombia and Peru. It is described by that authority as being in channelled and tubular pieces a decimetre long and from one to seven millimetres thick, with a longitudinally wrinkled, brownish or brown- ish gray external, and a striated, gray internal surface. Fracture short, scarcely fibrous ; taste bitter, subacrid. Cundurango was introduced to the American public about ten years ago, as a specific for cancer, and a num- ber of cases were reported at the time to prove its value. Further general trials, however, proved its absolute use- lessness, and it has nearly dropped out of the American market. It appears to have taken a little hold of Ger- man medicine as a general alterative, etc., and now fig- ures as an official there. According to Dr. Antisell it contains tannin and a resinous matter, and has some con- siderable physiological activity. Allied Plants.-The order contains nothing of spe- cial value in medicine. Allied Drugs.-Chian turpentine has recently had just such another spell of fashion as a cancer cure, and scores of other drugs have been through the same. W. P. Bolles. CURARE {Ourari, Wburali, Woorara), "a poison ob- tained from several South American species of Strych- nos, varying in different countries, but principally from Strychnos Castelnceana Wedd. " (Codex Med.). This famous arrow-poison is a composite extract made by different tribes of South American Indians in the Orinoco and Amazon Valleys and in Guiana. The ingredients com- posing it vary with the tribe and the locality, but always include the bark, juice, or root of one or another of the indigenous species of Strychnos; of the other substances some are known to be innocuous, others to be added merely to give adhesiveness or some other physical quality to it, while of still others the properties are yet unknown. The importance of the Strychnos may be considered as pretty well proved, first, by its universal presence, and, secondly, by observations such as that of Dr. Crevaux, who found that a tincture of the species named for him produced effects similar to those of Curare itself. Professor Planchon, whose studies of the American species of this genus (English translation in Pharm. Jour, and Trans, for 1880-81, etc.) have been very elaborate, refers the different Curares to the follow- ing : First, that of the Amazon Valley to 8. Castelnceana Weddell, a large woody climber growing in most parts of Brazil, and also in Colombia and among the Andes. The bark of the stem is the part employed. Secondly, that of the upper Orinoco region, to an imperfectly known species, possibly identical with 8. toxifera Bentham. Thirdly, the Curare of British Guiana he attributes to the just-named 8. toxifera; and, finally, that of French Guiana, on the authority of Dr. Crevaux, to 8. Crevauxii, Bailion, also a tall, woody vine, with minute flowers and two forms of leaves-one of medium-sized ovate or lanceolate blades, and another of small scales, the latter crowded together on slender forking branchlets at the ends of the twigs. Besides these a number of other species are men- tioned by older authorities as ingredients of the poison. The methods of preparation have been described by several travellers, some of whom saw it, while others re- ceived their information by hearsay. Waterton, who saw it made by the Macoushi Indians, says that thin scrapings of the ' ' wourari vine " {Strychnos, sp. ?) and of a bitter root are percolated in a rude way with water, and into this juice the green juice of two kinds of bulbs is pressed ; two kinds of ants, and the fangs of two 348 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cumin. Cyanides. Its real value in this disease is probably not much greater than that of Calabar Bean. It has been recommended in hydrophobia, epilepsy, and strychnine poisoning, but is probably valueless in all these cases. In poisoning by Curare, the most important thing to be remembered is that the respiration must be maintained, by artificial means if necessary, until the effects of the poison pass off. Administration.-Water is the best vehicle-subcu- taneous injection the most efficient method; the dose must be a tentative one, increased until its effects are evident. From one to four milligrams (0.001 to 0.004 Gm. = gr. f/o ad gr. -/y) may be given at first. The fol- lowing estimate is given by Schroff (Hager): Of a Cu- rare of which one milligram will kill a rabbit, from five to ten or twenty milligrams may be given as a human dose. Allied Plants.-See Nux Vomica. Allied Drugs.-A number of Methyl- and Ethyl-com- pounds of the haloids and of numerous alkaloids are said to have somewhat similar paralyzing power, but have no employment in medicine. Conium, Dita, Lobelia, have some resemblance to Curare in their action. Calabar Bean, although acting principally upon the nervous cen- tres instead of the periphery, causes similar symptoms of paralysis, and is sometimes used for the same convulsive affections as Curare. W. P. Bolles. Allied Drugs.-The juice of most agreeable acid fruits is somewhere used, either as a refreshing drink or flavor, or as an anti-rheumatic or anti-scorbutic. Lime- juice, Lemons, Grapes, Barberries, Tamarinds, etc., are familiar examples. W. P. Bolles. CUSSET is a small place in the department of Allier, France, only about two miles distant from Vichy, of which it may be regarded as a part, for many of the guests at the latter station drive out to Cusset to bathe, and the waters of the two places are very similar in their action. There are three springs at Cusset, the water from one of which is conducted to Vichy and there used. The names of the two remaining springs are the Sainte Marie and the Elizabeth. Their composition is as follows: Each litre contains- Elizabeth. Ste. Marie. Grammes. Grammes. Sodium bicarbonate ... 5.200 4.200 Potassium bicarbonate .... trace 0.005 Calcium bicarbonate . ... 0.661 0.436 Magnesium bicarbonate .... 0.330 0.120 Strontium bicarbonate ( trace Lithium bicarbonate j ' ' Sodium sulphate .... 0.502 0.400 Potassium sulphate .. . 0.010 Sodium chloride .... 0.460 I 0.501 Potassium chloride .... 0.020 f Sodium silicate .... 0.150 0.140 Aluminium silicate .... 0.150 0.021 Ferrum and manganese protoxide.... .... 0.009 0.022 Alkaline iodides and bromides, arsenic, and organic matters .... trace trace Total solids .... 7.492 5.845 CURCUMA (Curcuma long et rond, Codex Med.), Tur- meric. This is the rhizome of Curcuma longa Linn., Order, Zingiberacea, a perennial, flag-like herb of India, where, as well as in other parts of Asia, it has long been cultivated. Curcuma is distinguished in trade as "long" and " round" varieties, which for a long while were supposed to be from different plants. They are now knowm to be the principal and lateral rhizomes of the same. Round cur- cuma is in oval pieces, about as large as a pigeon's egg, rounded at the ends and encircled by the lines of numer- ous nodes. The long variety, which is more common, is in pieces from three to six centimetres long, and from one-half to one in diameter (2 inches x J- inch), encircled by a number of distinctly marked nodular rings. Col- or brownish externally, deep orange-red within; odor strong, peculiar, not disagreeable; taste aromatic, bit- terish. It contains a clear yellow essential oil, which is its aromatic portion, and a deep yellow, crystalline, color- ing matter, Curcumin, which becomes carmine-red with acids, and reddish brown with alkalies. Action and Use.-Similar to those of ginger, but not much used here-either as a medicine or condiment. It is extensively consumed in Asia as a spice, and is the basis of Curry. In the arts, Turmeric is employed to dye cloths yellow; in chemistry, to a slight extent, as a test for alkalies ; in pharmacy, now and then to color oint- ments and other preparations. Allied Plants.-See Ginger. Allied Drugs.-See also Ginger ; for pharmaceu- tical coloring agents, see Saffron. W. P. Bolles. The waters are used in the treatment of anaemia, chlo- rosis, general debility, gout, diabetes, gall-stones, and dis- eases of the digestive and urinary organs. T. L. 8. CUTTLEFISH BONE (Me ou Seiche, Codex Med.). A very light and fragile calcareous skeleton found in the Cuttlefish, Sepia officinalis Linn. ; Order, Dibranchiata Loliginea. This Mediterranean mollusk has a purple- spotted, gray body of oblong shape, and a short, thick so- called "head," which is provided with two large eyes and a mouth surrounded by a circle of sucker-lined "arms;" eight of these are sessile and taper to points, while the other two are very long, pedunculated, and ex- panded at the extremities. The body consists of the di- gestive, circulatory, and respiratory apparatus, enclosed in a sac-like envelope called the mantle. The " bone " is found in the dorsal part of the body beneath the mantle, and obtained by collecting the mollusks and allowing them to putrefy, or by picking up those that wash ashore. It is when whole of oblong or lanceolate outline strongly flattened, with one surface (the dorsal) hard and smooth, and one very spongy, light, and friable. The struct- ure is very open, laminated, and light, the entire bone when dry floats upon water. Odor, none or slight; taste, saline. There is a considerable demand for cuttle-bones-partly as a " dentifrice " for cage-birds and partly for dentifrices, polishing powders, face-powders, etc. It consists almost entirely of carbonate of lime, with a little phosphate of lime and some animal matter. Its early use as an ant- acid, etc., is now of the past. Allied Animals.-There are other Sepias of similar structure, but none of commercial importance. This and others of the order have a secreting organ filled with an intensely brown-black fluid, which they squirt into the water when frightened to hide themselves from danger. This liquid inspissated is the pigment sepia. It is very permanent, and has been found unchanged in fossil speci- mens of the family. Allied Drugs.-Oyster-shells, Crabs' Eyes, Red Coral, etc., or, more sensibly, Carbonate of Lime. IE P. Bolles. CURRANTS (Cassis, Codex Med., the leaves of Ribes nigrum Linn. ; Groseille, Codex Med., the fruit" of Ribes rubrum Linn.; Order, Saxifragaceri). Ribes rubrum is the common Red Currant, a native of Europe, but cultivated both there and here for table use; the berries contain about one and a half per cent, of citric and two per cent, of malic acids, besides sugar, pectin, coloring matter, etc. The juice and syrup are official in France ; their only use is as a pleasantly acid flavor for medicines, aerated wa- ters, etc. R. nigrum, the black currant, is less commonly cultivated here ; it has rather larger, black, and peculiarly fragrant fruit; the taste is less acid than that of the red currant, and slightly mawkish. Syrup, troches, and con- fections are made from it. The leaves are recognized by the Codex Med., and an infusion of them is used as a country remedy for gout and rheumatism in parts of France. Allied Plants.-A number of other species produce edible fruits-the best known is the Gooseberry, Ribes Grossularia Linn. CYANIDES. The only cyanides that concern the phy- sician are the argentic, mercuric, and potassic salts. Argen- tic cyanide is a white insoluble powder, officinal in the U. S. Pharmacopreia, but solely for pharmaceutical use, the salt being a possible source for the obtaining, extemporane- 349 Cyanides. Cylindroma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ously, diluted hydrocyanic acid (see Hydrocyanic Acid.) Mercuric cyanide is a soluble salt which will be found discussed in the article Mercury, and concerning which it is only necessary to remark in this place, that the salt adds to the irritant properties of the mercuric salts, gen- erally, a peculiar virulence due to the acid radicle of its composition. Potassic cyanide is a soluble, and therefore physiologically active, salt, wherein the comparatively mild properties of the basic radicle are entirely overshad- owed by the intensely poisonous potency of the acid ele- ment. For, in combination with the bases of the alkalies, hydrocyanic acid proves itself exactly as poisonous as in its free state, so that the alkaline cyanides, in proportion to their weight in acid radicle, are the medicinal or toxic equivalents of the uncombined acid. Potassic cyanide, being therefore practically but a carrier of hydrocyanic acid, is considered under the present heading rather than among the salts of potassium generally. Potassic Cyanide, K C N.-Potassic cyanide is officinal in the U. B. Pharmacopoeia, under the title Potassii Cy- anidum, Cyanide of Potassium. It occurs in "white, opaque, amorphous pieces, or a white, granular powder, deliquescent in damp air, odorless when perfectly dry, but generally of a peculiar, characteristic odor, having a sharp, somewhat alkaline and bitter-almond taste, and a strongly alkaline reaction. The commercial salt is •soluble in 2 parts of water at 15° C. (59° F.), and in 1 part of boiling water ; it is but sparingly soluble in alco- hol. When heated to a low red-heat the salt fuses " (U. S. Ph.). It should be kept in well-stopped bottles, since it tends to a slow decomposition by exposure. Po- tassic cyanide represents, in sixty-five parts, thirty-nine parts of basic and twenty-six of acid radicle ; and so, ac- cording to what has been said above concerning the al- kaline cyanides generally, about two and a half parts of this salt represent, physiologically, the virtues of one part of anhydrous hydrocyanic acid. The salt in concen- trated application is very painful to raw and sensitive parts, and taken internally acts precisely after the man- ner of hydrocyanic acid (see Hydrocyanic Acid), except that it is rather slower of operation. A dose anywhere between 0.20 and 0.30 Gm. (from three to five grains) is ordinarily fatal, and death commonly results in from fif- teen minutes to two hours. Poisoning can also arise from absorption, externally, through abrasions, and even the in- halation, in a close chamber like a photographer's " dark closet," of the fumes arising from an exposed strong so- lution may excite symptoms. In case of poisoning by the internal taking of the salt, Taylor (on Poisons) advo- cates the giving of ferrous sulphate as a special antidote, because of the reaction between the two salts whereby the insoluble and innocent substance Prussian blue is formed. The same author cites the case of a photographer who, upon accidentally swallowing a solution of potassic cyan- ide, immediately drank of a photographic "developing" solution containing ferrous sulphate, vomited Prussian blue, and survived. Medicinally, potassic cyanide is a possible substitute for hydrocyanic acid, proposed because of greater sta- bility. Internally, it may be given in doses of from 0.005 to 0.008 Gm. (from to | grain), in water or syrup. Many prescribe it in conjunction with vinegar or lemon- ade, with the view of setting free hydrocyanic acid from the salt, but the procedure is not necessary. Externally, an aqueous solution ranging from one-fifth to one per cent, in strength is occasionally prescribed as a lotion for the relief of surface pains or itching. A special use of potassic cyanide is to remove stains of silver nitrate from the skin, provided such stains be recent and not yet ex- posed to strong sunlight. A solution, or a moistened lump of the salt, is rubbed upon the blackened skin, and the part afterward well washed in water. Due regard must be paid to the very poisonous nature of the cyanide, and, especially, application of the salt to cut or excoriated parts should be carefully avoided. Edward Curtis. The cause of this discoloration is either that the proper amount of oxygenation of the blood is not performed, or that the venous system is overcharged with blood. Many explanations of this condition have been given, but the essential defect is that there is a want of proper arteriali- zation of the blood. The cause of this want of arterialization may be due to some form of asphyxia ; to some disease of the lung, or, as is generally the case, to some heart difficulty, most frequently congenital disease of the heart. It is frequently caused in new-born infants by inter- ference with the placental circulation before birth. An- other very common cause of this condition in young children is atelectasis (see article on that subject). Cyanosis is, of course, merely a symptom; as such it has been reported as occurring in many diseases ; frequently it occurs in bronchial asthma, bronchial catarrh, capil- lary bronchitis, pneumonia, pleurisy, pneumo-thorax, pul- monary emphysema, and in heart-disease. Niemeyer cites cases of its occurring in whooping-cough, in croup, and in atelectasis. He states that hump-backed pa- tients frequently suffer from cyanosis, due to collapse of the lung (but that often the symptoms do not appear until after puberty), the development of the collapse be- ing due to the chest deformity, which becomes more marked at this period ; also that it has been noticed as a post-mortem sign in Asiatic cholera. Any disease or injury which produces the essential condition, viz., want of proper arterialization of the blood, will produce cyanosis. Morbus Cceruleus.-The occurrence of cyanosis in connection with congenital disease of the heart has come to be described as a disease itself, although it is, of course, merely a symptom of the congenital deficiency of the heart. This affection is known as morbus cceruleus, or "blue" disease. The malformation may be one of several different forms ; the most common form consists in constriction of the pulmonary artery, and a deficiency in the septum of the ventricles, the aorta communicating with the right ventricular cavity (Dr. Eustace Smith). The heart is always enlarged, particularly the right side ; there are generally pathological changes in other organs, atelectasis frequently accompanying this affection; the liver and spleen are often enlarged by congestion ; effu- sions may occur in the pleura and peritoneum ; the brain also is frequently diseased ; endocarditis and pericarditis occur occasionally in this condition. Symptoms.-Tile most marked symptom of this condi- tion is, of course, the peculiar livid hue of the skin which develops if the child survives. The intensity of this hue varies from a dusky tinge to a purple or black color. It may be found in all parts of the body, but is most fre- quently seen on the cheeks, lips, and eyelids, and in the fingers and toes. The immediate cause of the cyanotic hue is probably a stasis of blood in the dilated capil- laries, due to continued congestion combined with the imperfect aeration of the blood (Dr. Eustace Smith). Associated with the cyanosis are generally noticed a club- bing of the ends of the fingers and toes, and an incur- vation of the nails. There is often flattening of the inframammary region on each side. There is also marked coldness of the hands and feet, and frequently of the whole surface of the body. The skin is habitually dry in these cases. Palpitation of the heart and dyspnoea generally ac- company this affection; these symptoms are increased when the child is disturbed or excites itself. Coughing also is common (due to bronchitis), and when the cyano- sis is extreme the sputa are apt to be bloody. The pulse is often irregularly intermittent; it is generally strong, however. (Edema of the legs, or ascites, occurs in some cases, but not very frequently. The digestion is often impaired ; the bowels are irregu- lar and costive. The gums may become ulcerated. Chil- dren suffering from this affection are irritable and easily disturbed, infants with this trouble are generally thin and badly nourished ; children who survive the period of infancy may become to all appearances strong and hearty. The patients are apt to be stupid, and not given to exer- CYANOS1S {Morbus Cceruleus'). This term is applied to that condition of the circulation in which there is a more or less marked bluish hue over the surface of the body. 350 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cyanide**. Cylindroma. cise, as they learn by experience that motion tends to increase their dyspnoea. Attacks of syncope are quite frequent in these cases. Affections of the nervous sys- tem are also frequent complications ; convulsions occur frequently, especially in infants ; sleep is often disturbed by sudden startings and twitchings. There may be constant heaviness and somnolence ; Dr. Eustace Smith says that attacks of uncontrollable sleepi- ness form a part of the disease ; these attacks may amount to coma lasting some hours. Other cerebral complica- tions are of frequent occurrence in these cases. Pulmo- nary tuberculosis is said to occur also. Diagnosis.-When the cyanosis is present, the history and physical signs make it almost impossible to mistake the true condition. Even in cases in which cyanosis is not present, a careful examination of the chest will generally give sufficient information for a correct diagnosis. When, too, slight causes, as moderate exertion, bring on an attack of dyspnoea or syncope, this affection is to be suspected. In children who have passed through the period of in- fancy without manifesting the symptoms of this trouble, this affection can be pretty confidently ruled out; if, on the other hand, even in a child over three years of age, the cyanosis be present, together with the other accom- panying signs, congenital defect of the heart is probably the affection which is to be suspected. Prognosis.-The length of life in those affected by this disease is very variable ; one-half of the cases die in the first year, and two-thirds before the third year (Dr. E. Smith). The prognosis as regards recovery is, of course, very bad; there being no possible chance of it. Certain periods of life are especially dangerous; the first performance of respiration, the period of dentition, wean- ing, and attacks of other sicknesses are particularly so. After the first year of life is past the prognosis is some- what more favorable, as shown by the above figures ; these patients, however, seldom live to adult life. Infants with this malady frequently die in convulsions. Fatal syncope is not infrequent. When attacked with intercurrent diseases, the chances of recovery for these pa- tients are much reduced by the badly-nourished condi- tion which is almost invariably present. Frequent attacks of syncope, of great drowsiness, or of cerebral irritation are serious symptoms (Dr. E. Smith) ; the occurrence of albumen in the urine and suppression of the same are bad signs, which are said to occur in this condition. Treatment.-It is evident that very little can be done in the way of medicinal treatment of these cases. The attention must be principally directed toward regulating the bodily functions and improving the general health. The patient must be warmly clothed ; extra precautions in this particular being necessary from the fact that the general surface of the body is colder than normal. Great care should be taken as to the diet in these cases ; the food must be very nourishing, and indigestion must be carefully avoided. The bowels should be kept open by the use of some mild purgative. As far as possible these cases must be removed from all causes of excitement, and they must be kept from un- due or even marked exertion. The position which the patient occupies is, perhaps, a matter of some importance ; although it is not likely that it makes much difference with the action of the heart, yet certainly, in some cases, the cyanotic hue is dimin- ished and the patient is easier when he or she is placed in a certain position ; the position most recommended is on the right side, with the head slightly raised. The treatment of the paroxysms consists in the admin- istration of anti-spasmodics and stimulants. Counter- irritation should be made locally to the chest or by pediluvia. This treatment, however, cannot be very con- fidently relied upon. The best medicine to give, with a view to regulate the action of the heart, is digitalis. Oxygen gas has been given with success in some cases ; it is probably most useful in the spasmodic attacks of dyspnoea. Dover's powder is also said to be beneficial. The regular action of the skin should be excited by the use of tepid baths, followed by careful friction over the whole body. In cases of extreme cyanosis, it is said that the perox- ide of hydrogen in doses of eight minims, repeated thrice daily, will give relief. Intercurrent diseases of the lungs, kidneys, and bowels require especially prompt attention. The treatment of symptomatic cyanosis is, of course, the treatment of the disease of which it is a symptom. For further information on this subject, see under the heading Heart. 'William II. Murray. CYLINDROMA. The name cylindroma was given by Billroth to certain tumors which had their origin in con- nective tissue, and were characterized by the presence of hy- aline, structureless cylinders and irregular bulbous knobs projecting from them. These structures are embedded in a connective tissue which either partakes of the character of ordinary fibrous tissue, or is very vascular and abundant in cells, in this respect approaching a true sarcomatous type. Billroth says that this tumor takes its origin in a growth of the endothelium of the blood-vessels, which in consequence become changed into twisted, convoluted tubules filled with small round or irregular cells. These tubes anastomose frequently with one another, and are embedded in fibrillar connective tissue. The cells within the vessels become larger, their line of juncture vanishes, and they finally fill the vessels so completely that no lumen can be seen in them. These tubular masses can always be distinguished from epithelial tubules by the fact that the nuclei of the cells filling them are elongated, and have their long axes parallel with the axis of the ves- sel. A hyaline metamorphosis of the vessel's walls takes place all the time that the growth of the endothelium has been going on, so that we can distinguish in the tubules a wall and an inner layer of cells. Fig. 789, taken from Billroth, shows a series of vessels which are undergoing this change. At various intervals irregular, club-shaped villous structures, with thick hyaline walls, containing in their middle a number of cells, are given off from these cylinders. There are also projections from the outer hyaline mass into the cells in the middle, so that on section it appears as though we had hyaline balls sur- rounded with a layer of cells. These cells can take, from mutual pressure, all manner of forms, in many cases simulating exactly epithelial cells ; and, the hyaline sub- stance inside of them being scarcely visible with low powers, they may easily be mistaken for glandular acini. At a further stage, this hyaline metamorphosis also affects the cells which are in the interior of the hyaline masses, so that we can have, in consequence of this change in the protoplasm, completely hyaline structures forming large cylindrical masses. These masses branch in a dendroid system, and, with their bulbous projections, they present a close resemblance to the branching of the cactus. Some- times this degeneration may begin in the interior and affect the cells here first, and in this way we may have the hyaline structures surrounded by a layer of cells. The smaller blood-vessels and capillaries also become fre- Fig. 7S9.-Hyaline Metamorphosis of Blood-vessels (Billroth). 351 Cylindroma. Cysts. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. quently surrounded by hyaline masses, so that appear- ances as in Fig. 790 are often seen. According to Forster the tumor originates in the lymphatic vessels by a growth of their endothelium, and the hyaline masses are formed from their walls. There are numerous other theories as to their histogenesis; many cases have been reported by various authors, each of whom has his own theory of origin. Volkman has described such a tumor, removed after death from the cheek of a woman aged fifty-nine. He found what he describes as glassy bodies, which often contained within them one or more cells. On crushing these bodies, they seemed to contain a watery fluid. By teasing he secured a number which were attached to each other, and he re- garded the whole connected mass as a gigantic cell, the small bodies within being formed by endogenous cell-growth. It is doubtful whether we are war- ranted, from a strictly histogenetic basis, in assigning to these tumors a special class. That they are very closely allied to the myxomas is shown from the fact that we often find in the im- mediate vicinity of the hyaline bodies a well-marked myxomatous tissue. In other cases the stroma of the tumor, if we can so designate the tissue lying be- tween the cylin- ders, is composed of spindle-cells or well-formed fibrous tissue. Rindfleisch has not given them a special place, and Ziegler places them among the sarcomas characterized by pecu- liar formations. There is, however, more in their clinical aspects to warrant them being considered separately than in their anatomi- cal. They present a striking uniformity as to their situa- tion. All the typical cases that have been as yet reported have originated either in the upper or lower maxillary re- gion, in the orbit, or within the skull. After removal they almost always return to their original seat. In a case reported by Sattler, the tumor returned four times after operations ; various intervals elapsed after each operation before the return of the growth, the longest being five years. Internal metastasis and an involvement of the lymph-glands have been seen in but three cases. There is never any constitutional disturbance nor ca- chexia from the primary tumor. As a rule the tumors are very painful and marked by extensive ulceration. The only special diagnostic point is the presence of the hyaline cylinders. IF. T. Councilman. it retains the shape imparted to it, an outline of which is readily traced upon a piece of paper. The material best suited for this purpose is a piece of soft lead, one-fourth inch pipe, or a flat strip of any flexible alloy of lead one- half inch wide and long enough to surround the chest. The strip should be cut into two equal parts, and then Fig. 793.-Chest of the Same. slipped into a long piece of common india-rubber tubing. The tubing protects the patient's skin while the metal is moulded against it by the lingers, and it serves to make a hinge for the two separate pieces so that they can be swung outward and removed, after being moulded to the chest or head, without losing the shape im- parted to them. Cyrtometric tracings are especially interesting for showing graphically the relative sizes and shapes of the heads and chests of rachitic chil- dren, and the amount of unilateral bulging or re- traction of the chest- wall which may take place in different stages of pleurisy. Four such tracings, taken by the author, are inserted here as examples. The cyrtometer was first described by Andry and Bouil- lard, but it was first employed extensively by Woillez (" Recherches cliniques sur 1'Emploi d'un Nouveau Pro- cede de Mensuration dans la Pleuresie," Paris, 1857). William Gilman Thompson. Fig. 794.-Chest, showing Bulging of Right Side Anteriorly from Pleurisy. Fig. 790. CYSTICERCI OF THE SKIN. Several cases have been reported in which these parasites have become encysted in or under the skin. The affection is characterized by the presence of a number of tumors of pea to hazel-nut size, rounded or oval in outline, smooth and firm. They are not usually painful on pressure, and having attained a certain size they may remain unchanged for years, new tumors arising from time to time in some cases. The tumors caused by the presence of cysticerci in the skin may be mistaken for lipoma, carcinoma, sarcoma, molluscum epitheliale, sebaceous cyst, or syphilitic tu- mors. Microscopic examination reveals the presence of the parasite. Arthur Van, Harlingen. CYRTOMETER. The cyrtometer(Kvpros, curved, perpov, a measure) is an instrument for measuring and outlin- ing circumference. It is chiefly employed for demonstrating the differ- ence in contour of the two sides of the chest, where pleurisy or other disease has produced de- formity, and for repro- ducing the outline of cir- cumference of rachitic or hydrocephalic heads, "pigeon breasts," etc., and the outlines of large tumors and other deformities, before operation, for com- parison afterward. The instrument consists simply of a narrow strip of some material which can be accurately moulded to the contour of the body, and when removed CYSTS. A cyst is a cavity filled with a substance more or less fluid, and surrounded by a capsule, by means of which it is separated from the surrounding tissues. The cavity may be newly formed, or it may be a natural cavity which has become distended. It is difficult to draw the line which should separate cysts from the mere exudations and dropsies on the one hand, and the true neoplasms on the other. Strictly speaking, if we call every accumulation of fluid in a pre- formed space, with consequent dilatation of this space, a cyst, then the serous accumulations in the pleural and peritoneal cavities should be placed in this category. Some authors have attempted to limit the cysts to accumulations in pathological cavities only, but most of the structures which have always been recognized as cysts, do not arise in cavities of new formation, but are only natural cavities which have become enlarged from an accumulation of their secretion. Virchow has included more under the head of cysts than has any other author ; he considers both Fig. 791.-Chest. Spinal Curvature. 352 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cylindroma. Cysts. the hydrocele and the bronchocele under this head. He has a certain right to do this because between these formations and the atheroma there is only a difference in the causative moment. There are a certain number of cysts which are al- ways associated with so much new formation of tis- sue, aside from the development of a cyst-wall, that they must be reckoned with the neoplasms. Nowhere do we see this difference better marked than in the Avary, where we have cysts which represent true new formations, the Kystoma of Virchow, and others which arise from the dilatation of cavities which already exist, as the Graafian follicles. We shall here only consider those cysts which are formed by the dilatation of cavities which already exist, or which are formed by a tissue which already exists in the body, and in no sense represents a new formation pressing apart the normal tissues. The other group, the cysts due to actual new formation, the Kystoma of Virchow, including many of the ovarian and the dermoid cysts, will be considered under other heads. Cavities with more or less fluid contents can arise in many different ways, and in considering their etiology we must take into consideration the different types in which they present themselves. They may be divided into two groups : First, those which are formed by the dilatation of cavi- ties which already exist. The filling of these cavities can take place in different ways : by extravasation, by exudation, and by retention. Virchow makes the divi- sion into extravasation cysts, exudation cysts, and reten- tion cysts. Besides these, there are certain forms of cysts which arise by the cutting off of a portion of a large cavity, and the accumulation in the cut-off portion of the secretion which should have passed off. In the second group of cysts the cavities are formed by softening and degeneration of a tissue. There is still another group of cysts which are formed around foreign bodies and parasites. The contents of the cysts will vary with their mode of origin. Surgeons have, for a very long time, been accus- tomed to use a classification based on their contents, and to speak of serous cysts, fat cysts, blood cysts, grumous cysts, etc. The extravasation cysts contain blood, the ex- udation ones serum. The contents of the retention cysts vary according to the physiological secretion of the gland in which they are formed. Those cysts which arise from softening contain the products of retrogressive tissue-meta- morphosis. Such a classification, owing to the changes which may take place in the contents of cysts, would be obviously impracticable. The contents of an ordinary retention cyst may be changed into a fluid which closely resembles serum. The contents of the cyst are always enclosed in a cap- sule. This must naturally be of the same structure, in all essential particulars, as that lining the cavity in which the cyst arose, and hence must vary greatly in its ana- tomical structure. In the best characterized cyst, the inner surface of the membrane is lined with epithelium, which may vary very much in character according as it represents the lining of the acinus of a gland or that of a serous cavity. It has been held to be the rule that, when we find a cyst with a well-defined epithelial lining, the cyst is not due to a new formation. Very often, however, in the dermoid Cysts and in those of the broad ligaments, both of which are new formations, we have a distinct epithelial lining. This epithelial lining can undergo various altera- tions. By constant distension it can become so thin that a glandular epithelium may resemble the lining of a serous cavity. We see this also in the difference observed in the character of the epithelium in the urinary bladder, ac- cording as it is examined in the contracted or in the dis- tended condition of the viscus. The epithelium may also, in great part, be lost by fatty degeneration. Besides the epithelium, the membrane is made up of firm, fibrous connective tissue, which is always more dense than the tissue around it. Its firmness and consis- tency separate it from other parts, and render it possible for the cyst to be shelled out. This membrane is very much better marked in some cysts than in others. In consequence of irritation or inflammation due to trauma or to medication, the membrane can become intimately adherent to other parts, and then its complete separation becomes difficult or impossible. Even in cysts formed in bones, we find ordinarily an inner connective-tissue mem- brane. Cysts may be either simple or compound. A simple cyst consists of a single cavity; the compound cysts either consist of a conglomeration of simple cysts, or of many cavities which. communicate more or less freely with one another. These compound cysts are generally spoken of as multilocular cysts. They can arise by cystic formatioh in a number of cavities which are adjacent to one another, or by cyst formation in organs which adjoin one another. Communication between the different cavi- ties arises from a destruction of the partition walls, caused usually by distension due to an increased amount of fluid. The cavities in such a cyst are never of the same size, and when the cyst is stuffed out and dried in this condition, it looks like a honeycomb. Such a multilocular cyst can also be transformed into a unilocular or simple cyst from the complete destruction of the partition walls. Communicat- ing cysts can also arise primarily where an entire acinous gland becomes changed into a cyst-as the salivary gland, for example. The various acini of the gland become distended and communicate freely with each other. A similar condition may arise from the dilatation of the lymph spaces in connective tissue into cysts. We may have a complication of cyst formation with tumors, and on account of the great complexity of the structures which so arise, much confusion has been caused. The most ordinary case is that in which a tumor develops in a glandular organ, and by its growth cuts off a portion of the glandular acini. Their secre- tion accumulates, and a cyst is formed. Often tumor masses, following the line of the least resistance, grow into these cysts, and when we have cysts formed in the tumor itself, by the softening and breaking down of its tissue, it may easily be imagined what very complicated structures may arise. Such tumors arise in the mamma, and are known as cysto-adenoma, cysto-sarcoma, etc. They may arise in connection with any form of tumor, but are least frequent with the carcinoma. In a late stage it is often impossible to say which was the primary formation, the cyst or the tumor. Age has little or no effect on the formation of cysts; they may develop at any age, and some are congenital. Puberty exercises some effect when the organ in which a predisposition to cystic formation exists is connected with the genital apparatus, and at this time experiences an increased flux of blood. The growth of cysts is, in general, a slow one ; still some exudation and extravasation cysts, as might be supposed from their origin, attain often an enormous size in quite a short time. The cysts may be of very variable size, from microscopic smallness up to the most colossal proportions. When a cyst has existed for some time the contents al- most invariably become changed. When blood forms the contents, this undergoes the various changes famil- iar to us from the study of the blood extravasations. It becomes changed into a dense, firm coagulum, and the coloring matter is deposited in the shape of amor- phous coloring matter and crystals. In some cases it should be remarked that the blood remains fluid and ap- parently unchanged for a very long time. When the con- tents of the cyst consist of a serous fluid, this is especially liable to undergo change. The most frequent change which takes place is the colloid degeneration, in consequence of which the contents become changed into a more or less hyaline, thick, honey-like liquid. This has given rise to the special designation of meleceris, or honey cyst. Cho- lesterin and all manner of fatty crystals are often found in great abundance. Calcareous masses are very often present, and may arise in various ways. They may be calcified clots of fibrin or precipitates from the retained glandular secretion ; they may also arise from papillary growths from the inner surface of the cyst wall, which become broken off and undergo calcification, and remain as free calcified bodies. Such bodies are sometimes found 353 Cysts. Damiana. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in hydrocele. The contents of cysts filled with epithe- lium often become changed ; here the formation of cho- lesterin and calcareous concrements is very common. Other changes are not so common. The writer once saw a cyst taken from the shoulder, and evidently arising in a hair-follicle, which was lined with a well-defined epi- thelium, and filled with a mass of about the consistency of cold paraffine. The mass was cut readily with a knife, and under the microscope was seen to consist of flattened epithelial cells and an amorphous material of a fatty character, as the reaction with ether and caustic alkalies showed. Some deposit of lime salts was also present. The cyst membrane also undergoes change in the course of time. Usually this consists in an increase of its thickness and consistency, although the opposite of this may take place. Calcification and, according to some authors, even ossification may be developed. This usually takes the form of plates, in the cyst wall, which are not connected with each other; in some cases, however, the entire wall may be changed into a firm calcareous mass. When the calcification has reached such a point all the blood-vessels become occluded, the epithelium dies, no further increase of size can take place, and the tumor represents merely a foreign mass in the tissues. Destruc- tion of the cyst may also take place in other ways. In- flammation may lead to this. This may result from trauma or from an extension of the inflammatory process from the surrounding tissue, as in cases of erysipelas, phleg- monous inflammation, etc. If a trauma has caused a haemorrhage into a cyst filled with serous fluid, the whole mass may become coagulated and obliterated in this way. By an increased flow of blood in the wall absorption may rapidly take place, leading to the disappearance of the contents. Obliteration of the cavity can then be accom- plished by granulations springing from the opposing sur- faces. Surgeons very often make use of this in the treatment of cysts, causing the inflammation by the in- jection of some irritating fluid. Very often the inflam- mation leads to suppuration ; this opens the cyst, and a communication with the outside is established. By this process the cyst may be changed into an abscess cavity, from which a foul sanious pus is emptied. By this sup- purative process the epithelium is usually destroyed and the cyst obliterated. This is not always the case ; large masses of epithelium may remain unchanged, and go on se- creting, the product being emptied through fistulous open- ings. This discharge is mixed with pus, and, should the opening become closed, a cyst formation can arise anew. A frequent result of inflammation within the cyst is that, whereas its connection with the surrounding tissues may previously have been a loose one, the connection is now likely to become much firmer, the cyst rendered immov- able, and its removal much more difficult. Cysts are throughout non-malignant tumors, and most of them can be carried during the entire lifetime of the patient without any ill effects. While the patient is free from all dangers of metastasis, they may become dangerous from the inflammation and suppuration which they often undergo, and from their size and seat. Thus cysts on the neck can lead to disturbances of the respira- tion, or they may endanger life by interference with the act of swallowing. The large cysts of internal organs present the most serious dangers. Here life is endangered by the secondary disturbances which the cyst, by its size, causes in the organs of the abdominal cavity and the thorax, or by changes which take place in the cyst itself, as suppu- ration, etc. Peritonitis, resulting in death, may also be caused by the bursting of the cyst and the escape of its contents, which are often of a highly irritative character, into the peritoneal cavity. Nothing definite can be said as regards the diagnosis of cysts. Among their characteristics may be mentioned the fact that they represent circumscribed tumors more or less loosely connected with the neighboring tissues. When seated beneath the skin or mucous membrane they are usually not adherent to this, and give a clear fluctu- ation. In suitable localities the serous contents of a cyst will give a translucent appearance to the tumor. The different contents-blood, serum, masses of broken-down epithelium-the manner of origin, the nature of the cyst- wall, the anatomical seat, are all moments which must serve as points in a differential diagnosis. W. T. Councilman. DACTYLITIS SYPHILITICA. [Syn.: syphilitic whit- low, syphilitic panaritium ; Ger., Syphilitscher Dactylitis, Gummoser Dactylitis, Syphilitische Panaritien; Fr., Pan- aris syphilitique; Dan., Syfilitiske Panaritium.] History.-The history of this disorder began with its recognition as a distinct syphilitic manifestation, under the title of syphilitic panaritium (panaris, paronychia). By this name it was also briefly alluded to by Bumstead, in his standard work upon venereal diseases, even as late as the year 1870. Prior to this, however, the lesion had begun to attract that more exact observation and study which has given to us a definite knowledge of its pathol- ogy, and to itself its present designation. This history is best to be studied from the bibliography which concludes this article. Since 1874 (Baeumler, op. cit.) and 1875 (Taylor, op. cit.), we find the disease definitely recognized under its present title in text-books. Definition and Seat.-Dactylitis (SoktuAos, finger or toe) syphilitica is an inflammation due to syphilis, the seat of the manifestation of the process being one or more of the phalanges of one or more fingers or toes, or both. The nature of this inflammation is gummatous. The proximal phalanges are the ones most commonly affected. Varieties.-Every tissue of the body, and conse- quently of the fingers, may be attacked by syphilis. Thus Van Oordt's thesis contains (Obs. 4) the descrip- tion of a gumma affecting the third extensor tendon over the metacarpal bone of the middle finger. The fibrous sheaths of the tendons, the synovial membrane, the inter- osseous muscles, and subcutaneous cellular tissue may also be implicated. The term syphilitic panaris formerly covered all these conditions, as well as that gummatous infiltration of the bones and subcutaneous connective tis- sue to which is now usually restricted the name which heads this article. Etiology.-The disorder arises from syphilis, either contracted directly by inoculation of the virus or inher- ited. When hereditary it occurs, as a rule, during the earliest years of life. Taylor considers that cases of this latter variety are more numerous than those due to ac- quired disease. Representations are here given (see Plate VII.) of the lesion as encountered in my own practice. Nos. 1 and 2 portray the hand and foot of a woman infected by acquired syphilis. Nos. 3 and 4 repro- duce the appearance of the hand and foot of an infant boy (hereditary). Fig. No. 3 hardly does full justice to my drawing of the right hand of this latter case, the first phalanx of the ring finger of which was severely affected. The plate of the foot deserves prominence on account of the greater comparative rarity of the lesion in this situation ; this being, so far as I know, the first case recorded and portrayed. More pronounced forms than are here given, belonging to the curiosities of medical literature, may be found represented originally in Bergh's paper (op. cit.), or as copies in various recent handbooks. The disorder may occur at any period of the so-called ter- tiary stage, and is usually accompanied by other severe affections of bones, of the skin, and of the viscera, and proves a saturation of the physique by the virus of syphi- lis. Course.-We recognize pathologically two forms of this morbid process. In the first wre find gummatous material formed primarily in the subcutaneous tissue, or, at times, perhaps in the periosteum, and only later, and to a less degree, affecting the deeper structures, causing thickening of one or more phalanges, usually the first, and of the articular capsule. Here the formation of the infiltration may be rapid and even painless, though the process runs a chronic course, often with one or more re- lapses. Motion of the joint is often retarded by the swell- ing, which ends suddenly, with a well-marked line of demarcation from the contiguous integument, and is most marked upon the dorsum. The skin may be temporarily sensitive ; smooth and tense from the tumefaction, adher- 354 Reference Handbook of THE Medical Sciences. PLATE. 1. I. 4. 3. Dactylitis Syphilitica. otoLt<xu.T.n<.|.> imide bi| <9 u|c|LmadL) REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Cysts. Daniiana. -ent to the subjacent tissue, in color reddened or viola- ceous, with at times a perceptible coppery hue. Next to this retarded motion, there follows, sooner or later, act- ual implication of the joint by infiltration, and subse- quent erosion of the articular capsule, with crepitation. Effusion into the joint is rare, and follows only the par- ticipation, in the general process, of the synovial mem- branes. The joint being thus destroyed, with or without ulceration of the skin, the bone itself may finally be at- tacked. The resulting deformity is not necessarily spe- cially marked. In the second form the original inflammation is an osteo-periostitis, or an osteo-myelitis, the joints being only subsequently affected, while the subcutaneous con- nective tissue may or may not be implicated. The sole symptom may be for a long time boring pain within the bone. Most frequently there is little or no pain ; this be- ing contrary to the general rule in cases of disease of the periosteum and bones (Comp. " Zeissl's Lehrbuch," third edition, vol. ii., p. 230). By degrees the phalanx en- larges in its entire circumference, or most noticeably upon the dorsum, and becomes so thin that it may be in- dented by the physician's finger, while at the same time ■crepitation may be perceived. The gumma may next break through this thin shell of bone, and finally even through the other tissues, including the skin, although such ulceration is rare. The orifices of exit may be sin- gle or multiple. Through the openings there escapes a brownish-yellow viscid fluid, containing white curdy masses like soft cheese, but with no pus except as the product of simple inflammation. These fistulous open- ings do not enlarge, tending rather to eventual spontane- ous closure. Nor do the edges become everted, thick- ened, and bluish. The skin may be normal in structure and color, or reddened by tension. One or more pha- langes may be involved, but the resulting deformity of the parts participating in the process depends less upon the number affected than upon the character of the infil- tration. Where the original swelling was acute, the tis- sue proliferated is apt to be colloid, which breaks down and is eliminated. The consequent destructive changes are marked. Thus whole joints may be absorbed, with perhaps fibrous anchylosis of the remainders of the adja- cent phalanges, or false joints may result from union of the surviving ends after absorption of the centres of the phalanges affected. The skin in such cases contracts and moulds itself to suit the changed conditions to quite a re- markable degree. Where the primary tumefaction was due to a chronic process, the indolent infiltration is firm in consistence, and tends rather to fatty degeneration and interstitial absorption. The nails in general escape all morbid change. Pathological Anatomy and Histology.-Our sub- ject is to be classed pathologically with the improperly so- called spina ventosa (Virchow : "Die krankh. Geschw.," ii., p. 405), the external appearances of which may also arise from tuberculosis, or from enchondroma or sarcoma of the marrow of bone. Microscopically the anatomical character is that of a periostitis gummosa or osteo-mye- litis gummosa. The form which is indurated, with uni- form enlargement of a whole member, square at the end, with a clearly circumscribed swelling most marked upon the dorsum, seems to affect the toes rather than the fin- gers. When the bone is first attacked the final condition may be one of shortening or of increased length, of thick- ening and solidification or of thinning with porosity. Microscopically the neoplasm is composed of gumma- tous material, an immature form of connective tissue ; a granuloma. When this tends to liquefaction rather than absorption, the yellowish-brown fluid is thin when mixed with effusion from a joint, thick when arising from de- generated bone or connective tissue, in which case the microscope may show minute osseous particles mixed with the amorphous granular matter and scanty connec- tive-tissue cells. Diagnosis.-A correct diagnosis of the character of this affection is of the highest importance, prompt and suitable treatment being attended with gratifying, if not ■ always complete, success. The differential diagnosis from scrofula in hereditary cases in young children can often be made solely from the coexistence in parents or child of other concomitant or consecutive syphilitic mani- festations. Taylor thinks that possibly, in the variety of swelling due to debility and struma, the enlargements and destructive changes may be more rapid than in syph- ilis, and the joints perhaps more often involved. In adults struma does not affect the phalanges; rather the tarsus and carpus, and bones rich in cancellated tissue. Rheumatoid arthritis is attended by fever, the large joints are more especially affected, and, if the phalanges, then these especially at the joints, and more so than in syph- ilis ; and this localized inflammation is much more pain- ful than when lues is the cause. Rheumatism also dis- torts the fingers by attacking the sheaths of the flexor tendons, and, like gout, may be accompanied by tophi. Gout, and paronychia as well, are distinguishable from dactylitis syphilitica by their acute inflammatory symp- toms, their rapid course, and marked pain. The charac- ter and history of enchondromata and exostoses, as well as their size and location, render their differentiation easy. The palmar surface suffers from enchondroma, the dor- sum from dactylitis. Prognosis.-This is much better than might be ex- pected, if correct treatment is early instituted and sys- tematically and thoroughly pursued. Treatment.-The treatment is by potassic iodide and tonics, to which a mild mercurial internally, and mercu- rial or iodic applications externally, should be added. The importance of attention to the principles of hygiene as to bathing and massage, out-door exercise and ven- tilation, regular hours, sleep, diet, clothing, and temper- ance, must be strongly inculcated. Operative procedures are to be discountenanced. Baumes: Precis theorique, etc., i., p. 178. Paris, 1840. Van Oordt: These de Paris, 1859, pp. 41 and 45. Chassaignac : Clinique europeenne, 1859, p. 238. Nelaton: Gaz. des Hopitaux, Feb., I860, pp. 105 et 106; also, Bullet, de therapeutique, t. Iviii., p. 233. Bergh: Hospital Tidende, No. 13, 1860 ; Trans, in Behrend's Syphilodo log., hi., 3, 1861; also, Arch. f. Dermat. u. Syph., ii., 1870, p. 223. Luche: Berl. klin. Wochensch., Nos. 50 u. 51, 1867. Archambault: L'Union Med., No. 140, 1869. Risel: ['' Volkmann's case"] Berl. klin. Wochenschr., No. 7, 1870. Taylor: Amer. Jour, of Syph. and Dermat., Jan., 1871; also, Brown-S6- quard's Arch, of Scien. and Pract. Med., No. 4, 1873 ; also, Syphilitic Lesions of the Osseous System in Infants and Young Children. New York, 1875. Smith: Amer. Jour, of Syph. and Dermat., Jan., 1872. Wigglesworth : Ibid., April, 1872. Illustrated. Morgan : Med. Press and Circ., Dec., 1872, and Jan., 1873 ; also, Dublin Jour, of Med. Sci., April, 1873. Bulkley : N. Y. Med. Jour., May. 1874. Baeumler: Handb. d. Spec. Path. u. Therap., Bd. iii. Syphilis, p. 161. Leipzig, 1874. Edward Wigglesworth. Bibliography. DAGGAR'S,OR DIBRELL'S, SPRINGS. Location and Post-office, Daggar's Springs, Botetourt County, Va. Access.-By Norfolk & Western Railroad to Buford Station, thence by carriage to springs, twenty-eight miles. The water is a mild sulphur. The springs are situated in the beautiful Alleghany Mountains, and for many years have enjoyed a select, though limited, patronage. G. B. F. DAMIANA. The leaves and twigs of Tumera aphro- disiaca L.F. Ward, and of T. diffusa Ward ; perhaps also of other species of Tumera; Order, Tumeracece (Bixacece Bailion), Of the considerable number of products called Damiana by the Spanish-Americans of Mexico, etc., the leaves of these Turneras are now generally regarded as the ones to which the aphrodisiac reputation of Damiana for what it may be worth belongs. They are herbs or small shrubs, with small, fragrant, alternate, generally serrated leaves, and regular, polypetalous, pentamerous flowers. Fruit a one-celled, three-valved, many-seeded capsule. The leaves of both species are similar ; those of the former are larger, from one to three centimetres long by from one-half to one broad (| to 1 inch X I to | inch), while the others have about half these dimensions. They are lanceolate or obovate, coarsely toothed, with 355 Damiana. Davos. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. prominent midribs and primary veins ; the latter run so near the outer borders of the teeth as to appear to end at the sulci. Both are also glandular and fragrant. Those of T. aphrodisiaca, when fully grown, are smoothish- those of T. diffusa pubescent beneath. The buds and youngest twigs of both species also pubescent. Twigs and young branches, and sometimes flowers, are also present hi the drug as collected. Odor mint-like, agreeable; taste bitter. These species of Turnera are natives of the high lands of Mexico and Central America, probably also of South- ern California, whence a good deal of the Damiana of commerce is now obtained. Its use was learned from the Mexicans, among whom it has been used for many years, and from whom stories of its efficiency as enter- taining as remarkable have come. Composition.-According to Mr. Henry B. Parsons (Rep. U. S. Dep. Agriculture, 1878), it-that is, T. aphro- disiaca-contains about eight per cent, of " Volatile oil, soft resin, and chlorophyll," about six and a half of hard brown resin, seven of a bitter substance, three and a half of tannin, besides the usual inert substances, sugar, starch, gum, etc. It is not certain to which of the above its peculiar qualities, if it has any, are due. Action and Use.-From its sensible properties and composition, Damiana belongs evidently to the numerous group of aromatic, bitter tonics of the mint, chamomile, and boneset type. The specific properties for which it has been vaunted, i.e., a direct stimulant or tonic action upon the male sexual organs, cannot be considered as proved. There is still, however, several years after its first introduction, a moderate demand for it, mostly with this in view. Allied Plants.-The order contains about seventy species, of which most are members of the Genus Turnera. None of the others have any special economic value. The related order, Bixacea, with which it is incorporated by Baillon, contains Annatto, etc. (see vol. i.). Allied Drugs.-The leaves of a composite plant, Aplopappus Venetus, are also called Damiana in Mexico, and were imported under this name when it was first employed here, but they have fallen out of use. It can hardly be said that there are any specific aphrodisiacs, although many things have been used as such. Among them may be mentioned Cantharides, which simply irri- tates the urinary tract and may cause an erection of the penis in the same way that a urethritis sometimes does. Cannabis Indica, alcohol, and other intoxicants do little more than remove self-restraint and modesty. General tonics (strychnine in some cases) and moral and physical hygiene are the best means at command for most cases. If Damiana is a specific aphrodisiac, it stands apart by it- self. W. P. Bolles. hesive plaster-Emplastrum adheesivum (Ph. G.), of which it comprises fifty of the six hundred and fifty parts-litharge plaster, yellow wax, and resin being the others. It is harder and perhaps less irritating than com- mon resin, but not otherwise different. It is invaluable as a basis of varnishes, etc., for which it is principally used. Allied Plants.-Several other species of both the genera yield similar resins-D. Australis is the source of the Kauri Gum of New Zealand, also extensively used in varnishes. For the order Coniferce, see Turpentine ; for Dipterocarpacece, see Gurjun Balsam. Allied Drugs.-See Turpentine. W. P. Bolles. DANDELION (Taraxacum, U. S. Ph., the root ; Ta- raxaci Radix, Br. Ph.; Radix Taraxaci cum Herba, Ph. G.; Pissenlit ou Dent de Lion, Codex Med., root and leaf). Taraxacum officinale Wiggin (T. dens leonis Desf.; Leontodon Taraxacum Linn., etc.), Order, Composita! (Chicoracece), the common Dandelion (Dent-de-hon, dens leonis, etc., lion's tooth, suggested by the edges of the leaves), is too familiar a plant to need description. It grows wild throughout the temperate regions of Europe, Asia, and North America, and is also considerably culti- vated for its tops, which are used as a pot-herb and as salad. The root is required by the American and British Phar- macopoeias to be gathered in autumn, and Hager also recommends it to be gathered then, but the German Pharmacopoeia directs the whole plant to be collected in the spring. Bentham and Hooker, on the other hand, assert that the root is the most bitter in July, and next so in March, and that the root of autumn is least so, espe- cially after frost. The milky juice is most abundant in the spring, the amount of inulin in the summer. Dandelion is an old remedy, doubtful references to it occurring in the most ancient medical writings. It has been used in all countries and times, but has scarcely ever been prominent in any. The officinal description of the root is as follows : " Slightly conical, about twelve inches (30 centimetres) long, about one inch (25 millimetres) thick above, crowned with several short, thickish heads, somewhat, branched, dark-brown, longitudinally wrinkled, when dry breaking with a short fracture, showing a yellowish, porous wood, surrounded by a thick, white bark, con- taining numerous milk-vessels arranged in concentric circles ; inodorous, bitter. It should be free from the root of Cichorium Intybus Linn., which closely resem- bles it, but is usually paler, and has the milk-vessels in radiating lines." Fresh dandelion contains a bitter, milky juice, which readily sours, curdles, and becomes reddish-brown. The bitter principle, taraxacin, is contained in it, as well as a waxy substance, taraxacerin, both isolated by Kromayer in 1861 ; the root also contains inulin, gum, sugar, resin, etc., in varying quantities. The medicinal value of Dan- delion is generally conceded to be due to its taraxacin. Action and Use.-Dandelion is an impure bitter-that is, in addition to the tonic qualities of bitters in general, it adds considerable power of disturbing the alimentary canal, and, therefore, has had extensive employment in the concoction of "spring medicines," and cures for " liver complaints." While there is no proof that it has any particular action upon the liver or its secretion, it does appear to be a useful tonic where slow digestion and indolence of the bowels are also present. The fresh juice, mixed with other similar ones (Fumaria, Blessed Thistle, Buck-bean, Celandine, etc.), is sometimes em- ployed abroad, but here only the root is used, and, at least until a few years ago, nearly all of what was sold as dandelion was chicory, with no dandelion whatever in it. Wild Dandelion roots grown on poor land are con- ceded to be the best, that is, the most bitter. Administration.-Powdered Dandelion may be, but is not often, given. Dose, from two to eight grams (2 to 8 Gm. = gr. xxx. ad 3 ij.). A Solid Extract from the fresh root, of variable strength, and a Fluid Extract, strength f, are officinal (Extractum Taraxaci, U. S. Ph., and Extractum Taraxaci Fluidum, U. S. Ph.). The DAMMAR RESIN (Resina Dammar, Ph. G.). Resins obtained from Dammara alba Rumph, and D. orientalis Lambert ; Order, Coniferce ; and also from Hopea mieran- tha and II. splcndida ; Order, Dipterocarpacece. The Dammara trees are large, straight-trunked, hand- some firs, from whose branches an abundance of turpen- tine exudes both spontaneously and upon incision. It dries rapidly, and hardens to dense, brittle, irregular tears or masses of resin, often of large size. The Hopeas are also tall large trees, and belong in an order which yields a number of other volatile and resinous products (Borneo Camphor, Gurjun Balsam, Indian Copal, and so forth). The above trees are all natives of the East-the Moluccas, Java, Borneo, India, etc. Dammar conies in fine, hard, transparent yellow, or nearly white, odorless tears, of irregular shape and size, but often large. It is brittle, breaking with a brilliant, conchoidal fracture, but softens slightly in the hand, and melts at about 120° C. Soluble in chloroform, ether, car- bon disulphide fats and oils, but not entirely so in cold alcohol or in benzin. It is a compound of several resin- ous constituents-damarylic acid and its hydrate, dam- maryl and damaryl subhydrate (Dulk: copied from Huseman). Uses.-This resin is an ingredient of the German ad- 356 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Damiana. Davos. root, roasted and ground like coffee, affords a beverage compared by some to that ; it has probably no medicinal properties. The Dandelion coffees of the shops were made from chicory. Allied Plants.-Chicory, Lettuce, etc. For the or- der, see Chamomile. Allied Drugs.-The numerous cathartic or nauseat- ing bitters, of which several are mentioned above, and Yellow Dock, Leptandra, Hydrastis, and others, maybe referred to. Calomel has also long held a principal place among medicines supposed to stimulate biliary and intes- tinal digestion. W. P. Bolles. Dr. J. Burney Yeo ("Climate and Health-Resorts." p. 244, London, 1885) tells us that the number of patients who passed at Davos the winter of 1869-70 was seventy in 1872-73 the number of such patients was two hundred ; in 1874-75 it was four hundred ; in 1875-76 it was five hundred ; while in the winter season of 1878-79 the num- ber had increased to seven hundred. The Davos Valley lies to the west of, and a little to the north of, the upper valley of the river Inn, or what is known as the Upper Engadine, and the bed of the former valley is but a few hundred feet less elevated above sea- level than is the bed of the latter. From the river Inn to the stream, called the Landwasser, which drains the val- ley of Davos, the distance, as represented on Baedeker's map, is about fifteen miles. The width of the Davos Valley is put by Dr. Wise (in his little wrork, entitled "The Alpine Winter-Cure") at from five hundred to a thousand yards ; its length is about fourteen miles. The elevation of Davos Platz above sea-level is generally given as 5,100 feet. Dr. Yeo, on the authority of Dr. Frank- land, makes it about two hundred and fifty feet higher, viz., 5,352 feet. The direction, of the valley is from northeast to southwest; the mountain masses by which it is hemmed in rise from 2,000 to 5,000 feet above the val- ley bed. Within this trough, as it may be considered, perched high up among the Alpine peaks of the Canton des Grisons, lies Davos Platz, and at a trifling distance from it the two sister hamlets of Davos Dorfli and Davos Frauenkirch. Practically these three places form but a single health-resort, although minor differences of ex posure, and consequently in climate, exist between them. Davos Dorfli lies about a mile and a half to the northeast of Davos Platz, that is, farther up the valley; Davos Frauenkirch is situated about the same distance, or per- haps a mile or so farther, from Davos Platz, and in the opposite direction. The elevation of these two latter places above sea-level is nearly the same as that of Davos Platz, but while Dorfli is a trifle higher Frauenkirch is a little lower than the intermediate, larger, and better known station am Platz. Wiesen, lying some eleven miles below Davos Platz in the same valley, has come into notice within the past few years as a rival health- station, and it certainly appears to possess some advan- tages over Davos. The minor differences in climate existing respectively between Davos Dorfli and Wiesen, when compared with Davos am Platz, will be referred to later on. Concerning any special peculiarities in the climatic conditions of Davos Frauenkirch, the writer possesses no information. The climate of Davos is a decidedly cool one in summer and a very cold one in winter ; but the great dryness of its atmosphere is commented upon by all observers, as are also the intensity of the sun-heat, the general cloudlessness of the sky, and the prevailing stillness of the atmosphere. The comparative absence of wind is the most character- istic peculiarity of the Davos climate, especially during the winter months, that is to say, during that portion of year when invalids chiefly resort thither. During the summer, the Davos Valley is decidedly subject to the local winds, which generally prevail in all places simi- larly situated, and which are known by the Germans as "Berg-" and " Thal-winde," or mountain and valley winds ; the heat of the sun is also said by Dr. Hermann Weber to be very disagreeably felt at that season, owing to the paucity of shade-trees in the neighborhood of the village, while the dust is also annoying. Its low tem perature in summer, and its great cold in winter, as well as the very considerable difference between the day and night temperatures, are features of climate which Davos shares with all the more elevated Alpine stations The mean annual temperature of Davos is about 36.5° F. The mean temperature of the tw7o warmest months of the year is only 54.5° F. (12° to 13° C.), according to Dr. Her- mann Weber, while that of the months from November to March inclusive, according to the same authority, is nearly always below the freezing-point. In January, the coldest of the winter months, Dr. Weber tells us that the average temperature is only -6° or -7° C. (21.2° to 19.4° F.). DANSVILLE. The village of Dansville, in Livingston County, N. Y., situated near the head or southern end of the Genesee Valley, has acquired some degree of reputa- tion during late years as a health station. The elevation of the town above sea-level is about one thousand feet, and the hills, which partially surround it, are said to be from six hundred to a thousand feet higher. Upon the eastern slope of the valley, and some two hundred feet above the village itself, a large sanatorium has been erected. The soil of this eastern slope is said to be " one immense gravel-bank," and the water-supply of the sana- torium is derived from springs. Owing to the partial shelter afforded by the surrounding hills, it is claimed that the climate of Dansville is somewhat milder than that of the surrounding region. No meteorological sta- tistics are as yet obtainable to substantiate this claim. H. R. DATES (Datte, Codex Med.), the fruit of the Date Palm, Phoenix dactylifera Linn., Order, Palmae. It is a fine large tree, indigenous to Africa and parts of Asia, but long cultivated in many varieties in the tropical parts of the old world. Like the Cocoa-nut palm, it supplies a multitude of needs to millions of people in the warmer parts of the world ; the young bud is eaten as a vegetable, the older leaves supply fibres for textile purposes, a sort of wine is made from its juice, the seeds are ground up for cattle or used as " coffee," and the fruits form an im- portant article of food. Dried, or preserved in sugar, they are exported to all parts of the world as a sweetmeat and dessert. The larger variety is the Alexandrian, the smaller the Barbary date. Composition, etc.-Glucose, fifty or sixty per cent.; gum, pectin, etc., ten per cent.; coumarin, a trace. Dates are simply an article of food and luxury, with no medic- inal qualities not common to other sweet fruits. Allied Plants.-Another species of Phmnix is one of the sources of Sago. For the order, see Areca Nut. Allied Drugs.-Figs, Prunes, Baisins, etc. W. P. Bolles. DAVOS (Davos am Platz, Davos Dorfli, and Wiesen). Of all the "high-altitude" health-stations of Europe not one has acquired so great a reputation during recent years as has the little hamlet of Davos Platz, lying in the valley of Davos, in the Canton des Grisons, Switzerland. Indeed, the student of climatotherapy of to-day cannot well think of the subject of " high-altitude " resorts with- out having the name of Davos at once presented to his mind, while for the strong advocate of stations of this class the village of Davos has become, as it were, the capital city of the world. Unquestionably, a good share of the great reputation acquired by this now famous Alpine station has been well deserved, although it is quite superfluous to add that its claims, like those of every other health-resort, have been not a little exagger- ated. According to Dr. H. C. Lombard, the attention of the medical profession was first called to Davos by the extremely favorable result obtained in his own case by Dr. Ungern, who, after seeking in vain a restoration to health at the Silesian mountain-resort of Gorbersdorf, betook himself, some twenty-five years ago, to Davos, and there experienced the relief from serious symptoms of pulmonary phthisis of which he was in search. The growth of Davos as a health-station can hardly be said to have begun, however, until about the year 1869. Thus 357 Davos. Davos, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. maximum sun and average maximum shade tempera- tures, a difference which is seen to be very great. The following table exhibits the mean temperatures of the months from October to March, as given by Dr. H. C. Lombard (" Traite de Climatologie Medicale," vol. iv\, p. 650), by Dr. J. Burney Yeo (" Climate and Health- resorts," p. 262), and by Dr. Kisch (in Eulenburg's " Real Encyclopadie," vol. iii., p. 702). Oct. Nov. Dec. Jan. Feb. Mar. Aver- age. Mean Max. Snn Temp. 133.07 106.12 109.08 108.30 111.36 122.32 115.04 Mean Max. Shade Temp. 60.40 36.63 39.00 36.07 34.55 36.46 40.51 Difference 72.67 69.49 70.08 72.23 76.81 85.86 74.53 Sun and Shade Temperatures at Davos (1876-77). Mean Temperatures at Davos During the Winter Season.* Authority. Oct. Nov. Dec. Jan. Feb. Mar. 36.01 26.67 21.3-1 17.36 25.68 25.79 J. B. YeoJ 27.68 21.02 18.14 24.62 Kisch + 27.86 22.10 18.50 23.90 25.7 The following table, which was kindly obtained for the writer, some three years ago, by M. Henri Pittier, may be of interest as showing the effect produced by increased altitude above sea-level upon the important climatic fac- tor of direct, or radiant, sun-heat. The figures of the table present, in parallel columns, the mean and maxi- mum sun-heat observed, by a black bulb thermometer in vacuo, at New York City and at Chateau d'Oex, Switz- erland, during ten months of the year 1880. The following table, showing the mean temperature of Davos, at the hour of 7 a.m., during the winter season 1883-84, is quoted from the little work by Dr. A. T. Tucker Wise, ' to which a reference has already been made. The figures were furnished to Dr. Wise by Pro- fessor Billwiller, director of the meteorological stations of Switzerland. Month. New York City, lat. 40°, 45', 58". Ele- vation above sea- level, 32 m. Chateau d'Oex, lat.. 46°, 28', 31" Ele- vation above sea- level, 1,000 m. Mean Sun Temp. Max. Sun Temp. Mean Sun Temp. Max. Sun Temp. March 88.0 124 107.8 124.3 April 108.1 125 109.6 128 1 May 124.5 147 113.9 136.0 June 129.6 141 122.9 141.1 July 131.9 142 128.7 145.6 August 130.6 144 123.8 137.5 September 126.2 151 114.1 134.4 October 112.2 135 90.0 124.5 November 84.3 108 75.0 100 9 December 67.2 95 76.8 102.0 Mean Daily Temperature, at 7 a.m. (Winter of 1883-84.) Nov. Dec. Jan. Feb. Mean for the whole winter. 25.34 20.66 20.30 17.78 21.38 The absolute maximum temperature of the year at Davos Platz is stated by Dr. Hermann Weber to be 75.2° F. (24° C.), while the absolute minimum temperature given by this author is -13° F. (-25° C.). Reference already has been made to the intensity of the direct or radiant heat of the sun at Davos. To this fea- ture of its climate is due a very large share of the popu- larity which the place has attained, and has deservedly attained, as a winter-resort. How great this intensity of the direct sun heat is, may be learned from the figures of the following table, which are quoted from Dr. Weber (" Ziemssen's Handbuch der Allgemeinen Therapie," vol. ii., p. 154). The upper line of the table, giving the mean of the maximum sun temperatures derived from daily observations during the winter of 1876-77, is quoted by Dr. Weber from Francis Redford ; the figures of the second line, viz., those showing the mean of the maxi- mum temperatures in the shade, Dr. Weber quotes from W. Steffen. The third line of the table (added by the present writer) gives the difference between the average Probably it is not alone the greater altitude above sea- level of Chateau d'Oex that causes this place to compare so very favorably with New York in point of direct sun- heat, despite the very considerable difference of latitude existing between the two places ; for the proximity of New York City to the Atlantic sea-coast, and the partial clouding of its atmosphere by the smoke and dust insepa- rable from any great city, are perhaps factors which op- erate to reduce somewhat the direct heating power of the sun's rays at the latter place. Certainly it has appeared to the writer, judging from his personal sensations, that the burning and the tanning effect of the sun's rays in New York City during the height of summer was decid- edly less than at less densely populated places lying far- ther away from the sea-coast. Dr. Yeo tells us (pp. cit., p. 262) that on January 31, 1881, a maximum of solar radiation was observed at Da- vos which amounted to no less than 153° F., while the maximum shade temperature on the same day was only 42.5° F. The difference (110.5° F.) between these two figures is very striking. The minimum shade tempera- ture on the same day was 18° F.* "The lowest shade temperature recorded during the winters 1879-80 and 1880-81 was 16.7 degrees Fahrenheit below zero, on December 9, 1879. The mean daily minimum for the same month was 5.5 Fahrenheit, and the mean daily maximum 23.13. The maximum sun temperature, 138 degrees Fahrenheit. This was during a month of the finest Davos winter weather ; the amount of aqueous vapor in the air being exceedingly small, and the read- ings of the hygrometer very low, as low as 3.0 degrees (!) on one day, and never over 38.5 degrees " (Dr. J. B. Yeo, loc. cit.). The exclamation mark introduced by Dr. Yeo in the passage above is doubtless well placed, and it appears to the present writer that both the figures for rela- tive humidity might well be queried ; for, despite the gen- eral testimony to the great subjective dryness of the Da- vos winter climate, and despite the low degree of absolute humidity which is known to characterize its atmosphere. * N. B.-The figures in this table are reduced to the Fahrenheit scale. In the works from which they are quoted, the Centigrade scale was used. From the abundant testimony offered by other statements made in the context of Dr. Kisch's article in Eulenburg's Encyclopaedia, and in Dr. J. Burney Yeo's account of Davos, it is perfectly evident to the present writer that a very serious typographical error exists in the tem- perature figures which have just been quoted from them, to wit, none other than the accidental omission of the minus sign which should pre- cede every one of these figures. This error he has taken the liberty of correcting in the table as presented above. That such a course is en- tirely justifiable can easily be proved, and to do this, the uncorrected table is herewith presented to the reader. Mean Temperatures at Davos during the Winter Season. Authority. Oct. Nov. Dec. Jan. Feb. Mar. Lombard 36.01 26.67 21.34 17.36 25.68 25.7!) J. B. Yeo 36.32 42.98 45.86 39.38 Kisch 36.14 41.9 45.5 40.1 38.3 This table bears the evidence of its incorrectness on its face. As an example of the manner in which its great inaccuracy is proved by the context both of Dr. Kisch's and of Dr. Yeo's accounts of Davos, it will suffice to quote the following remark made by the former author: " The winter temperature [at Davos]," says Dr. Kisch, "is on the average about 5° lower than that of the plain of North Germany" ("die Winter- temperatur ist durchschnittlich um 5° niedriger als die der nord- deutschen Ebene," op. cit., p. 702). Now. according to Dr. Kisch's uncorrected figures, the mean winter temperature of Davos is no less „ <5.5° C. x 7.5° C. x 4.5° C. \ than 41.9° F. g =5.5° C.J; and if to this fig- ure we add 5° C., or 9° F., we should get the absurdly high figure 50.9° F. (or 14.5° C.) as the mean winter temperature of Northern Germany. + Duration of period of observation not specified. t These figures are quoted by Dr. Yeo from A. W. Waters. The ob- ervations in this case extended over twelve years. Mr. Waters' figures sre probably for Davos Dortii. * Dr. Weber (on pp. 126 and 127 of the second volume of Ziemssen's Handbuch der Allgemein. Therap.) gives in detail the results of obser- vations both of the sun and shade temperatures at Davos Dorfli on De- cember 21, 22, and 23, 1873, and compares them with similar observa- tions made at Greenwich on the same days. 358 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Davos. Davos. the relative humidity figures which are generally given for Davos are by no means low. Thus the mean relative humidity of the year at Davos is 75.5, according to Dr. Julius Hann (" Handbuch der Klimatologie, p. 36), while Dr. Weber (quoting from W. Steffen) gives the fig- ure 75.2 as the relative humidity of the year 1876. In the winter season the percentage of relative humidity is greater than in the summer; thus, according to Dr. Kisch, the mean relative humidity for November is 84.2, for December 88.2, for January 86.2, for February 78.6, and for March 85.0. Taking an average of these figures, we should have the figure 84.4 to represent the mean re- lative humidity of the five coldest months of the year. For the entire year 1876, the mean relative humidity at 7 a.m. was 80.4, at 1 p.m 57.6, and at 9 p.m. 87.6. The great difference existing between the mid-day figure and the figures for morning and evening is very striking ; a comparison of these Davos figures with those showing the results of observations made at the New York State Observatory, in Central Park, brings out the fact that the difference just referred to is much greater at Davos than at New York City. The absolute humidity of the air at Davos is very slight, and W. Steffen, of Davos Platz, attributes to this climatic factor the physiological effects of what may be termed a subjective low atmospheric humidity. Dr. Julius Hann, in a passage occurring on pages 36 and 37 of his " Hand- book of Climatology " (to which passage a reference has already been made in the article on Climate), controverts this opinion, and claims that the low atmospheric press- ure at Davos (630 mm. = 24.8 inches) is also to be taken into account in explaining these phenomena of subjective dryness. The great stress which is laid upon absolute as compared with relative humidity both by W. Steffen, and by many other advocates of cold climate health-resorts, is based chiefly upon the great evaporative capacity of cold air having a low absolute humidity, when brought into con- tact with the pulmonary mucous membrane. Estimating the temperature of the expired air to be 37° C. (98.6C F.), Steffen claims that for purposes of comparison the rela- tive humidity of all health-resorts should be reduced to this uniform standard of temperature. Dr. Weber, who is disposed, and doubtless justly disposed, to place a high value upon the absolute humidity as a factor in the cli- matic treatment of lung diseases, nevertheless questions the propriety of estimating at so high a figure the temper- ature of the air expired from the lungs, when the tem- perature of the inspired air is very low, and he considers 30°-35° C. (86°-95° F.) as more accurately representing the temperature of the air which is expired under such circumstances. On page 154 of vol. ii. of Zieinssen's " Handbuch der allg. Therap.," Dr. Weber gives a table showing what would be the relative humidity at Davos, for each month of the year, if the mean temperature were assumed to be 37° C., the absolute humidity of the atmos- phere remaining unchanged. The figures of this table are given below, and in par- allel columns the present writer has inserted, for purposes of comparison, figures which show the relative humidity of New York City, derived in a similar manner from Col. A A and Col. K of his New York City chart (see article "Climate"), by the use of the humidity table printed on page 452 of ' ' Parkes's Practical Hygiene " (fifth English edition). Relative Humidity oe Davos for a Mean Temperature of 98.6° F., Compared with Relative Humidity of New York City for a Mean Temperature of 98° F. Davos. New York. Davos. New York. January.... 5.3 8.2* July 18.2 34.2 February ... 6.6 8.1* August 18.7 33.4* March 7.5 9.2 September.. 12.9 27 3* April 10.5 12.7 October 12.1 18 7* May 11.0 19.3 November 7 1 11 8* June 16.2 28.5 December... 6.8 8.5 N.B.-The showing of this table in the case of New York City is not altogether fair, as, in the absence of any table giving the absolute humid- ity at saturation for divisions of temperature of less than one degree Fahr- enheit, or for any temperature below 32° F., the mean monthly tempera- tures at New York have, in every instance except one, been assumed to be somewhat higher than those given in Col. AA of the U. S. Signal Service chart. The error resulting from this assumption is especially great in the case of the six months marked with an asterisk, but in no case does it add as much as 1. per cent, to the relative humidity figure. In the month of May this error does not exist. Being for the same rea- son unable to take 98.6° F. as his standard in making calculations, the writer has selected 98° F. instead of 99° F. From this cause also the rel- ative humidity figures for New York have been made a trifle too high in the case of each of the twelve months, including the month of May. The small percentage of cloudiness, and the large num- ber of cloudless days occurring throughout the course of the year, and chiefly during the winter season, are strong points in favor of the climate of Davos, when considered from a sanatory point of view. The total annual rainfall is about forty inches (37.4 inches in 1867, and 41.4 inches in 1876, Weber, op. cit., p. 154). During the year 1876, there were 159 days upon which rain or snow fell. The average percentage of cloudiness is stated by Weber to be 47. Lombard states that during the season from No- vember to March the number of clear days (beaux jours) at Davos is 67 ; the number of fine, or partly clear days (jours a moitie clairs) is 45 ; and the number of cloudy days (jours de mauvais temps) is 40. Out of a total num- ber of 181 days, during' the winter season of 1877-78, Dr. Kisch tells us that there were 76 fine clear days, while 52 were partly clear (mittelgut), and 53 were disagreeable (schlecht). A table for the year 1875-76, which divides the days after this same system of classification, is quoted by Dr. J. B. Yeo from Holsboer's " Die Landschaft Da- vos. " This table is given below. Clear and fine days. Moderately fine. Bad. November 12 3 15 December 19 10 2 January 14 12 5 February 12 11 16 March 10 9 12 Following this table, Dr. Yeo presents to his readers (op. cit., pp. 258-260) four others in which the days are somewhat differently classified, being divided into abso- lutely cloudless days, fine but not cloudless days (" in- cluding," says Dr. Yeo, "days that are described as ' glorious, a few white clouds ' "), cloudy days, and days of rain or snow ("days when snow or rain, however little, fell "). The data of these four tables are herewith presented, combined in a single table : Cloudless. Fine but not cloudless. Cloudy. Rain or snow. 879-80. 880-81. 883-84. 884-85. lverage of years. 879-80. 00 o co 00 883-84. 884-85. iverage of years. 8 ci So 5 8 00 1 iverage of years. 879-80. op I 3 884-85. iverage of years. r-< T"( October 18 6 11 1 9 4 2 6 8 5 3 15 14 22 13.5 6 8 5 10 7.2 November 5 10 11 16 10.5 4 6 5 4 4.7 7 9 14 10 10 14 5 4 7 7.5 December 14 8 13 7 10.5 6 7 2 7 5.5 6 6 16 17 11.2 5 10 11 9 8.5 January 15 10 12 20 14 2 7 9 3 2 5.2 5 10 16 9 10 4 2 11 3 5 February 8 7 10 8 8.2 7 7 5 1 5 8 6 14 19 11.7 6 8* 2 6 5.5 March 16 10 13 6 11.2 5 3 7 6 5.2 3 11 11 19 11 7 7 4 6 6 Total of each winter season 76 51 70 58 33 34 28 28 32 57 85 96 42 40 37 41 Monthly average of each winter season.. 12.6 8.5 11.6 $$ 5.5 5.6 4.6 4.6 5.3 9.5 14.1 16 7 6.6 6.1 6.8 * Snow fell on eight consecutive days. 359 Davos. Davos. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. Yeo calls especial attention to the large proportion of fine weather which was experienced at Davos in the winter of 1879-80, and also to the distribution of the rain- fall (and snowfall), and to the exceptionally large number of days of rain or snow occurring during the month of November. The following winter, that of 1880-81, was a bad one at Davos, and of this season Dr. Yeo remarks : ' ' Although there were fewer days (forty to forty-two) on which snow fell, the distribution of the snowfall was less advantageous. The heavy snowfall in November of the former winter was followed by a continuation of mag- nificent weather, whereas the small snowfall in November of this season was followed by frequent snowfalls in December and eight consecutive days on which snow fell in February." In a preceding passage (on page 256 of his book), Dr. Yeo had given the following succinct ac- count of the climatic characteristics of a good winter sea- son at Davos, and had made a reference to the prognostic significance of a heavy snowfall in November. "The winter snowfall in the Davos valley, as well as in the Engadine, usually begins early in November. An early and heavy snowfall of three or four feet is considered to promise a good winter. The snow continues to fall through November and a part of December. In the roadways it gets beaten down to a depth of three or four feet. In good seasons, tine settled weather, with absence of snowfall, sets in before the end of December. The atmosphere becomes still and calm, the air intensely cold and dry, and absolutely clear. At night the bril- liant starlight, or the cold silvery moonlight, streaming over the snow-mantled valley, gives it an aspect of singular beauty. The temperature at night often falls very low, frequently some degrees below zero. The days are cloudless, with an intensely blue sky, and an amount of heat from solar radiation which enables in- valids to pass hours sitting in the open air ; and the bril- liancy of the sunshine in widwinter makes umbrellas and sunshades necessary for protection. The instant, however, the sun is withdrawn the intense coldness of the air makes itself felt, and a fall of 50 or 60 degrees Fahren- heit is common immediately after sunset. Of course, all delicate invalids should be indoors before this hour. Owing, however, to the great dryness of the atmosphere and the absence of wind, the extreme cold at night is by no means so much felt as might be expected. ' There are no patients,' says one of the local physicians, ' who can- not, if they are so inclined, sleep with safety with an open window during the winter.' ' I was recommended,' says Mr. Symonds, ' to be in the open air from sunrise to sunset, to walk for two hours in the open air before going to bed, and to sleep with open windows. The invalid can take more liberties with open air at Davos than anywhere else.' " 'The winters of 1881-82 and 1882-83 are not described by Dr. Yeo, nor by any other author whom the writer has been able to consult; but the characteristics of every winter from 1878-79 to 1884-85, with the exception of these two (out of the seven), are given by Dr. Yeo ; and, judging from what he tells us respecting these five winter seasons, the rule for Davos would appear to be that a good winter follows a bad one and a bad winter a good one, alternately. This point, taken in connection with Dr. Yeo's remarks concerning the supposed prog- nostic value of an early and heavy snowfall, may be of service as an aid to the invalid in determining the ques- tion as to whether or not he shall undertake to pass a particular winter season at this place. Besides the more frequent occurrence of rainy, snowy, and cloudy days, the bad winter seasons (1878-79, 1880- 81, 1884-85) appear to have been further characterized by an unusual prevalence of wind, when compared with the good years (1879-80, 1883-84). The comparative windlessness of the Davos valley cannot be more emphatically shown than by Dr. Yeo's remarks, respecting the prevalence of wind during the bad (and relatively windy) season of 1880-81. J. E. Muddock, author of " Davos Platz as an Alpine Winter Station," who is quoted by Dr. Yeo {op. cit., p. 257), describes this season as follows : " Davos Platz proved as capricious and fickle as our own misty island. The snowfall did not set in until late, and then it was singularly light, while a high temperature and fogs and wind were the ride and not the exception. Those people who derived any benefit were in a very small minority, while the death-rate among the visitors rose to an alarming extent. " "Mist or fog," says Dr. Yeo (op. tit., p. 259), "'is men- tioned as occurring four times during this winter-once in October, once in November, and twice in March." And yet, with reference to the prevalence of wind in this very season he goes on to say, " ' No wind in the valley,' is stated of no less than one hundred and thirty-four days, and ' no upper current ' on forty-one days, and a strong wind is only mentioned on five days in the whole winter. It has already been said that this was a very unfavorable specimen of a Davos winter But perhaps the most remarkable and characteristic fact that comes out of this meteorological record, is the singular absence of wind in the valley. It is this peculiar stillness of the air that enables the invalid to support so well its comparatively low temperature ; so that he is not chilled and depressed by it, but, on the contrary, is braced and exhilarated." Another of the bad and windy winters is described by Dr. Yeo in the following passages quoted from pages 260 and 261 of his book, and the character of, and monthly distribution of, its winds, as compared with those of the preceding good season, are set forth in the two tables in- cluded in the quotation. " But when we examine and compare the weather of the last two winters, 1883-84 and 1884-85, we shall find that this absence of wind cannot always be relied upon. . , . . With regard to wind in 1883-84 : ' Strong breeze' or ' High wind.' ' Moderate breeze.' In October there were 4 days. 2 days. In November " 4 " In December " 2 days. 5 " In January " 3 5 " In February " 4 " In March " 1 day. 2 " 1884-85 : In October there were ... 10 days. 6 days. In November " 3 " In December " 5 days. 1 " In January " 2 " 2 " In February " 3 " 4 " In March " 2 " 13 " " This is a most instructive record, for it shows us that in this winter climate, one of the chief characteristics of which, under favorable conditions, is stillness of atmos- phere, there can be a considerable number of windy days. There were fifty-one windy days last winter as compared with thirty-two the winter before. One-fourth of the days in February were windy, one-half of those of March, and more than one-half of those of October ! " Dr. Yeo also calls attention to the fact that in this same bad winter ' ' there were more cloudy days than clear ones; " that snow or rain fell on twice as many days during the two months of February and March as during these same months of the preceding year ; that rain fell ' ' as early as the 17th of February, whereas, in the preceding winter no rain was noted before the 4th of April ; " that the mean temperature was nearly 2° C. (3.6° F.) warmer than the average, and that mist occurred twice during the month of March. A good share of the freedom from wind characteristic of the Davos winter climate is due to the shelter afforded by the, protecting mountain ridges which enclose the val- ley. As stated by Dr. Wise {op. cit., p. 9), these lofty chains afford, to that portion of the valley in which Davos Platz and Davos Dorfli are situated, an effectual shelter from north and west winds, and a rather less effectual protection against winds coming from the south and east. The direction of the valley exposes it to winds coming from the northeast and southwest, and a corre- spondent of Dr. Yeo's, writing to him from Davos on March 27, 1885, after alluding to the very bad season, goes on to remark that "Davos, which is usually sup- 360 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Davos. Davos. posed to be free from wind, has had a northeast gale blowing for a fortnight or more." * The local or valley winds, whose prevailing direction, at Davos is from northeast to southwest, cease, for the most part at least, to blow during the winter season. Dr. Frankland, quoted by Dr. Yeo, speaks of this phe- nomenon and of its causation as follows: "The sum- mer climate of Davos ... is cool and rather windy, but so soon as the Praettigau and surrounding moun- tains become thickly and, for the winter, permanently covered with snow, which usually happens in Novem- ber, a new set of conditions come into play, and the winter climate becomes exceedingly remarkable. The sky is as a rule cloudless, or nearly so ; and as the solar rays, though very powerful, are incompetent to melt the snow, they have very little effect upon the temperature of the valley or its enclosing mountains ; consequently there are no currents of heated air, and as the valley is well sheltered from more general atmospheric movements, an almost uniform calm prevails until the snow melts in spring." Bearing in mind the prevailing direction of the valley winds at Davos, and the relatively high tempera- ture and unusually early rainfall of the spring of 1885, it seems very probable that the northeast wind mentioned by Dr. Yeo's correspondent may have been a purely local, rather than a general, atmospheric movement. It should also be remembered that the month of March is commonly the snow-melting month at Davos. Dr. Kisch, however, tells us (Eulenburg, loc. cit.) that the northeast wind is one of the two winds which can sweep through the val- ley with least hindrance, but he characterizes this wind as one which for the most part brings good weather. The other of these two winds is the southwest "fohn," a very remarkable wind which appears to be sucked down from the upper layers of the atmosphere overlying the lofty ridge, or backbone, of the Alpine system, to fill the relative vacuum existing at those centres of low pressure which from time to time approach the west coast of Eu- rope on a line drawn between the Bay of Biscay and the Irish coast. A very interesting discussion of the "fohn" wind, its character, causation, and distribution, may be found in Dr. Hann's " Handbuch der Klimatologie," pp. 208- 218. A note from Mr. A. W. Waters's " Davos Dorfli," also describing this wind, is appended by Dr. Yeo to the chapter in his book describing the Davos valley, and Dr. Wise gives an account of the Alpine " fohn " on pages48, 49 of " The Alpine Winter Cure." The " fohn " at Davos is a warm, dry wind which exerts a very de- pressing effect upon most invalids ; after it has blown steadily for two or three days the temperature falls and rain or snow is precipitated. The frequency with which this wind occurs at Davos the writer has not been able to ascertain, but at Bludenz, some twenty miles north of Davos in the valley of the Ill (which runs from south- east to northwest), Dr. Hann found that the average num- ber of times that the "fohn" was recorded as occurring throughout the course of a year was not less than 31.9 times, about sixty-five per cent, of such visitations be- longing to the autumn and winter seasons, while but thirty-five per cent, occurred during the spring and sum- mer months. Unfortunately for the health-resorts situated in the Davos valley, the very mountain ranges which protect them from wind also shut out not a little of the in- tensely warm sunlight, which is so valuable a sanatory factor of their winter climate. In this respect both Davos Dorfli, and Wiesen appear to be rather more favored than Davos am Platz ; thus, Dr. Weber states that the duration of the daily period of possible sunlight at Dorfli is about half an hour longer than at Davos am Platz. On the other hand, Davos Dorfli is said by the same authority to be rather the more windy station of the two. Wiesen, on the other hand, while enjoying rather more sunlight than Davos Platz, is said (by Dr. Wise, op. cit.) to be better sheltered from the wind as well, and to have a slightly higher and more equable winter temperature and a winter season which is several weeks or a month shorter than the winter proper at Davos. The mean daily tem- perature at Wiesen during the months of November, December, January, and February in the winter season of 1883-84, was-3.3° C. (26.06° F.), as against-5.5° C. (22.1° F.) at Davos (Dr. Wise, op. cit., quoting from Pro- fessor Billwiller). The following figures, showing the number of hours of possible sunshine at Wiesen and at Davos am Platz, are also quoted from Dr. Wise : Number of Hours of Possible Sunshine during Winter. Wiesen. Davos. November 1 7% hours November 15 ** ** December 1 5* " 5k •* December 15 5V13 " 5V1» " January 1 5% " 5 January 15 5V« " 5X " February 1 7X " 6S " February 15 Th " 7% " There seems to be no difference in respect to sunlight between the two places until after January 1st ; but an average of their respective January and February figures gives 6.479 hours for Wiesen against 6.146 hours for Davos Platz, thus showing an average daily difference of 0.333 hour, or 20 minutes, in favor of Wiesen. Invalids generally do not do well in the Davos valley during the period of snow-melting in the spring, and are therefore recommended to leave Davos at this season and to betake themselves to less elevated stations from which the snow has already disappeared. In some cases they go to the Italian lakes, or to places lying along the shores of Lake Luzerne or Lake Leman ; but it is usually con- sidered better for them to break the descent to such far lower elevations, and to tarry awhile at some intermedi- ate point. Several stations of this latter class are speci- fied, and are briefly described by Dr. Yeo, such as Promontogno, Seewis in the Praettigau, and Glion above Montreux. Dr. Wise seems to think that Wiesen may be advantageously used in this way by patients leaving Davos Platz. " An early clearance of snow," says this writer, " makes Wiesen a desirable locality for a change from Davos toward the end of the season. During the worst time of snow-melting in Davos (which happens either in March or April, according to the mildness or severity of the season) Wiesen clears of snow rapidly; and there being no marshy valley below, like at Davos, when the snow melts any injurious consequences pro- ceeding from dampness and evaporation from marshy land are avoided." Concerning the existence of any greater tendency to snow-melting at Wiesen during the height of the winter season, Dr. Wise remarks that, de- spite the warmer temperature of Wiesen, nevertheless, " the periods of liability to actual snow-melting seldom take place with more frequency" at Wiesen than they do at Davos. To judge from his account of its situation and surroundings, the scenery at Wiesen must be rather more attractive than at Davos, and there seem to be more abundant forests of pine-trees in the immediate vicinity. A special point in favor of Wiesen, which is mentioned by Dr. Wise, is its considerable elevation (1,000 feet) above the river-bed, in contradistinction to the com- paratively low-lying position of Davos Platz ; which latter place, although somewhat more elevated than Wiesen above sea-level, is, nevertheless, less raised above the bottom of the valley. At Wiesen also, this writer tells us, " there is in fine weather no morning nor even- ing mist, and no smoke accumulates; " whereas at Davos " a perceptible mist generally covers the valley each morning ; this is soon dissipated by the sun, but the usual haze which is seen over villages and small towns is plainly apparent, and remains stagnant all day unless moved by wind. " The comparatively scanty population of Wiesen is also specified by Dr. Wise as a strong point in favor of this place. The "fohn " wind occurs with about equal frequency at Davos Platz and at Wiesen. Dr. Yeo speaks highly of the accommodations provided at the * "Notwithstanding the bad weather," Dr. Yeo tells us, "many cases that were spending their first season at Davos did well, but those who had passed one or more previous winters there suffered greatly from the bad weather." 361 Da VOS. Deaf-JI utes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. two hotels existing at Wiesen. The good drainage of at least one of these hotels is also alluded to in his book (" Climate and Health-resorts," p. 275). In this connec- tion it is most important to remark that, owing to its very rapid growth, Davos, during late years, has been charged with possessing two faults which are unpardonable in any health-resort, to wit, defective drainage and insuffi- cient ventilation of its hotels. The drainage system, Dr. Wise tells us (1884), "is undergoing alteration none too soon." The very favorable comments which have just been made on the advantages possessed by Wiesen as a winter health-resort are fully endorsed in an article from the pen of Dr. Jas. A. Sewell, published in the London Lancet (November 14, 1885). " Wiesen," says Dr. Sew- ell, " though in the same valley as Davos, and but a few miles distant from it and from St. Moritz, in the valley of the Inn, has climatic characteristics and qualities not possessed by either of these places, nor by any other high Alpine winter- or summer-resort at present available." In view of the detrimental effects produced at Davos by over-crowding, it is greatly to be hoped that the sani- tary authorities at Wiesen will take pains to insure that the drainage facilities and the house ventilation at that place shall keep pace with its growth in popularity. Moreover, if high-altitude health-stations continue to be so popular and so well thought of as they are at the pres- ent time, the establishment of a much larger number of really good resorts of this class will become a matter of the most imperative necessity. The soil of the Davos valley " is dry and thin, except- ing the central portion, which is of a peaty character " (Dr. Wise, op. cit.). The difference in this respect exist- ing between Davos and Wiesen has already been referred to (see the passage from Dr. Wise's book discussing the snow-melting season, which is quoted above). The water supplied at all the stations described in this article is said to be of excellent quality. We have now passed in review all the leading features of the Davos valley health-resorts, and have gone into considerable detail in describing the climate of these places. It remains to say a few words about the class of invalids who should be sent thither to pass all or a part of the winter season. All these stations being very typi- cal representatives of the class of ' ' high-altitude " health- resorts, the selection of cases likely to derive benefit from a sojourn at any of them may be fairly well determined by a careful perusal of such articles as are to be found in the pages of this Handbook under the titles ' ' Health- resorts," " Mountain-resorts," "Climatic Relations of Phthisis," etc., and may be still more accurately solved by an examination of such special treatises as have been referred to in the body of this article, and of such as are alluded to in the more general articles just mentioned. Persons either predisposed to, or actually suffering from, the earlier and less serious organic lesions of pulmonary phthisis are those who will be likely to derive most bene- fit from a visit to the Davos valley. The very feeble, and those far advanced in the active stage of consumption should, as a rule, avoid this region, The climate is also ill-suited to persons having a naturally irritable or ere- thitic temperament. Children are said to do extremely well at Davos ; but Dr. Wise {op. cit., p. 47) expresses a doubt whether in the case of very young children, i.e., those under three years of age, "sufficient exercise can be taken [at these high Alpine stations] to ward off the cold, . . . unless the child be swathed to such an ex- tent in furs and flannels as would impede the free motion of the limbs and thorax, so essential to development in childhood." The establishment at Davos of boarding- schools for boys and girls is alluded to by Dr. Lombard and by Dr. Weber.* This point is mentioned by the present writer as perhaps likely to interest some readers, although he has no information which will warrant him in expressing a judgment one way or the other concern- ing the excellence of these schools. The good results obtained from climatic treatment at Davos vary consider- ably in different seasons; accordingly the remarks con- cerning the good and bad winters, and the hint given in the course of this article as to the chances of determining in advance the probable character of a particular winter, are worthy of attention on the part of the reader. Huntington Richards. DAX is a city of eight to ten thousand inhabitants, in the department of Landes, situated on the Adour River, about twenty-eight miles from Bayonne. It lies in aval- ley, at an elevation of one hundred and twenty feet above the sea, and possesses a mild and dry climate, so that the waters can be taken throughout the whole year. There are seven principal springs in the place, the most impor- tant of which are the Fontaine Chaude, and the source de Bastion. The waters of all the springs are, however, of a nearly uniform composition. The Fontaine Chaude gives a large volume of water, estimated at nearly three hundred and ninety-seven thousand gallons in the twenty- four hours, which is received in an immense reservoir in the Central Square. The temperature of the water in this reservoir is from 140° to 160° F., and in cool weather vapor sometimes rises from it in such clouds as to envelop the entire city in a fog. The following is the analysis of the source de Bastion, as made by M. Hector Serres, and quoted by Rotureau in Dechambre's " Dictionnaire Encyclopedique." Each litre contains: Grammes. Calcium sulphate 0.35921 Magnesium sulphate 0.16893 Sodiu m sulphate 0.04306 Potassium sulphate trace Sodium chloride 0.30077 Calcium carbonate 0.09151 Magnesium carbonate 0.01558 Ferrous carbonate trace Manganese carbonate trace Calcium silicate 0.04318 Calcium phosphate, iodine, bromine, and organic matters trace Total solids 1.02224 The gases are nitrogen, hydrogen, and carbonic acid. There is a large and well-appointed thermal establish- ment at Dax, where patients can receive electricity and other therapeutic adjuncts to a course of the waters. Facilities are here afforded for water, mud, needle, douche, and vapor baths. The waters are also taken in- ternally. Dax is frequented by sufferers from rheumatism, neu- ralgia, hysteria, chorea, and other neuroses. It is useful in plethoric conditions, and in the treatment of local con- gestions. T. L. 8. DEAD FINGERS. In the year 1874* the writer called attention to a peculiar condition of the extremities, man- ifested by a local vascular spasm of one or more fingers, with limited and distinct blanching, and the sense of sub- jective cold. A few years later (1878) Dr. T. A. McBride published additional cases, and during the past ten years several other examples have been reported. These cases were curious in the fact that, without warn- ing or adequate cause, the lingers would lose their natu- ral color and become like those of a corpse. In the two cases I observed the right hand was affected once, and the left once, and in the latter the two outer fingers of the left hand became bloodless at first, and then the whole ulnar side of the hand. The temperature was lowered one or two degrees. Common sensibility was unimpaired and there w'as no loss of power. In a recent case the blanching was preceded by a dull pain and aching, such as would follow exposure to intense cold. Then the lit- tle finger (invariably) would become livid, and then per- fectly blanched. In two or three minutes the color would return quite slowly, and the pain disappear. This spasm * " Ein beachtenswerther Umstand in Davos ist die Griindung von Er- ziehungsanstalten fur Knaben (Geheimer Rath Perthes) und Miidchen " (Weber). " Cette grande affluence des 6trangers, an nombre desquels il y avait beaucoup de jeunes gens, a necessity la fondation d'un pensionnat, Ie Fridericianum, dirig6 par le Dr. Perthes, oil les inalades et les val^tudi- naires peuvent suivre leurs etudes pendant tout le temps de leur sejour a Davos" (Lombard). 362 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. DavoH. Deaf-Mutes. would occur several times in the day, or oftener, and was seemingly uninfluenced by changes in the weather. It was associated with migraine, and seemed to be more decided and frequent in its occurrence in proportion to the pa- tient's immunity from headaches. It resisted galvanism, and was only slightly helped by repeated doses of nitro- glycerine. Dr. Fox,2 in his recent work, calls attention to this dis- ease, and he is not certain whether to regard it as an angio-spasm or the reverse. He believes it to be a stage of the pathological process which, in some cases, ends in dry gangrene. Probably the acro-neurosis which results in nail exfoliation and cutaneous malnutrition belongs to this class of diseases. There is no doubt of its being an affection of the sympathetic system, and most probably an excessive local or reflex irritation of the vaso-motor fibres. The opposite condition of local congestion is un- doubtedly due to a paresis of the vaso-constrictor fibres. In this class we find great and sudden hyperaemia, sweat- ing, pain, etc., as well as the symptoms described by See- ligmiiller, and Sturge. Dr. Clymer,3 many years ago, presented the case of a patient who was able, by an effort of will, to produce cutaneous vascular changes which were connected with prsecordial sinking, etc. In some of the cases there is mitral stenosis. Allan McLane Hamilton. deaf. Those first established were called "asylums for the deaf and dumb ; " then, as soon as the nature of the work began to be understood, came "institutions for the education of the deaf and dumb ; " later, when the objections above mentioned to the word "dumb" were felt, " institutions for the education of deaf-mutes" were founded ; while those most recently established are en- titled simply "schools for the deaf." In the present article the words ' ' deaf " and ' ' deaf-mute " are usually employed synonymously. Some deaf-mutes are either born deaf, or, losing their hearing in early infancy from unobserved causes, are supposed to have been so born ; others become deaf from various diseases or from accidents. The deaf are thus di- vided into two great classes: the ' ' congenitally " and the " adventitiously" deaf, or, as they are often called, " con- genital deaf-mutes " and " adventitious deaf-mutes." Ex- cept where hearing is known to have existed, it is impossible to say positively to which of these classes a deaf-mute belongs (see Proportion of Congenital and Adventitious Cases, infra); the distinction nevertheless is an important one. Among the adventitiously deaf, a large proportion lose their hearing in early childhood, before they have learned articulate language ; in other cases, where some progress in speaking has been made, the length and severity of the disease that causes deafness, often temporarily affecting the brain at the same time, seems to efface the language previously acquired ; and in others the neglect of parents and friends to aid and encourage the deaf child in the ex- traordinary efforts necessary for the retention of speech after hearing is lost, produces the same result. Speech as well as hearing is gone, and the child as truly belongs to the class of " deaf-mutes " as if he had never heard. No doubt there is a difference in his mental condition- greater or less according to the age at which deafness oc- curred-from that of the congenital deaf-mutes. (See Men- tal Condition and Characteristics, infra.) But inasmuch as, before receiving special instruction, there is no apparent difference in any respect between persons of this class and congenital deaf-mutes, while the real difference is much less than that which separates them from the class to be described in the next paragraph, they may be desig- nated for educational purposes as ' ' quasi-congenital deaf- mutes" (Storrs, "American Annals of the Deaf and Dumb," 1883). Many persons have lost their hearing by accident or dis- ease, after having acquired the use of articulate speech, and retain this speech more or less perfectly notwithstanding their deafness. If the loss of hearing occurs in adult life, they usually escape the improper classification with deaf-mutes above referred to ; but if it happens in child- hood, so that they cannot be educated in the usual man- ner of hearing children, but must be sent to special schools for instruction, they are erroneously included among deaf-mutes. Many of the processes of deaf-mute instruc- tion are, it is true, equally applicable to persons of this class, and they may therefore properly be associated with deaf-mutes for the purpose of education ; but they differ from deaf-mutes essentially, not only in having the ability to express themselves orally, but still more in their natural mode of thought, which is in words and not in gestures. (See Mental Condition and Characteristics, infra.) This difference is fully recognized by all teachers of the deaf, who in this country distinguish the members of this class by the useful and convenient, though not accurately de- scriptive, title of "semi-mutes." The deaf may be further classified according to the degree of their deafness. Deafness varies all the way from a slight difficulty in hearing to the inability to per- ceive the loudest sounds. Persons in whom the defect is so slight as to allow of their education through the ear in ordinary schools, are not regarded as deaf-mutes, and do not come within the scope of the present article; they maybe designated as simply "hard'of hearing." The whole class of the deaf, aside from the hard of hearing, are divided into " the totally deaf" and " the semi-deaf." The totally deaf may belong either to the congenital or adventitious classes, and the same is true of the semi-deaf. 1 N. Y. Medical Journal, vol. xx., 1874, p. 356. 2 The Influence of the Sympathetic on Disease, p. 516. 3 N. Y. Med. Record, vol. v., p. 148. DEAF-MUTES. Definition and Classification.- The word "deaf-mutes" signifies, strictly speaking, per- sons who, having been born deaf or having lost their hear- ing in early life, have not acquired the power of speech. There is usually no defect in the vocal organs, except such imperfection of development as may be the result of lack of exercise ; muteness is simply the consequence of deafness. Ordinary children learn to speak by hearing and imitating the sounds made by others ; the deaf child does not hear such sounds, therefore does not imitate them, therefore remains mute. The term ' ' deaf-mutes " seems to have originated in the United States within the last fifty years. The synony- mous term generally employed in England, and still fre- quently used in this country, is " deaf and dumb." Of these two designations, "deaf-mute" is the preferable one ; for (1) the words "deaf and dumb" tend to perpet- uate the popular error that deafness and dumbness are two distinct physical defects, instead of standing, as above ex- plained, in the relation to each other of cause and effect; and (2) the word "dumb" is open to the further objec- tion that it carries with it an implication of stupidity and brutishness, being associated in the minds of many people ■with disparaging allusions to the lower animals, as in the scriptural expression "dumb dogs," and in Longfellow's reference to " dumb driven cattle." There are many persons usually spoken of as " deaf- mutes," or " deaf and dumb," and educated in institutions established for the instruction of this class, who are not properly described by either of these terms. Some of them, having lost their hearing by accident or disease, after they had learned articulate language, still retain their speech notwithstanding their deafness ; others, for- merly mute, have acquired the art of speech through the instruction of skilful teachers of articulation. Such per- sons are not really " dumb " or " mute," and their improper classification as such-especially in the case of those who have learned to speak before losing their hearing-gives rise to serious errors in the mind of the public concerning the nature of deaf-mute education and its results. The strictly correct designation for the whole class of persons under consideration in this article is " the deaf," a term which is coming more and more into use, and which will probably ere long supersede "deaf and dumb" alto- gether, leaving the word "deaf-mute" to be applied to persons deaf from birth or infancy, who have not ac- quired the use of articulate speech. The progress that has already been made in this direction is indicated by the corporate titles of our schools for the education of the 363 Deaf-ITIiites. Deaf-mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The semi-deaf are often semi-mute also, having acquired language before their hearing was lost, or possessing suf- ficient hearing to distinguish and learn words and sen- tences spoken in a loud voice or through a hearing-tube. In other cases of the semi-deaf, where no use whatever has been made at home of their slight degree of hear- ing-its very existence often being unknown to parents and friends-experience has shown, as will be explained more fully under the sub-title "Auricular Instruction," that this slight degree of hearing may often be educated and, apparently, by education developed, so that a con- siderable number of pupils who enter the institution as deaf-mutes may be graduated as merely hard of hear- ing. The term "mute" is often used as synonymous with deaf-mute, but it should be avoided as less exact, since it may also refer to persons who hear, but are not able to speak on account of feeble mental power or of some de- fect in the vocal organs. It is open to the further objec- tion that it suggests to many minds an undertaker's as- sistant at a funeral. Persons "mute" or "semi-mute," but not deaf, are, of course, not to be included among deaf-mutes, and are not suitable candidates for admission to schools for the deaf. If, as is usually the case, their deafness is due to defective mental power, they may properly be sent to a school for the feeble-minded, where the skilful efforts of devoted teachers often succeed in awakening the dormant intellect, imparting speech, and restoring the child to society. We have, then, as terms of definition and classification essential to a discussion of the subject, (1) the whole class of "the deaf," sometimes called "the deaf and dumb," "deaf-mutes," and "mutes ; " (2) the division of this class into, (a) " the congenitally deaf " and " the adventitiously deaf ; " (b) " deaf-mutes " and " semi-mutes ; " (c) " the to- tally deaf," " the semi-deaf," and "the hard of hearing." Some combinations of these terms often convenient, and other terms so self-explaining as not to need definition, are " congenital deaf-mutes " and " quasi-congenital deaf- mutes ; " " the congenitally semi-deaf" and " the adven- titiously semi-deaf ; " the speaking deaf " and " the semi- speaking deaf" (including semi-mutes and such deaf- mutes as have been taught articulation); ' ' the speaking semi-deaf" and "the mute semi-deaf;" "the hearing mute " and " the hearing semi-mute ; " the last two classes being usually persons of feeble mental power and not be- longing to the general class of the deaf (E. M. Gallaudet: International Review, 1881). Extent of Deaf-mutism.-For a large part of the world we have, of course, no statistics of deaf-mutism ; but during several decades most of the countries of Europe and North America have included such statistics in their census returns. The returns from different countries, and from different parts of the same country, show remarkable differences in the extent of deaf-mutism. These differences are doubtless due in part to the greater accuracy with which the census is taken in some places than in others ; but it is probable that climate, race, and modes of living have considerable influence. Mountain- ous regions give a larger proportion of deaf-mutes than low, level countries; the Caucasian than the African race ; Jews than Christians ; the poor and ignorant than the intelligent and well-to-do classes. Compare, for in- stance, in the following table the statistics of Switzerland with those of Belgium and the Netherlands ; the white with the colored population of the United States ; the Jews in Bavaria and Prussia with the Catholic and Protestant inhabitants of those countries. The table is compiled from Mayr (" Beitrage zur Statistik," etc., 1877), Hartmann (" Taubstummenheit," etc., 1880), and the Tenth Census of the United States, 1880. Of the United States Census returns it may be remarked that extraordinary pains were taken by Mr. F. H. Wines, the expert and special agent in charge of the statistics of the defective classes for this census, to secure accuracy and eliminate errors. In consequence, probably, of * their greater correctness, they show a larger proportion of deaf-mutes than any previous census of the United States. Date of census. Total population. Number of deaf- mutes. Number of deaf- mutes in each million of popu- lation. Austria 1869 20,394,980 19,701 966 Belgium.... 1858 4.529,560 1,989 439 France 1872 36,102,921 22,610 626 Germany 1871 39,862,133 38,489 966 Great Britain and Ireland 1871 31,845,379 19,237 604 Hungary 1870 15,417,327 20,699 1 343 Netherlands 1869 3'575,080 1,199 335 Norway 1865 1501'756 1,569 922 Spain 1860 15'658,531 10,905 696 Sweden 1870 4'168'525 4'266 1,023 Switzerland 1870 2,669 147 6.544 2,452 United States 1880 50,155583 33.878 675 United States : White 1880 43.402,970 30,661 706 United States: Colored 1880 6,580,793 3,177 483 Jews in Bavaria and Prussia 1871 1,652 Christians in Bavaria and Prussia.. 1871 949 The statistics of the twelve countries above named show an average of 920 deaf-mutes in every million of popu- lation, If we suppose the proportion to be the same for the entire population of the globe, the total number of deaf-mutes in the world is nearly 1,500,000. Proportion of Congenital and Adventitious Cases.-The deaf are divided into two principal classes -those who are supposed to have been born without hearing (the congenitally deaf), and those who could hear at birth and have become deaf afterward from disease or accident (the adventitiously deaf). The following are some of the fullest statistics that have been obtained on this subject : Total number of cases. Number of congenital cases. Number of adventitious cases. Congenital cases in 1,000. Adventitious cases in 1,000. Fifteen European countries... 5,171 3,465 1,706 670 330 United States Census, 1880.... 22,473 12,155 10,318 540 460 Twenty European schools... 1,455 (530 825 433 567 Seventeen American schools.. . 6,018 2,578 3,440 428 572 The results given in this table for European countries and those of the United States Census show an excess of congenital over adventitious cases ; while those compiled from the reports of European and American schools give an excess of adventitious over congenital cases. The statistics of European countries are compiled from Schmalz("UeberdieTaubstummen,"etc., 1848), and Hart- mann ("Taubstummenheit," etc., 1880), who do not indi- cate the sources from which they are derived ; those of European and American schools are compiled from the official reports of the principals of those schools, and are unquestionably more trustworthy than the census re- ports, inasmuch as the inquiries made by principals oh the admission of pupils are generally more intelligent and careful than those of the census-takers. We may con- clude then that, so far at least as the result can be deter- mined by the testimony of parents and friends under the questioning of competent investigators, adventitious cases of deafness arc more numerous than congenital cases. It may be remarked that the earlier reports of schools for the deaf give a much larger proportion of congenital cases than the later ones. Thus seven American schools, about the year 1850, report a total of 3,381 cases of pupils admitted up to that time, of whom 1,812, or 536 in a thousand, were congenital, and 1,569, or 464 in a thou- sand, were adventitious ; while of 272 pupils admitted into six schools in the year 1873, only 88 are recorded as congenital, the remaining 184 being adventitious. The statistics of the Western New York Institution, estab- lished at Rochester, N. Y., in 1876, contrast still more strongly with those of the older schools. Of the 241 pupils admitted since that time only 20 have been re- corded as congenital, the remaining 221 being adven- 364 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. titious. In Europe similar decrease in the proportion of congenital deaf-mutes, though in a less degree, is shown by comparing the cases reported by Hartmann in 1880 with those given by Schmalz in 1848. Of the 3,982 cases compiled by Schmalz, 2,810, or 705 in a thousand, were congenital, and 1,172, or 295 in a thousand, were adven- titious ; of the 2,644 given by Hartmann (including the twenty European schools cited above and the districts of Nassau, Cologne, and Magdeburg), 1,285, or 486 in a thousand, were congenital, and 1,359, or 514 in a thou- sand, were adventitious. This change is, perhaps, to be attributed to the increased prevalence during recent years, both in Europe and America, of some of the diseases often resulting in deafness, especially cerebro-spinal menin- gitis ; perhaps, also, to the greater skill of physicians in these later days in the treatment "of scarlet, typhoid, and other fevers, enabling them to save the lives of their pa- tients in more cases than formerly. The life is saved; but-often from the neglect of proper precautions against exposure after the physician's attendance has been dis- continued-the hearing is lost (Ackers: ' ' Deaf not Dumb," 1876). Although the statistics of congenital and adventitious deafness reported by the principals of schools for the deaf are more reliable than those of the census-takers, they are probably far from correct. Their only sources are the statements of parents and friends when they bring their deaf children to school; and, however willing parents and friends may be to state the facts correctly, in many cases it is not in their power to do so. Deafness is not usually discovered until the child arrives at the age when children generally begin to talk ; at that time it is impossible to say whether the deafness has existed from birth, or hearing has been lost at some time since birth. If the child has suffered from some unmistakable disease that is known to be a frequent cause of deafness, the case is recorded as adventitious ; it may possibly, however, have been congenital. If, on the other hand, no such disease is remembered, the case is recorded as congenital; but it is, perhaps, quite as likely that hearing has been lost in consequence of some unnoticed inflammation of the mucous membrane of the tympanic cavity or of the air-passages immediately after birth, or at some subse- quent period before the deafness was observed. Deaf- ness truly congenital is probably of much rarer occur- rence than is indicated by the most trustworthy statistics. Causes of Deaf-mutism.-The immediate cause of mutism, in the great majority of persons who do not speak, is simply deafness. (See Definition and Classifica- tion, supra.) Where this is not the case, as occasionally occurs in children improperly brought to schools for the deaf, there is usually some mental defect which has pre- vented the development of speech. Such mutism " is the result of the absence either of ideas, or of reflex ac- tion in the motor organs of speech. In the former case, imbeciles have nothing to say ; in the latter, they feel no desire to speak " (Griesinger : " Mental Pathology," etc., 1867). Very rarely, indeed, it happens that mutism is due to some defect or paralysis of the vocal organs that interferes with articulation. But as neither of these groups of "hearing mutes" belongs to the class of deaf- mutes, they do not come within the scope of the present topic. Since deafness is the immediate cause of mutism in all deaf-mutes, in order to ascertain the causes of deaf- mutism we must inquire into the causes of deafness. The causes of deafness may be divided into direct and indirect causes. The direct causes are the defects in the organ of hearing, whether congenital or adventitious, which prevent the perception of sound. The indirect causes are the circumstances of environment, disease, or accident, either ante-natal or post-natal, or both, accom- panying or preceding deafness in so large a number of cases as to give us reason to suppose that they have an important influence in producing those defects. The first class of causes, the manner in which they are pro- duced, and the manner in which they produce deafness, I do not venture to discuss; they are treated elsewhere in this Handbook by competent otologists. The indirect causes of which I shall speak are those that have been observed by teachers of the deaf, or gathered by them from the statements of the parents and friends of the children brought to them for instruction. In discussing this subject it has until recently been usual, setting out with the classification of deaf-mutes into congenital and adventitious cases, to ascribe all the former to ante-natal, and all the latter to post-natal, causes. This distinction cannot be maintained. There are probably both congenital and adventitious cases (though a much smaller number of the former than is generally supposed), and there are, doubtless, both ante- natal and post-natal causes ; but (see Proportion of Con- genital and Adventitious Cases, supra) it is impossible in any case of supposed congenital deaf-mutism to say certainly that it is not adventitious, while, as will appear below, there is reason to believe that ante-natal causes often combine with post-natal to produce adventitious deafness. Every case should be considered by itself ; just as careful inquiry should be made, on the one hand, concerning all possible ante-natal causes in cases known to be adventitious as in those supposed to be congenital, and, on the other, concerning all possible post-natal causes in cases supposed to be congenital as in those known to be adventitious. This has not usually been done ; when it is, we may expect to arrive at a much clearer understand- ing of the causes of deafness than has yet been reached. Heredity.-The first, and probably the most effective, indirect cause of deaf-mutism is heredity. This is some- times questioned, for the reason that deaf-mute parents do not, as a rule, have deaf-mute children; but, aside from the fact that the exceptions to this rule are of them- selves numerous enough to establish the principle of heredity, its existence is clearly proved by the large num- ber of deaf-mutes who are related to one another by blood. Out of 5,823 pupils admitted into six American schools up to the year 1877, 1,719, or 295 in a thousand, had one or more deaf-mute relatives (Bell: "Memoir upon the Formation of a Deaf Variety of the Human Race," 1884). Of 2,106 pupils admitted into the Hartford School up to the same year (included in the 5,823 cases just mentioned), 593 had one or more deaf-mute brothers and sisters; 271 had two or more ; 116, three or more; 51, four or more ; 15, five or more ; 11, six or more. Of these same 2,106 pupils, 693, or 329 in a thousand, had one or more deaf-mute relatives ; 374 had two or more ; 224, three or more ; 120, four or more ; 65, five or more ; 35, six or more ; 15, seven or more ; 9, eight or more ; 4, ten or more ; 3, fifteen or more. Probably many of these cases are counted more than once in these statistics, mak- ing the groups of related deaf-mutes much fewer than the total number of related deaf-mutes reported ; but they none the less forcibly illustrate the tendency of deaf-mut- ism to prevail in certain families-a tendency which can be explained only by the principle of heredity. There are some families in the United States that have become fa- mous in the annals of deaf-mutism for the large number of deaf-mutes they contain. Among these may be men- tioned the Brown family, of New Hampshire, having deaf-mutes in four consecutive generations, and number- ing at least thirty-four such cases ; the Hoagland family, of Kentucky, containing 21 deaf-mutes in three consecu- tive generations ; and a group of ten families residing in neighboring villages in Maine, not known certainly to be connected, but containing in all 105 deaf-mutes (Bell: " Memoir," etc.). Of the 5,823 cases above mentioned, 2,262 were re- corded as congenital, and of these 1,234, or 545 in a thou- sand, had deaf-mute relatives; 2,864 were adventitious, and of these 396, or 138 in a thousand, had deaf-mute relatives. The large proportion of cases supposed to be congenital, among those having deaf-mute relatives, indi- cates that the hereditary tendency to deafness, where it exists, is generally so strong as to produce the result- whether independently or in conjunction with some other indirect cause that is not observed-either before or soon after birth ; while the considerable number of known ad- ventitious cases having deaf-mute relatives shows that the inherited tendency not infrequently awaits the con- currence of some disease not hereditary in its character, 365 Deaf-Mutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or of accident, before manifesting itself. Striking in- stances of the combination of hereditary tendency with adventitious causes to produce deafness are offered in the cases of the Surber and Huston families of Iowa, re- ported by Talbot in the "American Annals of the Deaf and Dumb," 1870. The father of the Surber family is a deaf-mute, supposed to be congenital, and has several deaf- mute relatives. Of twelve children in this family, only one is supposed to have been born deaf, but four others lost their hearing in whole or in part from apparently adven- titious causes. The father of the Huston family, and all of his brothers, became deaf, or at least hard of hearing, early in life ; of the ten children three are recorded as having been born deaf, and two as having lost their hear- ing by disease. While the principle of heredity is thus clearly estab- lished as an indirect cause of deaf-mutism, it is a curious fact that, in a great majority of cases, the defect is not transmitted by deaf-mute parents to their children. Such transmission is so rare that many writers, especially those who first investigated the subject, have denied that it ever occurs ; and so late as the year 1881, the Commis- sioners of the Irish Census, in their Report of the Census of that year, say that, "as the result of the investiga- tions of the censuses of 1851, 1861, and 1871, it appears evident that the question of deafness and dumbness in the parents has no influence in propagating the defect." The inquiries of the Irish Census of 1871 were conducted under the immediate direction and supervision of the late Sir William Wilde, an eminent aural surgeon and statis- tician. He reported that there were in Ireland 115 in- stances of marriages in which one or both of the partners in marriage were congenitally deaf. In 81 instances one only of the partners was congenitally deaf ; from 67 such marriages 264 children were born, none of whom were deaf ; in the remaining 14 instances there was no issue. There were 4 instances of the marriage of a congenital with an adventitious deaf-mute, from 3 of which 7 chil- dren resulted, one of whom was a deaf-mute. There were 13 instances of the marriage of partners, both con- genitally deaf, and from 12 of these marriages 44 children resulted, of whom one was a deaf-mute, and one was deaf only. In 4 instances where one parent was congenitally deaf, the condition of the other parent and of the offspring could not be ascertained. Of the 315 children resulting from all the above-mentioned marriages, only two were deaf-mutes, and one was deaf only. Much similar testi- mony as to the rarity of deaf-mute children resulting from the marriage of deaf-mutes might be brought from other countries. In almost every instance, however, in which a large number of cases have been collated-as indeed in Ireland, notwithstanding the assertion of the Census Commissioners-the proportion of deaf-mute children has been found to be greater than in the community generally. The marriage of deaf-mutes, both with one another and with hearing persons, is far more common in the United States than in Europe. This country, therefore, affords the best field for investigating the results of such mar- riages, and a considerable body of statistics, though still very incomplete, has been collected by the principals of American schools for the deaf. They show, as do the Irish statistics above quoted, that many married deaf- mutes have no deaf-mute children, and that, with deaf parents as with hearing parents, hearing children are the rule, deaf children the exception; but they also show, especially when a large number of such cases are brought together, that the proportion of these exceptions with deaf- mute parents is far greater than with hearing parents. Thus, in 110 families in which one or both parents were deaf, formed by graduates of the Hartford school, there were 275 children, of whom 38 were deaf-a .pro- portion of deaf to hearing children many times greater than in the community at large (Turner: "Proceedings of the First Conference of Principals of American Insti- tutions for the Deaf and Dumb," 1868) ; and of 16,719 deaf-mute pupils admitted into thirty-three American schools upto the year 1883,207, or 12.4 in a thousand, had one or both parents deaf (Bell: " Memoir," etc.). While considerable allowance must be made in these last statistics for the fact that the deaf-mute children of deaf-mute parents are more likely to be sent to school than those of hearing parents, the proportion of such children to the whole num- ber of deaf-mutes still remains many times greater than the proportion of deaf-mutes to the whole population. Another curious fact shown by the statistics of deaf- mute marriages is that the proportion of deaf-mute chil- dren is greater when one of the parents is deaf and one is a hearing person, than when both parents are deaf. In 57 families formed by graduates of the Hartford School, in which one parent was deaf and the other a hearing person, there were 14 deaf children, or 24.6 deaf children for every 100 families; while in 239 families, in which both parents were deaf, there were 34 deaf children, be- ing only 14.2 deaf children for every 100 families (" Re- port of the American Asylum for the Deaf and Dumb." 1877). Dr. Bell's suggestion ("Memoir," etc.), that in many cases the hearing parent probably belonged to a family containing deaf-mutes, is doubtless the correct ex- planation of this phenomenon; since other statistics collated by him prove that an hereditary tendency to deafness, as indicated by the possession of deaf relatives, is a far more important element in determining the pro- duction of deaf offspring than deafness in one or both of the parents. Of 162 deaf-mutes married to hearing per- sons, 55 who had deaf-mute relatives had 15 deaf chil- dren ; while of the remaining 107, who had not deaf rela- tives, only one had a deaf child. One exception to the statement at the beginning of this paragraph should be noted : where both parents are recorded as congenitally deaf, the proportion of deaf offspring is greater than where one of the parents is a hearing person ; the strong hereditary tendency which produced deafness in both parents, before or soon after birth, being transmitted with intensified force to the children. Of the 110 families above mentioned as reported by Turner, 24 which had both parents congenitally deaf numbered 17 deaf to 40 hearing children, being at the rate of 70.9 deaf children to every 100 families. While the statistics of heredity are still too limited and incomplete to enable us to form positive conclusions, the following seem probable : 1. Persons who have deaf-mute relatives, whether themselves deaf-mute or hearing, marrying persons who have deaf-mute relatives, whether themselves deaf-mute or hearing, are likely to have deaf-mute children. 2. Persons deaf-mute from birth or from early infancy, marrying each other, especially if either partner has deaf- mute relatives, are likely to have deaf-mute children. 3. Persons adventitiously deaf and not having deaf- mute relatives, marrying each other, are not likely to have deaf-mute children. 4. Deaf-mutes, whether congenitally or adventitiously deaf, not having deaf-mute relatives, and marrying hear- ing persons who have not deaf-mute relatives, are not likely to have deaf-mute children. Consanguinity of Parents.-The consanguinity of par- ents is often assigned as a cause of deaf-mutism. The attention of teachers of the deaf was early called to the fact that a considerable number of their pupils were the children of parents related by blood, and for many years they have gathered statistics on this subject. The following table, compiled from the reports of four Amer- ican schools, gives the statistics of the pupils admitted up to the year 1877. 2 'So S'" <S ns 'c o . 03 o| o .2 eg o- o g - Parents first-cousins 45 63 48 49 Parents second-cousins 10 19 10 15 Parents third-cousins 7 11 7 8 Parents fourth-cousins 2 3 2 2 Parents uncle and niece 1 1 1 1 Parents not related 880 1,181 ! 932 925 Whole number of cases 1 945 1,278 ; 1,000 1,000 366 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-HI utes. Deaf-Mutes. While these statistics are less appalling than those pre- sented by Boudin (" Dangers des Unions Consanguines," etc., 1862), with respect to some French cities (the cor- rectness of which, however, has been denied), they are certainly striking, and seem at first glance to justify the assertion often made, that the consanguinity of parents is one of the most frequent causes of deaf-mutism as well as of idiocy, insanity, blindness, and other calamities. But they cannot be regarded as conclusive on this point until we discover the extent to which relatives marry each other. If the proportion of the deaf-mute children of consanguineous marriages to all deaf-mutes is greater than the proportion of consanguineous marriages to all marriages, such unions are doubtless a cause of deaf- mutism ; but, unfortunately, the proportion of consan- guineous marriages to all marriages has not yet been as- certained. The official statistics of marriages in Prussia, from 1875 to 1878, indicate a smaller proportion of consan- guineous marriages (viz., 0.8 per cent.) than the pro- portion of the deaf-mute offspring of such marriages usually is, but we have no statistics on the latter point for Prussia ; on the other hand, Mr. George H. Darwin's estimate of 2.2 per cent, for England, which was based on careful and ingenious calculations, though within nar- row limits, shows the two proportions to be about the same for that country. The larger proportion of deaf-mutes among Israelites than among Christians, and among mountaineers than dwellers in lowlands (see Extent of Deaf-mutism, su- pra), is sometimes attributed to the greater frequency of consanguineous marriages among Israelites and moun- taineers ; but other plausible explanations of the prev- alence of deafness among these classes are offered, and numerous instances are cited of communities in vari- ous parts of the world, where consanguineous marriages prevail to a great extent, and yet the children are more than ordinarily free from deaf-mutism and other de- fects. My own opinion is, that consanguineous marriage is not in itself a true cause of deaf-mutism, but that the numer- ous instances in which deaf-mutism follows such marri- ages are to be considered as casqs of heredity. If two persons marry, both of whom belong to a family in which an hereditary tendency to deafness exists, the tendency is transmitted to their offspring with increased intensity, and deaf-mutism in the offspring is the result; just as is the case in the marriage of two persons belonging to dif- ferent families in which such a tendency exists. As a general rule, investigators seeking the causes of deafness have accepted the kinship of the parents as a sufficient cause without pursuing the subject further; whereas further inquiry would probably have revealed other ade- quate causes in many instances, and an analysis of all the cases in connection with the possession of deaf-mute rela- tives would have demonstrated the existence of an hered- itary tendency to deafness on the part of many parents. Yet I should not advise relatives to marry, even where no hereditary tendency to deafness or othei' defect is known to exist; for, as Mr. Darwin forcibly suggests, no man knows with certainty, until toward the end of life, what ills may lie hidden in his edition of the family con- stitution. Maternal Impressions.-Fright or some other influence acting on the mind of the mother during pregnancy, is frequently assigned by parents or friends as a cause of deaf-mutism, and striking narratives, especially with re- spect to gesticulating deaf-mutes seen by the mother for the first time during that period, are related in support of the theory. Inasmuch, however, as further inquiry usually brings to light other causes which seem to be adequate, we need not accept this as a true cause. Scrofula.-So many deaf-mutes-from thirty to seventy- five per cent, in different schools-show traces of scrofula, that we are probably justified in supposing some connec- tion to exist between this disease and deaf-mutism. "Scrofula, as a predisposing cause of deafness, acts al- most always as a predisposing cause of inflammation in general, which inflammation being excited in the ear, produces changes resulting in deafness " (Dudley Peet: "American Annals," 1856). "The organ of hearing takes a prominent place among those organs of the body that are affected by the diseases caused by scrofula ; and not only do independent diseases of the ear occur more frequently in scrofulous individuals, but affec- tions of this organ caused by other diseases, as scarlet fever, measles, etc., take a more unfavorable course in such individuals" (Hartmann : " Taubstummenheit," etc.). The scrofulous diathesis manifests itself quite as frequently in cases of adventitious as of supposed con- genital deafness, confirming Hartmann's statement that its presence increases the likelihood that other dis- eases of an entirely different nature will result in deaf- ness. Social Circumstances. - Unfavorable social circum- stances, poverty, and ignorance may probably be classed among the indirect causes of deaf-mutism, since the pro- portion of deaf-mutes among these classes seems to be greater than in the whole community. This is a matter of common observation rather than of statistical record up to the present time, but it is confirmed by some sta- tistics recently published by the Pennsylvania Institution concerning its former pupils (" Report of the Special Committee to Collect Information," etc., 1884). Of the 344 families which sent to that school 364 children, con- cerning whom information was obtained, 283, or almost eighty-two per cent, of the parents, were simple day- laborers or mechanics, the largest number of them, in proportion to the whole population of the State, being miners of the Lehigh, Schuylkill, and Wyoming regions. It is certainly reasonable to suppose that negligence, damp and ill-ventilated dwellings, insufficient nourish- ment, the lack of proper medical treatment, and other evils springing from poverty and ignorance, may combine with more direct causes to produce deafness. Mountainous Regions.-The large percentage of deaf- mutes in Switzerland, as compared with all other coun- tries of which we have statistics (see Extent of Deaf- Mutism, supra), and of the more mountainous regions of Switzerland, Austria, France, Spain, and Germany, as compared with the lower and more level districts (45 in 10,000 in Berne, Lucerne, and Wallis, to 24.5 in the whole of Switzerland ; 30.6 in Salzburg, Steiermark, and Car- inthia, to 9.7 in all Austria ; 24.5 in the Alpine depart- ments of France to 6.26 in the whole country ; 10.4 in South Germany to 6.05 in North Germany) shows that there must be some influence in mountainous countries which, in some manner, tends to cause deaf-mutism. The opponents of consanguineous marriages charge the result to the kinship of the parents, who are said to be more likely to be related to each other than in the lowlands, on account of the scanty means of communication between different districts ; others, who attach much importance to social conditions, ascribe it to the poverty of mountain- ous regions, and the close, unhealthy houses in which the people live in winter ; others to the dampness and cold- ness of the climate. We must await a fuller knowledge of all the causes of deaf-mutism, and of all the circum- stances of mountaineers, before we can explain this phe- nomenon satisfactorily. Diseases and Accidents.-Turning to the causes which more unmistakably produce deafness after hearing is known to have existed, statistics show that it so often follows certain diseases and accidents as to leave no room for doubt that these diseases and accidents may be counted as true causes. The fullest statistics that we have on this subject are those of the United States Census of 1880 ; and though they were not collected by experts, yet as they correspond generally in their proportions with those recorded of the pupils in our schools, and as the returns were carefully reviewed and analyzed by competent au- thorities, we may consider them tolerably correct. The cause of deafness was assigned, with more or less definite- ness and probability, in 9,209 cases, of which 366 were referred to diseases of the ear, 8,250 to other diseases, and 593 to accidents ; 850 cases of disease and 128 of accidents were rejected in the compilation of the returns as too vague or improbable to be counted and classified. The 367 Deaf-lTIiites. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. list of causes accepted is as follows (Wines : " American Annals," 1884): that children of this class do learn language more easily and successfully, and adapt themselves more readily to the modes of thought of hearing persons, than those who are born deaf or lose their hearing soon after birth. When we remember how vivid are the impressions of childhood, how full a vocabulary, and how much fuller a comprehension of language as spoken by others, a bright child obtains during the first two or three years of his life, it is not strange if the mental condition of one who loses hearing when he has reached this age is essentially different from that of one who has never heard. The wonder is rather that, of the immense mental and linguis- tic acquisitions he has made through the sense of hearing, so little appears to remain. The uneducated deaf-mute who has never heard, or whose hearing has been lost in early infancy, has no knowledge whatever of the language of words. This lack of language is the key to his mental condition and characteristics. He has an intelligent mind ; he observes, reasons, and forms conclusions ; but his train of thought, being carried on by means of mental pictures and rude gestures, is imperfect and incomplete, while his reason- ing, being based upon his own limited range of observa- tion uncorrected by the superior wisdom and wider experience of others, is apt to lead him to erroneous con- clusions (E. M. Gallaudet: Internatzoal Review, 1875). Careful inquiries made of educated deaf-mutes with re- spect to their ideas before instruction have elicited the fact that, although-like young children in general-they usually accept the phenomena of nature as a matter of course, and do not trouble themselves concerning their origin, yet they do sometimes reflect on these subjects and frame for themselves various fanciful explanations of the means by which the more striking natural phenomena are produced ; as, for instance, that the wind is blown from a great bellows, that the rain is poured dowm through small holes in the sky, that snow is ground out like flour from a celestial mill, that thunder and lightning are the dis- charges of cannon, that the stars are candles or lamps lighted every evening, that death is caused by the medi- cine administered to the sick person, etc., etc. None seem to have arrived at the idea of the existence of the soul, nor of a God, nor of immortality ; and there are only two instances on record in which they have reflected at all upon the origin of the world and its inhabitants. One girl, who had reached the age of fifteen before com- ing to school, said that she " had tried to think about it, but could notshe " thought the people came from the South ; " and one very intelligent boy, at the age of nine years, having gained from his own observation an idea of the descent from parent to child, the propagation of ani- mals, and the production of plants from seeds, struggled long and earnestly with the question whence came the first man, the first animal, and the first plant; but, like many wiser men, without reaching any satisfactory conclusion. The deaf-mute very early invents a language of signs sufficient for the expression of the common wants of his every-day life, and if he has intelligent friends who are ready to aid his attempts at the exchange of ideas in this way, or if he associates with other deaf-mutes, this lan- guage will be extended and elaborated to a high degree. It becomes his usual mode of thought; and while he may, after long years of effort by his teachers and himself, learn to think more or less in spoken or written words, the language of signs always remains his easiest and most natural method not only of expression but of thought. The language of words written or spoken is for him something strange, foreign, artificial; he may master it as the hearing student masters a foreign tongue, so that he will think in it to some extent, use it with considerable freedom, and read it understandingly and profitably ; but, except in very rare cases of peculiar education and envi- ronment, the language of gesture is, and always remains, the vernacular of the deaf-mute. The language of words being a foreign language to the deaf-mute, he is liable, even after years of instruction, to make mistakes in its use. Such mistakes of course be- come less frequent as his education advances ; but the deaf-mute who has never heard, or has lost his hearing in Meningitis 2,856 Scarlet fever 2,695 Malarial and typhoid fevers . 571 Measles 448 Fevers, non-malarial 381 Catarrh and catarrhal fevers 324 Other inflammations of the air-passages 142 Falls 323 Abscesses 281 Whooping-cough 195 Nervous affections 170 Scrofula 131 Quinine 7S Blowsand contusions 74 Inflammations of the ear. 72 Diphtheria 70 Hydrocephalus 63 Teething 54 Mumps 51 Small-pox and variola 47 Erysipelas 36 Fright 32 Water in the ear 25 Sunstroke 21 Noises and concussions 21 Tumors 11 Chicken-pox 10 Struck by lightning 10 Foreign bodies in the ear.... 9 Salt rheum 3 Malformation of the ear 2 Syphilis 2 Consumption 1 Total 9,209 It will be noticed that meningitis, which in the census returns includes cerebro-spinal meningitis, pachymenin- gitis, convulsions, fits, etc., stands at the head of the list. The proportion of cases from this cause would probably be still further increased in a census of the deaf in the United States under thirty years of age, since epidemic cerebro-spinal meningitis has been the most frequent oc- casion of deafness in the pupils admitted into many of our schools during the past twenty years. The same is true of some parts of Europe, especially the northeastern provinces of Germany. Scarlet fever is second on the United States Census list, and either first or second on most of our school lists ; until the prevalence of cerebro- spinal meningitis it almost always ranked first in this country. In Europe typhoid fever seems to come next after cerebral affections and before scarlet fever (Hart- mann : " Taubstummenheit," etc.). Mental Condition and Characteristics.-With respect to mental condition and characteristics, the division of the deaf into several distinct classes, men- tioned at the beginning of this article, is of the greatest importance. Semi-mutes, who have acquired an idio- matic use of spoken language before hearing was lost, retain to a greater or less degree the modes of thought and mental characteristics of hearing persons. They think in words and express themselves easily and nat- urally in the language of their childhood. In the course of time, especially if they are not encouraged to use the voice in conversing with others, they may lose their mem- ory of sound and may cease to pronounce words men- tally ; but even then, if they have learned to read and write, words in their written or printed form will serve them as natural and convenient instruments of thought. Since semi-mutes, on account of their deafness, cannot, as a rule, be educated in common schools, and their num- ber in any community is usually too small to justify the establishment of special schools for them, they are edu- cated with deaf-mutes, many of the processes of instruc- tion beyond the elementary stage being equally applicable to both classes ; but the semi-mute always has a great ad- vantage over his deaf-mute classmate in his command of language. This distinction, though it is often explained by candid teachers, is not always understood by visitors to the school-room; and the public are thus sometimes misled as to the actual attainments of deaf-mutes. In mental vigor, and in the acquisition of general knowledge, the true deaf-mute, notwithstanding he is heavily handi- capped in respect to language, will not infrequently sur- pass the semi-mute ; but most of the cases of remarkable facility in composition and of great success in articulation that astonish the undiscriminating public at exhibitions be- long to the class of semi-mutes, as do also nearly all the deaf persons who have distinguished themselves in later life as authors and poets. Between the semi-mute and the congenital deaf-mute, but more closely allied with the latter than the former, stands the " quasi-congenital " deaf-mute. He retains no conscious memory of words ; he must acquire written language or vocal speech by the same laborious processes as if he had never heard ; in his attempts at composition he makes the same curious mistakes as the congenital deaf-mute ; and yet it is a fact often observed by teachers 368 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. early infancy, rarely, if ever, acquires such a mastery of language as to employ it in speech or writing with the same readiness and freedom as persons who learn to speak in childhood through the hearing. The peculiari- ties in his phraseology are sometimes called " deaf-mut- isms," and their origin has been ascribed by some writers to the inversions of the sign-language; but their main cause, like that of the blunders of foreigners, is merely an incomplete knowledge of the language of words. The " deaf-mutisms " most frequently observed in the school-room (Pettengill: " American Annals," 1878) are the transposition of letters, as " kinfe," " tryant ; " the in- version of words in compounds, as "general-major," "a looking-good man ; " the coining of new words in analogy with those already learned, as " longly " (from " shortly "), "youthhood the doubling of negatives, as " Nobody cannot gaze at the sun ; " the substitution of synonyms, as " a secret tutor ; " the use of possessive pronominal ad- jectives agreeing in gender with the noun following instead of the antecedent, as " My mother wrote a letter to his husband ; " the employment of unidiomatic though not ungrammatical phrases, as " He gave up his ghost," " Some martyrs were burned at the stakes ; " and the in- appropriate use of expressions in themselves correct, as " Abraham showed his piety by almost killing his son Isaac ; " " Men and women forget things, but God has an uncommonly good memory." The characteristics of an uneducated deaf-mute, es- pecially when in unfavorable social circumstances his natural language of signs has not been developed beyond its most rudimentary stage, are what might be expected. Cut off from communication with his kind, misinterpret- ing alike the order of nature and the actions of his fellow- men, he is apt to become melancholy, suspicious, treach- erous, and cruel. The neglect on the part of parents and friends which, from any motive whatever, allows thedeaf- mute child to grow up in this condition, when, as in the United States, the benefits of education are freely offered to all, is simply criminal. A wisely conducted education, giving the deaf-mute writing or speech as a means of communication, and im- parting just views of his relations to God and his fellow- men, tends to correct the defects above mentioned, and enables him to take his proper place in the world as an active and useful member of society. Almost the only peculiarity that distinguishes the educated deaf-mute in general from hearing persons, aside from the physical fact of deafness, and more or less constraint in the idio- matic use of language, is the tendency to ' ' clannishness " -the manifestation of a decided preference for the so- ciety of others like himself rather than of those who hear and speak. There are deaf-mutes of whom this is not true, but they must be regarded as exceptions to the gen- eral rule. This tendency is deplored by many of their best friends, since it leads them to regard themselves as a sep- arate class, to weaken the ties binding them to the rest of the community, which ought rather to be strengthened, and to result in their marriage with one another (E. M. Gallaudet: " American Annals," 1873). Some writers even condemn the present methods of instructing the deaf, on the ground that they foster this tendency (Bell: " Memoir," etc., 1884); but no one has yet proved that there is any practicable method of instruction yielding satisfactory results that will prevent its development. It should be added that the results of the disposition of the deaf to associate together are not wholly evil ; see " Religious Work for Adults," infra. Morbidity.-Since the scrofulous diathesis frequently exists in deaf-mutes, and since the maladies that cause deafness are in some cases the result of an imperfect physical constitution, and in others leave a previously sound constitution debilitated and impaired, we should expect to find the percentage of morbidity in persons of this class higher than among hearing persons. We have few records on this point except those of our schools, and the latter not in a statistical form ; but it is the general tes- timony of the heads of schools that their pupils, as a rule, enjoy excellent health-quite as good as the average health of hearing children. This is probably due to the regular habits, wholesome food, well-ventilated rooms, and out-of- door exercise afforded by institution life, which counteract any unfavorable constitutional tendencies that may exist. Thirty years ago consumption was regarded as a dis- ease to which deaf-mutes were peculiarly liable, since statistics collected by Porter and Peet in this country, Wilde in Ireland, and Muller in Germany, showed that a large proportion of deaths among them were due to this cause (H. P. Peet: " American Annals," 1834); but within recent years consumption has not been observed to be specially prevalent among deaf-mutes. It is sometimes asserted that the lungs of deaf-mutes are ill-developed on account of their lack of exercise in speech. But, aside from the fact that deaf children do generally use their voices considerably, making a great variety of sounds, the expansion of the lungs in respira- tion really suffices for their proper development (Hart- mann : "Taubstummenheit"). A careful examination of the lungs of the students of the National Deaf-Mute College at Washington, with a view to cautioning them against violent gymnastic exercises in case of pulmonary weakness, showed only one out of fifty with any tendency in that direction. The Census of the United States for 1880 gives a sur- prisingly large number of deaf-mutes who are defective in other respects, 245 being blind, 268 insane, 2,122 idi- otic, 30 blind and insane, and 217 blind and idiotic, mak- ing a total of 2,882 who are doubly or trebly afflicted (Wines : " American Annals," 1884). These returns seem to indicate that there exists some co-relation between the several defects of the senses, since persons having one of these defects appear to be more liable to the others than persons normally constituted, and doubly defective per- sons appear to be more liable to be otherwise defective than persons having a single defect (Bell: "Science," 1885). It is not safe to comment on these statistics in advance of the publication of the Census Report, which will doubtless give details throwing important light upon them. I will only venture to suggest that probably a considerable number of those reported as deaf-mute and blind have lost their sight and hearing from the same disease, and possibly some of them are deaf-mutes who have lost their sight in old age ; that many of those re- ported as deaf-mute and idiotic are not deaf, but are mute from mental incapacity; and that a majority of those reported as deaf-mute and insane are uneducated deaf- mutes, the social condition and environment of whom are often such as would naturally result in insanity. Mortality.-The reasons given above for expecting a higher rate of morbidity in deaf-mutes than in hearing persons, together with their greater liability to fatal acci- dents in the street, on the railway, etc., on account of their inability to hear warnings of danger, indicate the probability of a higher rate of mortality also ; but there are at present no comparative tables on a scale sufficiently extended to enable us to form a definite conclusion. An in- quiry made thirty years ago into the number of deaths of 650 pupils in four American schools during ten years showed a rate thirty-seven per cent, higher than in the gen- eral population (H. P. Peet : " American Annals," 1834) ; but two of these schools were in large cities, and their mor- tality was considerably greater than in schools more fa- vorably situated, while the total numbers and the limits of age were too small for generalization. Hartmann (" Taubstummenheit") compares the deaf-mutes of Prus- sia and Bavaria, numbering 4,247, with all the inhabi- tants of thirteen German states in quinquennial groups of ages from five to fifty years of age, and concludes that there is a somewhat greater mortality among the deaf- mutes than among the total population, but that the dif- ference is so slight that no conclusion can be drawn from it. It is to be hoped that the necessary statistics for de- termining this important question may soon be afforded, since at present some insurance companies refuse to ac- cept risks on the lives of deaf-mutes on any terms, in the belief that their expectation of life is considerably less than that of hearing persons. Marriage.-Since the education of deaf-mutes has be- come general, marriage among them has ceased to be 369 Deaf-Mutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Tare. In Germany, according to the Census of 1871, 6.3 per cent, of the male deaf-mutes and 3 per cent, of the female deaf-mutes were married (Mayr. " Beitrage zur Statistik," 1877). For other countries I have no com- plete statistics, but the records of the graduates of Ameri- can schools for the deaf indicate a much larger propor- tion of marriages than those given for Germany. Of 5,738 pupils admitted into live American schools up to the year 1882, 1,089, or nineteen per cent., have been married. As the total number of pupils here given includes the chil- dren in school at the date of the report, and some others not yet arrived at a marriageable age, the true percentage is considerably higher. Of 1,259 of those pupils who were born before 1840, 571, or 45.4 per cent., were mar- ried (Bell: " Memoir," etc.), and this rate is probably an approximation to the true percentage of married deaf- mutes in the United States. The larger proportion of marriages in the United States than in Germany is prob- ably to be explained by the more prosperous circum- stances of American deaf-mutes. Of the 1,089 former pupils above recorded as married, 856, or 78.6 per cent., married deaf-mutes. The objec- tion to marriages of this kind is the probability that un- der some circumstances the defect will be transmitted to the offspring. On the other hand it is to'be said in favor of such marriages, that, as a rule, they are more likely to be harmonious and congenial than when deaf-mutes are unequally yoked together with hearing persons. As the statistics already gathered show that under certain cir- cumstances the deaf may, and under others they cannot, marry one another without danger of transmitting the defect, we may reasonably hope that the time is not dis- tant when the conditions under which deafness is trans- mitted will be so well understood that, in many cases, the deaf may be advised to follow the choice, of their own hearts in this respect without any fear whatever of evil consequences ; while in other cases, where they ought not to marry persons similarly afflicted, or, possibly, not to marry at all, they may be warned more effectively than at present of the danger incurred. (See Heredity, supra.) Occupations.-Uneducated deaf-mutes can and do perform unskilled labor, but the competition here is so great, and they are at so much disadvantage in various ways as compared with hearing persons, that, though they are sometimes self-supporting, they are often moreor less a burden upon their friends or upon the community. With educated deaf-mutes the case is very different. In most of our American schools the importance of in- dustrial instruction is fully recognized and several hours of each day are devoted to this purpose. The occupa- tions taught are, for the boys, baking, basket-making, book-binding, broom-making, cabinet-making, carpentry, chair-making, coopery, farming, gardening, glazing, mat- tress-making, painting, printing, shoemaking, tailoring, and wood-turning; for the girls, cooking, domestic and ornamental sewing, both with and without the machine, dress-making, shirt-making, tailoring, and the folding and stitching of sheets for the book-binder. Instruction in clay-modelling, drawing, decorating, etc., enables some of both sexes to engage in various pursuits of industrial art and in pure art. In some instances the pupils are made thorough masters of their trades while at school, so that they immediately command remunerative positions upon graduating; and even in the greater number of cases where they merely acquire the principles of a trade, familiarity with the use of tools, dexterity, and hab- its of industry, they find it much easier to master the business afterward, or to learn some new trade, than would be possible if no attention had been paid to indus- trial education. The list of occupations pursued by educated deaf-mutes includes not only the industries above mentioned as taught at school, but almost every pursuit that does not require the actual use of hearing and speech. The great majority are engaged in various branches of skilled in- dustry ; some are artists, or workers in industrial art; while among the more intelligent and highly educated, especially those who have enjoyed the advantages of the College at Washington, are many government clerks. many teachers of the deaf, several clergymen preaching to the deaf, and several editors, publishers, merchants, inventors, chemists, and lawyers. Legal Rights and Responsibilities.-Under the Justinian Code, deaf-mutes who could not read and write were classed with the insane and idiotic, and had there- fore no legal rights nor responsibilities. A better com- prehension of their mental condition has led to consider- able modification of their legal status, so far at least as their rights are concerned. It has been decided repeat- edly, both in England and America, that an uneducated deaf-mute who possesses sufficient intelligence to express his ideas, wishes, and intentions by signs can make con- tracts, execute deeds, dispose of property by gift or by testament, and give evidence in court. The degree of in- telligence and facility of communication can usually be determined by the testimony of acquaintances or of ex- perienced teachers of the deaf (H. P. Peet : " Legal Rights and Responsibilities of the Deaf and Dumb," 1856). The uneducated but not unintelligent deaf-mute who commits crime against property-usually theft-is gener- ally and properly held responsible for the act; but in the case of serious crime against the person-as, for instance, homicide under the provocation of cruelty-his moral and legal responsibility is not so easy to determine. In such cases, which have been unhappily frequent in pro- portion to the number of this class of persons, judges and juries, especially in view of the death penalty, have naturally shrunk from the decision that the deaf-mute without any education was morally and legally responsi- ble, and he has either through an appeal by his counsel to the old law classing deaf-mutes with the insane and idiotic escaped trial altogether, or through the sympathy or the disagreement of the jury been acquitted (I. L. Peet: "Psychical Status and Criminal Responsibility of the Totally Uneducated Deaf and Dumb," 1872). Educated deaf-mutes who can communicate with others orally or by writing, occupy the same position before the law as hearing persons. It is creditable to the character of the present genera- tion of deaf-mutes in the United States, as peaceable and law-abiding citizens, that of the 33,806 returned by the enumerators of the Census of 1880, only four were found in jails or other prisons (Wines : " American Annals," 1884). Origin and Growth of Schools and Methods.-It was not until the latter half of the eighteenth century that the first schools for the deaf were established. Be- fore that period there were isolated cases of the education of individual deaf-mutes, beginning with the conferring of speech upon a deaf boy (supposed at the time to be miraculous) by St. John of Beverly, Archbishop of York, in the year 685, and becoming more and more numerous during the sixteenth and seventeenth centuries. Several teachers of private pupils in the seventeenth century, es- pecially Bonet in Spain, Wallis in England, and Amman in Holland, published descriptions of their methods which were afterward found valuable in the more general in- struction of the deaf. The first instruction of deaf-mutes in schools began about the year 1760, when nearly at the same time three schools were established independently of one another- in Paris by the Abbe De 1'^pee, in Dresden by Samuel Heinicke, and in Edinburgh by Thomas Braidwood. Heinicke's school a few years later was removed to Leip- sic. Of these three teachers, De 1'Epee is justly the most renowned, on account of the benevolence and disinterest- edness of his character. While Heinicke and Braidwood received only the children of rich parents and kept their processes of instruction as secret as possible, De 1'Epee devoted his life and his fortune to the education of the poor, and published his methods widely, in the hope that they might be made useful to deaf-mutes elsewhere. As the successful results of the instruction given in these schools became known, others were established in other cities and countries. The first school in America was founded in Hartford, Conn., in the year 1817, by the Rev. Thomas Hopkins Gallaudet, LL.D., a young man of high education and culture, deeply religious spirit, and lively sympathy with the class to whose welfare he de- 370 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes.; voted his life. As it was supposed at that time that one school would suffice for the needs of the whole country, it received the name of the American Asylum. There are at present sixty-one such schools in the United States. The Abbe De 1'Epee, though he gave some attention to articulation teaching, depended chiefly upon an ingenious sign-language devised by himself as his means of in- struction, and is thus regarded as the founder of the "manual," sometimes called the "French," method of teaching. (For definitions of the manual and other meth- ods, see the article entitled " The Sign-Language and the Combined Method of Instruction "). Under his successor, the Abbe Sicard, articulation teaching was abandoned, and the manual method was pursued exclusively in the Paris and other French schools. As new schools were established in other countries, the manual method was adopted almost everywhere, except in Germany. Heinicke and Braidwood, while not neglecting other branches of education, devoted themselves chiefly to teaching their pupils to speak and read the speech of others, and so were the founders of the ' ' oral " or " Ger- man " method. In Great Britain the brilliant results achieved in France by De 1'Epee and Sicard, which were regarded as superior to Braidwood's, led to the adoption of the manual method, or of a combination of the manual and oral methods, in the schools afterward established. Even in Germany the ideas of De 1'Epee and Sicard had considerable influence, leading to the development of a sign-language and the introduction of French methods to some extent. Within recent years, however, the ten- dency in Germany has been to return to the pure oral method, and this method has made great progress in other countries also, even in France supplanting the manual method to a considerable degree. At an International Convention of instructors held at Milan, Italy, in 1880, nearly all the teachers present, except those from the United States, voted in its favor, and since that date a majority of the European schools have adopted it in practice. In others a combination of the manual and oral methods is preferred. When the first school in the United States was opened at Hartford, Dr. T. H. Gallaudet introduced the manual method, which he had learned from Sicard in Paris. This method, developed and improved by able teachers in America, prevailed almost exclusively in this country until the year 1867, when two oral schools were estab- lished-one in New York and one in Massachusetts. In the same year Dr. E. M. Gallaudet, President of the National Deaf-Mute College at Washington, D. C., a son of the founder of deaf-mute instruction in America, spent six months in visiting European schools, and on his re- turn presented a report in which, while he maintained the soundness of the principles upon which the system of in- struction pursued in America was based, he strongly urged the importance and value of speech and speech- reading to the deaf, and recommended that all pupils should be afforded opportunities of acquiring these ac- complishments until it plainly appeared that success was unlikely to crown their efforts; while with those who evinced facility in oral exercises the instruction should be continued during their entire school life. At a con- ference of Principals of American Schools, held in Wash- ington in 1868, after a full and free discussion, President Gallaudet's views were almost unanimously adopted. Since that time most of our schools, while still using the sign-language and the manual alphabet, have made speech and speech-reading in various ways a part of the course of instruction for a part at least of their pupils, thus seeking to combine the advantages of both the oral and manual methods. The pure oral method is followed in a few schools and the pure manual in a few others ; but the combined method in some form prevails in a large major- ity of the schools in the United States and other English- speaking countries. (For a fuller description of the com- bined and oral methods and their advantages, respectively, see the articles bearing those titles.) On the Continent of Europe schools for the deaf are chiefly supported by tuition fees and the voluntary con- tributions of the benevolent, often in connection with re- ligious societies, aided to a large extent by state, provin- cial, and city governments. In Great Britain they are almost wholly dependent upon tuition fees and voluntary contributions. In tile United States they are generally supported by the State governments, and education in them is free to all children who are too deaf to receive in- struction in the common schools. The following tables, compiled from information ob- tained from foreign governments through the courtesy of the Department of State at Washington, and from direct correspondence, show the number of schools for the deaf in the several countries of the world, the numbers of pupils and teachers, and the methods of instruction prevailing in each country. For English-speaking coun- tries further statistics are given with respect to each school. Country. Australia a .2 S o 5 o o rt q 1879 1879 1879 1879 1884 1880 1882 1881 1882 1885 1880 1880 1882 1882 1880 1882 1882 1881 1882 1881 1881 1878 1884 2Sco | No. 01 institutions. No. Total. 147 1,147 864 32 747 326 3,482 5,608 2,650 1391 65 29 30 4G5 22 283 ' 8 584 222 <180 380 7,485 of Pup Male. 82 656 482 32 380 150 1^042 1,413 815 37 15 23 256 13 155 7 363 125 421 182 4,329 LS. Female. 65 454 382 '.367 170 908 1,237 '676 28 14 209 9 128 1 221 97 259 198 3,156 tc s £ aS O 4-> O 6 11 64 13 87 41 '580 244 '237 7 3 7 40 2 34 1 59 16 76 39 508 Manual. Methods of I Oral. NSTRUCTION. Combined. Not reported. ... 1 No. of institu- «•»•«•••• 44- • 00- rfxMM- • • M | tionS. cc 'a a 0 6 £ 14 32 142 254 558 65 30 122 lii 457 ... I No. of teach- CO • • 0 • •• • -O • • tU • • or to • •• IC ers> . . . .«»«»■• m. 1 No. of institu- Ct- • ox-3- | tions. 'a p a 0 6 % 1^147 339 '150 1.962 5,608 496 1,405 "29 '465 22 224 '2i7 68 380 641 ce cn O & 6 64 "23 580 56 '227 "3 "46 2 23 "26 "ib 39 67 o;,. w. . . . I No. of institu- -• a-w- hi os- -»• -j. o<. . | tjons. 1 "cc* co to to ' • • • • • • 'co- 00' o<' • No. of pupils. Op • to IO • Ot CO • UT • -1 • kU • IO • • Oi • ^tCO<' 0 O' o- »-*• -Q« OX' • : : : : : : : >_l: : : : : : : I No. of teach- 0 • co to • *-4 • 0 • • • 00 • • • • prR | . . . 1 No. of institu- h. -j. ■ h coh. i-i- ■ is | tions. a •a 5 0 6 133 "32 "34 395 '240 'in I . . to >4 I No. of teach- • co- w • <® | ers. Austria-Hungary Belgium Brazil Canada Denmark France Germany. Great Britain and Ireland India Italy Japan Luxembourg Mexico Netherlands New Zealand Norway Portugal Russia Spain Sweden Switzerland United States Total 404 26,750 10,978* 8,592* 2,059 33 1,753 146 238 13,173 1,160 97 10,949 38 1,019 63 * The reports from France and Prussia do not indicate the sex of the pupils. 371 Deaf-Mutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. THE UNITED STATES.-1885. A.-Public Schools. Name. Location. Date of open- ing. Chief Executive Officer. 1 American Asylum for the Deaf and Dumb Hartford, Conn .. 1817 Job Williams M A Principal 2 New York Institution for the Instruction of the Deaf and Dumb... Washington Heights, New 1R18 J Isaac Lewis Peet, LL.D., Principal ; York, N. Y.... 1 C. N. Brainerd, Superintendent. 3 Pennsylvania Institution for the Deaf and Dumb Philadelphia, Pa 1820 A. L. E. Crouter, Principal 4 Kentucky Institution for Deaf-mutes Danville, Ky 1823 W. K. Argo, A. B. Superintendent 5 Ohio Institution for the Education of the Deaf and Dumb Columbus, O 1829 Amasa Pratt, M.A., Superintendent. 6 Virginia Institution for the Education of the Deaf and Dumb and the Blind Staunton, Va 1839 Thomas S. Doyle Principal 7 Indiana Institution for the Education of the Deaf and Dumb Indianapolis, Ind 1844 Eli Baker, Superintendent. 8 Tennessee School for the Deaf and Dumb Knoxville, Tenn 1845 Thomas L. Moses, Principal. 9 North Carolina Institution for the Deaf and Dumb and the Blind .. Raleigh, N. C 1844 W. J. Young, M.A., Principal. 10 Illinois Institution for the Education of the Deaf and Dumb Jacksonville, Ill 1846 J Philip G. Gillett, LL.D., Superinten- 11 Georgia Institution for the Deaf and Dumb Cave Spring, Ga... 1846 | dent. W. O. Connor, Principal. 12 South Carolina Institution for Education of the Deaf and Dumb and the Blind Cedar Spring S. C 1849 Newton F. Walker, Superintendent 13 Missouri Institution for Education of the Deaf and Dumb Fulton, Mo 1851 Wm. D. Kerr. M.A., Superintendent 14 Louisiana Institution for the Deaf and Dumb Baton Rouge, La 1852 J John Jastremski, M.D., Superinten- 15 Wisconsin School for the Deaf Delavan, Wis.. 1852 | dent. John W. Swiler, M A , Superintendent 16 Michigan Institution for the Education of the Deaf and Dumb Flint, Mich 1854 M. T. Gass, M. A., Superintendent. 17 Iowa Institution for the Education of the Deaf and Dumb Council Bluffs, la 1855 Henry C. Hammond, M.A., Sup't 18 Mississippi Institution for the Education of the Deaf and Dumb.... Jackson, Miss 1856 J. R. Dobyns, Superintendent. 19 Texas Deaf and Dumb Asylum Austin, Tex 1856 Rev. Wm. Shapard, Superintendent. 20 Columbia Institution for the Deaf and Dumb Kendall Green, near Wash- ington, D. C 1857 E. M. Gallaudet, Ph.D., LL.D., Pres't. 21 Alabama Institution for the Deaf and Dumb Talladega, Ala 1860 Joseph H. Johnson, M.D. Principal 22 California Institution for the Deaf and Dumb and the Blind Berkeley, Cal 1860 Warring Wilkinson, M.A , Principal. 23 Kansas Institution for the Education of the Deaf and Dumb Olathe, Kan 1861 S. T. Walker, Superintendent. 24 Le Couteulx St. Mary's Institution for Deaf-mutes Buffalo (Z), N. Y 1862 Sister Mary Ann Burke, Principal. 25 Minnesota School for the Deaf Faribault, Minn .., 1863 Jonathan L. Noyes, M A. Sup't. 26 Institution for the Improved Instruction of Deaf-mutes New York (a), N. Y 1867 D. Greenberger, Principal. 27 Clarke Institution for Deaf-mutes Northampton. Mass 1867 Miss Harriet B. Rogers Principal 28 Arkansas Deaf-mute Institute Little Rock, Ark 1868 F. D. Clarke, M.A., Principal. 29 Maryland School for Deaf and Dumb Frederick City, Md .. 1868 Chas. W. Ely, M.A , Principal 30 Nebraska Institute for the Deaf and Dumb Omaha, Neb 1869 John A. Gillespie, M.A , Principal. 31 Horace Mann School for the Deaf Boston (&), Mass 1869 Miss Sarah Fuller, Principal. 32 St. Joseph's Institute for the Improved Instruction of Deaf-mutes (/). Fordham, N. Y 1869 Ernestine Nardin, President. 33 West Virginia Institution for the Deaf and Dumb and Blind Romney, W. Va 1870 John C. Covell, M.A., Principal. 34 Oregon School for Deaf-mutes Salem, Oregon 1870 Rev. P. S. Knight, Principal 35 Maryland School for the Colored Blind and Deaf-mutes Baltimore (c), Md 1872 F. D. Morrison, M.A., Superintendent. 36 Colorado Institute for Mute and Blind Colorado Springs, Col... 1874 D. C. Dudley, M.A., Principal. 37 Chicago Deaf-mute Day-schools (h) Chicago, Ill... 1875 P. A. Emery. M. A., Principal. 38 Central New York Institution for Deaf mutes Rome, N. Y 1875 Edward B. Nelson. B.A., Principal. 39 Cincinnati Day school for Deaf-mutes Cincinnati (e), O 1875 A. F. Wood, Principal. 40 Western Pennsylvania Institution for the Deaf and Dumb Edgewood, near Wilkins- burg, Pa 1876 Rev. J. G. Brown, D.D., Principal. 41 Western New York Institution for Deaf-mutes Rochester, N. Y 1876 Z. F. Westervelt, Principal and Sup't. 42 Portland School for the Deaf Portland, Me 1876 Miss Ellen L. Barton, Principal. 43 Rhode Island School for the Deaf Providence (d), R. I 1877 Miss Anna M. Black, Principal. 44 St. Louis Day-school for Deaf-mutes St. Louis (g), Mo 1R78 D. A. Simpson, B AT, Principal 45 New England Industrial School for Deaf-mutes Beverly, Mass 1880 Miss Nellie H. Swett, Principal. 4* Dakota School for Deaf-mutes Sioux Falls, D. T 18RQ James Simpson. Superintendent. 47 Milwaukee Day-school for the Deaf Milwaukee (i), Wis 1883 Paul Binner Principal. 48 Pennsylvania Oral School for Deaf-mutes Scranton, Pa 1883 Miss Emma Garrett, Principal. 49 New Jersey School for Deaf-mutes Chambersburg, near Tren- ton, N. J 1883 Weston Jenkins, M.A., Superintendent. 50 Deseret School for Deaf-mutes Salt Lake City, Utah 1884 Harry White, B.A., Principal. 51 Northern New York Institution for Deaf-mutes Malone, N. Y 1884 Henry C. Rider, Superintendent.* 52 Florida Institute for Deaf-mutes St. Augustine, Fla 1884 Park Terrell, Superintendent. 53 Public Schools. 9 Denominational and Private Schools (k). 62 Schools in the United States. 53 National Deaf-mute College (j) Kendall Green, near Wash- ington, D. C 1864 E. M. Gallaudet, Ph.D., LL.D., Pres't. (a) Lexington Avenue, between Sixty-seventh and Sixty-eighth Streets. (6) No. 63 Warrenton Street. (c) No. 258 Saratoga Street. (d) Corner Fountain and Beverly Streets. (e) Ninth Street, between Walnut and Main. (/) This Institution has three branches ; one situated at Fordham, another at Brooklyn (510 Henry Street), and another at Throgg's Neck, West- chester County, N. Y. (a) Corner Ninth and Wash Streets. (A) There are five schools in different parts of the city. Mr. Emery's address is 43 May Street. (i) Corner Seventh and Prairie Streets. (J) The National Deaf-mute College is a distinct organization within the Columbia Institution. (A ) See page 375. (I) No. 125 Edward Street. 372 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. VeaMfiites, Deaf-Mutes. THE UNITED STATES.-1885-Continued. A.-Public Schools-Continued. Name. | Total. D 'S No. of Pupils iring the Year.* Age of « Deafness. 8 i-7~ £ a.s|b.|c. No. taught articula- tion. I Present Decem- | ber 1, 1884. Whole No. ] „ Male. | § p OF TOE J *3 1 3 8 M 5 15 4 9 23 1 1 I 5 9 2 4 • 4 7 11 4 12 '• 9 0 1 1 J 1 5 1 5 3 2 2 1 2 • 5 Deaf-mute. J " ? Semi-mute. 1 -+ Method of instruc- tion. School-hours. Trades. || 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 •31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 .50 51 .52 American Asylum New York Institution Pennsylvania Institution... Kentucky Institution Ohio Institution Virginia Institution Indiana Institution... Tennessee School North Carolina Ins't (e).... Illinois Institution Georgia Institution South Carolina Institution. Missouri Institution Louisiana Institution (e).. Wisconsin School Michigan Institution Iowa Institution (e) Mississippi Institution Texas Asylum Columbia Institution (/).. Alabama Institution California Institution Kansas Institution Le Couteulx St. Mary's Ins't Minnesota School Inst'n for Improved Instr'n Clarke Institution Arkansas Institute Maryland School Nebraska Institute Horace Mann School St. Joseph's Institute West Virginia Institution.. Oregon School Md. Institution for Colored Colorado Institute Chicago Day-schools (e) ... Central N. Y. Institution.. Cincinnati Day-school Western Penna. Institution Western New York Inst'n.. Portland Day-school Rhode Island School St. Louis Day-school N. E. Industrial School.... Dakota School.. Milwaukee School Pennsylvania Oral School.. New Jersey Institution.... Deseret School 211 419 466 152 476 97 374 153 114 580 103 59 248 43 242 310 290 88 129 65 53 135 191 160 148 184 111 73 112 129 92 262 75 29 20 43 57 166 36 124 175 45 29 46 20 33 25 20 110 126 270 258 87 260 51 203 97 66 344 59 30 149 25 152 173 170 46 79 47 29 82 104 85 82 105 55 40 56 81 45 119 13 13 21 23 105 23 87 91 25 12 31 11 23 13 13 62 85 149 208 65 216 46 171 56 48 236 44 29 99 18 90 137 120 42 50 18 24 53 87 75 66 79 56 33 56 48 47 143 30 16 7 22 34 61 13 37 84 20 17 15 9 10 12 7 48 158 218 212 116 78 74 450 78 39 125 140 99 ,.26 107 90 86 98 97 65 55 81 67 57 58 16 46 32 59 74 38 15 28 18 76 34 69 91 22 12 10 • - <6 81 11 17 16 71 42 18 M 26 15 12 6 19 13 6 0 36 63 3 6 6 : 10 19 82 64 14 7 6 62 13 20 41 33 11 23 12 3(1 32 32 43 20 14 19 21 16 4 7 4 15 38 4 1 "2 24 45 (a) 143 17 100 49 45 15 150 10 11 70 48 41 25 25 43 0 35 32 90 33 184 111 23 71 27 92 262 0 0 12 0 17 140 45 29 9 0 25 20 31 176 369 426 130 394 81 311 115 104 502 77 49 207 38 207 263 260 68 120 58 55 127 172 150 127 166 92 73 95 98 79 246 60 25 19 37 57 148 31 120 155 41 27 40 20 30 25 10 97 IS 16 34 11 26 18 10 14 16 19 6 10 6 5 9 11 11 10 15 13 6 10 8 9 20 5 3 2 4 6 12 » 8 3 3 2 2 3 2 7 8 10 6 11 8 9 4 7 8 5 4 6 2 6 7 10 4 6 4 3 5 4 0 6 3 0 2 4 3 0 2 4 ? 3 2 8 1 3 13 0 0 1 0 1 0 2 1 3 2 1 2 3 2 3 8 2 3 1 1 3 2 2 2 3 2 3 3 3 1 2 3 0 1 3 1 0 1 1 1 1 0 1 3 2 0 1 0 0 1 1 1 0 c 0 2 4 3 2 6 2 7 i 3 0 ? 1 3 3 1 (1 1 0 0 2 0 3 0 0 1 1 1 0 1 2 0 0 ? ? 0 0 2 0 Combined. Combined. Oral and Combined. Combined. Combined. Combined. Combined. Combined. Combined. Combined. Manual.. Combined. Combined. Combined. Combined. Combined. Combined. Combined. Combined. Combined. Manual. .. Combined. Combined. Combined. Combined. Oral Oral Combined. Combined. Combined and aural. Oral Combined and Oral.. Manual... Manual... Combined. Combined. Manual.. Combined. Manual... Combined. Combined. Oral Oral Manual... Combined. Manual... Oral Oral Combined. 9 to 12 and 2 to 4 8 to 12 and 1 to 5 (b)... 8 to UX and 1 to 3.... 8 to 1. .. SX to 10X, 1«X to 12X, 2 to 4 (c). 8X to 1% 8 to 1 SX to 11X and 1 to 3.. 8 to 2 8 to 11 and 12, 1 to 3 and 4X- 8 to 1 8 to 1 8 to 1.. 8 to 1 8 to 12 and IX to 3X- • 8% tollmans! 1 to4 (&). 8 to 12X... 8 to 1 8X to IX 8X to 12X and 2 to 3.. 8 to 1 8 to 1 9 to 12 and IX to 3.... 8 to 12 and 1 to 4 (6)... 8 to 12X 9 to 12 and IX to 3X.. 9 to 12 and 2 to 4 8 to 12X 7X to 9X, 9X to 12X, 2 to 4X (c) 8X to 12 and IX to3.. 9 to 2 9 to 3X 8X to IX 9 to 12 and IX to 3. .. 6 hours 8X to 1 9 to 12 and 1 to 3 9 to 12 and IX to 3X-. 9 to 12 and IX to 4.... 9 to 12 and 1 to 3X. 8X to 12X and 2 to 4.. 9 to 12 and 2 to 4 9 to 1 8% to 12 and IX to 3X ■ 9 to 12 and 2 to 4 9 to 12 and 2 to 4..... 9 to 12 and 12X to 2X • 9 to IX 9 to 12 and IX to 3 Ji.. Cab., Sh., Ta. Art, Bak., Cab., Cl., Dr., Ga., Pa.,Pr., Sh., Ta. Dr., Knitting, Sh., Ta. Bo., Car., Ga., Pr., Se. Bo., Car., Pr., Sh. Bo., Cab., Car., Pa., Pr., Sh. Cab., Ch., Sh. Pr., Sh. Cooking. Sh., Se. Bak., Cab., Ga., Pr., Sh., Wt. Sh. Pr., Se., Sh. Cab., Pr., Sh. Car., Pr., Ga. Ba., Car., Pr., Se., Sh. Car., Pr., Se , Sh. Br., Cab., Fa., Pr., Sh. Car., Dr,, Pr., Sh. Bo., Dr., Pr., Sh. Cab. Ch., Ma., Sh. Pr., Wood-working. Cab., Pr., Se.. Sh. Dr., Pr., Sh., Ta. Co.,Dr., Pr.,Se., Sh., Ta. None. Cab., Sc. Pr., Dr., Ga., Sh. Cab., Pr., Sh. Car., Pr., Se. None. Ba., Dr., Sh., Car.. Ta. Cab., Pr., Sh., Ta. None, Br., Ch. Car., Dr., Pr. None. Car., Dr.,Gl., Pr., Se.,Sh. None. None. Car., Dr., Fa., Ga., Pr. None. None. None. Fa., Se. Fa. None. None. None. Northern New York Inst'n. Florida Institute 25 22 3 17 5 3 4 25 3 3 ° 0 1 Combined. 9 to 12 and IX to 3X-. None. Cab., Pr., Sh. Public Schools 53 9 7331 4236 154 93 3095 3038 61 77 902 773 1953 88 6084 144 490 216 274 Rd 69 . .. Denom'J and Pri. Sch'ls (d) 17 15 18 8 10 0 0 86 62 Schools in the United States 7485 4329 3156 3115 919 788 (£7)2041 6228 508 224 284 69 53 National College 54 54 0 0 8 39 0 41 9 0 1 2 8 to 12X and IX to 3X None. * Including those who have left school during the year. + Including the principal. t Not including the semi-mute. § A.-Number of pupils born deaf, or who lost hearing before two years of age. B. = Number who lost hearing between two and four years of age. C. -Number who lost hearing after four years of age. (a) All the pupils are taught lip-reading for one hour daily. (6) One session for school and one for shops, by a system of rotation, (c) Two sessions for school and one for shops, by a system of rotation, (d) See page 375. (e) for the year 1883. (/) Not including the students of the National College, (g) Not including the pupils of the New York Institution. || Bak. = Baking. Bas. = Basket-making. Bo.= Book-binding. Br. = Broom-making. Cab. = Cabinet-making. Car. = Carpentry. Ch. = Chair- making. Cl. = Clay modelling. Co. = Coopery. Dr. ' Dress-making. Fa. = Farming. Ga. = Gardening. GL = Glazing. Ma. - Mattress-making. Pa. - Painting. Pr.=Printing. Se. -Sewing. Sh. = Shoemaking. Ta. = Tailoring. Wt. = Wood-turning. 373 Deaf-Mutes. Deaf-Mutes. Reference handbook of the medical sciences. THE UNITED STATES.-1885- Continued. A.-Public Schools-Continued. Name. Vacation. How supported. Value of buildings and grounds. Expenditures last fiscal year. | No. vols. in library. Total no. pupils have received instruction. For support. For build'gs and grounds. Last Wed. in June to second Wed. in Septem- ber Endowment andN. E. States. $250,000 $47,802 $3,750 2,000 2,359 2 Thurs. after fourth Wed. in June to Thurs. State, counties, and pay pu- after first Wed. in September pils 554,500 102,687 6,645 3,197 3.030 Last Wed. in June to first Wed. in September. State and pay pupils 550,000 95,606 9,016 5,300 2,113 4 Kentucky Institution Last Thurs. in June to about 15th September. State 136,000 27,850 1,500 842 5 Ohio Institution Third Wed. in June to second Wed. in Sep- tember State 700,000 78,120 7,500 2,000 2,062 G Virginia Institution* Second Wed. in June to first Wed. in Septem- ber State 175,000 33,272 500 554 7 Indiana Institution Last Wed. in June to Wed. after 15th Septem- ber State 457,700 53,321 2,185 3,292 1,552 8 Tennessee School Second Wed. in June to third Fri. in Septem- ber State 100,000 21,389 2,787 9 North Carolina Institution *. Second Wed. in June to third Wed. in Septem ber State 75,000 10 Illinois Institution Second Wed. in June to third Wed. in Septem- ber State 355,800 87,993 11,000 6,455 1,742 11 Georgia Institution Third Wed. in June to second Wed. in Septem- ber State 40,000 16,000 1,200 362 12 South Carolina Institution * Last Wed. in June to first Wed. in October.. State and pay pupils 40,000 10,921 4,697 197 13 Missouri Institution Second Wed. in June to second Wed. in Sep- tember State 175,000 35,000 3,300 1,015 867 14 Louisiana Institution .... State 25,000 15 Wisconsin School ... June 9th to first Wed. in September State 87,000 40,000 1,500 600 693 16 Michigan Institution Wed. after June 15th to second Wed. in Sep- tember State 470.123 45,000 33,000 2,374 1,010 17 Iowa Institution State 171,669 657 18 Mississippi Institution July 1st to October 1st State 75,000 16,000 5,000 500 19 Texas Asylum June 1st to September 1st State 100,000 29,940 65,796 450 265 20 Columbia Institution t Wed. before last Wed. in June to Thurs. before last Thurs. in September United States and pay pupils. 660.000 60,610 3,000 3,000 522 21 Alabama Institution ... June 15th to September 15th State 75.000 16.000 1,000 500 200 22 California Institution * Second Wed. in June to last Wed. in August. State 350,000 44,010 <780 1,100 23 Kansas Institution Second Wed. in June to second Wed. in Sep- tember State 100,000 28,830 28,165 525 394 24 Le Couteulx St. Mary's Inst.. July 1st to September 1st State, counties, and pay pu- pils 90,000 30,000 5,000 600 £60 25 Minnesota School June 10th to second Wed. in September State 200^000 29,569 2'518 1,120 338 26 N. Y. Inst, for Imp'v'd Ins'n. Third Wed. in June to first Wed. in September State, counties, and pay pu- pils 300,000 30,497 4,911 329 27 Clarke Institution Forty weeks after third Wed. in September Endowment, State, and pay to third Wed. in September pupils 90,000 26,694 1,174 1.035 237 28 Arkansas Institute Thurs. after last Wed. in June to first Wed. in October State 50,000 13,269 20,000 221 Third Wed. in June to second Wed. in Septem- ber State 250.000 25,070 1,274 2,150 290 Middle of June to middle of September State 66,000 21.000 800 211 31 Horace Mann School Last Tues, in June to first Mon. in September. State and city 127 224 32 St. Joseph's Institute Last Fri. in June to first Mon. in September.. State and counties 196.175 61,554 14,887 333 33 West Virginia Institution *.. Forty weeks after first Mon. in September to first Mon. in September State 80.000 23,030 696 210 34 Oregon School.... May 1st to September 1st State 5,000 <181 3,429 75 35 Md. Institution for Colored * Last Wed in June to second Wed.in September State 25,000 7,633 2,547 44 SK Colorado Tnstitnhe * Second Wed. in June to second Wed. in Sept.. State 53^000 20,000 275 77 37 Chicago Day-schools Last Fri. in June to first Mon. in September.. State 130 38 Central N. Y Institution Second Wed. in June to September 1st State and counties 65,000 60,128 12,445 225 250 39 Cincinnati Day-school June 19th to September 7th City 86 40 Western Pennsylvania Inst'n. Last Wed. in June to first Wed. in September State and voluntary contribu- tions 139,500 20,550 101,468 41 Western New York Inst'n .. . Third Mon. in June to Mon. after first Wed. in September State and counties 40,000 39,650 600 241 42 Portland Day-school Last Fri. in June to second Mon. in September City and pay pupils 49 43 Rhode Island School June 25th to first Mon. in September State 2,800 311 50 44 St. Louis Day-school Second Thurs. in June to first Mon. in Sept. . City 76 45 N. E. Industrial School . Last Wed. in June to second Wed. in Sept.... Voluntary contributions 9,700 2,788 150 225 32 46 Dakota School Second Wed. in June to second Wed. in Sept. Territory 23,000 3,140 12,500 38 47 Milwaukee School July 3d to 1st Mond, in September State aid ;. 2,000 25 48 Penna. Oral School Third week in June to September 1st City and voluntary contribu- tions 21 49 New Jersey Institution State 100,000 150 111 501 Deseret School Territory - 51 Northern New York Tnst'n Second Wed. in June to second Wed. in Sept. State and counties 25 59 Plnrida Tnstitnte State 17,000 53 Public Schools 23,984 8 Denominational and Private Schools 362 61 Schools in the United States 24.346 53 National College Wed. before last Wed. in June to Thurs. be - fore last Thurs. in September Columbia Institution 2,500 227 * Contains a department for the blind also, the expenses of which are included in the statement of expenditures, t The expenses of the National Deaf-mute College are included in the statement of expenditures. 374 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes, Deaf-Mutes, THE UNITED STATES.-1885- Continued. Name. Location. । Date of open- | ing- Chief executive officer. 1 Whipple's Home School for Deaf-mutes Mystic River, Conn 1869 N. F. Whipple, Principal. 2 German Evangelical Lutheran Institution for the Deaf and Dumb Norris, Mich 1875 D. H. Uhlig, Director. 3 St. John's Catholic Deaf-mute Institute St. Francis, Wis 1876 F. Knapp, Principal. 4 Mr. Knapp's Institute Baltimore, Md 1877 5 St. Joseph's Deaf-mute Institute Hannibal, Mo 1881 Sister Agatha, Superintendent. 6 Mr. Bell's Private School for Deaf Children Washington, D. C. (a) 1883 A. Graham Bell, Ph.D., Principal. 7 Chicago Voice and Hearing School for the Deaf Englewood, Ill 1883 Miss Mary Me Cowen, Principal. 8 Private School for Teaching Deaf Children to Speak Philadelphia (d), Pa Tacoma, W. T 1885 Miss Mary S. Garrett, Principal. 9 Washington School for Defective Youth 1885 Rev. W. D. McFarland, Director. B.-Denominational and Private Schools. Name. No. of Pupils. No. of In- structors. t Method of in- struction. School-hours. Trades. During the year.* | Present Decem- ber 1, 1884. Total. | Male. | Female. Age of deafness No. taught articula tion. Whole No. Male. Female. Deaf-mute. J Semi-mute. Vv PQ . O 1 2 3 4 5 6 8 9 Whipple's Home School 12 German Evangelical Lutheran Institution 40 9 27 27 3 13 18 11 28 0 8 1 4 12 40 2^ 2 8 40 44 5 15 8 9 2 3 3 3 (6)2 ! 2 1 3 2 'o 1 0 0 1 1 0 1 3 1 3 1 1 0 o 0 b 0 0 0 0 0 0 0 0 0 0 (1 0 Oral 9 to 12 and 1 to 4X. 5'4 hours Gardening. None. Fa., Printing, Sewing, Shoe-making. None. None. None. None. None. None. Oral St. John's Catholic Institute.... Mr. Knapp's Institute 45 Combined ... Oral Eight hours 9 to 2 St. Joseph's Institute Mr. Bell's School Voice and Hearing School Philadelphia School Washington School 21 5 20 8 9 7 14 8 4 14 2 6 0 6 11 4 14 0 1 3 1 5 Combined ... Ex'pm'l (c) .. Oral & aural. Oral 9 to 12 and 1 to 4... 9 to 2 9 to 4 9 to 2 Combined.... 8 to 1 9 154 61 77 17|15 88 144 18 8 10 0 Name. Vacation. How supported. No. Pupils have received instr'n. 1 Whipple's Home School Last Wed. in June to first Wed. in September.. Tuition fees and State 63 2 German Ev. Lutheran Institution.. July 15th to September 1st Tuition fees and Lutheran congregations. 110 3 St. John's Catholic Institute End of June to first week in September Voluntary contributions and tuition fees. 153 4 Mr. Knapp's Institute 5 St. Joseph's Institute June 21st to September 1st Voluntary contributions 6 Mr. Bell's School Middle of June to October 1st Tuition fees and Mr. Bell 7 Voice and Hearing School Private funds and tub ion fees 20 8 Philadelphia School June 15th to September 15th Tuition fees and subscriptions 8 9 Washington School Last Th. in May to last Wed. in August Director 9 - - 9 36,2 * Including the pupils who have left during the year. + Including the principal. $ Not including the semi-mute teachers. T A. = Number of pupils born deaf, or who lost hearing before two years of age. B. = Number who lost hearing when between two and four years of age. C. = Num- ber who lost hearing after four years of age. (a) No. 1234 Sixteenth Street. (&) The staff consists of the principal, one teacher, and two students who give occasional assistance, (c) Experimental. For a description of the methods pursued, see the " American Annals of the Deaf and Dumb " for October, 1884, pp. 263-265. (d) No. 7 Merrick Street. Name. Location. 1 Date of open- 1 ing. Chief executive officer. 1 Catholic Deaf and Dumb Institution for the Province of Quebec .... Mile-End, nr. Montreal, Can.. 1848 Rev. J. B. Manseau, P'tre S. V., Prin. 2 Institution for the Female Deaf and Dumb of the Province of Quebec Montreal, Can. («) 1851 Sister Philippe, Superior. 3 Halifax Institution for the Deaf and Dumb Halifax, N. S 1857 J. Scott Hutton, M.A., Principal. 4 Ontario Institution for the Deaf and Dumb Belleville, Ontario 1870 R. Mathison, Superintendent. 5 Mackay Institution for Protestant Deaf and Blind Montreal, Can 1870 Miss Harriet E. McGann, Supt. 6 New Brunswick Deaf and Dumb Institution Portland, N. B 1873 A. H. Abell, Principal. 7 Fredericton Institution for the Education of the Deaf and Dumb... Fredericton, N. B 1882 Albert F. Woodbridge, Principal. 7 CANADA.-1885. (a) No. 401 St. Denis Street. 375 Deaf-lVIutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Name. No. of Pupils. During the year.* 1 Present Decem- | her 1, 1884. 1 No. of In- structors.+ Method of instruction. School-hours. Trades.** Total. Male. Female. A5. B. 0. No. taught articula- tion. Whole No. Male. | Female. Deaf-mute.t | Semi-mute. 1 2 3 4 5 • 7 Catholic Institution (Male). Catholic Institut'n (Female) Halifax Institution Ontario Institution Mackay Institution New Brunswick Institution. Fredericton Institution.... 126 165 73 286 45 32 20 126 0 38 156 26 23 11 0 165 35 130 19 9 9 52 83 33 16 32 51 6 'i 16 152 6 2 50 59 13 32 8 0 2 100 140 57 235 40 25 16 §25 §35 4 15 4 2 2 25 0 3 8 2 2 2 0 0 1 7 2 0 0 3 0 0 2 1 2 0 0 0 0 2 0 0 0 Manual and oral. Ditto .... Combined.. Combined.. Combined.. Manual .... Combined.. Five hours 8% to 11% and Ito 3%. 9 to 12% and 2 to 4 .... 9 to 12 and 1% to 3 9 to 12 and 1% to 3 9 to 12 and 2 to 4 9 to 12 and 2 to 4 Bo., Cab., Car., Ga., Pa., Pr., Sh., Ta., Wt. Se. Ga., Pr„ Sh. Car., Dr., Sh., Ta. Car., Dr., Pr. Car., Fa., Pa., Sc.,Sh.,Ta. None. 746 380 367 184 91 176 161 613 87 42 45 8 2 CANADA. -1885- Con ti nued. -7 Or >U CO >0 -1 I Name. Vacation. How supported. Value of buildings and grounds. Expenditure last Fiscal Year. No. volumes in li- brary. Total No. pupils have received instruction. For sup- port. For build- ings and erounds. Catholic Inst'n (Male) .. Catholic Inst'n (Female) Halifax Institution Ontario Institution Mackay Institution New Brunswick Inst'n . Fredericton Institution. Last Wed. in June to first Wed. in Sept.... July 1st to first Tuesday in September Second Wed. in July to first Wed. in Sept.. Third Wed. in June to second Wed. in Sept. Third Wed. in June to second Wed. in Sept. May 17th to August 6th July 1st to September 1st State and pay pupils State and voluntary contributions.. State, pupils, and vol. contributions State State, pupils, and vol. contributions Pupils and voluntary contributions. State and voluntary contributions . $200,000 162,491 50,000 8,000 $8,666 40,986 6,766 4,100 3,000 $2,000 848 120 500 800 1,475 50 1,200 400 450 "291' 661 98 99 31 7 1,630 * Including those who have left school during the year. + Including the principal. $ Not including the semi-mute teachers. J A. = Number of pupils born deaf, or who lost hearing before two years of age. B. = Number who lost hearing when between two and four years of age. C. = Num- ber who lost hearing after four years of age. § Comprising industrial instructors. * * Bo. = Book-binding. Cab. = Cabinet-making. Car. = Car- pentry. Dr. = Dressmaking. Fa. = Farming. Ga. = Gardening. Pa. = Painting. Pr. = Printing. Se. = Sewing. Sh. = Shoemaking. Ta. - Tailoring. Wt. = Wood-turning. GREAT BRITAIN AND IRELAND.-1882.f estab- mt. Number of Pupils. Number of Teachers. Method of in- struction. Location. Date of lishme Chief executive officer. Total. Male. Female. Boarders. Day scholars. Male. Female. Deaf. Public Schools. England and Wales. Old Kent Road, London 1792 [- Richard Elliott (Head Master)... ( 70 39 31 70 5 3 0 j Oral. Margate 1862 1 241 130 111 241 11 7 2 ) Combined. Edgbaston, Birmingham 1812 Edward Townsend ' 108 60 48 108 2 5 4 Combined. Old Trafford, Manchester 182.' W. S. Bessant (Head Master) F. B. Illingworth 155 81 74 10 5 1 Oral. Oxford Street, Liverpool 1825 107 61 46 72 35 4 3 0 Combined. Exeter 1826 W. H. Addison 38 22 16 38 2 1 Doncaster 1829 James Howard 152 90 62 152 6 4 2 Combined. Newcastle-on-Tyne 1838 William Neill 95 48 47 95 5 1 1 Combined. Brighton 1842 William Sleight 85 43 42 85 3 4 3 Tyndall's Park, Bristol 1841 William B. Smith 43 26 17 43 1 2 Manual. Bath 1844 Miss Elwin (Hon. Sec.) 13 4 9 13 3 1 Combined. Combined. Swansea, Wales 1847 B. H. Payne (Principal) 40 25 16 40 1 1 1 Lower Clapton, London* 1851 34 34 34 1 3 0 Llandaff, South Wales 1862 Alexander Melville 19 11 8 19 2 1 2 Manual. Walmer Road, Notting Hill, London 11 Fitzroy Square, London, W 1864 1871 S. Schontheil William Van Praagh (Director)... Monsignore de Haerne 25 66 17 36 8 30 22 3 66 2 2 1 6 0 0 Oral. Oral. Boston Sna. Tadcaster. Yorkshire ....... 1870 97 55 42 97 8 0 Combined. Somerford Street, Bethnal Green : Chester Street, Pentonville; Turin S Bethnal Green; Victory Place, worth; Bell Street, Edgware I Farncombe Street, Bermondsey. Snriner Bank. Hull Win- 1874 Rev. W. Stainer (Superintendent of Instruction under London School Board). Walter MacCandlish 186 92 94 186 1 14 0 Oral. creet, Wal- oad; 19 10 9 7 12 1 0 Manual. Castlebar Hill, Ealing, W 1878 J Arthur Kinsey (Principal) ( 11 5 6 8 2 0 Oral. Division Street, Sheffield 1879 | Miss S. C. Hull (Lady Principal) f Geo. Stephenson 29 17 12 29 1 0 Leeds 1881 Joseph Morton 20 10 10 20 1 0 Derbv W. R. Roe 0 Twenty-seven Public Schools in England and Wales 1,653 881 772 1.299 354 63 71 19 - - - - * This is also an Asylum and a Home for females of adult age. + Chief executive officers corrected to 1885. 376 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. Location. Date of estab- lishment. Chief executive officer. Number of Pupils. Number of Teachers. Method of in- struction. Total. Male. Female. Boarders. Day | scholars. Male. | Female. ■J"9G Public Schools. Scotland. Henderson Row, Edinburgh 1810 60 33 27 60 3 Combined. Cathcart, Glasgow 1819 John Thomson 140 82 58 140 3 6 1 Combined. Belmont street, Aberdeen / about 1826 1846 J-Alex. Pender 18 14 4 12 6 1 1 0 Manual. ' 1 Dundee James Barland 19 12 7 19 1 1 Manual. Edinburgh 1850 Alfred Large 118 68 50 118 5 3 0 Combined. Lanark 1871 Sister Teresa Farrell 27 10 17 27 3 0 Greenock 1878 Miss Nichol 4 4 4 1 0 Oral. Seven Schools in Scotland 386 219 167 376 10 13 15 3 Ireland. Dublin (Claremont) 1816 Edward W. Chidley (Head Master) Rev. J. Kinghan (Principal) 43 23 20 43 2 3 0 Manual. Belfast 1831 105 67 38 100 5 5 1 2 Combined. Cabra, Dublin 1846 The Christian Brothers 190 190 190 12 u Manual. Cabra, Dublin 1846 Under the care of Dominican Nuns 207 207 207 20 3 Manual. Four Schools in Ireland 545 280 265 540 5 19 24 5 Thirty-eight Public Schools 2,584 1,380 1.204 2,215 369 94 108 27 Private Schools. 27 Alexandra Villas, Finsbury Park, N... FairView, Cliftonville, Northampton.... 1856 William Stainer 8 8 8 2 Oral. 1860 Thomas Arnold 9 7 2 9 2 Inglefield, Brondesbury, N. W 1866 John Barber 12 6 6 12 1 2 Oral. 8 Burlington Buildings, Redland, Bristol. 1869 Mrs. Thomas 7 4 3 7 1 2 56 Gresham Road, Brixton, S. W 1878 Sophia M. Rhind 3 3 1 2 1 Oral. 125 High Street, Garnet Hill, Glasgow ... 1881 Miss Griffiths 9 9 5 4 1 Oral. 3 Notting Hill, London. W 1881 Miss Fanny C. Howe 3 3 1 Oral. Oral. Aston Park, Birmingham 1882 Miss Rutherford 3 2 1 3 1 Eight Private Schools 66 33 33 54 9 6 8 Forty-six Schools in Great Britain and 2,650 1,413 1,237 2,269 378 100 117 27 GREAT BRITAIN AND IRELAND.-1882 '-Continued. * Chief executive officers corrected to 1885. Location. Date of estab- | lishment. Chief executive officer. Number of Pupils. Number of teachers. Method of in- struction. How supported. Male. Female. Sidney, New South Wales Melbourne. Victoria Adelaide, South Australia I860 1860 1874 Samuel Watson Frederick J. Rose Samuel Johnson.' 28 46 8 25 34 6 4 5 2 Manual Voluntary contributions and pay pupils. Voluntary contributions and pay pupils. State, voluntary contributions, and pay pupils. Three Schools in Australia 82 65 11 AUSTRALIA.-1879. Bombay | 1884 T. A. Walsh ;-i-i i INDIA.-1885. Sumner, ChristChurch | 1879 G. Van Asch | 13 9 2 | Oral. State and pay pupils. NEW ZEALAND.-1882. School Age.-There is a difference of opinion among experienced teachers as to the best age for sending deaf children to school. On the one hand, such children have so much to learn as compared with hearing children that their education ought to be begun as early as possi- ble ; on the other, there are obvious objections to taking them away from their homes-as in the great majority of cases is necessary in order that they may receive proper instruction-while they are still very young. The decision must depend largely upon the circumstances of the individual, and the facilities offered by the State in which he resides. Where the term of instruction af- forded by the State is limited to six or seven years, and where children are surrounded by favorable influences at home, probably ten or twelve is the best age for them to be sent to school, since experience has shown that the six or seven years following that age are those in which the most can be accomplished for the physical, mental, and moral development of the deaf-mute ; but where, as is the case in some States, there is no limit to the term of instruction, where proper provision is made for the care and teaching of the little children by kindergarten meth- ods apart from the older pupils, and especially where the home influences are bad, it is desirable to send thenr 377 Deaf-flutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as young as six years of age. From six to ten they will make less progress at school than from ten to fourteen ; but if, in addition to those four years under ten, they re- main six or seven years longer, they will be able to ac- quire a much fuller mastery of the language of their fel- low-men, and to reach a far more advanced stage of education in all respects, than if their education had not been begun until the years of early childhood were passed. Boarding-schools and Day-schools.-The experi- ence of more than a century has shown that the educa- tion of deaf-mutes can be most efficiently and success- fully carried on in special boarding-schools. Except in large cities, the number of deaf children in the com- munity is too small to render the organization of day- schools practicable, and in cities the evil influences that surround many of them at home, the temptations of the street out of school-hours, the danger of accidents in go- ing to and from school, the interruptions to progress from tardiness and absence, and the lack of facilities for industrial instruction, make the results much less satis- factory than in the well-organized boarding-school, where the influences of the workshop, the play-ground, and the evening study-hour all combine with those of the school- room to promote the proper development and education of the child. Excellent work, however, is done in some of our day-schools ; for children who are surrounded by good influences at home, with parents, brothers, and sis- ters who will take pains to guard them from harm, and to advance their education out of school, the day-school is to be recommended in some cases, especially during the earlier years of school-life, in preference to sending them away from home to the boarding-school. But for the great majority of deaf-mutes the advantage of the board- ing-school over the day-school is shown in the fact that in the former the physical, intellectual, and moral wel- fare of all the pupils is cared for in every way all the time, while in the latter the good gained during the five hours, more or less, that they are in the school-room five or six days of each week, is counteracted in many cases by the pernicious influences that surround them during the much larger portion of time that they are out of school. The idea of having deaf-mutes taught in the public schools, wholly or in part with hearing children, has com- mended itself to many distinguished educators, and in several countries of Europe the experiment has been faithfully and zealously tried with the sanction and aid of the government. It has, however, on account of the essential difference in the methods of instruction required for deaf and hearing children, invariably resulted in fail- ure, and all systematic and organized efforts in this di- rection have now been abandoned in Europe (Gordon : " American Annals," 1885). A plan for the establish- ment of deaf-mute schools in connection with public schools, the instruction given to be partly special and partly in common with hearing children, has recently been proposed in the United States by Dr. Alexander Gra- ham Bell ; but experienced teachers do not share his ex- pectation that it will effect a revolution in the methods of deaf-mute instruction, nor believe that under the most favorable circumstances it will produce any other good results than those which have followed similar experi- ments in Europe, viz., the awakening of more interest in the subject of deaf-mute education, the growth of special schools in some places where they are needed, and in others the preparation of deaf children in common schools for their future education in special schools by teaching them habits of neatness, order, and obedience, the use of the pencil and pen, counting, and some ele- mentary knowledge of words (Walther : " Geschichte des Taubstummen-Bildungswesens," 1882). Private Instruction at Home.-It has been said by a high authority that "the best deaf-mute school is a school of one pupil," but the statement is not to be re- ceived without some qualification. In order to attain a mastery of spoken or written language the more indi- vidual attention the deaf child receives the better, and in this respect private instruction at home has a decided advantage over class instruction at school. On the other hand, the child taught alone at home, and thus lacking the stimulus of association with others placed on an equal footing with himself, is apt to become listless in study and melancholy in disposition. The best advice, therefore, to be given to parents whose means enable them to provide a private teacher is this: Obtain a com- petent tutor or governess for your child at three or four years of age. Let the efforts of this teacher for seven or eight years be devoted almost wholly to giving the child language, articulation, and speech-reading by the natural or intuitive method, which imitates as closely as the na- ture of the case allows the manner in which hearing chil- dren learn to speak, and let the teacher's efforts be heart- ily seconded by all the other members of the family. When the child is ten or twelve years old send him to school to pursue other branches of study and complete his education. The command of idiomatic language ac- quired by the home training is something that could not Fig. 795.-Single-hand Alphabet. be imparted at school, while the moral and intellectual development received at school could not be attained at home. Intelligent parents and friends, whose pecuniary cir- cumstances do not allow them to employ a private teacher, can themselves do a great deal in the way of preparing their deaf children for school-life by forming in them habits of order and obedience, and by teaching them the use of the pencil and pen, counting, and common words in their written forms. If the child already pos- sesses speech gained before hearing was lost, great efforts should be made to retain the speech and to cultivate the habit of reading the speech of others. If any hearing ex- ists, it should be utilized in practice, the aid of the hear- ing tube, trumpet, and audiphone should be tried, and whichever instrument proves most effective should be 378 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. employed. In all cases the deaf child should be gov- erned with the same firmness as his hearing brothers and sisters. While due allowance should be made for his in- ability to understand, and he should be protected as far as possible from the teasing of playmates, he can and should be taught strict obedience to parents, and due re- spect for the rights of others. Auricular Instruction.-A very large proportion of persons so deaf as usually to be classed as deaf-mutes, possess more or less hearing. Sixty years ago Dr. Itard estimated the proportion of the semi-deaf among deaf- mutes at eighty per cent., and a commission of the French Academy of Medicine in 1828 recommended the estab- lishment in the Royal Institution for Deaf-mutes at Paris of a special class for the semi-deaf, with a view to the education of the aural sense. Nothing, however, was actually accomplished in this direction until the year "can and ought," as Mr. Gillespie claims, "to be gradu- ated as hard-of-hearing speaking people, instead of deaf- mutes, as heretofore." Manual Alphabets. - The manual alphabets em- ployed by educated deaf-mutes afford a means of com- munication more rapid and convenient than writing, and more exact than articulation and speech-reading. They are easily acquired by the friends of the deaf, and prac- tice gives great facility in their use. The single-hand alphabet is used in the schools of the United States following the combined and manual methods of instruction, and to some extent in those of Great Britain and her colonies. It is also employed in France, and with some variations in the other countries of Europe. It has the advantage over the two-hand al- phabet of leaving one hand free for other uses, as driving, or carrying an umbrella, at the same time that one is spelling. The two-hand alphabet is used in most of the English schools, and educated deaf-mutes in all English-speaking countries, even where the single-hand alphabet is pre- ferred, are generally familiar with it. It is said to admit of even greater rapidity than the single-hand alphabet. The Dalgarno, or glove alphabet, is preferred in some schools where prom- inence is given to oral teaching, since it can be used by the sense of touch while the eyes of the pupil are fixed upon the teacher's lips, and, not being generally understood, it af- fords a less frequent means of escape from practice in speech and speech- reading. By a modi- fication of this alpha- bet, employed by Dr. Alexander Gra- ham Bell, the letters are indicated by touching various parts of the pupil's shoulder instead of the hand. All the letters of a short word or of a syllable can be made simul- taneously, and the force of accent and rhythmcan be given. Visible Speech and Line-writing.-In the year 1872, Dr. Alexander Graham Bell applied the system of " Visible Speech," invented by his father, Professor Alex- ander Melville Bell, to the instruction of deaf-mutes in ar- ticulation. Visible Speech is a species of phonetic writing, and as it is based not upon sounds but upon the action of the vocal organs in producing them, its principles are as easily comprehended by the deaf as by hearing persons. Each letter of the Visible Speech Alphabet, to a person familiar with the system, is a picture of the vocal organs placed in the proper position for producing the sound indicated, so that the writing of any word in this alphabet shows its correct pronunciation. Visible Speech has been intro- duced into several schools in the United States following the oral and combined methods, and is regarded by some teachers as a great aid in their work. Others, including some of the most experienced oral teachers, look upon it as more of a hindrance than a help to young children, for whom, it is said, its symbols are no less arbitrary than the letters of the English alphabet. All are agreed, how- ever, that the principles of physiological speech taught in Professor Melville Bell's works are very valuable to teachers of articulation. Fig. 797.-Glove Alphabet. Fig. 796.-Two-hand Alphabet. 1882, when Mr. J. A. Gillespie, Principal of the Nebraska Institute for the Deaf and Dumb, having arrived, inde- pendently, at conclusions similar to Itard's, organized in his school a class of semi-deaf children. About fifteen per cent, of the pupils were found capable of instruction through the ear, directly, or with the aid of acoustic instru- ments. Mr. Gillespie's success led to the further investiga- tion of the subject by a committee appointed for the pur- pose by the Convention of Articulation Teachers held in New York in 1884, who have tested the hearing of the pupils in various schools by means of the audiometer, the audiphone, ear-tubes, ear-trumpets, tuning-forks, bells, musical instruments, the voice, etc. While definite con- clusions are not yet reached, it is evident that the hear- ing power that often exists unnoticed in the deaf can in many cases be educated by careful and skilful training, and that a considerable number of the pupils of our schools 379 Deaf-Mutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dr. Graham Bell has recently (1885) introduced a modi- fication of one of his father's alphabets called Line-writing, which has the advantage of being much more rapidly writ- sions for the wants of this class in the National Deaf-Mute College established by Congress at Washington, D. C., in the year 1864, through the efforts of Edward M. Gal- laudet, Ph.D., LL.D., who has been its president from the beginning. This college affords a course of training corresponding to that of American colleges in general, with such modifications as seem desirable in view of the peculiar needs of the deaf, and confers upon its graduates the usual academic degrees. Of the students who have been connected with the college a large number are now engaged in teaching, several are editors and publishers, others are in the civil service of the government, one is a lawyer practising in the Supreme Court of the United States, one is at the head of large assaying works in Chi- cago, one is a missionary to the deaf in Pennsylvania, and nearly all are occupying positions of a higher grade than would have been possible without the educational advantages conferred by the college course. Religious Work for Adults.-The moral and reli- gious instruction given in most of the American schools for the deaf is of an unsectarian character, the pupils be- ing advised by their teachers to connect themselves dur- ing their vacations, or after leaving the schools, with the churches to which their parents belong. Adult deaf- mutes, however, can derive much more pleasure and profit from special services in the sign-language than from ordinary religious exercises, and in places where their numbers are sufficiently large to form a congrega- tion, the holding of such services is entirely practicable. The Rev. Thomas Gallaudet, D.D., of New York, estab- lished a church for deaf-mutes in that city in 1852, and, through his efforts and those of other friends of the deaf, arrangements are now made by which religious services in the sign-language are held weekly in several cities of the United States, and at less frequent intervals in many other places. The Episcopal Church, with which Dr. Gallaudet is connected, has been by far the most active in providing for the religious welfare of adult deaf-mutes, but other churches have also had a part in the work. There are now five ordained clergymen in the United States who are themselves deaf-three of them Episcopa- lians, and two Congregationalists-and there are a large number of deaf laymen who assist in missionary work. Similar work for the benefit of adult deaf-mutes is carried on in Great Britain and Ireland. In connection with the religious organizations there usually exist be- nevolent and relief societies, and in some cases literary and social unions. While this association of the deaf with one another, rather than with hearing persons, is to be regretted on some accounts (see Mental Condition and Characteristics, supra), it is also productive of good in the mutual aid and support it leads them to render, the comfort and enjoyment they derive from the free inter- change of thought and sentiment, and the opportunities it affords for their intellectual, moral, and religious in- struction. Edward Allen Fay. CONSONANTAL ELEMENTS. p b ni f v wh. w t d n * r * 1 th(in)th(en) a z sh. zb f y k g ng h VOWEL ELEMENTS AND GLIDES. (Illustrated, by Words.) eel ale e'll ill shall pool pole Paul pull Polly ah. up sir how eye boy Fig. 798.-Line-writing. ten than the symbols of Visible Speech heretofore used in the instruction of the deaf. The characters of the English elements of speech as represented in Line-writing are given above, and below are a specimen of Line-writing and a key giving the English equivalents of the same. Key. DEAF-MUTES: The Language of Signs, and the Combined System of Instructing Deaf-mutes. I. The Language of Signs.-The French philosopher Condillac begins his treatise, " Grammaire generale et rai- sonnee," as follows: " The means of which men first made use to communicate their thoughts were gestures, move- ments of the countenance, and inarticulate sounds. The combination of these may be called the language of ac- tion." This view of Condillac's as to the origin of lan- guage may have " no sufficient support from observed facts," as the distinguished English anthropologist Ed- ward B. Tylor asserts ; but it may certainly be accepted as a plausible hypothesis, for the overthrow of which no " observed facts " can be adduced. It is, however, for- eign to the purpose of this article to inquire what was the primitive language. The aim will be to show that there is a true language of gestures ; that it is as natural and may be as complete a vehicle of expression as speech ; that this language has great utility among people wdio hear ; that in the humane and scientific education of the deaf it is indispensable; that its judicious use by deaf- When Franklin made his discovery o£ the identitjrof lightning and. elec- tricity, it was sneered st, and people asked, "Of what use is it? To ■which his apt reply was, " What is the use of a child ? It may become a man ' " When Galvani discovered that a frog's leg twitched when placed in contact with different metals, it could scarcely have been imagined that so apparently insignificant a fact could have led to important results.^ Yet therein lay the germ of the Electric Telegraph, which binds the intelli- gence of continents together, and, probably, before many years elapse, ■will "put a girdle round the globe."-Smiles. Fig. 799.-Specimen of Line-writing. Higher Education.-The standard of education in schools for deaf-mutes at the present day corresponds in general to that of the common schools-an education fit- ting the pupil for intelligent citizenship. But there are some among the deaf who are capable of advancing be- yond this standard and preparing themselves for scientific and literary pursuits. The United States makes provi- 380 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. mutes is a source of great benefit and pleasure during the entire period of their lives; and that among this in- teresting and intelligent class of the community nothing can be found that will take its place. That there is a true language of signs, history gives abundant evidence. Quintilian, the Roman orator and teacher of rhetoric in the first century of our era, says : ' ' Amidst the great diversity of tongues pervading all na- tions and people, the language of the hands appears to be common to all men." In the days of Quintilian the lan- guage of signs was an important feature in public amuse- ments, the mimics or pantomimists of the time of Augus- tus carrying the art to the highest degree of perfection. The famous actors Pylades and Bathyllus expressed in mimic language the greatest variety of scenes and inci- dents, including even the history of illustrious men. Amusements of this character were maintained for more than five centuries, when they had become so gross and indecent that Charlemagne put a stop to them in the name of morality. The language of gestures was not, however, banished from among men by the act of the great Emperor. On the contrary, it has been cultivated in many parts of Europe, notably in Southern Italy, and is employed to this day under a great variety of circumstances. Alexander Dumas relates an incident that came under his notice in Sicily, which shows how fully the language of signs often serves in that part of Europe as a means for conveying information. Dumas was attending an opera at Palermo with a friend, Arami. "In the inter- vals of the acts," he says, " I saw lively conversations carried on between the orchestra and the boxes. Arami, in particular, recognized a friend whom he had not seen for three years, and who related to him, by means of his eyes and his hands, what, to judge by the eager gestures of my companion, must have been matters of great inter- est. The conversation ended, I asked him if I might know without impropriety what was the intelligence which had seemed to interest him so deeply. ' Oh, yes,' he replied, ' that person is one of my good friends, who has been away from Palermo for three years, and he has been telling me that he was married at Naples ; then trav- elled with his wife in Austria and in France; there his wife gave birth to a daughter, whom he had the misfor- tune to lose ; he arrived by the steamboat yesterday, but his wife had suffered so much from sea-sickness, that she kept her bed and he came alone to the play.' ' My dear friend,' said I to Arami, ' if you would have me believe you, you must grant me a favor.' ' What is it ? ' said he. ' It is that you do not leave during the evening, so that I may be sure you give no instructions to your friend, and when we join him, that you ask him to repeat aloud what he said to you by signs.' ' That I will,' said Arami. The curtain then rose ; the second act of ' Norma ' was played ; the curtain falling and the actors being recalled as usual, we went to the side-room, where we met the traveller. ' My dear friend,' said Arami, ' I did not perfectly com- prehend what you wanted to tell me ; be so good as to repeat it.' The traveller repeated the story word for word, and without varying a syllable from the translation ■which Arami had made of his signs : it was marvellous indeed." Another illustration of the use made of sign language in Italy is afforded in an event connected with the compara- tively recent history of Naples. When King Ferdinand returned to his capital after the revolutionary movements of 1822, he made an address to the lazzaroni from the balcony of the palace wholly by signs, which in the midst of the most tumultuous shouts was perfectly intelligible to his public. He reproached, threatened, admonished, forgave, and finally dismissed the rabble as thoroughly persuaded and edified by the ges- ticulations of the royal Punch, as an American crowd might be by the eloquence of a Webster. The language of gestures has been employed in very many instances by persons of widely differing nationality and race, and utter strangers to each other up to the mo- ment of resorting to this means of communication. At the time when the Amistad Africans were in prison in Hartford, Conn., awaiting their trial before the United States District Court, a visit was paid to them by the Rev. T. H. Gallaudet, then Principal of the Institution for Deaf-mutes in that city. Having no means of communi- cating orally with these negroes, Dr. Gallaudet found no difficulty in carrying on conversation with them by means of expressive action, which elicited various infor- mation respecting the families they had left in Africa, besides some particulars of their own recent history ; all of which they imparted with the peculiar pleasure result- ing from this unexpected facility of communication with a stranger. In the summer of 1818 a Chinese young man passed, through Hartford, Conn. He was so ignorant of the English language that he could not express in it his most common wants. The Principal of the School for Deaf- mutes, Dr. Gallaudet, invited the stranger to spend an evening within its walls, and introduced him to Mr. Clerc, an assistant in the school, himself a deaf-mute. It was desired to ascertain to what extent Mr. Clerc, who was entirely ignorant of the Chinese language, could con- duct an intelligible conversation with the foreigner by signs and gestures merely. The result of the experiment surprised all who were present. Mr. Clerc learned from the Chinaman many interesting facts respecting the place of his nativity, his parents and their family, his former pursuits in his own country, his residence in the United States, and his notions concerning God and a future state. By the aid of appropriate signs, also, Mr. Clerc ascertained the meaning of about twenty Chinese words. When the conversation began, the stranger appeared to be bewil- dered with amazement at the novel kind of language that was addressed to him ; soon, however, he became deeply interested in the very expressive and significant manner which Mr. Clerc used to make himself understood ; and before one hour had expired, a very quick and lively in- terchange of thought took place between these two, so lately entire strangers to each other. The Chinese him- self began to catch the spirit of his new deaf and dumb acquaintance, and to employ the language of the coun- tenance and gestures with considerable effect to make himself understood. To how great an extent the sign language has served as a means of communication among the aborigines of America, is shown by Colonel Garrick Mallery, U. S. A., in his admirable monograph on ' ' Sign Language among North American Indians compared with that among Other Peoples and Deaf-mutes," published by the Gov- ernment of the United States, under the auspices of the Bureau of Ethnology of the Smithsonian Institution. After presenting a mass of interesting and conclusive evi- dence proving that sign language has been widely used among the Indian tribes of America, Colonel Mallery of- fers the following summation which seems to be incon- trovertible : " The studies thus far pursued lead to the conclusion that, at the time of the discovery of North America, all its inhabitants practised sign-language, though with differ- ent degrees of expertness, and that, while under changed circumstances it was disused by some, others, in especial those who after the acquisition of horses became nomads of the Great Plains, retained and cultivated it to the high development now attained, from which it will surely and speedily decay." Antony Deusig, of Groningen, Holland, in a treatise entitled "The Deaf and Dumb Man's Discourse," a trans- lation of which, by George Sibscota, was published in London as early as 1670, describing the various modes of communication possible to persons deprived of hearing and speech, says: "Experience teacheth us, and there are also many ob- vious examples among us, that those that are originally dumb and deaf, do by certain gestures and various mo- tions of the body, as readily and clearly declare their mind, to those with whom they have been often conver- sant, as if they could speak, and likewise, by such ges- tures of other persons, they do absolutely understand the intentions of their mind also. " The emperor of the Turks maintains many such 381 Deaf-Mutes. Deaf-Mutes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mutes in his court, who do express the conceptions of their minds one to another, and as it were interchange mutual discourse, by gesticulations and a variety of ex- ternal significations, no otherwise than we that have the faculty of signifying our own thoughts, and conceiving those of other persons by outward speech. Nay, the Turkish emperor himself and his courtiers take great de- light with this kind of speech shadowed out by gestures, and use to employ themselves very much in the exercise hereof, to make them perfect in it. Cornelius Haga, am- bassador to the emperor of the Turks, sent thither by the States of the United Provinces, did once invite all those mutes to a banquet, where, though there was not a sylla- ble heard, yet they did exchange several discourses, as is usual at other treats, which the ambassador understood by an interpreter on both sides, by whose assistance he himself did discourse with the mutes on all subjects." Enough has been said to show that there is a true lan- guage of signs, and that it has been of great use among people who hear. But to discover the field of its greatest utility, and to find it in its fullest development as a vehicle of expression, one must become informed as to the service it performs in the intellectual and social life of the deaf. A few isolated instances are recorded, previous to the last century, of deaf persons who, under favorable condi- tions, have developed for their own use a measurably complete language of signs. But it was only toward the middle of the eighteenth century that this language was used by considerable numbers of deaf-mutes. Before de- scribing this general use, however, it is important to con- sider, somewhat carefully, the limitations as to means of communication which absolute deafness imposes on those who suffer from it. The means of expression possible to creatures of intel- ligence, by which information as to thought and feeling may be given and received, are five in number, corre- sponding to the senses. All expression, i.e., all communi- cation from one intelligent being to another, must, there- fore, be either audible, visible, tactile, odoric, or palatal. The senses of taste and smell are addressed so rarely and with such difficulty, for the purpose of communicating thought, that they may be left out of view. The same may be said of the sense of touch, except that, in the case of persons both blind and deaf, it becomes the main channel of communication, and may be made useful under cer- tain conditions with such as are only deaf ; as, for exam- ple, in the dark, or when it is desirable to address the deaf without diverting the eye from some object-such as a landscape, a passing pageant, or spectacle. George Dalgarno, in his curious and interesting work " Didascalocophus," or "The Deaf and Dumb Man's Tutor," published in Oxford in 1680, presents an alphabet arranged upon the palm of the hand, certain letters being associated with certain joints and other parts of the hand, by the use of which one may communicate with a deaf person without demanding the attention of his eyes, his hand being touched by the fingers of the speaker so that words are rapidly spelt. The Morse telegraph alphabet may also be made use of in communicating through the sense of touch, by giving taps or pressures of varying length as to time, the hand of one resting lightly on the arm of the other. Visible expression employs a great variety of forms in the accomplishment of its purpose, but these forms may be grouped in two perfectly distinct classes : the gestural, which produce their effects only from moment to mo- ment, having no enduring quality, and the graphic, which are more or less permanent. Audible expression, almost infinite as it is in variety, is susceptible also of division into two great classes, arti- culate and inarticulate, the former comprising all forms of word utterance, and the latter including cries, moans, sighs, music, percussions, and explosions. Among all these possible means of transmitting intel- ligence from one to another, it will readily be seen that the three principal means of communicating thought and feeling made use of by man are : 1, Articulate speech ad- dressed to the sense of hearing ; 2, gestural; and 3, graphic expression presented to the sense of sight. By gestural expression must be understood all positions and movements of the body or any of its members, in- cluding the countenance, and all noiseless signals such as are made use of in military or engineering operations, on the sea, on roads, or on rivers. In short, all devices for communicating information through the eye of man, which are not in any manner recorded or made perma- nent. Graphic expression will then include all forms of writ- ing and printing, all productions in the fine arts, all marks of whatever character that are in any degree per- manent, and are designed to communicate information or to express thought and feeling. And the range of this form of expression is wide enough to embrace at one extreme the Duomo of Milan, or Milton's noblest poem, and at the other the cattle brand of a Texan cow-boy, or the blaze of a backwoodsman's axe in the primeval forest. In determining the value of gestural expression to the deaf, it is necessary to keep constantly before the mind the fact that, where hearing does not exist no mental im- pressions can be received through the means of articulate speech. In other words, that he who would communicate with the deaf is limited to gestural and graphic means. Even in cases where a deaf person retains the power of speech, or is taught to speak and to understand the speech of others by watching the motion of the lips, such mo- tions are to him nothing other than a certain form of gestural expression. The peculiar element of sound, the perception and understanding of which enables a hearing person to comprehend speech without seeing the vocal organs of the speaker, is wholly wanting to the deaf. And so essential is the possession of hearing to the free use and enjoyment of articulate speech as a means of communication from man to man, that to the deaf this can be no more, at its very best, than what an artificial leg is to one who would walk, or run, or dance. Service- able, no doubt ; far better than no leg at all, but never an equivalent for the missing member. Have the deaf, then, no means of expression that can be as free and as perfect as speech is to their more fa- vored brethren ? A distinguished scientist and philanthropist, justly honored and respected in the city of his adoption (Wash- ington, D. C.), who has long been interested in the edu- cation of deaf-mutes, but who has had little experience in teaching them, said recently before one of the learned societies of Washington : " Nature has been kind to the deaf child ; man, cruel. Nature has inflicted upon the deaf child but one defect, imperfect hearing ; man's neglect has made him dumb and forced him to invent a language which has separated him from the hearing world." " Let us then," says the learned writer, " remove the afflictions that we ourselves have caused." And after some eminently reasonable suggestions he adds, " And last, but not least, let us banish the sign-language from our schools." Nature has indeed been kind to the deaf child, in that she has left him capable of using as freely as his hearing brother, the gestural and the graphic means of communi- cating thought; in that she has made it natural and easy for him to employ a method of expression in the use of which he is at no disadvantage as compared with his hearing brother, and which is beyond all dispute the only means of communication which can be to the deaf what speech is to the hearing as a vehicle of thought. And this " language of action," which philologists agree is the foundation of all human intercommunication, which is the acknowledged vernacular of the deaf, the distin- guished theorist, and not a few others with him, would " banish from our schools." Of such an act of " kind- ness " proposed by certain teachers of the deaf on both sides of the Atlantic, one of the most eminent and suc- cessful oral teachers of deaf-mutes in Germany says: " If this system were put into execution, the moral life, the intellectual development of the deaf and dumb would be inhumanly hampered." The founder of deaf-mute instruction in America, who is to be ranked among the most successful teachers of the 382 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deaf-Mutes. deaf in the world, says in an article on " The Natural Language of Signs," written some years after he had completed his work for the deaf, and when he had had time to review his methods with calmness : " My object is to show the intrinsic value and, indeed, indispensable necessity of the use of natural signs in the education of the deaf and dumb. . . . In attempting this, I wish I had time to go somewhat at length into the genius of this natural language of signs ; to compare it with merely oral language, and to show, as I think I could, its decided superiority over the latter, so far as respects its peculiar adaptation to the mind of childhood and early youth. " In what relates to the expression of passion and emotion, and of all the finer and stronger sentiments of the heart, this language is eminently appropriate and copious. " So far as objects, motions, or actions addressed to the senses are concerned, this language, in its improved state, is superior in its accuracy and force of delineation to that in which words spelt on the lingers, spoken, written, or printed are employed." This claim of the superior accuracy and precision of sign-language, as compared with words, may perhaps excite surprise at first thought. But it is believed that its reasonableness will appear when it is remembered that the meanings attached to words are almost wholly arbi- trary, very few giving the slightest hint of their significa- tion in their shape or sound ; while nearly every gesture used in sign-language carries with it a plain sugges- tion of its meaning, and in very many instances gives a vivid and easily recognized portrayal of the idea to be conveyed. The signs for such objects, for example, as salt, pepper, milk, coffee, would be at once understood by one unac- customed to the use of gestures, were they made at the table. In a school-room the most ignorant child would catch the meaning at once of signs for such objects as slate, pen, book, and, indeed, of a host of familiar things. But slight explanation is needed to make clear to one uninstructed in gesture-language the meaning of the signs in common use for such emotions as love, hatred, fear, pain, anger. That children often learn, repeat, and sometimes even make use of words the meaning of which they compre- hend very imperfectly, is a familiar fact to parents and teachers. An incident in the childhood's experience of a lady belonging to one of the most cultivated families of New England, well illustrates this point. The pastor of the church to which her family belonged was in the habit of teaching the children of his charge the Assem- bly's Shorter Catechism viva voce; and the children committed it to memory thus, without making use of any book. Mrs. T said, that when nearly grown, she came across a copy of the book, and was much surprised to find that the first question was not " What is man's chefand ? " which she had always supposed it to be. Since experience has proved that sign-language is nat- ural to the deaf, that it is acquired and made use of by them more easily than speech is by the hearing, that it furnishes a full and adequate means for communicating thought and feeling, often surpassing speech in vivid- ness and exactness, it is not strange that teachers of the largest experience and broadest view unite in approving its use in the education of the deaf. Nor is it surprising that those who would "banish signs from the school-room " are, for the most part, per- sons who have never learned to use them, and have, therefore, no experimental appreciation of their value in teaching. And these persons are utterly incapable of giving the deaf, either in school or after they have passed into adult years, the great comfort and benefit of public addresses. For it is through the use of sign-language alone that the deaf can enjoy lectures, sermons, or de- bates. At this point the question will naturally arise in many minds : ' ' Does the sign-language give the deaf in these respects all that speech affords to the hearing? " The experience and observation of the writer leads him to answer the question with a decided affirmative. On many occasions it has been his privilege to interpret through signs to the deaf, addresses given in speech ; he has addressed assemblages of deaf persons many times, using signs for the original expression of thought ; he has seen hundreds of lectures and public debates given originally in signs ; he has seen conventions of deaf-mutes in which no word was spoken, and yet all the forms of parliamentary proceeding were observed, and the most excited and earnest discussions carried on ; he has seen the ordinances of religion administered, and the full ser- vices of the church carried on in signs ; and all this with the assurance growing out of his own complete under- standing of the language, a knowledge of which dates back to his earliest childhood, that for all the purposes above enumerated, gestural expression is in no respect inferior, and is in many respects superior, to articulate speech as a means of communicating ideas. But the greatest value of the sign-language to the deaf, when the whole period of their lives is taken into ac- count, is to be found in the facility it affords for free and unconstrained social intercourse. And in this, as in the matter of public addresses, nothing has been discovered that can fully take its place. It may even be asserted that so long as the deaf remain without hearing, nothing else can give them what speech affords their more fa- vored brethren. They may have much pleasant inter- course with others by the employment of writing-tablets ; they may even enjoy conversation under many limita- tions with single individuals through articulation and lip- reading ; with the aid of the manual alphabet they may have a still wider and more enjoyable range for the inter- change of thought ; but it is only by employing signs that they can gain the pleasure and profit that conies from conversation in the social circle, that they can enjoy such freedom of intercommunication as shall make it possible for them to forget they are deaf. Graduates of oral schools, from which the attempt has been made to "banish signs," have repeatedly testified that they could in no way attain to such pleasure in so- cial intercourse as through the use of sign-language, abil- ity to employ which they readily acquire by mingling with those more favored deaf-mutes who have become familiar with it earlier in life. " But," say those who urge that the use of signs is an injury to the deaf, " they can use that language only with their fellow-unfortunates, or with the very few others who learn it for their sake, and their use of signs tends to make them clannish, thus narrowing the sphere of their lives, and leading them to employ in excess a language other than the vernacular of their country." It is admitted that, in the education of the deaf, injudi- cious teachers may allow, or even encourage, too free a use of the sign-language in the schools-that such teach- ers may suffer their pupils to go out from under their in- fluence without being impressed with the importance of making special and persistent efforts to overcome the ten- dency to clannishness which is natural to the deaf, no matter what method of instruction is employed. It is not disputed that in teaching the deaf, signs may be so employed as to affect unfavorably the acquisition by the pupil of verbal language, whether in its written or spoken forms. But nothing is more certain, as proven by the experi- ence of nearly three-fourths of a century in this country, than that the unfavorable results which some have charged upon the use of the sign-language, are attributa- ble in all cases to its abuse by injudicious, incompetent, or inexperienced teachers. Since 1817, when the first school for deaf-mutes in this country was established, more than twenty-three thousand children have been edu- cated in forty-nine schools now in successful operation, in all of which the sign-language has been made use of. A majority of these persons are living to-day, and may be found in every city, probably in every county of the land. Among these, thousands could be named who, while associating freely with their fellow deaf-mutes, and de- riving both profit and pleasure from such association, mingle readily with persons who hear ; who are not clan- 383 Deaf-JIntes. Deafness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nish to any degree that would subject them to just criti- cism ; who use the vernacular of the country with free- dom and reasonable accuracy ; who maintain themselves reputably and comfortably by their own labor ; who are, in short, good and intelligent citizens, adding strength, wealth, and character to the communities in which they reside. And could the history of these persons be fully known to one competent to attach due weight to all the elements that had combined to give them what they have enjoyed, it would certainly be discovered that no one factor had contributed more to the sum of their happiness than the free and intelligent use of that form of communication which a beneficent Providence has made easiest and most natural to them-the language of signs. II. The Combined System of Instructing Deaf- mutes.-It is a matter of singular coincidence that schools for the deaf should have been first established in the three leading nations of Europe at about the same pe- riod, and as the result of entirely independent effort. This occurred very near the middle of the last century. The Abbe de FEpee inaugurated in France what will be presently described as the manual method. Samuel Heinicke was the founder in Germany, as Thomas Braid- wood was in Great Britain, of the oral method. The promoters of these two methods were each earnest in urging the superiority of his own over the other, and for a full century the deaf-mute schools of the world were either manual or oral, with little thought in the mind of any one that there might be found a golden mean between the two extremes. Within the past twenty years, however, it has been proved possible, by many teachers of no little prominence in Europe and America, to appropriate the elements of greatest value in the two methods so long in conflict, and to secure, under what has been termed the combined system, all that is of advantage in the education of the deaf. Professor Edward A. Fay, Ph.D., Editor of the Ameri- can Annals of the Deaf and Dumb, gives in vol. xvii., pp. 32 and 33 of that journal, the following excellent definitions of the several methods : "By the manual method is meant the course of in- struction which employs the sign-language, the manual alphabet, and writing as the chief means in the education of the deaf, and has facility in the comprehension and use of written language as its principal object. The de- gree of relative importance given to these three means varies in different schools ; but it is a difference only of degree, and the end aimed at is the same in all. If the pu- pils have some power of speech before coming to school, or if they possess a considerable degree of hearing, their teachers usually try to improve their utterance by prac- tice ; but no special teachers are employed for this pur- pose, and comparatively little attention is given to articu- lation. " By the oral method is meant that in which signs are used as little as possible ; the manual alphabet is generally discarded altogether; and articulation and lip-reading, together with writing, are made the chief means as well as the end of instruction. Here, too, there is a difference in different schools in the extent to which the use of signs is allowed in the early part of the course ; but it is a difference only of degree, and the end aimed at is the same in all. " The combined method is not so easy to define, as the term is employed with reference to several distinct meth- ods, such as (1) the free use of both signs and articula- tion, with the same pupils and by the same teachers, throughout the course of instruction ; (2) the general in- struction of all the pupils by means of the manual method, with the special training of a part of them in articulation and lip-reading as an accomplishment; (3) the instruc- tion of some pupils by the manual method and others by the oral method in the same institution ; (4)-though this is rather a combined system-the employment of the manual method and the oral method in separate schools under the same general management, pupils being sent to one establishment or the other as seems best with re- gard to each individual case." The only criticism suggested in Professor Fay's defini- tions is that the term combined system, which he applies only to the last case, be made use of under all circum- stances instead of the term combined method; for in no case that he mentions under that head can any single method be said to be employed, but in each instance there is a combination of the two methods once opposed to each other, this combination being effected under differ- ing circumstances. With such favor have the claims of the combined sys- tem been received in this country, that on December 1st last (1884), out of 61 schools existing in the United States, 40 were being conducted in accordance with this system, as against 12 oral and 9 manual schools. In the 40 com- bined schools there were 5,289 pupils; in the 12 oral schools 564 pupils, and in the 9 manual schools 375 pupils. And it is known that several of the last named class are about to adopt the combined system. The principal considerations which commend this sys- tem may be presented in a few words. The experience of nearly a century and a half of prac- tical instruction of the deaf has established no conclusion more clearly than that it is impossible to teach all deaf- mutes to speak. Some are found to be lacking more or less in mental capacity ; some have only a weak and in- efficient imitative faculty; with others an infirmity of vision is discovered; others again have little quickness of tactile perception. And it is far from being true, as the eminent scientist to whom reference has been made has affirmed, that "nature has inflicted upon the deaf child but one defect-imperfect hearing." In former times these doubly or trebly defective chil- dren were summarily dismissed from oral schools, with the unjust and inhuman condemnation that they were imbeciles. And even at the present they are quietly dropped from such schools under one pretext or another, because the oral teachers are perfectly well aware that they cannot be educated under their method. 'The essential defect in the oral method is, then, that it practically rejects a large proportion of the deaf as incap- able of education-that it fails with those who stand in greatest need of a helping hand. The radical deficiency of the manual method is that it makes no provision for imparting the extremely valuable accomplishments of articulation and lip-reading to the large percentage of the deaf that is certainly capable of acquiring these great gifts. The doors of the combined-system schools are wide open to alt the deaf-to the weaker as well to those more richly endowed with capacity for improvement. In these schools no method or appliance is rejected that can be shown to be of practical help to any number, however small, of the great class of the deaf. He who would assume the responsibility of advising parents as to the most desirable course to be pursued in the education of a deaf child should never forget that to teach such a child to speak comes very far short of edu- cating him. In oral schools there is a strong tendency to lay the stress and emphasis of the work of instruction on speech ; and to secure success in this many matters of greater importance to the pupil are sacrificed. For, in spite of the zealous assurances of promoters of oral teaching that speech is an inestimable boon to the deaf, the thing of paramount importance, it remains true that there is not one of the main objects sought to be accomplished in the general education of the deaf which will not be seen with a very little reflection to be of more consequence to a deaf child than the mere ability to speak and to read from the lips of others. To be able to read and write intelligently ; to possess the knowledge that is imparted in a common-school training ; to be master of a trade, by means of which one may gain a livelihood ; to be well grounded in principles of morality ; to enjoy an abiding faith in God, and a hope of immortal life ; surely each one of these, weighed over against a mere ability to speak, would be found of far greater value to the deaf. The achievement of imparting speech to one who has 384 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deaf-Mutes. Deafness, ear (otitis media purulenta acuta et chronica') which also have their origin in the pharynx, or result as a sequel of rhinitis. The coryza of the exanthemata very commonly has this termination. In view of the destructive char- acter of the process, and considering the anatomical pe- culiarities of the middle ear and its relations, the gravity of this affection cannot well be overestimated. Its ravages are not always confined to the parts which are primarily involved, but may invade the mastoid antrum, or by secon- dary invasion may give rise to caries, pysemic disturbance, cerebral abscess, and death (see Schwartze 3). For diag- nosis and treatment see Burnett.4 The following table indicates how much more fre- quently the cause of deafness is found to be located in the middle ear than in the external ear or the labyrinth. it not comes so near to being a miracle that one is daz- zled by the brilliancy of the triumph, and is apt to feel that everything else in the education of the deaf must be subservient to this. Parents and friends of the deaf need to be placed on their guard against this grave error, and to be advised that those schools and systems best deserve their confidence and support that seek to give the broad- est and most valuable education possible to all the deaf. Edward M. Gallaudet. DEAFNESS (Ger., Taubheit; Lat., Surditas). As blindness results from an alteration in any of the media through which the transmission of light is effected, so deafness occurs when there is a deviation from the normal condition in any of the media through which the conduc- tion of sound is accomplished. What deafness is may be best understood when we comprehend well what hearing is. To understand the philosophy of hearing, the converse of which is deafness, it becomes necessary to consider the instrumentality through which it is effected or the machinery necessary to its operation. The auditory apparatus, exclusive of the sensorium, presents a series of agencies for the reception, conduction, and perception of the sound influence, which stand in such a nice relation to each other that if one link of the chain be broken, the operation of the whole at once becomes suspended. The auricle concentrates the sound-waves and directs them to the external auditory canal, where the peculiar conformation of the canal and the air it contains serve both to intensify its force and regulate its impact against the drumhead. The impulse thus received is conveyed to the foot-plate of the stirrup (in the oval window) through the intervening ossicula auditfls which span the cavum tympani. This impression transmitted now to the laby- rinth operates in turn upon the labyrinthine fluid which delivers the oscillation to the expansion of the auditory nerve in the cochlea. We have thus presented to us the natural division into an external, middle, and internal ear, or an apparatus for the reception or collection of the sound-waves, another for their conduction, and a third which has to do with their final disposition. Deaf ness, then, may be defined to be an interference with the auditory function in any of the three parts which are essential to its performance. The interference may lie at the periphery, or may exist centrally. It may be conse- quent upon mechanical obstruction, or may be referable to pathological changes. An essential condition to normal hearing, and the one most liable to derangement, is a vibratile drumhead. This presupposes an unobstructed external canal and a pervious Eustachian tube, as an equal-pressure of air on both sides of the membrane, and an unaltered structure are indis- pensable to its vibratory function. The diseases which most commonly impair the efficiency of the membrana tympani, and so disturb the hearing, are those which have their origin in colds and are denominated catarrhal. These disorders, affecting first the naso-pharyngeal mu- cous membrane, find in the pharyngeal mouth of the Eustachian tube a point of entry to the ear. The simplest form of deafness is where the inflammation is limited to the tube, and the degree of deafness is proportionate to the intensity of the process and the continuance of inter- ference, from inflammatory closure, with the air-supply to the middle ear. The extension of inflammation to the middle ear constitutes an otitis media catarrhalis (non-sup- purative inflammation, Roosa). In the acute form, this disease is as amenable to treatment as are other acute in- flammations affecting other organs of the body. Neglect in the early stage permits the disease to become chronic, and paves the way for tissue changes, which are relieved only to that extent which might be realized from treatment of similar conditions elsewhere. For the diagnosis and treat- ment of otitis media catarrhalis, acute and chronic, see the treatise of Buck1 or of Roosa.2 The relative frequency of this in comparison with other forms of ear disease is as one to two and a half. The next most frequent cause of deafness is to be found in the suppurative forms of inflammation of the middle Reporter. Number of cases. External ear. Middle ear. Internal ear. Blake 6 1,652 466 1,128 58 Burnett 6 1.187 279 868 40 Spencer 1,263 243 978 42 It is seen that the ear affections which have their ori- gin in inflammations of the naso-pharyngeal mucous mem- brane constitute the vast majority of all the diseases of the ear. This is of the greatest significance. It should lead to a more careful study of the diseases of the nose. See Woakes,' Spencer Watson,8 Bosworth,9 Robinson,10 and Wagner.11 As would be naturally inferred, the constitutional treat- ment becomes also a very important factor in the treat- ment of deafness having this origin. The interferences with the hearing that may exist in the external auditory canal are best classified briefly into mechanical obstructions, and those which arise from in- flammatory action. Under the former heading are to be placed foreign bodies, accumulations of cerumen, exos- toses, and obstructive deformities; and under the latter, the inflammatory diseases of the meatus. See Buller, Affections of the Auditory Canal (in Vol. I. of this Hand- book). The diseases of the internal ear are rare. They are of primary or secondary inflammatory nature. Structural changes may be induced as a consequence of tympanic disorders, or they may result from the effect of toxic dis- eases or arterial disturbances. See Burnett, Affections of the Auditory Nerve (Vol. I.). Deafness may be unilateral or bilateral. Circumstances of exposure or individual habit or accident determine the diseased process to one side or to both. This must be the explanation if one ear is found to be affected more frequently than the other, as is claimed by some writers. The watch and the voice, in pronunciation of vowel sounds, are the most reliable tests which can be applied for discovering the extent to which the hearing is im- paired. The tuning-fork may be employed for the pur- pose of detecting if aerial conduction is obstructed. The vibration of the fork being communicated through the tissues of the head, the affected ear will be the one which is conscious of the sound. The greater liability of children to those diseases of the ear which give rise to high degrees of deafness, and which render them also liable to deaf-mutism, appeals urgently to the medical profession for a more general and accurate knowledge on this subject. Deaf-mutes are only dumb for the reason that deprived of hearing they are incapaci- tated for the acquisition of language. The causes of acquired deafness exist largely in such diseases as small- pox, measles, typhus, convulsions, paralysis, hydro- cephalus and other affections of the brain, and scarlatina, which more frequently than any other disease leaves the patient deaf. Hereditary transmission may be cited as another cause of deafness. Acquired deafness, which is of such a degree that it leads to dumbness, stands in relation to congenital deaf- ness as forty per cent, to sixty per cent. For statistical and other information about deaf-mut- 385 Deafness. Death. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ism (acquired and congenital) see Hartmann12 and Sex- ton.13 H. N. Spencer. 1 Diagnosis and Treatment of Ear Diseases. By Albert H. Buck, M.D. New York: William Wood & Co. 1880. 2 Treatise on the Diseases of the Ear. By D. B. St. John Roosa, M.A.. M.D. New York: William Wood & Co. 3 The Pathological Anatomy of the Ear. By H. Schwartze. M.D. Translated by J. Orne Green, A.M., M.D. Boston : Houghton, Osgood, & Co. 1878. 4 Treatise on the Ear. By Charles H. Burnett, A.M., M.D. Philadel- phia : H. C. Lea's Son & Co. 1884. 6 Statistical Reports by Clarence J. Blake, A.M., M.D. Archives of Otology, vol. iii., p. 84. 6 Annual Reports, Philadelphia Infirmary for Diseases of the Ear. 7 Post-nasal Catarrh and Diseases of the Nose causing Deafness. By Edward Woakes, M.D. London. 8 Diseases of the Nose and its Accessory Cavities. By W. Spencer Watson, F.R.C.S.. Eng., B.M. London. 9 A Manual of Diseases of the Throat and Nose. By F. H. Bosworth, A.M , M.D. New York: Wm. Wood & Co. 10 A Practical Treatise on Nasal Catarrh. By Beverley Robinson, M.D. New York: Wm. Wood & Co. 11 Diseases of the Nose. By Clinton Wagner, M.D. New York: Bir- mingham & Co. 12 Deaf-mutism and the Education of Deaf-mutes by Lip-reading and Articulation. By Dr. Arthur Hartmann, Berlin. Translated by James Patterson Cassells, M.D., London. Bailliere, Tindall & Cox. 13 Causes of Deafness among School-children, and its Influences on Education, with Remarks on the Instruction of Pupils with Impaired Hearing, and on Aural Hygiene in the Schools. By Samuel Sexton, M.D., New York. Government Printing Office, Washington, 1881. On the Necessity of Providing for the Better Education of Children with Defec- tive Hearing in the Public Schools. By Samuel Sexton, M.D., New York. Medical Record. December 20, 1884. The Classification of Deaf Pupils with a View to Improve the Facilities for their Education, Based on the Causes of their Disability. By Samuel Sexton, M.D., New York. (A paper presented to the International Congress of Educators, New Or- leans, 1885.) Syncope may be transient, however, as in fainting. There is then a momentary cessation of the heart's action, producing an anaemia of the cerebral centres, resulting in a brief period of unconsciousness and apparent death. In a fatal syncope the individual suddenly turns pale, a cold sweat starts, he becomes dizzy, the pupils dilate, vision becomes dim, the pulse slow, irregular, flickering, and in an instant life is gone. Or, he may suddenly be- come pale, make two or three convulsive gasps and drop dead. When the death is a little less sudden, as in fatal cases of haemorrhage, the perforation of intestinal ulcers, etc., we may observe great restlessness, tossing to and fro, labored respirations, muttering delirium, and, as the scene closes, single or repeated convulsions. In the Vessels.-When the cause of a sudden failure of the circulation is situated in the blood-vessels, it generally proves to be a rupture of their coats and the rapid reduc- tion of blood-pressure by the resulting haemorrhage. A condition closely allied to this sometimes results from an extreme dilatation of the blood-vessels of a single region. The most notable example of this is seen in the state of collapse that follows severe blows upon the abdomen, in which case the abdominal vessels are so distended as virtually to remove the greater part of the blood from the general circulation, and the heart soon ceases to beat from a lack of its normal stimulus. The individual is then said to die of shock. Cases of shock differ from those of syn- cope in that the victim may for some time retain his con- sciousness ; there may, however, be associated with shock a syncope due to the reflex inhibition of the heart, in which instance we have combined the symptoms of each. Shock, like syncope, may be transient, the vitality being gradually regained after a longer or shorter period of great depression. A Gradual Failure of the Circulation is the usual termination of a large number of diseases, particu- larly those of a chronic character. The heart ceases then on account of a failure of its own contractile power. This may result from degenerations of the muscular fibres, produced by continued high temperature, senile, fatty, or atrophic changes, the action of the micro-organ- isms of the infectious diseases, or of the poisons which they develop, or from such toxic sedatives as aconite, digi- talis, and tobacco. In this category are classed also deaths from cholera, acute peritonitis, and such wasting affec- tions as phthisis, diabetes, and cancer, as well as inanition and cold. In this mode of death, the most prominent symptoms are great muscular debility and a feeble, rapid pulse. The senses, however, may remain perfect to the last; but this, as well as the presence or absence of many other symptoms, must depend largely on the character of the disease upon which the death ensues. Cessation of the Respiration.-Death from this cause is known as death by apnoea or asphyxia, and may be sudden or gradual. Sudden failure of the respiration is due to a number of influences operating within or without the respiratory organs. The former class includes all obstructions and occlusions of these organs and all paralyses of their mus- cles as a result of injury or disease, local or central in character. Causes external to the respiratory organs in- clude all obstructions by foreign bodies or by pressure upon any part of the respiratory passage, as in suffo- cation, strangulation by hanging or drowning, and the action of noxious gases. The phenomena attending this mode of death are, vio- lent efforts at respiration, followed, we are told, by sen- sations of pleasure and a brief period of remarkable clear- ness of intellect. Unconsciousness and convulsions, or a few irregular twitchings of the muscles supervene, the face becomes swollen and cyanotic, the eyeballs protrude, then follow's a period of relaxation, and last of all, the heart stops. A gradually fatal apnoea is a common result of disease. It is produced by any morbid process which gradually obliterates the lumen of the respiratory passages, e.g., papillomata and other neoplasms of the larynx, oedema of the mucous membrane, false membranes of the trachea DEATH, MODES OF. The modes of dying are as va- rious as are the causes of death, and may conveniently be considered in a corresponding classification. Life, whether systemic or molecular, depends upon the proper performance of the functions of circulation and respira- tion ; so death, w'hether the result of disease, of violence, or of senile decay, is due ultimately to the cessation of one or the other of these functions. The causes which result in the permanent suspension of circulation and respiration operate directly upon their mechanism, or remotely through the nerve-centres which regulate their action. So important indeed to the proper continuance of these functions is the maintenance of an uninterrupted action of the nerve-centres of organic life, that it is customary to adopt the classification of Bichat and to speak of death beginning at the head, death beginning at the heart, and death beginning at the lungs. For practical purposes this is sufficiently accurate, and it must be admitted that any attempt at more definite classifica- tion is merely theoretical. The phenomena attending each of these modes of dissolution are at least sufficiently distinct to merit separate consideration. Cessation of the Circulation may be sudden or gradual. The former is witnessed in deaths from syn- cope and shock ; the latter, in those from asthenia. The chief force in the maintenance of the circulation is the normal difference in pressure of the blood in the arteries and veins. Any influence, therefore, that overcomes this difference will cause the circulation to stop. As the maintenance of this blood-pressure is due chiefly to the action of the heart, the lesions that most frequently pro- duce a fatal interruption of it are found for the most part in that organ. But they may also be found in the ves- sels. In the Heart.-When, from the occurrence of any organic or structural lesion, the heart is rendered no longer capable of propelling its contents into the arteries, the circulation is obliterated and death ensues. But the movements of the heart may be suddenly and perma- nently arrested also by either direct central impulses, as by a gun-shot injury, a blow upon the head, or a violent emotion, as of fright, joy, grief, etc.; by such reflex im- pressions as those resulting from a blow upon the epigas- trium or the rupture of abscesses, cysts, the gravid uterus, etc.; by the action of corrosive poisons on the mucous membrane of the stomach, or even by the ingestion of very cold drinks, in excess, or in the presence of an over- heated condition of the system. 386 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deafness. Death. and bronchi, and the pneumonic exudation. Failure of the respiration is occasionally the prominent symptom in death from phthisis (catarrhal pneumonia), and it may result from the pressure of large abdominal tumors or ascites. Individuals dying in this manner exhibit much the same series of symptoms as those whose death is more sudden, but the struggle is less pronounced. Death from Central Paralysis.-Paralysis of the vital nerve-centres, or "death beginning at the head," operates by causing a failure of the circulation or respira- tion. Diseases, whether primary or secondary, and in- juries located in the cerebrum or the cerebellum, may result fatally through extension of the inflammation or pressure upon the pons or medulla. Certain drugs, es- pecially the narcotics, and certain poisons created within the body as a result of the non-elimination of such waste products as urea, impress both cerebral and spinal centres, and ultimately overcome respiration and circulation. The most prominent symptom indicative of approach- ing death from this cause is unconsciousness, or coma (carus). All reflex movements soon cease ; the respira- tion becomes stertorous, gradually more slow and labored, and at last stops, tranquilly, or after convulsive mani- festations. Finally, it should be remembered that the instances in which a death can be clearly traced to the failure of a single group of organs is the exception and not the rule. On the contrary, it will generally be observed that with the ebbing of life, the failure of one system follows so closely upon that of another as to render it extremely difficult to determine which of the vital functions is the last to cease. James M. French. needle into the muscular substance of the heart, intro- ducing it at the third or fourth intercostal space on the left side. Should life be still present, no injury need result, if the needle be aseptic, and any movement will be indi- cated by a corresponding movement of the needle. Absence of Respiration.-The respiratory move- ments may become so reduced, particularly in cases of poisoning by the narcotics, that their detection is of the utmost difficulty. In addition to careful auscultation, the methods ordinarily employed are, placing a flake of cotton-wool or feather-down upon the lip in order to de- tect by its motion the presence of air-currents ; holding a cold mirror close to the mouth to discover the presence of moisture in such currents, and placing a vessel of wa- ter or mercury upon the abdomen in order to reveal by the reflection on its surface whether movements occur. The following signs, although most of them not indi- vidually competent, are of great value when taken col- lectively. The Skin.-With the cessation of the vital functions the surface of the entire body becomes pale and of an ashen hue, owing in part to the removal of blood from the tissues, and in part being the result of its decomposition. For the same reason the skin loses its transparency, and the thinner parts of the hands, as the borders of the fin- gers when approximated, will no longer transmit the rays of the sun. The subcutaneous tissues also lose their elas- ticity, so as to assume the mold of the surface upon which the body rests ; and the skin, if pinched up between the fingers, but slowly regains its natural position when re- leased. The features have usually a shrunken appearance, acquired in the dying hour (facies Hippocratica); the nose is pinched, the lips are cold, livid, and inelastic. A froth may have collected about the mouth and nostrils, and, when present, is of value as indicating the absence of respiration. Burns, bruises, and cauterizations made in the skin of one dead are not followed by the efforts at repair which occur in the living, and may be employed as a test of the presence of life ; but the pale appearance of the borders of ulcers is not to be relied upon. Hypostasis.-Owing to the loss of elasticity in the walls of the blood-vessels within a short time after death, the blood gravitates to the more dependent parts of the body, and produces deep discolorations of the skin. These hypostatic spots may be distinguished from ecchy- moses, or extravasations into the tissues, by the fact that the blood is confined within the vessels, as may be dem- onstrated by incision, and that, as long as the blood re- mains fluid, these spots may be caused to disappear by pressure, or by reversing the position of the body a simi- lar discoloration will in a short time appear in the part that is thus made most dependent. Hypostatic discolora- tion generally makes its appearance within eight or ten hours after death, but its value as a sign of death is di- minished by the fact that similar discolorations not in- frequently appear as a result of disease, or in the bodies of invalids long confined in one position. The Eye.-In the death-agony the eye assumes a pe- culiar vacant stare; the pupil, usually contracted, di- lates, as the iris relaxes, with a wavy motion and becomes fixed at a moderate degree of expansion. Gradually the cornea becomes clouded so as to render indistinct its line of junction with the sclera ; the eyeball becomes less tense and sinks deeper into its socket. The dark corneal spots described by Larcher, and appearing first at the outer angle, then at the inner, although of some value, are but the early indications of decomposition and appear after other equally positive signs of death. Liersch has proposed, as a test, the puncture of the anterior chamber. After real ' death the evacuation of the aqueous humor does not occasion a contraction of the pupil ; and, as a further test, it will be found that the fluid is not re- formed. Ophthalmoscopic Appearances. - Much more positive than the merely superficial appearances of the eye are those revealed by the ophthalmoscope. With the cessa- tion of the heart's action the arteries of the retina rap- idly diminish in size. The optic disc loses its reddish hue as the blood is withdrawn from its capillaries, and ap- DEATH, SIGNS OF. Immediately after death certain changes occur in the body which directly tend toward the return of its elements to those of the outer world ; and from the earliest days of antiquity a universal dread of being buried alive has led to repeated efforts to dis- cover in these changes some criterion by which real death may be easily discerned. The conditions most readily mistakable for death are syncope, asphyxia, and cata- lepsy. Although no easily applied and unfailing test has yet been discovered, the following signs will in most cases suffice. Information of some value may be elicited by the merely superficial examination of the body. The sus- pension of all intellectual and sensorial faculties, the facial expression, and the absence of muscular power, as well as the position of the body and the presence of cer- tain wounds will at times greatly facilitate a decision. But in most cases in which the physician is called upon to determine the reality of a death, it will be necessary to search for more positive indications. Absence of the Circulation is the most positive sign of death and, if demonstrated, renders further in- vestigation unnecessary. Mere pulselessness of the arte- ries must not, however, be accepted as proof that the heart has ceased to beat. The methods generally employed to determine this fact are several. Palpation, and both mediate and immediate ausculta- tion of the precordial region should be carefully practised by one skilled in the art. Ordinarily, a few minutes will suffice for the examination, but the reported cases of Colonel Townsend, and of certain Indian fakirs who were accredited with the power of voluntarily passing into a state resembling the hibernation of animals, although probably owing their credence to inaccuracy of observa- tion, demand that a much longer time, half an hour or more, be spent in the investigation of doubtful cases. The application of a ligature to a finger or toe is an old method. If the body be dead no change results, but if the blood still circulates, it is asserted that, in the course of a few minutes, the distal portion of the extremity will assume a livid hue, owing to the arrest of the venous cir- culation, with a narrow band of arterial, anaemia at the seat of ligature. As a final and crucial test of the presence or absence of cardiac movements, it has been proposed to pass a fine 387 Death. Decidua. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pears as a distinct white spot, the fovea centralis also be- coming pale and indistinct, or even more intensely white than the surrounding zone. As the blood is expelled from the arteries by the contraction of their walls, these vessels become gradually less distinct from centre to periphery, and finally, invisible. The veins remain for a while almost normal in appearance, later they not in- frequently disappear from the disc, and, owing to the breaking up of the columns of blood within them as the body cools, acquire a beaded appearance. The color of the choroid soon becomes less intense, owing also to the removal of the blood from its capillaries, and in part, probably, to the beginning opacity of the cornea ; its color varying from an orange or gray to a yellowish- brown, according to the depth of its pigmentation. In a short time these appearances begin to be less distinct, un- til, in the course of five or six hours, the increasing opac- ity of the cornea and other media veils the deeper structures from view. Cooling of the Body.-After death the generation of heat rapidly diminishes, and the temperature of the body falls gradually to that of the surrounding media. The rapidity of this thermal decline is not the same in all instances, but is regulated in general by the physical in- fluences which govern the radiation and convexion of heat in inorganic bodies. Among these are the tempera- ture and conductivity of the surrounding media. The presence of a thick layer of adipose tissue, a warm at- mosphere, much clothing, etc., retard cooling, while the opposites of these conditions, and immersion in cold water, greatly hasten it. The bodies of those dying at the extremes of life cool more rapidly than those of middle life, and certain modes of death influence the reduction of bodily heat. The bodies of those dying of cholera and yellow fever, for example, continue for several hours to generate heat, and cool slowly. It is asserted also that after death from a stab-wound or a stroke of lightning, the body retains its heat longer than after other modes of death. As mle, the corpse becomes cold to the touch in from eight to twelve hours after death ; twice or three times as long being required for the loss of the visceral heat. The superficial coldness of collapse, or of one ap- parently drowned, must not be considered a positive in- dication of death, for sufficient heat may yet remain within to admit of resuscitation. Absence of Muscular Contractility.-Fora period of about three hours after somatic death, the voluntary muscles retain sufficient vitality to admit of their being thrown into contraction upon the application of the Fa- radic current. Contractility, if present at a later period after apparent death,, is therefore a sufficient cause for further investigation. An exception to this rule is ob- served, however, in robust individuals who have suddenly succumbed to yellow fever or cholera, for in these strong muscular contraction sometimes occurs, as a result of merely mechanical stimulation or even spontaneously, several hours after death. Rigor Mortis.-Sooner or later after systemic death coagulation of the muscle-plasma takes place, causing firm contraction and a loss of the irritability and supple- ness characteristic of living muscle. The peculiar condi- tion thus acquired is known as post-mortem or cadaveric rigidity, and is one of the most positive signs of death. The change indicates the death of the muscle itself, and is attended by a moderate shrinkage and shortening which firmly binds the limbs in the position they held at the time of its development. The muscles usually enter rigor mortis in a fixed order: first those of the jaw and neck ; next those of the trunk ; then those of the arms, and lastly, those of the legs. The time that elapses before the onset of rigidity is variable, however, and is determined to a great degree by external circumstances, as well as by internal conditions of the body and, to some extent, by the mode of death. External warmth hastens and cold retards its development. Where death is the result of a chronic wasting disease, or follows immediately upon violent muscular exercise or great nervous excitement, as in soldiers and suicides, the rigor appears to fix the mus- cles in the position in which their last contraction placed them. Rigidity of so rapid development is, as a rule, however, more transitory than when of slower develop- ment ; hence we may say that the more delayed the onset of rigidity, the more pronounced and the more enduring it will be. The rigor mortis is rarely, or perhaps never, delayed longer than twenty-four hours after death, but its duration may vary, from so short a time as almost to escape observation, up to a week or even more. Cada- veric rigidity is distinguished from that of catalepsy by the fact that, if once forcibly overcome, it does not re- turn. Another distinction that is made is in the position of the hands. In real death the thumb, unless in some manner resisted, is drawn in upon the palm, the fingers flexing over it; in feigned death the thumb is usually free and extended. The stiffness of the limbs of one ap- parently drowned closely resembles that of death, but should not be permitted to prevent efforts at resuscita- tion in doubtful cases. The rigidity of freezing invades at the same time and to the same degree the muscles of all parts of the body, and if overcome, gives rise to a crackling sensation not observed in merely post-mortem rigidity. Putrefaction.-The most unequivocal sign of death is putrefaction, the process being considered only with reference to its occurrence in the more superficial parts of the body. Although many of the post-mortem changes already referred to are but the early indications of the general putrefactive process, the term is not usually em- ployed until the decomposition is recognizable by the ap- pearance of a distinct alteration of color and the presence of a peculiarly offensive (putrid) odor. Putrefaction is generally first observed as a greenish discoloration of the skin covering the abdomen; thence its advance is gradual until the entire surface is involved. Putrefac- tive changes may occur in the body during life, and the results of septic disease may resemble somewhat the cadaveric decomposition ; but such discolorations rarely if ever lead to error, as they can usually be distinguished from those of death by their form and location ; by the presence of tumefaction and other results of inflammation ; by the depth to which the tissues are involved, as readily shown by incision ; and by the absence of the cadaveric odor. Such lesions, as well as the results of contusions and abrasions of the surface, however, are favorite points for the development of the putrefactive process, and are not seldom the first to exhibit signs of further decompo- sition. In general the signs of putrefaction may be expected soonest in corpses exposed to a warm atmosphere (20° to 35° C. = 68° to 95° F.), in the presence of moisture. A very low or a very high (100° C.) temperature, and im- mersion in fluids, indefinitely suspend decomposition ; but these, in addition to being incompatible with life, soon produce other alterations by which its absence is demon- strated. Putrefaction occurs earliest in the bodies of in- fants and females, and is hastened by the presence of much adipose tissue. Such acute maladies as pyaemia, variola, and typhus, the presence of anasarca, and poison- ing by the narcotics, hasten the onset of decomposition ; while death from asphyxia or wasting chronic diseases, or from poisoning by arsenic, digitalis, alcohol, and acids, retard its development. These, then, are the signs most frequently sought for and upon which, when found, most reliance can be placed. Although the value of some of them varies greatly under certain conditions too numerous for present notice, others, when properly tested, are so certain as to preclude the possibility of error ; and it is safe to conclude that where the existence of life is overlooked, the accident is attrib- utable to neglect on the part of the observer rather than to a lack of sufficient evidence of death. James M. French. DECIDUA. The name decidua, more rarely caduca, is given to the mucous membrane of the uterus during men- struation and gestation, for during the activity of those functions the mucous membrane differs considerably in structure from the same membrane during the repose of the uterus. The term decidua properly applies only to 388 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Death. Decidua, the membrane during pregnancy, but as the changes dur- ing menstruation are similar in character, though less in extent, the same designation may be employed correctly in both cases. When the resting mucosa is transformed into the de- cidua it is thickened-becoming from about 2 mm. in- often bifurcated in their lower third ; round or oval in transverse section ; they run more or less perpendicularly to the surface of the membrane upon which they open ; yet, strictly speaking, this is true of the glands in their upper half only, and even in that part their course is not straight but wavy. In their lower half they deviate much more, being more irregular and tortuous, the fundus curved-sometimes even so much as to run parallel to the muscular layer (Engelmann).2 The glands are invagina- tions of the uterine epithelium, are lined by ciliated cylinder cells, and have a nucleated basement membrane formed by a layer of anastomosing connective-tissue cells (Leopold)4 ; they reach to and may even slightly penetrate the muscularis. The spaces between the glands are filled with cells, a small amount of connective-tissue fibres, numerous blood-vessels, and lymphatics. It is quite probable, it may be added, that there are really no con- nective-tissue fibres, but that what have been taken for such are only processes of the connective-tissue cells. The blood-Vessels enter as veins and arteries from the mus- cularis, and take a winding course toward the surface ; the capillaries form a network around the glands and under the surface of the mucosa; the capillaries of the superficial network are unusually wide. The inter- glandular cells are of two kinds : first, spindle-shaped ; second, round cells ; the former represent the true paren- chyma, and are connective tissue of a somewhat embry- onic type, being elongated cells with oval nuclei and branching processes which anastomose with one another (Fig. 800). The spaces of this cellular network com- municate, according to Leopold,4 with the lymphatic vessels of the muscularis and external serosa, and may therefore be regarded as lymph-roots or lymph-spaces. The branching spindle-cells resemble somewhat those found in the umbilical cord and other embryonic struct- ures, and known under the name of mucous tissue. They tend to crowd together around the blood-vessels and glands, sometimes forming a special sheath. The nucleated basement-membrane of the glands is such a sheath (Fig. 800). The round cells, which are probably inactive leucocytes or wandering cells, lie in the spaces between the spindle-cells, and are very numerous. Their number is probably variable, but no exact observations on this point have been made. Decidua Menstrualis.-The history of the mucosa during the monthly cycle has been elucidated in part only. Our present knowledge is based chiefly upon the articles of Kundrat,3 Engelmann,2 Leopold,2 Wyder,1 and Fig. 800.-Connective Tissue of Mucosa ; Pig's Uterus. (After Leopold.) aa, Capillaries; bb, sheath of the same; c, uterine gland; d, gland- sheath. creased to 6 or 7 mm. in menstruation, and to 10 mm., in some parts, during pregnancy. The thickening depends chiefly upon a proliferation of the cells in the connective tissue, accompanied probably by a considerable immigra- tion of leucocytes, and upon the appearance of an enor- mous number of very large, highly characteristic cells, with one or more nuclei each ; these are called decidual cells, and without these cells there can be no true decidua ; the thickening depends fur- ther upon an expansion of the uterine glands, especially in their deeper portions, and upon the development of hy- peraemia in the layer. All these changes are more marked in the decidua of pregnancy than in the de- cidua menstrualis. The mucosa of the cervix does not form a true decidua, although it becomes tumefied and altered during gestation. We proceed therefore to give a detailed history of the mu- cosa of the body of the uterus only. The mucosa corpus uteri, at birth, is about 0.2 mm. thick, soft, pale gray, or reddish gray ; it consists of a cover- ing ciliated cylinder epithe- lium, and a connective-tissue layer ; it is without glands, the glands not appearing usually until the third or fourth year, and developing very slowly up to the age of puberty. Wyder1 has shown that the time of the appearance of the glands is extremely variable. In the virgin resting uterus, after puberty, the mucosa is about 1 mm. in thickness. The glands are tubular, Fig. 801.-Vertical Section of the Mucosa Corpus Uteri of the First Day of Menstruation. Msc, muscularis; Muc. mucosa. The blood-vessels are much distended ; the glands much contorted ; there is a sub-epithelial blood infiltration, in consequence of which the epithelium is partly lost. (After Leopold.) Overlack.21 Williams'6,7 articles are misleading ; the author maintains that the whole mucosa disappears from the body of the uterus during menstruation. This view, which is now definitely known to be erroneous, is based upon, 1, failure to consider the effects of disease upon the uteri observed (cf. Wyder,1 p. 24); 2, erroneous observa- 389 Decidua. Decidua. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tions ; 3, erroneous interpretations, involving a total dis- regard of the elementary laws of histogenesis. It is deemed necessary to be explicit in regard to this view, as Williams is often referred to as an authority. The actual changes, so far as known, are as follows: A few days before the menstrual flow the membrane gradually thickens; the surface becomes irregular, the openings of the glands coming to lie in depressions. The tissue becomes more spongy ; the connective tissue pro- liferates, and the cells come to lie farther apart, and, it is said by some authors, are enlarged; the number of round cells (leucocytes ?) is greatly increased ; the glands expand and become more irregular, especially in the deeper portions of the membrane ; a short time before the bleeding begins the blood-vessels, capillaries, and veins become greatly distended. When all these changes have reached their maximum, menstruation proper begins. Besides these changes, another essential one is the appear- ance of very numerous large cells, with one or several nuclei and finely granular contents ; these are the well- known decidual cells, sometimes called simply giant- cells, although it is now usual to restrict the latter term to the larger multinucleate cells. The decidual cells vary greatly in size and form ; for the most part they ap- pear as oval or rounded disks ; oc- casionally with branching process- es. The origin of the decidual cells is At the close of menstruation the mucosa is two to three mm. thick, and the regeneration of the lost layers be- gins and is completed in a variable time, probably five to ten days. The hyperaemia rapidly disappears ; the ex- travasated blood-corpuscles are partly resorbed, partly cast off ; the spindle-cell network grows upward, while from the cylinder epithelium of the glands young cells grow up and produce a new epithelial covering; new sub-epithelial capillaries appear. Now follows a time of rest, which comprises probably less than half the monthly period ; approximatively the period is divided as follows : the progressive hypertrophy before menstruation, five days (but according to Hensen, ten days); menstruation, four days ; regeneration, seven days ; rest, twelve days. Decidua graviditatis is the decidua menstrualis pre- served in situ, and considerably metamorphosed in conse- quence of pregnancy. Absolutely nothing is known as to the physiological causation of this metamorphosis be- yond the fact that it is due to the presence of a fertilized ovum in the female passages. By analogy with animals, we must suppose that impregnation always takes place in the upper end of the oviduct, and never lower down, presumably because the ovum undergoes during its de- scent a very rapid degen- eration. Hence we must assume that in all placen- tal mammals, including man, the presence of a fertilized ovum in the up- per end of the Fallopian tube causes the omission of menstruation and the uncertain ; some authors have considered them transformed leucocytes; others modified connective - tissue cells ; but Overlach21 has rendered it probable that they arise endogenously in the epithelial cells, and thence migrate into the connec- tive-tissue layer of the mucosa. Menstruation proper is initiated by an infiltration of blood under the lining epi- thelium, probably in consequence of rup- tures of the distended capillaries ; and this increases during a day or two, and is apparently the immediate cause of a very rapid molecular disintegration of the su- perficial layers of the mucosa, which, in consequence, are lost; the superficial blood-vessels are now exposed, and by rupturing cause the well-known haemorrhagia of menstruation ; by the disappearance of the upper portion the thickness of the mucosa is abruptly reduced during menstruation. Over- lach21 thinks it probable that the infiltration of the tissue with blood takes place per diapedesin, since no one has hitherto actually observed ruptures of blood-vessels, ex- cept where they have been exposed by the loss of the covering tissue. Signs of fatty degeneration are found during the above-mentioned disintegration ; Kundrat and Engelmann3 supposed this degeneration to precede and cause the haemorrhage, but this view has not been con- firmed by subsequent investigation, it having been found that the degeneration begins later than the bleeding. commencement of the development of the decidua graciditatis. When several (probably six to eight) dayslater the ovum reaches the uterus, it then attaches itself, by unknown means, to some point, usually on the posterior wall of the uterus. Lowenthal,8 who shares the too frequent misapprehensions of gyneco- logists in regard to the site of impregna- tion, thinking that it is impossible for a re- mote ovum to exert such a marked influ- ence on the uterus, has advanced the hy- pothesis that the ovum is fertilized in the uterus, and affects it by direct contact. His critic, Nyhoff (Centralbl. Gyn., 1885, No. 26, p. 401), thinks impregnation may occur either at the ovary, in the Fallopian tube, or in the uterus. But, as already stated, there is no reason to sup- pose the ovum to reach the uterus until it has accom- plished several days' development. At the point where the ovum is attached there occurs a very rapid hypertrophy of the mucosa,9 and besides that there is a decidual covering (d. reflexa) formed over the whole of that portion of the ovum which is not at- tached to the uterine wall. Various theories, in default of any actual observations, have been advanced to explain the formation of the decidua reflexa. The most generally accepted view is, that when the ovum is attached the de- cidua forms a ring-like up-growth around the ovum. The up-growth grows higher and higher, arches over the Fig. 802.-Uterus about Forty Days Ad- vanced in Pregnancy. (After Coste.) Mwc, muscularis; Dv, decidua vera ; D. ref, decidua reflexa; Ov, ovary; Ovd, Fallopian tube; Lig, round liga- ment ; Vg, vagina. The uterus has been opened by cutting through the anterior wall, and reflecting the sides. 390 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Decidua. Decidua. ovum, and finally completely encloses it as under a dome. The decidua now consists of three parts : 1, the reflexa, covering the ovum ; 2, the serotina, the area over which the ovum is attached to the uterine wall; 3, the vera, or the mucosa over all the remaining portions of the body of the uterus. The serotina, together with the foetal chorion frondosum, constitutes the placenta. A clear idea of these relations may be gathered by an examination of a uterus in an early stage of pregnancy (Fig. 802). The mucosa is enormously hypertrophied, and contains a great many dilated, irregular blood-sinuses, and at one point turns back, as it were, to form a large bag, D. ref, which hangs down into, and nearly fills the cavity of the uterus. If the bag (sac of the reflexa) be opened, we come upon the villous chorion of the ovum, and find the tips of the chorionic villi attached to the in- ner surface of the decidua. If, instead of opening the uterus as described, a section be made through it in the proper plane, the disposition of the parts will be found essentially as shown in Fig. 803. In gross appearance the decidua is reddish-gray, spongy or pulpy, soft, and very moist; after the fourth month smooth ; the inner surface of the reflexa is more irregular, and the protuberant parts are united with the tips of the foetal chorionic villi; the surface of the serotina, on the other hand, becomes more and more irregular as preg- nancy advances, gradually forming more and more irreg- ular, jagged protuberances (cotyledons), which surround and attach themselves to the ends of the chorionic villi, and which may even reach a considerable distance up be- tween the villi toward the ovum, thus constituting the so-called decidual septa of the placenta. The blood- vessels of the mucosa are all enlarged ; those in the deeper parts to a lesser degree than the superficial capil- laries and veins, which are enormously dilated, forming huge sinus-like cavities in the upper stratum of the deci- dua. Many authors maintain that the walls of these sinuses in the serotina rupture, letting out the maternal blood to circulate in the intervillous spaces of the foetal chorion. Others consider that the vessels remain intact. Turner 13 reports that he has seen crescentic openings in the serotina vessels of a monkey (macacus) leading directly into the intervillous spaces; if this observation is con- firmed and extended to man, it would go far toward settling the controversies as to the placental circulation. A positive decision, however, between the conflicting opinions is at present impossible, but I am inclined to strongly doubt that the chorionic villi are normally bathed in maternal blood. Consult also Turner 10, ",12. With the growth of the foetus, and the consequent dila- tation of the uterus, the deciduae, of course, rapidly in- crease in superficial extension. There goes on a steady growth of the tissues, but not sufficient to effect the ex- pansion of the membrane in both superficies and thick- ness throughout the whole period of pregnancy. The growth begins by a thickening over the area of the uter- ine wall to which the ovum is attached, so that during the third, and perhaps fourth week, this area {serotina) is the thickest portion of the decidua (Kollmann9) ; but, the reflexa and vera also thicken and soon outdo the sero- tina. By the end of the fifth week the reflexa measures nearly 2 mm., and the vera fully 1 ctm. The absolute thickness of the serotina does not change greatly after this period, remaining 3 mm., or a little less, to the end of pregnancy. On the other hand, by the eighth month the reflexa has been gradually reduced to 0.3-0.5 mm., and the vera to about two mm. It must further be added that the reflexa is considerably thinner over the pole opposite the serotina, and that the vera thins out toward the cervix, and toward the opening of each Fallopian tube. During the fifth month the reflexa, which by the growth of the ovum is pressed close against the vera, unites with the vera, completely obliterating the cavity of the uterus. But after the union, and, indeed, even at the time of delivery, the reflexa and vera remain distin- guishable. Histology.-Besides the features of the development of the decidua of pregnancy already mentioned, we have still to consider, (1) the changes in the glands, (2) the ori- gin and history of the so-called decidual cells. The glands are already dilated in the menstrual mu- cosa ; in pregnancy the dilatation is continued, but still affects mainly the deeper parts of the glands ; in the same proportion as the uterus expands, the deep portions of the glands become stretched in their transverse diameter, and appear during the latter half of pregnancy rather as narrow fissures (Fig. 804); by the fifth month the glands can no longer be traced in the upper compact layer. The glandular epithelium is at first distinct, but is greatly al- tered in character even by the fifth week ; it becomes thin, its cells grow cuboidal, or else wide and flat, are irregular in size and shape, and for the most part hyaline, with gran- ular nuclei; some of them undergo fatty degeneration. Authors disagree as to whether the epithelium persists or not, but I am convinced that it remains even post partum, and is the source whence the regeneration of the uterine epithelium is effected. The partitions left between the glands are quite thin (Fig. 804); they carry the blood-ves- sels and contain numerous spindle-cells, and, it is said, also multinucleate giant-cells after the fourth month. The spindle-cells, as Langhans states, resemble smooth Fig. 803.-Semi-diagrammatic Outline of an Antero-posterior Section of the Gravid Uterus and Ovum of Five Weeks. (After Allen Thomson.) a. Anterior surface; p, posterior surface ; m, inuscularis; g, inner margin of metamorphosed mucosa; s to s, area of decidua serotina ; all the parts of the mucosa adherent to the uterine walls not in the area of the serotina constitute the decidua vera; ch, chorion, within which is the embryo enclosed in the amnion, and attached to the walls of the chorion ; appended to the embryo is the long-stalked yolk sac; the chorion is covered in by the arching extension of the mucosa, which is the decidua reflexa, r, r. it acquires, especially in the superficial layers, a duller brownish color, which subsequently becomes more marked ; this coloration is due to the decidual cells. The vera, and serotina are divided into a superficial, more compact layer, and a deeper cavernous or spongy layer (Fig. 804); the two layers are usually of about equal thick- ness, but the cavernous layer sometimes encroaches upon the compact layer. After the fifth month they are found very distinctly differentiated; the lumina of the deep layer are the cavities of the enlarged and irregular uterine glands. During the first three or four months the scattered openings of the uterine glands can still be dis- tinguished over the surface alike of the vera and serotina, and over both surfaces of the reflexa. The surfaces of the vera and reflexa, though irregular, remain more or less 391 Decidua. Decidua. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. muscle-cells in appearance, but when isolated are seen to be rather broad and rounded and flat. They ought probably to be regarded as true decidual cells. As to the possible function of the glands, see Uterine Milk. The decidual cells (Fig. 805) are the most striking of the histological elements of the decidua. They are very large, somewhat flattened, oval, or branching cells, which assume a characteristic brownish color after the fourth month. They usually have a single, often nucleolated nucleus, but sometimes two or more ; during life the nucleus appears homogeneous. They are very numerous, and constantly increase in number up to nearly, if not quite, the termi- nation of gestation. In size they vary from 0.03 to 0.1 mm. (Fig. 805). Kundrat and Engelmann and others main- tain that the cells undergo fatty degeneration before de- livery, and attribute the loosening of the placenta to the very fact of the fatty metamorphosis. This view is at best questionable, and it is even doubtful whether the fatty change is a constant phenomenon. Besides the cells just described, occur also very large decidual (giant) cells, often with branching processes, and having from two to sometimes even forty nuclei, the number of nuclei vary- ing with the size of the cells. The giant-cells appear quite abruptly and abundantly during the fifth month. They lie at first principally in the neighborhood of the blood-vessels of the deep parts of the decidua; they do not occur in the reflexa, and are far less numerous in the vera than in the serotina. The giant-cells are perhaps only an inter- mediate stage in the mul- tiplication of the smaller decidual cells, each nucle- us finally separating from the parent cell (with its share of the parent pro- toplasm) to make a deci- dual cell ; if this is the case it accounts for their final disappearance. The decidual cells are crowded together in the upper or compact layer, and contribute much to give that layer its main characteristics. By the eighth month they are found to have wandered into the cellular layer of the placental chorion (see Chorion), apparently finding an entrance at the edge of the placenta. The origin of the deci- dual cells is uncertain ; three views have been advocated : first, they are modified leucocytes (Hennig, Langhans et al.); second, they arise from connective-tissue cells of the mucosa (Leopold); third, they are produced by the epithelium (Overlach21). Hitherto the second view has been the one most generally held, but the observations of Overlach are very much in favor of the third view ; but as he has studied only one uterus with pseudo-menstrua- tion from acute phosphorus poisoning, his theory cannot be definitely accepted until verified by further observa- tions on normal uteri. Overlach found in the cervix of the uterus in question the lining epithelial cells to con- tain an endogenous brood of small cells, one to fifteen in each parent-cell ; the daughter-cells begin as nuclei, around which there gathers a protoplasmatic body for each. The cells are like the young decidual cells just below, so that we may assume the latter to have wandered forth from the epithelium. Probably the same process had been going on in the body of the uterus also, before the epithelium had been lost. Scattered among the decidual cells may be seen a num- ber of smaller cells, which are more conspicuous during tlie earlier months, and are usually regarded as wandering cells (leucocytes). Langhans14 regards the leucocytes as the parents of the giant and decidual cells. Changes in the Blood-vessels.-Besides the transforma- tion of the superficial capillaries and veins into large sinuses, and the other changes mentioned under the gross appearances, the following alterations in the blood-vessels must be noted. The vessels of the vera and reflexa reach their maximum development at the end of the second month, when they begin to atrophy, to finally disappear, persisting however much longer in the vera than in the reflexa. Friedlander 15,,B, has made the very important discovery, since confirmed by Leopold5 (xi., 492-500), that sponta- neous thromboses arise in the serotina during the eighth and last months. In the veins of the muscularis near the serotina, and to some extent in those of the serotina itself, there occur during the latter months of pregnancy a very great immigration of giant-cells, which cause (?) the for- mation of thrombi, and consequently, so it is supposed, venous congestion of the uterus. Now, if it is true, as Browu-Sequard has maintained (" Experimental Re- searches Applied to Physiol. Path.," 1853, 117), that car- bonic acid excites, toward the end of gestation, uterine Fig. 804.-Section of the Decidua Serotina, near the Margin of the Placenta, Normal Uterus about Eight Months Pregnant, me, Muscularis; D', D", decidua serotina ; D', cavernous or spongy layer; D", compact layer; Pi, scattered chorionic villi. The intervillous spaces were filled with blood, which is not represented in the figure.. contractions very readily, then it is possible that the venous congestion above mentioned may be one of the proximate causes of parturition. Changes in the Muscularis during Gestation.-The mus- cularis undergoes an extensive hypertrophy. This is due to an elongation of the muscle-cells (from inch to inch) and thickening of the same, and due, it is said also, to the development of new muscle-cells from small nucle- ated granular cells lying in the tissue (Cf. Elischer).17 Decidua Serotina at Eight Months.-In a normal uterus, about eight months pregnant, I find the following relations : The serotina is about 1.5 millimetre thick, and contains an enormous number of decidual cells (Fig. 804); the cavernous, D', and compact layers, D", are very clearly separated ; the mucosa is sharply marked off from the muscularis, although scattered decidual cells have penetrated between the muscular fibres. The muscularis is about ten millimetres thick, and is characterized by the presence of quite large and numerous venous thrombi, especially in the part toward the decidua. The decidua contains few blood-vessels. Upon the surface of the de- cidua can be distinguished a special layer of denser de- 392 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Decidua. Decidua. cidual tissue, which in many places is interrupted by the ends of the chorionic villi which have penetrated it; this is well shown in Fig. 804. The gland cavities of the spongy layer D' are long and slit-like ; they are filled for the most part with fine granular matter, which colors light blue with haematoxyline ; they also contain a little superficial portions of the serotina and vera. The split, according to Friedlander,15,16 usually occurs in the upper or compact layer just above the cavernous or glandular layer, leaving the surface of the uterus smooth and glis- tening ; but the surface of the placental area is thrown into irregular hills and valleys. Sometimes the split oc- curs at or just below the upper limit of the cavernous layer, in which case the surface of the uterus after partu- rition is jagged and irregular. In rarer cases the split oc- curs higher up in the compact layer, leaving consequently by far the greater part of the decidua in situ quo ante. In all normal cases, however, more of the mucosa is lost than in menstruation, and a considerable portion is always left in utero ; this latter portion contains the remnants of the uterine glands, and is the organ of regeneration for the entire mucosa ; it has, of course, no epithelium upon its surface, which instead is formed by connective tissue, and ruptured blood-vessels and lymphatics. The layer of vera left on the uterus is about one millimetre thick ; that of the serotina may be considerably less. Regeneration of the Mucosa Post Partum.-The regeneration varies greatly in rate, being very rapid in vigorous, healthy women, and slow in weakly women. The region of the vera is restored more rapidly than the placental area. The first step is the thickening of the mucosa to about two millimetres, owing to contraction of the uterus, which, of course, reduces the superficial ex- tent without altering the volume of the mucosa. In con- sequence of this change the gland spaces become rounder, and the course of the glands straighter. The second step is the restoration of the surface by the resorption of the blood and detritus; parallel with which advances the restoration of the glandular epithelium. These changes occupy apparently from seven to fourteen days. The cuboidal gland-cells at this time appear swollen, with in- distinct intercellular boundaries; the nuclei are almost all enlarged until they nearly fill the cells; rapid cell- division is going on. At this time, also, the thrombi are Fig. 805.-Decidual Cells from the Section Represented in Fig. 804. a, b, d, and/, various forms of cells from serotina ; c, giant-cell from the margin of the placenta; e, clear cells from the chorion. At a, seven blood-globules have been drawn in to scale. blood, sometimes a few decidual cells. I have also seen in them a few oval bodies, several times larger than any of the decidual cells, and presenting a vacuolated appear- ance ; what these bodies are I have not ascertained. In many places the glandular epithelium is perfectly distinct; the cells vary greatly in appearance, neighboring cells being often quite dissimilar ; nearly all are cuboidal, but some are flattened out; of the former there are some small with darkly stained nuclei, but the majority of the cells are enlarged with greatly enlarged hyaline, very refrin- gent nuclei. The decidual cells are smaller and more crowded in the cavernous layer (Fig. 804, D'}, and mostly larger in the compact layer. The largest cells are scattered through the compact layer, but are most numerous toward the sur- face. They extend around the margin of the placenta, and have penetrated the chorion, in the cellular layer of which they are very numerous (Cf. Chorion, ante, p. 143). This emigration imparts to the cellular layer of the chorion some- what the appearance of a decidual membrane ; misled by this peculiarity, Kolliker and others have held this layer to be maternal, and have de- scribed it as a decidua subchorialis. The decidual cells exhibit great variety in their features (Fig. 805). They are nearly all oval disks, so that their out- lines vary according as they happen to lie in the tissue ; they vary greatly in size, the larger they are the more nu- clei they contain, but I observed no cells with more than ten nuclei. The nuclei are usually more or less elongated, the contents of the cells granular. Some of the cells pre- sent another type, e ; these are more nearly round, clear, and transparent; the nucleus is round, stains lightly, and contains relatively few and small granules. Such cells are most numerous about the placental margin. Change in the Decidua at Parturition.-During labor a split occurs in the decidua serotina and vera; all the parts within this split, that is, toward the chorion, are expelled, their expulsion being part of the act of delivery. There is thus removed the whole of the reflexa, and the Fig. 806.-Section of the Placental Area of the Uterus Three Weeks Post Partum. Muc, mucosa Msc, muscularis. In the muscularis are seen lighter spaces, the partly restored thrombi; the darkly shaded spaces are blood-vessels (veins). (After Leopold.) very conspicuous, especially in the placental area, where they are found fresh and in various stages of progressing obliteration (Leopold, No. 2, xii., 185). The thrombi persist for a long period. The third step is the comple- tion of the restoration of the glands up to their external openings, and the regrowth of the normal connective tis- sue of the mucosa. The resulting stage was found by Leopold5 (xii., 199) to have been reached in a normal uterus three weeks after parturition. Of this specimen he gives the following description, which refers to the placental region: "As shown by the illustration (Fig. 806), the young mucosa is composed mainly of fine, short spindle-cells, which form the interglandular tissue. They exhibit extraordinary proliferation, and are shoving them- 393 Decidua. Dengue Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. selves in numerous processes into the musculature ; but still leaving the limits of muscularis and mucosa distinct, as in every non-pregnant and pregnant uterus. Secondly, between the young cells we find many blood-vessels, espe- cially capillaries, in the neighborhood of which are col- lected blood-corpuscles, hsematin crystals, and pigment. Many appearances indicate the new formation of capil- laries from simple cords of cells, which extend to the very surface. Thirdly, and most important, we find the young glands, which are short vertical follicles, im- parting to the surface a more definite sieve-like appear- ance. Their cuboidal epithelium is spreading out from their mouths to re-cover the surface; but at this time the new epithelium is not yet completed. The mucosa is still a wounded tissue ; for its complete restoration there is still lacking . . . the vascular network." The fourth step is a double one, the restoration of, 1, the su- perficial epithelium, which is accomplished by the spread- ing of the growing epithelium from the mouths of the glands; and of, 2, the subepithelial network of capilla- ries. The completion of this step has been observed in a normal uterus six weeks after parturition. Literature.-The literature of the decidua is remark- ably extensive; only a small part of it, however, is of scientific value. The principal articles are those of Fried- lander,15,18 Engelmann,2 Leopold,4,6 Langhans,14 and Overlach.21 Charles Sedgwick Minot. 1 Wyder, Aloys Theodor: Beitriige zur normalen und pathologischen Histologie der menschlichen Uterusschleimhaut. 1878. Arch, fur Gynak., xiii., 1-55, Taf. 1. 2 Engelmann, George J. : The Mucous Membrane of the Uterus, with Special Reference to the Development and Structure of the Decidua. 1875. Am. Joum. Obstet., viii., 30-87, Pl. 1. 3 Kundrat, Hanns, und Engelmann, G. J. : Untersuchungen uber die Uterusschleimhaut, Stricker's Med. Jahrbiicher, 1873, 135-177, Taf. 1. 4 Leopold, Gerhard: Die Lymphgefasse des normalen nicht schwang- eren Uterus. 1874. Arch, fur Gynak., vi., 1-54, Taf. 1-3. 6 Leopold, Gerhard : Studien uber die Uterusschleimhaut wahrend Menstruation, Schwangerschaft und Wochenbett. 1877. Arch. f. Gynak., xi., 110-144 and 443-500 ; xii., 160-210. 6 Williams : On the Structure of the Mucous Membrane of the Uterus and its Periodical Changes, Obstet. Journ. Gt. Brit, and Ireland, ii., 681 and 753. 7 Williams, John : The Mucous Membrane of the Body of the Uterus. 1875. Obstet. Journ. Gt. Brit, and Ireland, iii., 496-504. B Lowenthal, W.: Eine neue Deutung des Menstrualprocesses (con- tains a good historical review). Arch. f. Gynak., xxiv., 168-261. 9 Kollmann, J. : Die menschlichen Eier von 6 mm. Grosse, His' Arch, fur Anat., 1879, 275-311, Taf. 12-13. 10 Turner, Wm. : Observations on the Structure of the Human Pla- centa. Jour, of Anat. Physiol., second ser., vi., 120-133, Pl. 5. 11 Turner: Lectures on the Comparative Anatomy of the Placenta (first series), 8vo, pp. 124, 3 Pls. Edinburgh. Black. 1876. 12 Turner: Some General Observations on the Placenta, with Especial Reference to the Theory of Evolution, Journ. of Anat. Physiol., xi., 33-53. 13 Turner: On the Placentation of the Apes, with a Comparison of the Structure of their Placenta with that of the Human Female. 1879. Phil. Trans. Roy. Soc., London, vol. clxix., 523-562, Pl. 48-49. 14 Langhans, Theodor: Untersuchungen uber die menschliche Pla- centa, His' Arch. f. Anat., 1877, 188-267, Taf. 7-8. 15 Friedlander, Carl: PhysiologischanatomischeUntersuchungenilber den Uterus. 8vo. Leipzig, 1870. 16 Friedlander, Carl; Ueber die Innenflache des Uterus post partuni, 1876. Arch. f. Gynak., ix., 22-28. 17 Elischer, Julius; Beitrage zur feineren Anatomie der Muskelfasern des Uterus. 1876. Arch. f. Gynak., ix., 10-21. 18 Hennig, C.: Studien fiber den Bau der menschlichen Placenta und uber ihr Erkranken. 8vo, pp. 39, Taf. 1-8. Leipzig, 1872. 19 Underhill: Note on the Uterine Mucous Membrane of a Woman who Died immediately after Menstruation. Ib75. Edinburgh Med. Journ., xxi., 132-133. 20 Winkler, F. N.: Zur Kenntniss der menschlichen Placenta. 1872. Archiv f. Gynak., iv., 238-265. Taf. 5. 21 Overlach, Martin : Die Pseudomenstruirende Mucosa Uteri nach akuter Phosphorvergiftung. 1885. Arch. f. mikros. Anat., xxv„ 191- 235, Taf. 10-11. the patient has been lying for a long time in the prone position. Bed-sores are described as being both acute and chronic. The acute form (Charcot) is met with in injury or disease of the spinal or cerebral nervous centres. It appears oftentimes in a few hours after lesions of these parts, and although it comes in portions of the body undergoing pressure, the rapidity of its establishment suggests that other than merely local causes are factors in its produc- tion. The chronic form appears at any time after a pa- tient has been lying in bed for a long time. The manner in which these bed-sores commence varies with the disease or injury which they complicate. Three different methods of formation, at least, are easily recog- nized : 1, by an erythematous reddening of the skin, especially if the part has been irritated by urine or faeces ; 2, by a primary necrosis of the skin, seen in weak indi- viduals ; 3, by a phlegmonous inflammation, with the formation of pus and undermining of the tissues. Whatever may have been the method of formation, the issue in all is the same ; as much of the integument as has been compromised sloughs ; the sloughs are cast off in shreds or as a whole ; there remains an ulcer, often- times weak and indolent, with sloping edges, and without any tendency to heal. At times the sloughing does not stop at the integument, but all of the soft parts, and even bony structures, become involved in the necrotic process, leaving a lesion revolting in appearance and disgusting in odor. Etiology.-In the causation of bed-sores pressure plays the most important role, as noted above ; those situ- ations subjected to the most continuous pressure are the most frequently affected, and especially those parts which immediately cover bone. Over such places the skin is pressed close against the unyielding bone, the blood-ves- sels of the part are closed by the pressure, the nourish- ment of the part becomes imperfect or ceases completely, and as a result sloughing takes place. There are certain predisposing causes, however, which hasten the develop- ment of bed-sores. These predisposing causes are; 1, any circumstance which lowers the vitality of a part or of the whole body ; 2, the presence of fluids or substances which irritate the skin ; 3, diseases or injuries which pre- vent movement of the patient's body ; 4, trophic disturb- ances (?). In the first class of causes are included different forms of diseases, as typhus and typhoid fever, phthisis^ scurvy, and any long-continued disease. Of the fluids and substances which irritate the integu- ment, urine and faeces are the most common, either passed in bed involuntarily in cases of spinal trouble, or voluntarily when the patient's morale is lowered. Par- ticles of food, and larger substances, sometimes contrib- ute to the irritation when the patient does not receive proper attention. The diseases and injuries which prevent movement of the patient's body are all those which cause hemiplegia or paraplegia; in these cases voluntary motion is lost, and in many cases movement of the body by attendants is ex- tremely painful, so that, of necessity, the same position is assumed almost continuously by the patient. The question of the role played by trophic nerves in the causation of bed-sores cannot be satisfactorily dis- cussed, as their presence in the human body has not been proven. The rapidity with which the skin sloughs in injuries of the central nervous system (acute bed-sore of Charcot) makes it evident that nutritive changes have taken place in such parts, which can only be explained by assuming that the nervous power controlling the nu- trition of the part has been lost as an effect of the central lesion. This view is substantiated by the tegumentary lesions seen in cases of dementia paralytica (Shaw ; "St. Barth. Hosp. Kep.," vol. xiii., 1878, pp. 130-133) in the last stages. In these cases so-called bed-sores appear, i.e., superficial sloughing of the skin on both the anterior and posterior surfaces of the body, and without reference to the portions of the body pressed upon. Symptoms.-Bed-sores so frequently occur in patients in whom the sensibility is blunted or lost, that subjective DECUBITUS (Bed-sores; gangraena per decubitum), a term applied to gangrene of the skin and underlying soft structures, resulting from pressure of the body upon an object, usually the bed, in long-continued recumbency. The situations in which bed-sores are most frequently seen are over the tuber ischii, over the sacrum, the scap- ulas, the spinal column, the great trochanters, the tuber- osity of the os calcis, and in other portions of the body which may have received continuous pressure. Some- times they are the result of the pressure against each other of contiguous surfaces of integument. They are- rarely seen upon the anterior surface of the body, unless 394 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Decidua. Dengue Fever. symptoms are wanting, and the presence of the sore is only determined, often accidentally, by the attendant. The patient under such circumstances appreciates noth- ing, even though the sloughing of the soft parts be of great extent. In some instances, however, when the sen- sibility of the parts has not been greatly impaired, the patient experiences itching or burning sensations, with sometimes pains lancinating through the parts affected, the pain at times being severe enough to necessitate the use of anodynes to quiet it. The local symptoms of a bed-sore are those attending gangrene of the skin and soft parts. It is impossible to estimate how much the general sys- tem is affected by bed-sores. It is evident that extensive loss of tissue, from gangrene and suppuration, must have a marked effect in depressing the vital forces, and under such circumstances death has been known to occur either from pyaemic exhaustion or from the involvement of im- portant organs in the sloughing process. Treatment.-Prevention is the cardinal rule to be ob- served in the treatment of bed-sores. To carry this rule out successfully, it is necessary to recognize the circum- stances under which bed-sores appear, to know the dis- eases which they most frequently complicate, and, being fully aware of their readiness to appear in such diseases, to combat their appearance by constant care and appro- priate treatment. In the large majority of cases, bed- sores result from the neglect of this prophylactic treat- ment. So well is this fact recognized, that in the large hospitals, where the care of the sick is intrusted to trained attendants, it is considered a matter of personal reproach if a patient contract bed-sores, and it is difficult to dissi- pate the impression that they are not the result of negli- gence. This preventive treatment, which is frequently not easy to carry out, consists in : 1. Relieving the pressure to which the parts are sub- jected. 2. The keeping of these parts clean. 3. The use of chemicals to harden the integuments. The relief of pressure is, perhaps, the most important of all in the treatment of bed-sores, for in this way the engorgement or the anaemia of the vessels of a part is re- lieved. This can be accomplished by getting the patient to change his position in bed from the back to one side or the other. If a patient's mind be dulled by disease, so that he has no desire to move, or if some injury to the spinal cord has occurred, so that the lower portion of the trunk and lower extremities are paralyzed, and not only is voluntary movement impossible, but artificial move- ment very painful, the difficulties in the treatment of the case are much increased. The patient usually lies upon the back, and cannot be made to assume any other position. The pressure soon becomes continuous, as relief cannot now be afforded by a change of position, and the weight must be taken off these parts by appliances so arranged as to distribute the pressure upon other parts of the body. This can be ac- complished by the use of pillows, rings, or air-cushions. The ordinary air-cushion, made in the form of a ring with an aperture in the middle, is of especial service, and is so adjusted that the part from which the pressure is to be relieved falls over the opening in the ring. If no air- cushion can be obtained, a ring can be made out of oakum, jute, or cotton, which will serve the purpose, although not so well. Water-beds are of great assistance in the preventive treatment of bed-sores, because they adjust themselves to the irregularities of the body, and distribute the pressure evenly over its entire surface. In case such a bed cannot be procured, great pains must be taken to see that the bed used is suitable. It must be springy, but still hard enough to prevent hollows and irregularities where the patient lies. The bed-clothes must be perfectly smoothed out, no wrinkles must appear in the sheet on which the individual lies, and an important point is to see that no foreign bodies, as, for example, food, fall into the bed and get under the patient. Cleanliness is a very important factor in the treatment. Especially is it necessary when there is incontinence of either faeces or urine, or both. Either of these discharges is irritating to the skin, and may set up inflammations which are readily converted into bed-sores. There are beds constructed in such a manner that the portion under the genitals can be removed, so that a more or less complete vent for the discharges is af- forded ; but the best of these appliances are of very re- stricted value, and only constant care and watchfulness can prevent the patient from being bathed in these in- flammation-causing discharges. Of the medicines which are used to harden the skin alcohol is the most useful, combined with some astringent, as tannic acid, lead, or zinc. Bathing the parts several times a day with a preparation of this kind often gives a healthy tone to their circulation, and averts the formation of a bed-sore. William L. Wardwell. DENGUE FEVER. Definition.-The name dengue has been given to an acute, febrile, eruptive disease which generally occurs as an epidemic in hot climates-though occasionally sporadic cases are seen. Dengue is ordina- rily abrupt in development, but may occur after several days of prodromal symptoms. The initial symptoms are severe frontal headache, pain in the eyeballs, intense pain with swelling of the muscles and joints-the pains wan- dering from part to part of the body. A cutaneous erup- tion occurs on or about the third day in the majority of cases of dengue ; it commences on the palms of the hands, and rapidly extends over the entire body. As a rule, dengue is a disease of one febrile paroxysm-with or with- out remissions ; though in severe cases two or more paroxysms of fever, with distinct intermissions, have re- peatedly been observed, and verified by the thermometer, the intermissions being of variable duration. Synonyms.-This disease has, from its first appearance, been known by different names, which have varied ac- cording to the views held by different writers, who often have associated it with an idea of the prominent symp- tom, or with some fancied agency of causation, or with some indefinite idea of pathology; while with other writers the name was associated with some locality in which the disease frequently prevailed, or from which it was imported. Hence we find dengue called as follows : " African fever," so called from the fact that it first ap- peared after the arrival of a cargo of slaves from Africa ; " dandy fever," a name given to it by the English negroes on the island of St. Thomas, in consequence of the af- fected, stiff gait of those seized by the disease. In Cuba the word dandy was, upon the appearance of this fever there, corrupted in Spanish, and pronounced Dunga or Dengue. It is also called : Scarlatina rheumatica, Cock ; exan- thesis rosalia arthrodynia, Cock ; epidemic inflammatory fever of Calcutta, Meilis ; break-bone fever ; stiff-necked fever; broken-wing fever; eruptive epidemic fever of India ; Toohutia, natives of East Indies ; rheumatic fever, with eruption and gastric irritation ; neuralgic fever; eruptive articular fever; eruptive rheumatic fever; giraffe, so called from the symptom of stiff neck ; Aden fever, so named because it was thought to have been im- ported from Aden, Arabia ; sun fever ; date fever, etc. History.-The history of dengue can only be traced to the latter part of the eighteenth century. This disease has occurred sporadically, or epidemically, in India, Burmah, Persia, Egypt, West Indies, and in North and South America. It has never prevailed in England. Epidemics of dengue prevailing over vast tracts of coun- try have, from time to time, been observed, and the his- tory of each epidemic recorded. In America all writings on this subject prior to those of Dr. Samuel Henry Dick- son, then of Charleston, S. C., afterward of Philadelphia, were unreliable. Dr. Dickson's first publication on dengue appeared in Bell's "Medical Library," 1839 ; the paper was founded on his experience in the epidemic of 1828, in Charleston, S. C. From this first publication of Dr. Dickson his name has been inseparably connected with the subject of dengue, and he is to this day a stand- ard authority on the subject. The first notice of dengue in America is from the pen of Dr. Rush, giving a history 395 Dengue Fever. Dengue Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the epidemic in Philadelphia, which prevailed in the summer and fall of 1780. This author, writing of " Bilious Remittent Fever," says: "The disease was commonly called break-bone fever, in consequence of the violence of its attendant pains." According to Zuelzer, our first knowledge of this affec- tion dates from the year 1779. Dr. Brylon, at the time one of the most distinguished physicians of Java, writes of an epidemic disease, called knockelkoorts (" bone fever "), which attacked the Batavians. In addition to Dr. Rush's history of the epidemic of 1780, in Philadelphia, Wise recorded his observations of epidemics in Coro- mandel, Arabia, Persia, Africa, and Thibet. Aitken in- forms us that dengue prevailed in Calcutta in 1824, and the epidemic was so generally prevalent that but few persons out of a population of five hundred thousand es- caped the disease. In 1827-28 it prevailed as an epi- demic on the islands of Santa Cruz and St. Thomas to such an extent that but few individuals out of a popula- tion of twelve thousand escaped infection. Hirsch says: " The epidemic of dengue in 1827 first showed itself in September upon the island of St. Thomas, and the next month in St. Croix; it went thence in one di- rection over the Antilles toward the mainland of North America, in the other over the Carribean Islands toward Colombia, and lasted until September, 1828, at which time it had reached Savannah, Ga., and sporadic cases were found in many of the larger cities of the United States, notably in Boston, Mass., and New York." In 1850 an epidemic of dengue prevailed in the South- ern States, and attacked the inhabitants of Charleston, S. C.; Savannah and Augusta, Ga.; Mobile, Ala.; New Orleans and New Iberia, La.; and extended into the State of Texas. This epidemic was noted for its gen- eral prevalence in the above named cities. In Charles- ton, Dr. Wragg says, eight-tenths of the inhabitants had dengue within a period of six weeks. Dr. Henry F. Campbell, of Augusta, Ga., who witnessed the epidemic of 1850, and has written an interesting history of it, says that fully eight thousand out of a total population of eleven thousand were infected. In 1873 an epidemic of dengue prevailed in the Gulf States, and, like that of 1850, was noted for its general prevalence. In New Orleans, forty thousand inhabitants contracted the disease within a few weeks. The most recent, and probably the most widespread, epidemic of dengue in America was that of 1880. Among other places visited during that epidemic were Charles- ton, Beaufort, Port Royal, Columbia, Summerville, Ai- ken, Branchville, Midway, Blackville, Bamberg, and Georgetown, in South Carolina; Wilmington, N. C.; Augusta and Savannah in Georgia; Key West, Fla.; Biloxi, Miss.; Bay St. Louis, Mo.; New Orleans and Vidalia in Louisiana ; and Navasota, Tex. This dis- ease also prevailed in Egypt in 1880 as an epidemic. On October 14, 1880, Dr. Neroustsos Bey, President of the General Board of Health of Egypt, reported an epi- demic of dengue, which began at Cairo and soon spread over the whole of Egypt. In Cairo more than fifty per cent, of the entire population had the disease-the mortality was reported as small. However interesting it might be to further trace the rise and progress of epidemics of dengue, and attempt to track the infection from place to place, no such effort will be made, as the limits of this paper will not permit it. It is proper to add that it has been found impossible to state definitely the source of the epidemic of dengue in this country in 1880. Etiology and Propagation.-It is impossible to state definitely the origin of dengue fever. That it is an infectious disease, there can be no question. That the poison or germs of this disease possess the quality of por- tability, there can also be no question, for we might cite in- numerable instances in which infected articles of wearing apparel, bedding, or air confined in trunks, cars, or vessels, had served as the media for scattering dengue from an in- fected into a healthy locality. At the present time it is im- possible to determine whether or not it is contagious, in the ordinary meaning of the term. Such competent ob- servers as Samuel Henry Dickson and M. Sheriff adhere to the doctrine of contagion. Others of equal opportunity for accurate observation, and of equal professional reputa- tion, deny that it is a contagious disease. The majority of physicians who have encountered epidemics of dengue"are undecided as to whether or not it be contagious. Dickson, one of the highest authorities on this disease, says : " But no pestilence whatever, neither small-pox, nor plague, nor yellow fever, nor cholera, assails so large a proportion of any population as dengue has done on the two occasions of its prevalence." He is decided in opinion that it is a conta- gious affection, and cites the following history of his own household : In the epidemic of 1828 all of the members of his family, himself included, were attacked. Of his house- hold in 1850, himself and his cook, who alone escaped, were the only ones who remained of those who composed his family in 1828, his children being away and his kitchen filled with new occupants. In 1828 his household num- bered 12 ; in 1850, 30. Dickson supposed that the profes- sion admitted the contagiousness of dengue. This view has been combated by various writers, among whom is Dr. W. T. Wragg, of Charleston, S. C., himself an historian of the epidemic of 1850. Dr. Wragg cites the following considerations which induced him to believe the disease to be non-contagious: 1. Its rapid and almost simulta- neous diffusion, precluding the idea of personal commu- nication. 2. The very limited extent to which it pre- vailed in the vicinity of Charleston, and the absence of evidences of its having been transported into the interior, although the city was thronged with persons from all parts of the neighboring country on business. 3. The incred- ibly short period of incubation, on the supposition of a contagious miasm having been imbibed. To these con- siderations another important one should have been added, i.e., the short and uniform career of the epidemics in places where the disease prevailed, and their entire and speedy disappearance. It should also be remembered that dengue is dependent more or less upon climate, sea- sons, and atmospheric conditions. All of these considera- tions militate against the idea of dissemination by con- tagion. To show the portability of the poison or germs of den- gue, and the rapidity of dissemination under favorable conditions, the following is quoted from Zuelzer : "Asa result of the constant communication with ports in the southern seas, the disease was carried in 1871 to Zanzibar and other ports on the African coast Furthermore, it was imported directly into Bombay and Cananore by two troop-ships (M. Sheriff). Thence the epidemic extended, in 1872, through all India, though confined at first to the Madras and Bombay Presidencies, especially along the railroads. Even in other English stations in Burmah, China, and Nepaul, cases of this highly remarkable epidemic were found. In its diffusion the disease was as widespread as it was intense. In some of the cities attacked scarcely an inhabitant remained ex- empt. It prevailed most violently and most extensively in Madras, -where not a house escaped, and it attacked equally both sexes and all ages (the oldest patient was eighty years, the youngest two months old), and persons of every condition, even up to the highest classes. " Symptoms.-Dengue is generally sudden in its inva- sion, the patient having been in usual health up to the time of the initial symptoms. The period of incubation varies from forty-eight hours to five days. In the ma- jority of cases the initial symptoms are cephalalgia, pho- tophobia, lassitude, anorexia, nausea, chilliness with oc- casional flushes of heat, aching or intense pain in the limbs, joints, or muscles. The fever ranges from 101° to 107° F., and is usually coincident with the affection of the muscles and joints. The pulse is rapid, full, and bounding, varying from ninety-five to one hundred and forty beats per minute. The face is flushed, and the eyes are red, wild, and watery. These symptoms persist from a few hours to several days, when, in the majority of cases, an eruption appears on the surface of the body. The eruption is not uniform in character-a large por- tion of the various types being represented. While in a number of cases it has the appearance of a simple ery- 396 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dengue Fever. Dengue Fever. thema, in others it more nearly resembles that of scarla- tina, rubeola, lichen, urticaria, etc. In the vast majority of cases of dengue attended by me in the epidemic in Augusta in 1880-more than five hun- dred in all-there seemed to be but one febrile paroxysm, which ordinarily lasted from four to seven days. Remis- sions in temperature were commonly observed, but inter- missions of fever were very rare. After cessation of the fever the temperature in several cases observed by me de- scended to 97|° F. My observations with the thermom- eter in dengue confirm the statement of D'Aquin, of New Orleans, that there was a continuous and steady rise in tem- perature until the highest point was reached on the first, second, or third day of the attack (most generally in my experience on the second day); then a short stadium of a few hours; then a remission, soon to be followed by another rise in temperature, but never reaching the point of first maximum heat. With the-rise of temperature a corresponding rise of pulse will be observed, and a de- crease in frequency of pulse with a decline of fever. At the height of the fever the respiration is increased in fre- quency-usually preserving the ratio to frequency of pulse and height of temperature. During the height of the fever the skin is dry and "burning hot." The bow- els in the early course of the disease are constipated, but diarrhoea is the rule after the crisis is reached. The urine is generally high-colored, free from albumen, and never suppressed. There is always a marked tendency to the occurrence of haemorrhages, the haemorrhage being from either the nose, gums, bowels, stomach, or lungs, and in females from the womb. In pregnant women there is imminent danger of abortion or miscarriage. I have seen two cases of black vomit similar in appearance to that of yellow fever ; I have seen three cases of alarming haemorrhages from the bowels-one of these persisted for several months, and finally caused the death of the patient. Nasal haem- orrhages are frequent, and occasionally it is impossible to stanch the flow of blood until an instrument is intro- duced and the nose plugged. In fully seventy-five per cent, of the cases of dengue in my practice an eruption was seen by me or by some person in attendance. The time of its appearance, as well as the kind, varied with individual cases. It was ordinarily attended with great heat and itching. The palms of the hands, the face, neck, and chest were usually invaded in the order here given. Wherever it began it soon spread over the whole body. In many cases it was extremely light and transient-last- ing only a few hours ; in others it was severe, and per- sisted for several days. Desquamation is frequently seen. The eruption usually appears as the fever begins to de- crease, which is ordinarily on the third day. With its appearance the lymphatic glands of the neck, axillae, and groins become enlarged. These enlargements of the glands, and the soreness of the muscles and joints, often- times persist for weeks and months after the eruption and fever have disappeared. In many cases the prostration continues for months, and totally disqualifies the subject for mental or physical exertion. I have known both phys- ical and mental prostration to persist for six months after all symptoms of dengue had vanished. It may be truth- fully affirmed that well-nigh invariably the convalescence is slow and wearisome, and altogether out of proportion to what is witnessed in any other disease so non-fatal in its issue. During the entire course of dengue insomnia is frequently encountered. It is persistent and intoler- able, and whatever sleep is obtained is unrefreshing, and the patient longs for more. But that which particularly characterizes the whole course of dengue, and which gives to the patient an experience never to be forgotten, is the pain. It is disproportionate to all other symptoms. It is intense, insufferable, persistent; by day and by night the patient is tortured and harassed by agonizing pains in every portion of the body-pain in the head, limbs, back, joints, muscles, and apparently in the very sub- stance of the bones ; pains which are stabbing, boring ; at one time fixed, at another fugitive ; hard to bear when the body is quiet, intolerable when a limb is gently moved ; pain which no attitude of the body can assuage, and no medicine of the physician wholly subdue, causes the sub- ject of dengue to declare that this is the sum total of human misery. From personal experience I testify to the truthfulness of the assertion. Relapses are occasionally observed-sometimes after an interval of two or three weeks from the original attack. As a rule, the relapse runs a milder course than the pri- mary attack. Pathology.-Dengue being proverbially a non-fatal disease, the pathological processes occurring during its course are wholly unknown. Prognosis.-The prognosis is almost invariably favor- able. Death from dengue is extremely rare, save when it attacks very young or feeble children, or very old and de- bilitated individuals. When death is observed during the course of dengue the fatal result is almost invariably due to some complication, such as convulsions, diarrhoea, haemorrhage, or abortion, or it is the result of some inter- current disease. Differential Diagnosis.-From 1828, when Dr. Os- good wrote a description of dengue as seen by him in the epidemic in Havana, till the present day, the idea that it and yellow fever were identical, or, at least, that dengue was modified yellow fever, has continued to find advocates among a goodly number of reputable physicians who have studied these diseases at the bedside. While they have some features and characteristics which are common to both, there can be no question that in most important particulars they are essentially and radically different, and that each disease is sui generis, having its own specific poison, and producing its own kind. The following is a brief summary of the points of similarity and dissimilarity in dengue and yellow fever : In time of appearance, and generally in geographical distribution (but not in pathological lesions, so far as known), they seem related to one another. Dengue, however, has prevailed in Asia, Egypt, and India, where yellow fever is unknown. Both disorders are arrested by severe frost. Both dengue and yellow fever are diseases characterized by one febrile paroxysm. In dengue, how- ever, the fever rises regularly until the acme is reached, when a short stadium of a few hours occurs, followed by remission, when a second rise of temperature takes place, but never reaches the height observed prior to remission. In yellow fever the temperature rises steadily. In dengue the pulse increases in frequency with the rise of tem- perature ; in yellow fever the pulse becomes slower while the temperature rises. Duration of the fever in dengue is from five to eight days ; in yellow fever it lasts seventy- two hours. In dengue vomiting is rare; in yellow fe- ver vomiting is frequent. Dengue is characterized by an eruption in the vast majority of cases; in yellow fever an eruption is extremely rare. In dengue jaundice is extremely rare ; in yellow fever jaundice is almost in- variably present. In dengue the urine is generally high- colored, normal in quantity, free from albumen, and never suppressed; in yellow fever the urine is scanty, frequently albuminous, and often suppressed. In dengue there is a decided tendency to haemorrhages from nose, gums, bowels, lungs, and womb, with occasionally black vomit, but these haemorrhages are, as a rule, insignificant; while in yel- low fever they are frequent, alarming, and often fatal. Dengue is proverbially a non-fatal disease ; yellow fever is very fatal. Dengue is not protective against yellow fever, nor yellow fever against dengue. One attack of dengue is not protective against a second ; one attack of yellow fever is usually protective against another. Finally, dengue runs a more protracted course, and is followed by a more prolonged period of convalescence and by frequent recurrence of pains, while yellow fever is shorter in duration, with more rapid convalescence, and freedom from recurrences of pains. From the above- named considerations I have no hesitancy in avowing that yellow fever and dengue are radically and essentially dif- ferent diseases. It is true that dengue often prevails concurrently with, or precedes, or follows, an epidemic of yellow fever, but in my opinion these epidemic visita- tions simply indicate coincidences of time and locality. The Relation of Dengue to Malarial Fevers.-There is 397 Dengue Fever. Dentition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. no evidence to demonstrate that these diseases are related otherwise than in time of prevalence and geographical distribution. However, dengue prevails where malarial fever is unknown. In the epidemic of 1880 cases were seen at Summerville and Aiken, S. C., where, according to the local physicians, malaria does not occur. The ther- mometrical observations, together with the eruptions and glandular enlargements of dengue, will readily establish the differential diagnosis. The cachexia of malaria is also an important diagnostic point. From acute articular rheumatism dengue differs in that effusions into synovial cavities are extremely rare, while peri-articular enlargements frequently accompany or fol- low the disease. The pain is not confined to the joints, as in articular rheumatism, but extends to the head, back, and limbs. The inflammatory processes in the heart or its coverings, so frequent in rheumatism, are almost un- known in dengue. The physical, mental, and nervous prostration of dengue is also almost unknown in rheu- matism. Finally the eruption, the enlargement of the lymphatic glands, and the epidemic nature of dengue add to the certainty of diagnosis between dengue and articu- lar rheumatism. From muscular rheumatism dengue is to be differentiated by the more localized fixation of the pains in the former, and by the symptoms of dengue above given. From scarlatina dengue may readily be diagnosticated. These diseases in the beginning have great resemblance, but they may be diagnosticated by the intense muscular and arthritic pains, and glandular enlargements of dengue, and the diversified eruptions of the latter. Complications are comparatively rare. Abortion in pregnant women and convulsions among children were the most important complications met with in the epi- demic in Augusta in 1880. Sequelae.-Marked mental and physical prostration, persistent and annoying insomnia, over which narcotics had not the usual control; anaemia, palpitation of the heart, with no organic disease thereof ; marked nervous- ness, trying and debilitating neuralgias, severe diarrhoea, furuncles, abscesses, partial paralysis of one or more of the limbs, etc., constituted the sequelae of dengue, as ob- served in my practice. In the practice of some of my friends insanity, which persisted for several months, was in three instances observed in aged subjects. Treatment.-Quinine is claimed to be a prophylactic against dengue when taken in doses of ten or fifteen grains daily. From this view I most unqualifiedly dis- sent. I tested it in my own person-took from ten to fifteen grains daily for about two weeks-and at the very time when my system was thoroughly and unpleasantly saturated with quinine, I was taken ill with dengue of marked febrile intensity, the temperature on the second day reaching 105|° F. I have witnessed repeated failures of the alleged prophylactic powers of quinine in this dis- ease. Some writers, believing in the contagiousness of dengue, demand isolation of the sick, disinfection of infected clothing, bedding, etc.-in short, such preventive meas- ures as are enforced against small-pox, scarlet fever, and other contagious diseases. I am by no means satisfied that this is a contagious disease. If, however, in future it be demonstrated to be contagious, and amenable to isola- tion and disinfection, we need never expect to see these preventive measures put in operation against it. It being almost invariably a non-fatal disease, the average citizen can never be induced to adopt preventive measures, even if such were definitely known. While it is true that we know of no preventive meas- ures nor prophylactic medicaments against dengue, it is unquestioned that judicious symptomatic treatment can do much to abbreviate the disease, or at least mitigate the high fever and extreme suffering which so debilitate and emaciate the patient. One of the first and most important indications for treatment in severe cases of dengue is to repress the fever. For this purpose antipyretics, in the form of cold or warm baths, packings or spongings, and the internal ad- ministration of drugs which are known to have the power of reducing fever, are to be resorted to. Either of these methods, or a combination of them, will be found ser- viceable in the treatment of this disease. A very high temperature is not infrequently observed in dengue. I have several times seen it reach 106° F. The hydropathic treatment will be found advantageous in these cases. Some physicians prefer a cold bath, i.e., from 60° to 70° F., for periods of ten minutes, and repeated or not ac- cording to circumstances. I am not an advocate of the cold bath. I have seen great damage, in the form of shock, result from the cold bath when used in ty- phoid and other fevers. I prefer, and have used with marked benefit, in dengue and various febrile diseases, the warm or hot bath. If the temperature of the body is 104° F., I use the bath at a temperature of 99° to 101° F., thus abstracting from three to four degrees of heat, and thereby avoid the risk of shock so imminent when the cold bath or pack is used. Hot foot-baths, frequently re- peated, will often reduce the fever two degrees, and greatly relieve the head symptoms. Sponging the body with cool or tepid water, for ten to twenty minutes at a time, and repeated if it seems to be required, will likewise reduce the fever. In treating children in this and other febrile diseases, the prompt reduction of the fever is necessary to prevent convulsions. Of the various drugs administered for antipyretic effect, I know of none equal to quinine. I am aware that some observers deny its efficacy, but the failures are due rather to the method of using the medicine than to its lack of energy. To obtain the antipyretic effects of quinine it must be given in large doses, i. e., thirty to forty-five grains, within from two to four hours, to adults, and to children proportionate doses according to age. Within six hours after taking full doses of quinine, a marked diminution of the fever will be verified by the thermometer, and in twelve hours the reduction of heat to the minimum will have occurred. The effects of large doses of quinine usu- ally persist for from twelve to twenty-four hours. Even in typhoid fever such doses of quinine will rarely fail to reduce the temperature two or three degrees. The repe- tition of the drug is to be indicated by the height and persistency of the fever. It is only in severe cases of dengue that this treatment will be necessary. Another important indication for treatment in dengue is the miti- gation or relief of pain. Hypodermics of morphine act more promptly and lastingly than any other method of exhibiting the drug. Where arthritic pains are severe, the internal adminis- tration of opium with salicylate of soda, together with blisters to the spine or the seat of pain, is indicated. Hydrate of chloral with bromide of potassium should be given for insomnia. Threatened abortion, nasal and other haemorrhages, diarrhoea, convulsions, etc., are to be treated upon gen- eral principles. The practice of indiscriminately prescribing purgatives is to be condemned. In my experience, troublesome diarrhoea is frequently encountered in the later course of dengue. Mental aberration following dengue is generally caused by anaemia or insomnia, and is to be combated by hyp- notics, chalybeate tonics, and full and nutritious diet. Eugene Foster. DENTITION, DISORDERS OF. A distinguished au- thority upon children's diseases recently expressed to the writer decided incredulity regarding the propriety of the nosological distinction implied by the above title. This gentleman doubtless gave expression to the view held by a large proportion of the medical profession, in accord- ance with which morbid conditions other than those con- fined to the buccal cavity are in no sense dependent upon perverted dental evolution, and their appearance, during teething, is a pure coincidence. The writer be- lieves that the wide prevalence of this doctrine is suscep- tible of easy explanation by the application of the psycho- logical principle underlying all reactions from extreme erroneous opinions. Our great-grandfathers unnecessa- rily bled their patients to the verge of syncope. Our 398 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dengue Fever. Dentition. fathers, warned by the demonstrated inefflcacy of their ancestors' methods, abjured the use of the lancet. The present generation, wisely adopting the golden middle course, regards phlebotomy as a dangerous, yet valuable, therapeutic resource. Again, the success which homce- opathy at first attained may be considered as a protest against the officious interference of early practitioners with the beneficent and efficient vis medicatrix natures. And these examples'might be multiplied to show, by an- alogy, how the current professional skepticism regarding the existence of constitutional disorders bearing to teeth- ing the relation of effect to cause is a logical sequence of exaggerated nptions, still prevalent with the laity, con- cerning the potency of dentition in the causation of dis- ease. This modern incredulity has subserved an ex- tremely useful purpose by calling attention to the fact that comparatively few constitutional disturbances are really dependent upon teething, and in doing away with the erroneous belief that the checking of these disorders would exert a harmful effect upon the natural course of dentition. Dr. J. Lewis Smith remarks, in regard to this subject:1 " Every physician is called, now and then, to cases of serious disease, inflammatory and others, which have been allowed to run on, without treatment, in the belief that the symptoms were the result of denti- tion. I have known acute meningitis, pneumonia, and entero-colitis, even with medical attendance, to be over- looked during the very time when appropriate treatment was most urgently demanded. Many lives are lost in this manner, especially from neglected entero-colitis, the friends and physicians believing the diarrhoea to be symp- tomatic of dentition, a relief to it, and therefore not to be treated. Such mistakes are traceable to the erroneous doctrine, once inculcated in the schools and still held by many of the laity, that dentition is, directly or indi- rectly, a common cause of infantile diseases and derange- ments." Dr. Yale aptly says :2 " The difference of opin- ion is, then, not a simple dispute of terms, but one which has a real interest in the nursery. If the parents believe that dentition causes all the ailments attributed to it, they are, as we daily see, prone to consider the ailments as nearly, if not quite as much, a matter of course as the natural teething process, and they consider it useless to try to cure them until teething is complete. As a re- sult of all these errors and confusions, it too frequently happens that disorders which might have been very tract- able at the outset are allowed to progress unopposed, until they reach a serious stage. If, on the contrary, we assume that teething is rarely the real cause of disease, the parent will seek some other reason for any disturb- ance of the system that may exist, and will endeavor to remove it." Having thus clearly indicated, by the above quotations, the cogent reasons for the exercise of caution in attributing to dentition an active agency in the devel- opment of any constitutional disease occurring coinci- dently with it, the writer still advocates the retention of the term Disorders of Dentition. This he does because, in the opinion of many competent observers, functional and organic ailments do sometimes occur at points remote from the seat of morbid local processes incident to teeth- ing, as the result of these processes, although none of the disorders in question can be regarded as peculiar to dentition.3 It would, indeed, seem equally proper that the collective title of these diseases should indicate the etiological relations existing between them and the proc- esses of dentition, as, for example, that the disorders in- cident to utero-gestation should bear the generic name, "Diseases of Pregnancy," although each individual affec- tion embraced under this heading may, at times, be devel- oped in connection with various morbid processes instead of simultaneously with a single physiological one. The writer, therefore, designates by the title Disorders of Dentition all morbid states, whether local or general, which are visibly dependent upon local deviations from the normal course of physiological dentition. The Disorders of Dentition embrace : I., Anomalies of Development, and II., Disorders of Eruption. Under the former head are included anomalies relating to the time of the eruption of the teeth, to their number, their posi- tion, their direction, their form, and their texture, or their structure. These anomalies deserve attention as consti- tuting frequent exciting causes of the disorders of erup- tion. The disorders of eruption may manifest themselves either at the first, or, more rarely, at the second dentition, being either local, and due to the direct irritant effect of perverted dental development, or sympathetic, and pro- duced by the intervention of reflex nervous mechanisms. I. Anomalies of Development.-1. Anomalies in the Time of Eruption. Dentition is sometimes notably re- tarded in rachitic, strumous, syphilitic, and tuberculous children, or in those suffering from marasmus induced by chronic or acute disease. Malformations of the jaw also constitute a rare cause of delayed dentition. "The evolution of the teeth," says Dr. William H. Day,4 " tests the vigor of the child, and the more tardy and lingering the process, the less its strength and vitality." In some unusual cases the first teeth have not appeared until the third year, or even later. Steiner5 reports a case in point, observed by himself, in which the eruption of the teeth did not occur until the child was four years old. The milk teeth may, on the other hand, be prematurely devel- oped, even attaining their complete growth before birth, as in the cases of Louis XIV. and of Mirabeau, but their roots are generally rudimentary, and they soon fall out or decay, while early dental development is not an indi- cation that the growth of the entire organism will be more rapid or vigorous than usual. Cases have, how- ever, been reported6 in which deciduous teeth, especially the canines and molars, were present and well preserved in persons thirty years of age or upward. In these cases the dental follicles of the permanent teeth were either never developed or remained rudimentary. Irregularities in the ordinary succession of the teeth are sometimes observed, the upper incisors, usually the lat- eral ones, appearing before the lower incisors, and, very infrequently, the canines before the molars. Albrecht is of the opinion (loo. cit.) that cases of reputed third denti- tions are best explained by the assumption that certain teeth may be retained in the jaw until the atrophy of the alveolar process, incident to advanced age, exposes the previously hidden alveolae. Should the eruption of the teeth be delayed beyond the ninth month, diligent search for the cause of the retardation of dentition must be instituted, and, if possible, appropriate remedial meas- ures promptly adopted. 2. Anomalies in Number. In certain rare cases, alluded to by Charles Sarazin,1 neither deciduous nor permanent teeth were ever developed. This fact was, perhaps, refer- able to entire absence of the elementary dental follicles, or to their early destruction by al veolar disease. Symmetrical absence of two incisors, canines, molars, or wisdom teeth has been reported, but failure in development of a given pair of deciduous teeth does not necessarily presuppose a similar deficiency in the permanent set. On the other hand, the first set may be complete, and the second defi- cient. Supernumerary teeth, either deciduous or perma- nent, are frequently observed. Their development may sometimes be due to accidental segmentation of a primary dental follicle,8 or, again, to the existence of supernumer- ary follicles. Supernumerary teeth of the first dentition are generally developed in positions not normally occu- pied by teeth, and are distinguished from prematurely developed permanent teeth by their relatively small size, and by their conical crowns. Supernumerary teeth of the second dentition, which closely resemble the super- numerary milk teeth as regards size and shape, often ap- pear at an earlier date than the permanent teeth, and may usurp the place of the latter, which are consequently forced into an unnatural position. They frequently, how- ever, make their appearance between the first incisors or to the inner side of the latter. Sometimes they perforate the palate bone in the vicinity of the wisdom teeth. On account of their abnormal position, these teeth may in- jure the tongue and interfere with articulation, in which case their removal is urgently indicated. 3. Anomalies in Position and Direction. These anom- alies are occasioned either by the development of the rudimentary dental follicles in an abnormal position, or 399 Dentition. Dentition. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by the interposition of some obstacle in the path of the normally located follicle, by which the latter is forced to assume an unnatural position. The latter cause affects the deciduous teeth only. If the former cause be opera- tive, the teeth may be "developed far from their natural site, the wisdom tooth of the lower jaw sometimes ap- pearing in the ascending ramus, even so high as the bor- der of the coronoid process or near the condyle, and the teeth of the superior maxilla effecting their exit in the centre of the hard palate, or even occasionally projecting into the nasal fossae. Dentigerous cysts occur in various situations remote from the jaw, notably in the ovaries. The direction of the teeth becomes faulty when obstacles oppose themselves to the growth of the permanent set. These obstacles may consist of milk teeth which have too long retained the places destined for their successors. Again, a milk tooth may have been removed before the permanent one was sufficiently matured to take its place. Under these circumstances the deciduous tooth-follicle may have become ossified, thus erecting an impassable barrier before the tardily developed permanent tooth. In still other cases abnormal narrowness or shortness of the alveolar border may cause the teeth to deviate from their natural direction, and the same result may be produced by a faulty direction of the entire alveolar process. Ref- erence should here be made to an anomalous position sometimes assumed by the root of a deciduous tooth, at the time of the second dentition. If teething progress naturally, this root is gradually absorbed over its entire surface by the advancing permanent tooth, which thus gradually effects the extrusion of its predecessor. Should the advance of the permanent tooth be irregular, uniform absorption of the deciduous root does not occur, and the root, pressing against the alveolar process, causes ab- sorption of the latter, presents itself on the lateral surface of the process, and, by constant friction and pressure upon the neighboring soft parts, causes inflammation and ulceration of the gums, the tongue, or the cheek. The direction of the teeth should be either vertical or slightly inclined inward, the superior incisors overlapping the in- ferior ones. The operation of either of the last-mentioned conditions may cause all the inferior incisors to project beyond their fellows of the upper jaw, the canines and bi- cuspids being inclined outward (lateral deviation). The opposite condition, viz., inversion, sometimes obtains. These deformities affect individual teeth alone, provided the obstacle be a single milk tooth, too long retained in its socket, or the ossification of a vacant deciduous fol- licle. Single teeth may even be twisted in such a man- ner as to stand at right angles to their normal positions. 4. Anomalies in Size and Form.-An entire tooth oc- casionally attains abnormally large dimensions, thus occasioning displacement of its fellows. The crown may be alone hypertrophied, or the root be sinuous and un- usually elongated. In rare instances certain teeth are so distorted as not to present a vestige of their natural form. Several adjoining teeth, usually the incisors, may be united throughout and covered by common coats of enamel and of cement. Abnormal divisions of single teeth are also, rarely, encountered. 5. Anomalies in Structure.-Histological anomalies of the milk teeth ar^ generally referable to morbid constitu- tional conditions, such as struma and rachitis, leading to perversion in dental development, and affect either the enamel, which may be soft, opaque, thin, crumbling, and even absent, or the ivory, which is abnormally friable, although often of unnatural thickness, and is very prone to decay. Acute infantile diseases, particularly the ex- anthemata and typhoid fever, the abuse of mercurials, and stomatitis, occasion morbid histological changes in the permanent teeth, which being inadequently supplied with enamel, are soft and inclined to decay, are furrowed hori- zontally, separated by abnormally wide intervals, and present a repulsive yellow discoloration. The most in- teresting pathological processes affecting the' permanent teeth are produced by congenital syphilis, and were first exhaustively studied by Mr. Hutchinson, with whose name the appearances about to be described are inseparably as- sociated.9 Syphilitic teeth may present any or all of the changes described above as incident to various infantile diseases. The incisors, and sometimes the canines, may also be deformed and dwarfed, being " narrow, rounded, and peg-like, their edges jagged and notched." The morbid conditions pathognomonic of inherited syphilis are, however, positively characteristic, and affect, accord- ing to Mr. Hutchinson, the permanent median upper incisors, which often present the peculiar syphilitic de- formity when the other incisors are of normal shape. M. Fournier is, however, said by Dr. J. William White10 to believe that the deciduous teeth are affected by syphilis exactly as are the permanent ones, but that the disease is overlooked in the majority of cases. The characteristic syphilitic teeth are separated by an unnaturally wide in- terval, but their crowns are generally convergent, rarely divergent. The teeth are abnormally short and narrow, their corners are rounded, and they present a broad verti- cal notch at their edges, at the bottom of which the den- tine is exposed. Sometimes a shallow furrow passes up- ward from this notch, on both the posterior and anterior surface of the tooth, reaching nearly or quite to the gum. The anterior surface of these teeth looks upward. They are of crescentic form, their convexity being also directed upward. The teeth may present the appearances charac- teristic of mercurial poisoning simultaneously with the lesions due to syphilis. Dr. Thomas Barlow and M. C. MacNamara,10 state that only one of the upper central permanent incisors may be characteristically deformed, the other being normal or presenting diseased appear- ances not peculiar to syphilis. These authors also em- phasize the facts that the pathognomonic syphilitic tooth possesses a single vertical notch, and not a serrated bor- der, and that " the existence of normal, permanent upper median incisors by no means excludes the existence of hereditary syphilis." Constitutional treatment, appropri- ate for syphilis, should be promptly adopted so soon as the diagnosis of syphilitic dental disease is fully estab- lished. II. Disorders of Eruption.-A. Local Disorders of the First Dentition.-We may better appreciate the nature of these morbid processes and their adequacy to the ex- citation of reflex nervous phenomena by recalling some of the abnormal conditions occasioning them. Any unusual obstacle to the eruption of the first teeth is capable of leading to morbid local processes. Among these obstacles may be mentioned narrowing of the dental furrow and alveolae by the approximation of the labial and lingual borders of the alveolar process. This may be occasioned by the compression of these comparatively yielding structures, especially in rachitic children, by the constant activity of the tongue and lip muscles. The gum may also be abnormally thick and of cartilaginous density. In either case, the growing tooth, encountering an unnatural obstruction, exerts abnormal pressure upon the exquisitely sensitive branches of the fifth nerve, in its matrix, and occasions odontalgia, which may become ex- ceedingly severe. Inflammation of the follicle, resulting from congestion in the matrix, is also produced by the abnormal pressure of the tooth, and may result in gingi- vitis, ending in ulceration and complicated by severe stomatitis. In mild cases the inflammation does not reach so extreme a degree, and results only in slight exag- geration of the normal local inflammatory changes else- where enumerated, and often incident to the simultaneous eruption of several teeth, with, possibly, otalgia, fever, and some of the milder reflex phenomena soon to be described. In the worst cases, however, alveolar perios- titis, even of sufficient gravity to occasion necrosis of the alveolae and destruction of the teeth, and submaxillary and cervical adenitis and abscess of the cheek may be observed. The ordinarily mild local phenomena then give place to these characteristic of the above-mentioned inflammatory processes. The gums are swollen and tense, or ulcerated and sloughing, the tongue and buccal mucous membrane swollen and hypersemic, or sometimes aphthous and ulcerated, the cheeks red and tumefied, the saliva abundant and ropy. The child has a remittent form of fever attended by jactitation, insomnia, and an- orexia, or by somnolency and asthenia. 400 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dentition. Dentition. B. Sympathetic Disorders of the First Dentition.-The principal diseases usually embraced under this title are enteritis, gastro-enteritis, entero-colitis, otitis, conjuncti- vitis, coryza, bronchitis, cutaneous eruptions, such as urticaria, herpes, eczema, and prurigo, retention or in- continence of urine, dysuria, nervous cough, laryngis- mus stridulus,11 subsultus tendinum, and eclampsia. Many authors deny that dentition plays any essential role in the production of the disorders just enumerated, unless there exist a predisposition to their development. The nature and cause of this predisposition are not gen- erally more closely defined, but are inferentially stated to consist in a dyscrasia, or diseased constitutional state. West says, in this connection :12 "The period of teething, like that of puberty, constitutes one of the great epochs of life ; it is a time when great changes are going on in the whole organism-when the animal machine, being in a state of increased activity, its parts are more than usually apt to get out of order. Statistics embracing the largest numbers prove the dangers of this period. . . The error which has been committed with reference to this matter, not merely by the vulgar, but by members of our own profession also, consists not in overrating the hazards of the time when changes so important are being accomplished, but in regarding only one of the manifes- tations-though that, indeed, is the most striking one-of the many important ends which nature is then laboring to bring about. The epoch of dentition is to be looked at just in the same way as that in which we regard the epoch of puberty. Constitutional disturbance is more common, and serious disease more frequent at these times than at others ; but their causes lie deeper than the tooth which irritates the gum that it has not yet pierced, in the one case, or than the womb which has not yielded the due discharge of blood, in the other." The writer admits that these diseases may, in many cases, especially in those attended by slight local inflammation, be entirely acci- dental complications of dentition, the gastro-intestinal disorders being, for instance, referable to insufficient or improper food, great summer heat, and to the develop- ment of the digestive tract, and the cutaneous diseases to hereditary predisposition. In the graver forms of disease, however, the writer believes that the local inflammation due to perverted dental development itself plays the part of both predisposing and exciting cause of the sympathetic disorders. Some of the above-mentioned diseases cannot, perhaps, lay valid claims to the title of sympathetic dis- orders, but may be due to extension of inflammation from contiguity of tissue. This remark might apply to coryza, otitis, conjunctivitis, and, possibly, to the bronchitis. Vogel13 refers the bronchitis to the wetting of the chest by dribbling saliva, and the diarrhoea to the laxative effect of the saliva which is swallowed ; but this view is opposed by the fact that these symptoms occur when the chest has been well protected, and when the quantity of saliva is not excessive. Throwing the diseases possibly due to extension of local inflammation out of account, we must still explain the etiology of the graver sympathetic nervous disturbances, above enumerated, and the occur- rence of those ailments sometimes due to extensive inflam- mation when the latter causation cannot be demonstrated. The writer is of the opinion that their predisposing cause lies in the gradual depreciation of nervous energy by the continued local irritation, and that the influence directly precipitating them is a nervous reflex act, the centripetal impression for which is conveyed through the exquisitely sensitive fifth pair, and is converted, at the motor or vaso-motor centres, into centrifugal im- pulses affecting the organs in which the sympathetic dis- ease is located.14 Barrier refers eclampsia, when excited by dentition, to the causes just assigned by the writer, and, in addition, to the participation of the whole cerebral vascular sys- tem in the hyperaemia existing around inflamed dental fol- licles. The enumeration of the symptoms constituting the clinical history of the sympathetic diseases of teeth- ing would entail useless repetition of details to be found in the articles, in this Handbook, descriptive of these affections, since their course is essentially the same as when they are not complications of dentition. See ar- ticles Enteritis, Gastro-enteritis, Entero-colitis, Otitis, Conjunctivitis, Coryza, Bronchitis, Skin Diseases, Re- tention, Incontinence, Dysuria, Laryngismus Stridulus, Eclampsia. The general character of the graver nervous phenomena may, however, be alluded to. The convulsive move- ments either affect isolated groups of muscles or are general. They vary greatly in severity, and either occur suddenly or are preceded by premonitions, such as un- usual restlessness, fretfulness, and general discomfort, together with evidences of great local disturbance. The attacks are single or multiple. In the latter case the in- tervals are of variable duration. The entire paroxysm may be limited to a few minutes, or may be protracted over several days. One of the milder types of ec- lampsia consists in such a contraction of the facial mus- cles that a smiling expression of countenance results. In other cases the respiration is merely quickened, the pupils dilate, the eyes assume a staring aspect, and the face grows pale or livid. In graver cases laryngismus stridulus occurs; and all the muscles may be successively or simultaneously tetanized. The circulation and respi- ration are obstructed, and asphyxia, cerebral congestion, or syncope may entail a fatal issue. A lethal result is usually produced by a series of paroxysms rather than by a single convulsion. Partial paralysis, idiocy, strabis- mus, and cerebro-spinal meningitis are stated to have sometimes followed eclampsia, but their etiological de- pendence on the convulsions is not established. Diagnosis.-Since the constitutional diseases induced by dentition are often referable, even wrhen developed simultaneously with teething, to other causes, these must be diligently sought in every doubtful case. If no mor- bid condition of the gum or of the jaw be discoverable, the inference that the disease in question is due to other causes is justifiable. Should the disorder, however, mani- fest itself at each epoch of dental eruption, subsiding after the completion of the latter process, its etiological dependence upon dentition will be unmistakable. Treatment.-This embraces prophylactic and curative measures, which are either local or general. 1. Local prophylaxis consists in frequent cleansing of the buccal cavity with a solution of borax containing gr. xx. to an ounce of water, or some similar detergent lotion, in or- der to prevent thrush or simple stomatitis; in gentle fric- tion of the inflamed gums with the ball of the finger, a smooth bone, or the smooth handle of a silver spoon, and in providing the little patient with a hard-rubber object for the maxillary gymnastics to which he is naturally in- clined. 2. General prophylaxis. This aims at the main- tenance of the general health, and embraces all required hygienic measures. The child should spend a large part of the day in the open air, whenever the weather is suit- able. The diet should be carefully supervised, and es- pecial attention given to the care of the bottles of hand- fed babies. Too frequent nursing must be discounte- nanced. The bowels should be regulated, rhubarb and calomel and enemata being used for constipation, and chalk mixture, with bismuth subnitrate and a few drops of tr. opii camph. in each dose, in case of diarrhoea. If flatulence exist, a carminative, preferably a mixture of spts. tar and. co., spts. card. co., syr. zinzib., and aq. menth. pip., in equal parts, should be employed in 10 to 20- drop doses. If there be considerable febrile disturbance, spts. cether. nitrosi, in doses of 10 drops each, may be ad- ministered to a child one year old, or tincture of aconite gtt. ss.-f, may be given, at intervals of one hour, until four to six doses have been taken. Restlessness and jacti- tation may be best combated by a mixture containing bromides. Dr. Day16 recommends the following formula : B. Potass, bromid gr. ij. Potass, iodid gr. j. Spts. ammon. aromat HL ij. Syrup HL xx. Aquae q. s., ad f. 3 j. M. Sig.-To be taken every four hours. For children one year old. 401 Dentition. Denver. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. With a view to diminishing cerebral congestion, and thus preventing eclampsia, Vogel16 recommends affusions of cold water, repeated at intervals of from one to two hours, and Espnie and Picot 11 extol tepid baths for the fulfilment of the same indication. The head may prop- erly be bathed, in common with the rest of the body, and warm head-coverings should be discarded. 3. Local curative treatment is required for the relief of aphthous ulcerations of the buccal mucous membrane, rarely for abscesses in the buccal parietes, for inflamed and painful gums plainly rendered so by obstructed den- tal eruption, and for alveolar periostitis. Ulcerations of the mucous membrane require strict cleanliness, obtained by thorough rinsing of the mouth with tepid water, and the use of lotions containing ten grains of borax to an ounce of glycerine.18 West19 approves the internal use of potassium chlorate, in doses of four grains, every four hours, for a child aged one year. In graver forms of ulceration, nitrate of silver solutions, containing fifteen grains in an ounce of water, may be painted over the ul- cerated surfaces, and leeches may be applied at the angle of the jaw. Abscesses in the cheek must be promptly evacuated. Very painful and inflamed gums are best and quickest relieved by free incisions, executed with a scalpel, a lancet, or a curved bistoury, so guarded as to avoid injury to any but the inflamed parts. The lancet is not to be used save for good and sufficient reasons, but must be wielded with decision, if required at all. The child's head is held between the knees of the operator, the jaws being kept open by his disengaged hand. The incisions should extend quite down to the tooth, and should be longer than the advancing dental crown. The cuts should be crucial for the molars and linear for the cuspids. Sometimes a wedge-shaped piece of the gum may be advantageously removed, if this be the offending tissue. If severe alveolar periostitis exist, the dental fol- licle may have been so far disintegrated as to have occa- sioned necrosis of the tooth, which must then be extracted. The measures just described effect almost immediate re- lief of local symptoms by reduction of tension in the in- flamed tissues, and by their depletion. In children of an haemorrhagic diathesis the lancet must be avoided, and reliance placed in the local and general preventive and curative treatment. If the above measures be adopted so soon as the gums are markedly inflamed, the graver sympathetic disturbances will usually be averted. Hence, lancing of the gums is both curative of the local morbid state and prophylactic as regards the sympathetic affec- tions of dentition. For local preventive and curative treat- ment of otitis, conjunctivitis, coryza, bronchitis, cutaneous eruptions, and incontinence or retention of urine, consult the articles in this Handbook treating of these subjects. 4. General Curative Treatment.-The therapeutic meas- ures embraced under this head are intended to take the place of local surgical interference with the gums, when the condition of the latter is not such as to warrant the use of the lancet. These measures must be directed to the cure of whatever constitutional symptoms appear in a given case, and are identical with those required for the relief of similar symptoms when not complicating denti- tion. The reader is, therefore, again referred to the appropriate articles in this Handbook. The bromides and chloral are second only in value to incision of the gums, in the convulsions of dentition, and are employed with great benefit in cases not adapted to the use of the lancet. Five grains of the bromide of potassium may be given to a child one year old, by mouth, or ten grains by rectum, if the patient be unable to swallow, and the dose repeated every quarter of an hour until the convul- sions cease, after which occasional doses may be given as required. At the respective ages mentioned, equal quantities of chloral, dissolved in one-half ounce of luke- warm water, should be given by the rectum, if the bro- mides have no effect, and may be repeated after an hour, if necessary. Cold to the head, hot mustard baths, a cathartic, preferably castor-oil, and warm laxative ene- mata, are valuable adjuvant therapeutic agents. C. The Local Disorders of Second Dentition.- Etiology.-The chief cause of these local diseases which, although rare, greatly predominate over the sympathetic or constitutional disorders of second dentition, is obstruc- tion to the natural eruption of the permanent teeth. The chief obstacles to eruption are either deciduous teeth which have been too long retained, ossification of decidu- ous follicles from which the teeth have been too early re- moved, or narrowness or shortness of the alveolar border, by which the advancing teeth are forced from their nat- ural positions and obliged to effect their exit through bony tissues instead of through the gum, in the direction of their alveolae. Faulty direction of the original follicle, its development in an abnormal position, fibroid indura- tion of the gum, and the growth of supernumerary teeth, are other causes of obstructed eruption. Any of the primary teeth may encounter these obstacles, but the so- called dentes sapiential, or third molars, are peculiarly liable to do so, since the remaining teeth have attained their full development at the time of the appearance of the wisdom teeth, and in many cases have encroached upon the latter's domain. The wisdom teeth of the in- ferior maxilla are, from their position in proximity to the ascending ramus and the consequent limited space af- forded them for development, usually the starting-points of the morbid processes about to be described. Symptoms. -Encountering one of the obstacles just mentioned, the teeth are directed either against the neigh- boring teeth or against the cheek or the tongue, and ex- cite either simple ulcerative or suppurative stomatitis, glossitis, gingivitis, or cervical adenitis, while the exces- sive pressure within the follicles may occasion alveolar periostitis, exostosis,20 osteitis, and caries or necrosis of the teeth themselves. These diseases of the jaw and teeth apparently owe their origin, in some cases, to ex- tension of the inflammatory process from the gums to the osseous structures, rather than to excessive pressure within the follicles. Should abscesses, developing in the gums, tongue, or cheeks, be left to Nature's direction, the pus effects its exit either into the buccal cavity or upon the surface of the cervical or maxillary regions. In some cases the purulent matter may widely infiltrate the sub- cutaneous or intermuscular cellular tissue of the cervical region, producing sinuous sinuses and fistulte. Other and rarer inflammatory complications of the second den- tition are tonsillitis, pharyngitis, otitis, rhinitis, conjunc- tivitis, and cervical erysipelas. The symptoms of these diseases need not be here enumerated, and allusion will be merely made to the difficulties of articulation and mas- tication, to the dysphagia, the deafness, otorrhoea, coryza, profuse salivation, and the febrile disturbance which may result from the inflammatory conditions above referred to. D. Sympathetic Disorders of the Second Den- tition.-The principal sympathetic diseases incident to the second dentition are neuralgia of the fifth nerve, which, beginning as an odontalgia in the affected teeth, may develop into hemicrania, tic douloureux, or spastic contraction of the muscles of mastication, leading to a tight closure of the jaws. Other and rarer reflex dis- orders, included by some authors in this category, are facial paralysis, nystagmus,21 otalgia, aphonia, hysteria, tetanus, chorea,21 and even epilepsy.22 Treatment.-1. Prophylactic : With a view to the pre- vention of ossification of deciduous follicles and conse- quent obstruction to the exit of permanent teeth, the milk teeth should be prevented from decay by appro- priate hygiene, and if carious, should be filled, instead of being early extracted. Supernumerary permanent teeth, or those developed from misplaced original follicles, should be removed before their pressure shall have dis- placed the growing regular teeth, or shall have exerted injurious pressure on the soft parts. If the jaw be too small for the accommodation of a full set of permanent teeth possessing normal dimensions, or should unnatural size of certain teeth lead to injurious pressure, a sufficient number of teeth must he sacrificed to make room for the remainder. If ossification of a deciduous follicle be the cause of detaining a permanent tooth in the alveolar pro- cess, the only resource is the trephine, after which ex- traction of the included tooth may become necessary. 2. Curative treatment: Prompt and efficient local 402 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dentition. Denver. treatment will, in most cases, speedily relieve both the local and the sympathetic disorders of the second denti- tion. Should the root of a deciduous tooth prove to be the obstacle to the exit of its successor, it must be at once extracted. If the gum, over a wisdom tooth which is about to make its appearance, be seriously inflamed or ulcerated, it should be incised or partially excised, the borders of the incision being then cauterized, in order that immediate union shal1 not occur. Should the crown of the tooth be carious, or its direction so abnormal as to threaten injury to the tongue or lips, the tooth must be removed. If it be impossible to find the dens sapientia after incision of the gum, owing to its deep inclusion in the alveolar pro- cess, the second molar may be removed and place thus be made for the advancing wisdom tooth. In the event of the formation of abscesses, either in the cheek, the gum, the tongue, the cervical connective tissue, or the cervical glands, they should be promptly opened. The remaining possible inflammatory and reflex complications of the second dentition, enumerated above, are to be treated, after the adoption of the local measures advised, in ac- cordance with the principles enunciated in the appropriate articles of this Handbook. The spastic contraction of the jaws, already alluded to, occasionally simulates tris- mus, sometimes greatly interferes with the local treat- ment, and may best be overcome by anaesthesia. H. Flint. 1 A Treatise on the Diseases of Infancy and Childhood, p. 651. 1881. 2 Babyhood, March, 1885, p. 105. 3 Meigs and Pepper: A Prac. Treat, on the Dis. of Children, pp. 412, 445. Phila., 1883. J. L. Smith, op. cit., p. 652. 4 The Dis. of Children, 2d edition, p. 67. Philadelphia. 1881. 5 Compend. of Children's Dis., Tait's Translation, p. 222. N.Y., 1875. 6 Albrecht: Real-Encyclop. d. Gesammt. Heilkunde, B'd iv., 54. 7 Nouveau Diet, de Med. et de Chirurg. Prat., xi., p. 149. Paris, 1869. 8 Littre et Robin : Diet, de Med., p. 431. Paris, 1873. 9 Lancet, 1876, pp. 56, 535. Reynolds : System of Med., vol. i., p. 441. Phila., 1879. 10 A Syst. of Prac. Med., William Pepper and Louis Starr, vol. ii., p. 294. Phila., 1885. 11 Meigs and Pepper, op. cit., p. 578. 12 Leet, on Dis. of Infancy and Childhood, pp. 162, 452. Phila., 1866. 13 Dis. of Children : Raphael's Translation, p. 109. New York, 1873. 14 J. Lewis Cohen ; Dis. Mouth and Tongue, Pepper's Syst. Prac. Med., vol. ii., p. 374. 1885. 45 Op. cit., p. 72. 16 Dis. Children: Raphael's Transl., p. 107. New York, 1873. 17 Manuel Prat, des Mal. de 1'Enfance, p. 9. Paris, 1884. 18 Eustace Smith : Quain's Diet, of Med., p. 342. New York, 1883. 19 Op. cit., p. 457. 20 Thos. H. Tanner: Prac. of Med., p. 316. Philadelphia, 1866. 21 Magitot, Littre et Robin, Diet, de Med., p. 432. 1873. 22 Tanner, loc. cit. ent residents of the city, including many of its leading business men, are persons who were first attracted thither by the prospect of a restoration to health held out by the climate of Denver, when considered as the chief " high- altitude" health-resort of the United States, and the result in whose cases has abundantly proved that their hopes were not ill-founded. In all its leading features the climate of Denver is essentially identical with that of Colorado Springs, al- ready described in the present volume of this Handbook ; a comparison of the accompanying climatic chart for Den- ver, with the chart for Colorado Springs (Table A, on p. 236), will show this essential similarity between the climates of the two places, while indicating at the same time the points in which they differ. Further informa- tion of the same kind may be derived from a comparison of Table E (p. 237) with columns C and D of the Den- ver chart, and from an examination of the first and third columns of Table F (on p. 238). Throughout the year the temperature at Denver seems to be somewhat higher than at Colorado Springs, and the average difference between the day and night temper- atures (i.e., the nycthemeral variation) is less at the for- mer than at the latter place. Somewhat greater extremes both of heat and of cold are, however, encountered at Den- ver, so that the annual range of temperature is rather greater there than it is at Colorado Springs. The chief difference in this respect between the two places ap- pears to depend upon the excess exhibited by the Den- ver climate over that of Colorado Springs in the factor of summer maxima, but an accurate comparison of the two climates is impossible, owing to the unequal bulk of data (derived from United States Signal Service observations) representing the climate of the two points, which the writer has at his command. Just how far the climates of Colorado Springs and of Denver correspond in the important matter of windiness cannot w'ell be ascertained by any of the data presented ; but, judging from the records of the year 1880-81, the amount of wind prevailing at Denver appears to be much less than is commonly supposed. On page 239 of this volume of the Handbook, the reader will find a table, quoted from Professor Loud of Colorado Springs, giving the total annual movement of the wind at that place for the period from April, 1878, to March, 1879. The figure for such total annual movement (70,912 miles) would show an average velocity of eight miles per hour. Com- parison is made in the table with figures showing the total annual movement of the wind, during the year 1880, at twelve of the United States Signal Service stations. The same report of the Signal Service from which these latter figures were taken gives the total movement of wind at Denver as 52,151 miles, which is equal to an average velocity of only 5.9 miles per hour. Further- more, by calculation from the figures for Colorado Springs which are given in two others of Professor Loud's tables (Tables 1 and K, on pp. 239 and 240), we find that, so far as they go, these figures show an average wind velocity at that place of about nine miles per hour ; while the mean annual velocity at Denver, according to the Signal Service chart accompanying this present article, is only 6.3 miles per hour. Here again we seem to have very good proof that the windiness of the Denver climate is decidedly less than that of the climate of Colorado Springs ; so that, whatever degree of shelter may be af- forded to the latter place by the arrangement of the mountain chains and ridges which partially surround it, nevertheless such shelter does not appear to render Colo- rado Springs the peer of Denver in this very important matter of comparative freedom from wind. For repre- senting the maximum velocity of the wind at Denver, and for indicating the frequency of occurrence of winds having an exceptionally high velocity, the writer has no data at his command save only those which are given in the United States Signal Service Report, issued in Octo- ber, 1881.* On page 385 of this Report are given figures DENVER. (For detailed explanation of the accom- panying chart and suggestions as to the best method of using it, see Climate.) The city of Denver, Colorado, lies on the south bank of the South Platte River, some thirty-five miles east of the principal chain of the Rocky Mountains, and about fif- teen miles east of their outlying foot-hills, and stands upon the g'reat plateau which slopes away from these foot-hills toward the bed of the Missouri and Mississippi Rivers, many hundreds of miles distant. The elevation of Denver above sea-level is 5,291 feet. The streets of the city are wide, are well laid out, -and are shaded on either side by a row of trees which depend for their growth in this arid climate upon a system of irrigating ditches, con- structed along the borders of the roadways, Thanks to this arrangement of ditches and to the shade thus pro- vided for its streets, the city itself is said to present a very attractive appearance ; while the magnificent panoramic view of the Rocky Mountains which it commands is en- thusiastically praised by all lovers of beautiful scenery who have visited the town. Denver is the capital city of the State of Colorado, and is the chief business centre of the Rocky Mountain pla- teau. The growth of the town has been very rapid ; thus in 1870 its population was only 4,759 souls, while in 1880, according to the United States Census Report of that year, the population had increased more than sevenfold, being then estimated at 35,629. As the representative town of the Colorado region the reputation of Denver as a health-resort has now become world-wide, and mention of it is to be found in the works of most of the leading writers upon climatotherapeutics. Not a few of the pres- * The only other volumes of these reports which he was able to obtain on application to the Washington authorities (viz., the reports for 1871, 1872, 1877, 1879, and 1880), contain no data available for this purpose. 403 Denver. Deodorants. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. showing the maximum wind velocity attained at Denver in each of the twelve months beginning with June, 1880, and ending with July, 1881. Like data for New York City are to be found on page 526 of the Report. The maximum velocity attained at Denver, during the twelve months in question, was 42 miles per hour (January 12, 1881) ; at New York City the maximum velocity was 48 miles per hour (March 30, 1881). The following table, which shows for each of the two points the number of months out of the twelve, at some time during which velocities equal to or exceeding 30, 35, 40, and 45 miles per hour were recorded as being attained, is here intro- duced, and, in a very rough and superficial way, it will serve to illustrate the comparative windiness of Denver and of New York City during the period of a single year; and it may thus assist some readers of the Handbook in arriving at a more accurate and realizing understanding of the actual windiness of the Denver climate. just referred to. By assuming precisely the same stand ard of temperature in the present instance, the comparison between the Denver and New York City figures is ren- dered more just and accurate than it could be made in the case of the comparison between the latter place and Davos Platz ; but, nevertheless, neither the Denver nor the New York City figures are altogether accurate, for the same reason which was one of the two causes of inaccu- racy in the Davos-New York table, and to which, as ex- plained in the note accompanying that table^ the atten- tion of the reader is again called. According to the figures of this table, the mean rela- tive humidify of the year at Denver would be about 11.5 per cent., against 18.3 per cent, at New York, both figures being (approximately) calculated for a temperature of 98° F. The mean relative humidity of Davos Platz for a temperature of 98.6° F. is stated by Weber to be 11.1 per cent. ("Ziemssen's Handbuch der allgemeinen Therapie," vol. ii., p. 154). At Denver, as at Colorado Springs, the snowfall is said to be slight in depth, and, for the same reasons as were specified in the case of Colorado Springs, the snow is said never to lie long upon the ground. The soil at Denver is largely sandy, but Dr. Solly, in his pamphlet entitled " The Health-resorts of Colorado Springs and Manitou," alludes to the existence of a clay soil, at least in some parts of the city, and he claims that on this account an irritating alkaline dust is often found in the air at Denver, from which, by reason of the more purely sandy nature of its soil, Colorado Springs is happily free. His words are as follows: " Many of the older towns in Colorado, which were built for purposes of trade, are naturally in the river bottoms, where the soil is clay, and more or less saturated with moisture, and from which, when rain or snow has not recently fallen, an irritating alkaline dust is apt to arise. Santa Fe, Canon City, and parts of Denver and Pueblo, are places where these condi- tions more or less exist" (op. cit., pp. 95, 96). The only allusion to the character of the soil at Denver which the writer was able to find in Dr. Charles. Denison's book on " Rocky Mountain Health-resorts," was a passage in which the streets of the town are described as being ' ' naturally paved by the sandy porous soil." A personal friend of the writer, who was for six years a resident of Denver, tells him that he believes the soil to consist of a mixture of sand and clay. Until quite recently the water supply of Denver was derived from the Platte River, and the quality of the water was poor. During the past two or three years, however, a large number of Artesian wells have been sunk, from which a supply of drinking-water is now obtained, which is abundantly sufficient in quan- tity, while in quality it is exceptionally pure. So, too, with the matter of drainage ; there was none at Denver until within the past year or two, but at present the town is provided with a system of drainage which is said to be entirely satisfactory. Concerning the class of patients who may reasonably expect benefit, or perhaps even a permanent cure, from the Colorado climate, no special remarks are called for in this place, the climate of Denver being so essentially similar to that of Colorado Springs, in the account of which resort enough has already been said on this sub- ject (see Colorado Springs).* Much valuable informa- tion respecting the Colorado climate, and the beneficial effects which it has been proved to exercise upon cases of pulmonary phthisis, etc., may be found in the well-known writings of Dr. Charles Denison, a resident of, and for many years a practising physician at, Denver. Among these writings maybe specified his book entitled " Rocky Mountain Health-resorts;" a paper on " The Influence of High Altitudes on the Progress of Phthisis," which was read at the Philadelphia International Medical Con- gress in 1876 ; an article published in the New York Med- ical Journal (September 13 and 20, 1884), and entitled " Dryness and Elevation the most Important Elements in the Climatic Treatment of Phthisis," etc., etc. (For a general description of the State of Colorado, including High Winds of Denver and of New York City. (June, 1880, to July, 1881.) Wind velocity attained or ex- ceeded . Denver. Number of months. New York City. Number of months. 45 miles per hour 0 1 40 " ' " 4 2 35 " " 7 4 30 " " 10 8 Number ofcalm days through- out the period of 12 months. 11 days. 34 days. A comparison of column S of the Denver chart with the corresponding column of the New York City chart (see under titles "Climate" and "New York") shows that the average wind velocity at Denver is 6.3 miles per hour, against 9.2 miles per hour at New York. So far as we can judge from the various data now presented, the climate of New York City is seemingly characterized by a more frequent occurrence of perfectly calm days, by a less frequent occurrence of winds of exceptional velocity, and by a greater average velocity of wind, than is the climate of Denver.* The percentage of relative humidity at Denver is very low, and an inspection of the figures of columns K and AA in the accompanying chart will show that the amount of absolute humidity is also very slight. In the article de- scribing Davos reference was made to a method proposed by W. Steffen, of Davos Platz, for estimating the com- parative relative humidity of any two places. A table showing approximately the relative humidities of Davos Platz and of New York City, calculated as nearly as pos- sible for a common standard of temperature, was also presented to the reader. Figures for Denver, estimated in the same way, are herewith presented in juxtaposition with the New York City figures taken from the table Mean Relative Humidity at Denver and at New York City, Reduced to a Standard of 98° P. Denver. I'er cent. New York City. Per cent. January 6.0+(5.0?) 8.2+(7.6?) February 6.2* 8.1* ' March 7.3 9.2 April 9.5* 12.7 M*ay 13.4 19.3* June 16.7 28.5 J uly 21.2* 34.2 August 20.7 33.4* September 14.0 27.3* October 9.7 18.7* November 7.1* 11.8* December 6.3+(5.8?) 8.5 N. B.-Calculations based upon table in Parkes's "Hygiene." Concern- ing a source of error resulting from the use of the said hygrometric table, see remarks in small type at the foot of the Davos-New York table in the article on "Davos." * Months of no error. t Months of greatest error. In the three instances where the error is most marked, the more approximately correct figures, followed by a query, are added in parentheses. * From what has already been said respecting the average wind veloc- ity at Colorado Springs, the reader will observe that this place has, for this special factor of climate, almost exactly the same figure as New York City. ♦ See also general article on " Health-resorts." 404 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Denver. Deodorants. Climate of Denver, Col.-Latitude 39° 45', Longitude 105° O'.-Period of Observations, December 1, 1871, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, 5,291 feet. A | AA It C D E F a II Mean temperature of months at the hours of Average mean temperature de- duced from column A. Mean temperature for period of ob- servation. Average maximum temperature for period. Average minimum temperature for period. Absolute maximum temperature for period. Absolute minimum temperature for period. (Greatest number of days in any single month on which the tem- perature was below the mean monthly minimum temperature. [Greatest number of days in any । single month on which the tem- perature was above the mean 1 monthly maximum temperature. January.... February... March April May June July August September.. October .... November.. December.. Spring Summer.... Autumn.... Winter Year 7 a.m. Degrees. 20.4 24.5 30.7 36.7 47.1 56.0 61.6 £0.2 19.6 39.8 29.3 24.2 3 P.M. Degrees. 35.8 41.2 49.5 55.7 66.4 77.8 82.9 81.3 72.5 61.0 47.3 39.2 11 P.M. Degrees. 25.5 30.6 39.3 46.3 56.4 66.6 71.6 70.1 60.2 48.9 34.9 28.3 Degrees. 27.2 32.1 39.8 46.2 56.6 66.8 72.0 70.5 60.7 49.9 37.1 30.5 47.5 69.7 49.2 29.9 49.1 Highest. Degrees. 35.9 37.9 46.0 52.5 61.0 71.2 75.3 72.6 62.7 54.4 42.9 39.1 52.2 73.0 51.0 31.6 50.8 Lowest. Degrees. 16.8 22.0 33.3 39.7 52.4 63.2 67.8 68.6 58.5 45.7 22.0 22.6 45.5 67.9 43.5 28.2 47.4 Degrees. 41.1 43.1 54.1 60.7 69.5 80.4 86.8 85.1 76.1 62.7 49.0 43.2 Degrees. 16.4 19.8 28.7 35.7 44.0 53.8 60.0 59.1 48.1 36.6 24.7 20.2 Highest. Degrees. 67.0 72.0 81.0 83.0 92.0 99.0 102.3 105.0 93.0 86.0 76.0 71.0 Lowest. Degrees. 55.0 52.0 62.0 72.0 78.0 88.2 91.3 91.0 87.7 75.2 61.0 55.0 Highest. Degrees. 2.0 16.0 21.0 28.0 37.0 48.9 57.0 54.0 40.0 28.0 23.4 18.0 Lowest. Degrees. -29.0 -22.0 -10.0 4.0 27.0 37.0 42.0 44.0 28.0 1.0 -18.0 -25.0 20 19 22 20 20 18 25 24 24 20 24 23 25 21 24 21 26 25 24 20 19 24 25 20 J K M | N O It S are not the direct cause of any specific disease. We can not, therefore, adopt the popular usage which makes disinfectant and deodorant synonymous terms, for, as pointed out in the article on Disinfectants, we reserve the former title for those agents which have the power of de- stroying the infectious properties of infective material. Deodorants act either (a) physically, or (b) chemically. {a) In the first group-absorbents-the most prominent place, from a practical point of view, belongs to dry earth. Even the lower animals-dogs and cats-cover their ex- creta with earth, and from the earliest ages man has de- pended mainly upon burial in the earth as a means of disposing of organic material of an offensive character, or of that which is likely to become so as a result of putre- factive decomposition. In proof of the efficacy of this method of disposing of putrescible material we need only point to our cemeteries. The "earth system" of dis- posal of excreta, which has been advocated as a substi- tute for the " water system," and which some years since was largely practised, especially in England, has led to numerous experiments which have fixed very definitely the neutralizing power of different kinds of earth. In Range of temper- ature for period. Mean relative hu- midity. Average number of fair days. Average number of clear days. Average numoer of fair and clear days. Average rainfall. Prevailing direc- tion of wind, Average velocity of wind in miles, per hour. January... February.. March April May June July August.... September. October ... November. December. Spring .... Summer... Autumn... Winter .... Year 96.0 94.0 91.0 79.0 65.0 62.0 60.3 61.0 65.0 85.0 94.0 96.0 102.0 68.0 111.0 101.0 134.0 53.3 53.2 48.2 48.5 48.5 43.2 46.6 46.9 44.0 44.7 50.3 55.5 48.4 45.6 46.3 54.0 48.6 11.4 11.7 11.1 12.3 14.9 12.7 14.2 14.0 8.8 9.8 10.7 13.5 38.3 40.9 29.3 36.6 145.1 15.8 13.0 13.3 10.3 8.9 13.7 12.6 12.0 17.0 16.2 14.7 14.7 32.5 38.3 47.9 43.5 162.2 27.2 24.7 24.4 22.6 23.8 26.4 26.8 26.0 25.8 26.0 25.4 28.2 70.8 79.2 77.2 80.1 307.3 Inches. 0.69 0.43 0.86 1.71 3.05 1.60 1.89 1.54 0.96 0.79 0.72 0.71 5.62 5.03 2.47 1.83 14.95 From S. S. S. S. S. S. s. s. s. s. s. s. s. s. s. s. s. Miles. 6.3 6.1 7.3 7.3 6.8 6.3 6.1 5.6 5.5 6.0 6.0 5.9 7.1 6.0 5.8 6.1 6.3 are not the direct cause of any specific disease. We can not, therefore, adopt the popular usage which makes disinfectant and deodorant synonymous terms, for, as pointed out in the article on Disinfectants, we reserve the former title for those agents which have the power of de- stroying the infectious properties of infective material. Deodorants act either (a) physically, or (b) chemically. (a) In the first group-absorbents-the most prominent place, from a practical point of view, belongs to dry earth. Even the lower animals-dogs and cats-cover their ex- creta with earth, and from the earliest ages man has de- pended mainly upon burial in the earth as a means of disposing of organic material of an offensive character, or of that which is likely to become so as a result of putre- factive decomposition. In proof of the efficacy of this method of disposing of putrescible material we need only point to our cemeteries. The "earth system" of dis- posal of excreta, which has been advocated as a substi- tute for the " water system," and which some years since was largely practised, especially in England, has led to numerous experiments which have fixed very definitely the neutralizing power of different kinds of earth. In the first rank comes well-dried garden loam ; clay, and especially brick-clay, is excellent; while sand and gravel are comparatively worthless. Buchanan has shown that loam which has been used once, may, after two or three months, be dried in the sun or in an oven and used again, and that this may be repeated over and over again with- out any perceptible loss of deodorizing power. The quantity required to render inoffensive a single dejection has been fixed by the English authorities-Radcliffe and Buchanan-at one and a half pound. The same amount is said to be required to neutralize half a pint of urine. Vallin, the highest French authority, believes this amount to be insufficient. He says : " It will be seen that it is much easier to neutralize the one hundred and fifty grammes of solid matter discharged in twenty-four hours than the twelve hundred to eighteen hundred grammes of urine. The principle of the method is, indeed, the absence of moisture, the relative dryness of the mixture when first made. We can say at the outset, that the feeble point in the earth system is the difficulty of neutralizing the urine. There is no great difficulty in disinfecting and rendering inert the solid material, but the admixture of the urine is a source of difficulties almost insurmountable, because of the enormous amount of earth which this liquid re- quires." 1 Charcoal.-The deodorizing power of charcoal depends some account of the climate and of the business interests of the State, see article Colorado, in the " Encyclopaedia Britannica.") In the opinion of the present writer, it is probable that to persons who seek the climate of Colorado solely for the purpose of regaining their health, both Colorado Springs and Manitou offer attractions, as places of sojourn or residence, superior to those presented by the older and larger town, a description of which has formed the sub- ject-matter of the present article. Yet it may well be that the much greater business facilities of Denver will decide some persons to select as their residence the capital city of the State, inasmuch as by so doing they may suc- ceed in regaining their health, while at the same time continuing the pursuits of an active business life and re- siding in a rapidly growing town, which, more than any other, may justly be regarded as the centre of the mining, stock-raising, and railroad interests of the Rocky Moun- tain plateau. Huntington Richards. DEODORANTS. The sense of smell is no doubt a most important sanitary monitor, although, so far as we know, the offensive volatile products given off from or- ganic material undergoing putrefactive decomposition 405 Deodorants. Dermatitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon its capacity for absorbing gases. It also prevents putrefaction by absorbing moisture from organic material over which it is freely spread. When once saturated with moisture, or with the gases given off from putrefy- ing material, the deodorizing power of charcoal is to a great extent lost. The capacity of recently made char- coal for absorbing various gases is shown in the follow- ing table : One volume of charcoal absorbs : 90.00 volumes of am- monia, 65.00 volumes of sulphur dioxide, 55.00 volumes of sulphuretted hydrogen, 35.00 volumes of carbonic acid gas, 9.42 volumes of carbonic oxide, 9.25 of oxy- gen.2 (&) Chemical Deodorants.-Chlorine.-Not every disinfectant is a deodorant, e.g., mercuric chloride, and many deodorants are not disinfectants, e.g., ferric sul- phate or sodium chloride ; but in chlorine we have an agent which is both a disinfectant and a deodorant. The deodorizing power of this gas depends upon its affinity for hydrogen. " It decomposes sulphuretted hydrogen, phosphuretted hydrogen, ammonia, and volatile organic compounds, by taking possession of their hydrogen, and the hydrochloric acid which is formed also neutralizes a certain quantity of ammonia " (Vallin). Commercial chloride of lime, which is largely used as a deodorant, has the advantage of gradually giving off chlorine. When it is spread upon the surface of decomposing organic matter, it neutralizes the offensive gases as soon as they are formed. This gradual evolution of chlorine is due to the presence of carbonic acid in the atmosphere, which replaces the hypochlorous acid of the hypochlorite of lime-the salt to which " bleaching powder" owes its de- odorizing and disinfecting properties. A more abundant and rapid evolution of chlorine may be obtained by pour- ing a dilute mineral acid upon chloride of lime. For use in the sick-room, a solution of chloride of lime in water -four ounces to the gallon-is to be recommended, both as a deodorant and as a disinfectant; or Labarraque's solution of hypochlorite of soda-liquor soda chlorinata- may be substituted for the cheaper preparation. Metallic Salts.-Vallin says: " Nearly all the salts which have for base a metal capable of forming with sul- phur an insoluble sulphuret, may be used indifferently as disinfectants," i.e., as deodorants. The same author says of these agents, that " they are disinfectants in the popular sense of the word ; they diminish or cause to disappear bad odors, but their action is limited to the neutralization of ammonia and the decomposition of sulphuretted hy- drogen and sulphydrate of ammonia." According to Virchow, the first effect of sulphate of iron, when thrown into a latrine, is often to produce, temporarily, an in- crease in the fetid odor given off from its contents, on ac- count of the liberation of volatile fat acids-butyric, valerianic, etc., which had previously been in combina- tion with ammonia. The relative power of metallic sul- phates to fix ammonia has been given by M. Fermond as follows : Sulphate of copper, 90 to 100 ; sulphate of zinc, 70 to 80 ; sulphate of iron, 20 to 25. This is, perhaps, a fair estimate of their relative value as deodorants. A solution of chloride of zinc, known as " Burnett's fluid," has been largely used in England and Germany as a "disinfectant," and in our own country "Platt's chlo- rides " and other similar preparations have received the endorsement of many leading physicians for " disinfect- ing " purposes. There can be no doubt as to the value of solutions of zinc chloride as a deodorant and antiseptic, but. as pointed out in the article Germicides, the disin- fecting power of this salt has been greatly overestimated. A two per cent, solution may be used as a deodorant in the sick-room. It has the advantage of being odorless, and of not staining articles of clothing immersed in it, and is quite cheap. Vallin says : " When a spray of a solution of chloride of zinc is thrown into an infected apartment by means of a spray apparatus, all bad odor is neutralized almost immediately, in less than two min- utes. This proves that the salt acts less as a caustic or antiseptic than as an absorbent." Among the useful deodorants, potassium permanganate deserves to be mentioned. It is more especially applica- ble as a deodorizing wash for foul ulcers, ozsena, fetid feet, etc., and may be freely used in the proportion of 1 : 1000. Its effect, however, is quite transient, as it is quickly decomposed by contact with organic matter. For this reason it is not available for deodorizing masses of material in privy vaults, etc. George M. Sternberg. 1 Traite des Disinfectants, etc., p. 47. 2 Vallin, op. cit., p. 33. DERMATALGIA, or Dermalgia (Greek, skin, and &Kyos, pain), refers to painful sensation in the skin, other than itching, occurring independently of any recognized disease or alteration of structure ; it is known also as neu- ralgia cutis, and is a rare affection. The sensations in dermatalgia are variously described as of a raw, burning, stinging, and often of a darting, boring character ; the suffering therefrom may vary from moderate discomfort to positive agony. The affected skin has all the appearance of health, and remains normal dur- ing the existence of the disease, unless altered by outward applications or injury; but the surface of the affected part may be so exquisitely sensitive that the slightest touch causes great distress, although firm, moderate pressure may relieve the painful sensations. eThe extent of area affected varies, but generally only a small patch is painful, and that may change position ; sometimes there are several tender places, and occasionally the entire sur- face is the seat of more or less cutaneous pain. Etiology.-The disease occurs mainly in middle life, and is more frequent in females than in males, but is by no means confined to hysterical or nervous individu- als. The real cause is often extremely difficult to deter- mine ; in many cases it is impossible to fix upon any or- ganic or other lesion which could occasion it. Such in- stances are often spoken of as idiopathic, but it is quite possible that in some of them careful investigation and advanced knowledge may trace an efficient cause in le- sions of the brain or spinal cord, as locomotor ataxia, etc. ; in certain cases it appears to be reflected from ova- rian or uterine disorder. It has been called rheumatism of the skin, and ascribed to this poison ; undoubtedly in a certain number of cases it occurs as a pure neuralgia, in connection with anaemia, chlorosis, malaria, etc. Diagnosis.-This is usually easy to establish, no other condition presenting the features described without skin lesions ; when, however, applications to relieve the pain have altered the overlying skin, the diagnosis may be ob- scured. It is to be remembered that the painful sensations are very superficial, in well-defined areas of the skin itself, and not deep-seated, as in ordinary neuralgia, muscular rheumatism, etc. Treatment.-The general treatment will vary with the case. Anaemic and neurotic subjects must be treated on general principles ; the rheumatic or gouty state must be counteracted, if past or present history reveals it; spe- cial diseases in females must be remedied, and careful study must be given td trace any condition capable of ex- citing reflex nerve disorder, such as a loaded colon or rec- tum, etc. Locally, considerable difficulty may be expe- rienced in obtaining much or permanent benefit. Gal- vanism affords some relief, and blisters, with morphine, to the part have been recommended. The surface feels most comfortable when firmly bound with a dressing which prevents all friction, and an ointment of tar and zinc, with belladonna or aconite, spread thickly on lint, will often serve to keep the part free from pain while ap- plied. (Beau : Arch. gen. de med., t. xii., Paris, 1841. Duhring: Diseases of the Skin, p. 577, Phil., 1882). L. Duncan Bulkley. DERMATITIS. Under this term those inflammations of the skin induced by local influences, as wounds, toxic agents, heat, and cold, are here to be considered. The va- rious other affections to which the name dermatitis has been given, will be found under specific heads farther on. Traumatic dermatitis is that form of inflammation of the skin which is produced by mechanical agencies, as bruises, abrasions, etc., which need not at present be con- sidered further. Dermatitis venenata includes the various eruptions pro- 406 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Deodorants. Dermatitis. duced by toxic agents. Chief among these is the inflam- mation caused by contact with poisonous plants, of which the poison ivy and the poison oak are best known. The first of these plants, known to botanists as rhus venenata, is a climbing, ivy-like plant, which is usually seen climb- ing about walls and fences, or running up trees to a con- siderable height, supporting itself by lateral rootlets. The leaves are ternate, and grow on long semi-cylindrical petioles. Leaflets (three) ovate or rhomboidal, acute, smooth, and shining on both sides, the veins sometimes a little hairy beneath. The margin is sometimes entire, and sometimes variously toothed and lobed in the same plant. The flowers are small and greenish-white. They grow in pannicles or compound racemes on the sides of the new shoots, and are chiefly axillary. The berries are roundish and of a pale green color, approaching to white. The poison ivy is apt to be mistaken for the Virginia creeper, especially in autumn, when the brilliancy of its foliage makes it fatally attractive to the unsophisticated ■collector of leaves. It should be remembered that the Virginia creeper has five leaves on the stalk, while the poison vine has but three. The leaves of the latter also vary greatly in form. The poison oak, or rhus toxicodendron, is a decidedly rare plant, and is usually found growing in unfrequented swamps, where its fine smooth leaves give it the air of a tropical shrub or tree. The trunk is one to five inches in diameter, branching at the top, and covered with a pale grayish bark. The ends of the young shoots and petioles are usually of a fine red color. The leaves are pinnate, the leaflets one to thirteen in number. The flow- ers are small and green in axillary pannicles. The fruit grows in the form of a bunch of dried greenish-white berries, sometimes marked with slight purplish veins, and becoming wrinkled when old. The poison oak is apt to be mistaken for elder or sumach. The leaves of the latter, however, have serrated edges, and the tips are pointed. The poisonous qualities of the rhus toxicodendron and the rhus venenata are due to a volatile acid called toxico- •dendric acid. The effect varies greatly with the individual. Some persons are so susceptible that they cannot pass to the windward of the vines, or be exposed to the smoke from their burning without suffering severely, while others can handle them with impunity. The severity of the eruption may also vary from the production of a few ves- icles to a very severe eruption, and even death is said to have been caused in two cases. As regards the symptoms of this form of dermatitis, there is first a period of incubation varying from a few hours to several days. In children fretfulness and slight fever may precede the outbreak of the eruption. The first local symptoms are burning, heat, and itching, usu- ally observed on the face and hands, as these are the most exposed parts. The surface becomes reddened, with oc- casional livid spots, and the cellular tissue in the vicinity becomes oedematous. About this time the characteristic vesicles begin to appear, usually first of all between the fingers. The next locality involved, in males especially, is usually the genitals. From here the eruption may spread to other parts of the body. When the eruption is at its height, the surfaces in- volved are of a lurid red color, more or less oedematous, ■occupied by patches of papules and vesicles, the latter often confluent, with frequent excoriations exuding a clear yellow fluid, which gums on linen, and dries into a soft crust. The eyes are often closed from swelling of the eyelids, while the nose, lips, and ears are swelled, and drip with serum. The genitals are often enormously tumefied, and in the most aggravated cases there may be such excessive general oedema that the patient may be ren- dered actually helpless (Park). In the more marked eases there is sometimes a slight febrile reaction, with coated tongue and constipated bowels. General symp- toms are absent, however, in mild cases. The subjective sensations are usually itching and burning in the affected parts. In severer cases this may be intensified by a -burning, stinging heat, and the torture may be so great as to deprive the patient of sleep, and require the adminis- tration of narcotics. The eruption remains at its height for several days, but by the end of a week the acute symptoms have usually subsided, though a few stray lesions continue to appear. The diagnosis of dermatitis venenata is usually made without difficulty, because a history of exposure to the poison vine or oak may almost always be obtained. In addition, the localities attacked are characteristic. The vesicles are usually first found between the lingers, where the skin is thin, then on the dorsal surface of the fingers and hands, and last on the thickened skin of the palms. The eruption is more scattered than that of eczema, with which affection it is most liable to be confounded, and the vesicles are usually developed as such, springing often directly from the skin, without going through the preliminary condition of papules, as is usually observed in eczema. Dermatitis venenata is not, strictly speaking, contagi- ous. In recent cases the poison can be conveyed from one person to another, or from one part to another, by simple contact of the surface. Thus, the penis may be handled in micturition immediately after handling the poison vine, and thus this locality is very apt to be at- tacked. Eczema is very apt to occur as an immediate sequel to dermatitis venenata, but the latter disease does not pre- dispose to eruptions of any kind as a remote result of its influence upon the system. White thinks that there is no evidence of a continuance or renewal of the operation of the poison after its primary impression on the skin has exhausted itself, and therefore the accounts which we have of yearly recurring attacks of dermatitis venenata indicate renewed exposure, and not spontaneous periodical exacerbation of poisonous influence. A legion of remedies have been and are yearly sug- gested for the relief of dermatitis venenata, some of which are effectual, while others have appeared to prove successful merely because the affection, running a spon- taneous course toward recovery, has gotten well while they have been in use. In the experience of the writer the use of black wash, in the form of cloths kept wet with the wash and in con- stant contact with the skin, is one of the most useful remedies. At night the following ointment may be sub- stituted for it: 3. Acid, carbolic, Gm. .65 to 1.30 (gr. x. to xx.) ; hydrarg. chlor, mit., Gm. .65 (gr. x.) ; ung. aquye rosaj, Gm. 31.10 ( = j.). A wash composed of fluid extract of grindelia robusta, Gm. 3.90 to 15.50 (f 3 j. to f-3 iv.) in Gm. 480 (Oj.) of water is likewise often useful. Of late years I have used a solution of the sulphate of zinc in water, Gm. .13 (gr. ij.) ad Gm. 31.10 (f ~ j.), and I prefer this in the majority of cases to any other local application. Where constipation exists, it is well to give a purge at the beginning of the treatment. No other in- ternal treatment is required. • The prognosis of this form of dermatitis is of course favorable, although the occurrence of successive crops of eruption may delay the cure for some weeks. Other forms of dermatitis, due to toxic substances, are those produced by the local action of chemical agents, as strong acids, caustics, and the like. Mezereon and arnica likewise produce dermatitis at times. The symptoms in the milder cases consist of erythema, with more or less burning or itching, going on to the formation of vesicles, pustules, or bullae. In extreme cases gangrene and ul- ceration may ensue. The dermatitis produced by arsenic as used in wall- papers, playing-cards, or in the arts, may likewise be of all grades, from a fugitive erythema to a deep-seated gan- grene? Taxidermists and workers in arsenical prepara- tions suffer from limited ulceration about the nails, or deeper ulcers between the fingers. Poisonous clothing, particularly that which has been dyed with aniline colors, is a frequent cause of derma- titis. Stockings, underclothing, and shoes not infre- quently give rise to irritation, due either to the aniline contained in them or to arsenic used in fixing the dye. Dermatitis congdationis, or " chilblain," does not neces- 407 Dermatitis. Dermatitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sarily depend upon the influence of extreme cold ; indeed, the affection is commoner in hot than in cold countries, and may occur at a temperature not below 32° F. A cer- tain morbid predisposition on the part of the patient is a necessary condition of their occurrence. Ansemic and chlorotic persons are more apt to be the subjects of this affection. The erythematous form of chilblain shows itself in the form of circumscribed patches of a livid red color, and somewhat tubercular character, the color disappearing under pressure of the finger. The lesions itch and burn painfully. They occur most commonly upon the fingers and toes, but may appear also upon the ears, nose, or other parts of the face, or, indeed, on any part of the body which is exposed to cold. Their course is essenti- ally chronic ; usually they do not change in appearance, but sometimes become hard and infiltrated, while at other times, under the influence of pressure or rubbing, as of the shoe, or scratching, a bleb or a pustule forms. The pain is then considerably increased, especially when the bulla or pustule bursts and leaves an ulcer. These changes, however, frequently lead to the cure of the af- fection, which might otherwise have lingered on indefi- nitely. The bullous form of chilblain is formed under the influence of a more intense degree of cold, and is char- acterized by the formation of watery or sero-sanguinolent blebs, the size of hazel-nuts or goose-eggs. If they are not punctured they undergo no change for some time, but at last break after having effected considerable de- struction of tissue, the bones even of the feet and hands being occasionally laid bare and exfoliating. The escharotic chilblain is a still more extreme degree of the same process, sloughs forming which may be cast off without further effect, or which may poison the blood with fatal result. The treatment of the dermatitis due to irritation from arsenic, arnica, and other poisons, is to be followed on the same lines as that of dermatitis due to the poison vine. Sedative and astringent applications are chiefly called for, while, of course, the exciting cause must be removed. As regards the treatment of dermatitis congelationis, the most important thing is prevention. Protection from exposure, warm and sufficient clothing, and attention to the general health, should this be below par, must first be considered. As to local treatment, in mild acute chil- blain, rest i-n the horizontal position, frictions with cold w'ater or snow, and astringent sedative lotions, as lead water and opium washes, or lotion of the fluid extract of grindelia robusta Gm. 3.90 (f 3 j.)-Gm. 15.50 (f 3 iv.) to Gm. 480, (Oj.) of water may be prescribed. In the more chronic forms of erythematous chilblain, stimulant ap- plications are called for. When the lesions are unbroken they may be painted with tincture of iodine or with oil of peppermint, pure or mixed with one to six parts of gly- cerine. When the lesions are broken the following for- mula may be employed: fl. Terebinth. Venetian., Gm. 11.65( 3 iij.); ol. ricini, Gm. 1.50 (f 3 iss.); collodii ad Gm. 23.20 (f 3 j.). M. Sig. Apply with a brush, as often as re- quired to shield the lesion from the air. The cure of the severer forms of dermatitis from cold belongs rather to the province of the surgeon. When operative interference is not demanded they are to be treated in a manner suitable for burns of the like gravity. Arthur Van Harlingen, ous other diseases, particularly with pityriasis rubra, with which it has many points of similarity. A recent writer (Weyl: " Ziemssen's Handbuch der Hautkr.," Ite Halb Bd., S. 530) even considers it an acute, benignant form of pityriasis rubra. Brocq, how'ever, in an elaborate thesis, sustained before the Faculty of Medicine of Paris, in 1882, after a careful analysis of all published cases of pi- tyriasis rubra, desquamative scarlatiniform erythema, re- current exfoliative erythema, pemphigus foliaceus, etc., shows dermatitis exfoliativa to be a distinct entity. Brocq has analyzed and differentiated the cases coming under his observation, and those reported by others, so carefully that we cannot at present do better than follow his account of the affection under consideration. It appears, then, that dermatitis exfoliativa occurs most commonly among males and in adult life, although a few cases have been reported among females, and one case, of a somewhat doubtful character, in a little girl of six years. In many cases patients have been more or less exposed to injurious external agencies, heat, irritating liquids, etc. The occurrence of previous skin disease is so unusual that this cannot be regarded as an etiological factor. On the other hand, a certain predisposition to inactivity or morbid action of the cutaneous glands has been ob- served. The previous general health of patients has gen- erally been reported as good. The disease may begin at any time of year. It is, as may be understood, very rare ; only a couple of dozen cases, at the outside, have been re- ported which will stand the test of criticism. The earlier stages of dermatitis exfoliativa have very rarely been studied, as patients seldom come under obser- vation until it is fully developed. So far as is known, the affection develops insidiously ; one or more patches of erythematous eruption are usually first noted occurring in the flexures of the joints, about the genitals, or at some point as about the waist where the clothing binds. Thence the rash spreads progressively, first involving the trunk and upper limbs, then the lower limbs, and finally the face. The feet and hands are only invaded at a later period, sometimes not for one or two months. The erup- tion may invade most points with considerable rapidity, occasionally covering the greater part of the surface in eight or ten days. After the redness of the skin has developed the skin remains dry ; there are no vesicles or bullae at this stage of the disease. Itching, however, may be present, and the scratching resulting from this may cause weeping at one point or another, and especially in the flexures of the joints. At this period the disease resembles erysipelas, the skin being red, smooth, and shining, without the presence of scales. By the tenth day, commonly, the pa- tient is red from head to foot, and looks like a boiled lob- ster. The redness diminishes under pressure of the fin- ger, leaving a yellow' tint, which indicates that there is not only hyperaemia but infiltration. Occasionally the skin takes on the appearance of the second period of ec- zema, excepting that it remains perfectly dry ; no bullae, vesicles, or weeping can be observed. Infiltration of the skin usually exists to a slight extent, but is sometimes marked, and oedema, with subsequent thickening of the integument of the lower extremities, has been observed. Occasionally a feeling of tension or retraction is felt, as if the skin had grown too small for the body, and the least movement would make it burst or crack. Fissures do indeed occasionally form about the joints. This thick- ening and rigidity of the skin, when it affects the eyelids, gives rise to slight ectropion, and the eyes have a wide- open, staring look which is quite striking. The epidermis begins to desquamate at the end of about eight days after the appearance of the eruption, the scales being in most parts of the body quite large, sometimes roundish, the size of a quarter-dollar, and attached by the centre with free borders, at other times squarish or ob- long, of several inches area, or smaller, and attached by one end so as to lie like shingles on a roof. These epi- dermic scales are largest on the limbs, elsewhere they are smaller, and on the scalp they are almost bran-like. In the flexures of the joints some slight moisture, with gran- ulated crusts, may be present. The epidermis of the feet DERMATITIS EXFOLIATIVA. Generalized exfolia- tive dermatitis is a disease of the skin occurring in adults, generalized over the entire surface, not contagious, run- ning a regular course, characterized at its height by an in- tense diffuse redness of the skin with persistently recur- ring lamellar exfoliation of the epidermis and shedding of the hair and nails. It is also characterized by such gen- eral symptoms as fever, prostration, and marked enfeeble- ment, is rarely fatal, and usually terminates in recovery. It runs a course lasting on an average four months, but may be prolonged for eight months or a year by repeated relapses. Dermatitis exfoliativa has been confounded with vari- 408 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dermatitis. Dermatitis. and hands may be thrown off as casts, or gloves and slippers almost entire. The lesions of the hair and nails are of importance. Being appendages of the epidermis, they are, of course, involved in such an affection as that under consideration. Alopecia is nearly constant, the hair being shed in the earlier months of the disease, with more or less rapidity and completeness, and being replaced by downy hair, which may fall and be renewed several times in the course of an attack. The hair of the beard, eyelashes, pubis, etc., is shed usually just as the hair of the scalp, though complete baldness of these parts is rare. The nails are shed in various ways. Sometimes they are detached bodily, occasionally they come off with the epidermis of the fingers, forming a complete glove. In some cases the nails are altered in structure before be- coming detached-they may become rugous, discolored, and especially thickened. This thickening is the result of a sort of exfoliation which takes place from the matrix, and which sometimes does not affect the original nail, but lifts it up entire. These changes and exfoliation of the nails continue during the entire course of the disease. The importance of this complete, or nearly complete, shedding of the hair and nails in dermatitis exfoliativa, lies in the fact that it is almost, if not quite, pathogno- monic. No other skin disease is accompanied by such complete loss of these appendages. In addition to the characteristic redness and exfoliation of the skin, certain anomalous eruptions may occur at the same time, and if the case is examined when these are in full development, they may mislead the observer as to the true nature of the affection. These are an eczema-like eruption with serous discharge, most apt to occur about the flexures of the joints, but also encountered elsewhere, a bullous eruption, and a papular or pustular outbreak. These, however, are limited in extent and transitory, and careful watching of the case for a longer period will de- velop its real character. The mucous membranes are occasionally attacked in dermatitis exfoliativa. Injection and even inflammation of the conjunctiva, crusts, and haemorrhages from the nose, are at times noticed ; the lips are at times dry, cracked, covered with a sort of pseudo-membrane, as the gums may also be, or they are red and granular. The tongue may be normal, or red and somewhat fissured. In rare cases it may become inflamed. The mucous surface of the prepuce is sometimes swollen and inflamed. As regards the subjective sensations observed by pa- tients, itching is, in some few cases, very severe ; usually it is present to a greater or less degree at the beginning of the disease, and is not so marked later. It is often aggra- vated at night, and by sudden changes in the weather. Burning sensations also occur at times to a highly painful degree. Patients also sometimes feel so warm that they lie in bed uncovered. This condition usually coincides with decided feverishness and alternate chilliness. Pa- tients are very sensitive to cold, as also is the case in other generalized inflammations of the skin, as psoriasis and eczema. The general condition of a person suffering from der- matitis exfoliativa is markedly affected. Rapid and de- cided emaciation, sometimes to an extreme degree, loss of strength, and even profound cachexia are observed in some instances. In fact, the patient is almost as much reduced as by an attack of typhoid fever. Insomnia to q slight degree, and loss of appetite in the earlier stages, changing in the later periods to extreme voracity, are also present. Constipation alternating with diarrhoea is not un- common. Slight attacks of bronchitis from time to time are not uncommon, and in severe cases decided pulmonary congestion may manifest itself. Now and then marked swelling of the lymphatic ganglions is observed, which seems to affect all those commonly observed under the skin in different parts of the body. The urine is at first dimin- ished in quantity, high colored, acid, and loaded with urates and phosphates. Toward a fatal termination al- buminuria may be observed, otherwise it is absent. In convalescence the urine becomes normal. Among the complications of dermatitis exfoliativa may be mentioned the occurrence of abscesses in the axillae and elsewhere, and especially, in the later stages of the disease, of bed-sores. Deafness not accounted for by oc- clusion of the external meatus, and dimness or uncer- tainty of vision, together with more marked nervous symptoms, even paralyses of various parts or complete paraplegia, are observed in long-continued cases. Hydrar- throsis of the knee, with rheumatic attacks in other joints, have also been noted. The temperature is, in most cases, at times elevated above the normal, and is apt to show evening exacerba- tions of one or two degrees. There is a period of higher temperature with these variations during the height of the disease, the elevation of temperature gradually pass- ing away as the patient tends to recovery.1 Dermatitis exfoliativa presents itself in various degrees of severity in different cases. At times it may run a mild uncomplicated course, while in other cases it is se- vere, complicated by various intercurrent troubles, and may even end fatally. In average cases the various symptoms begin to abate in the course of the third month. The fever diminishes, the patient gradually gains strength, and the scales shed from the skin become smaller and less abundant, usually disappearing from the trunk first, then from the limbs, and last from the face and scalp. The redness gradually diminishes, the baldness or downy hair gives place to a more healthy growth, and finally the nails reappear, though only very slowly. A brown pig- mentation lasts for a considerable time after all trace of disease has left. Dermatitis exfoliativa rarely terminates fatally. In slight or moderate cases the eruption gradually fades away, and, after one or two slight relapses, disappears at the end of three or four months. Complications and re- lapses may prolong its course to eight months or a year. Recurrences may be in the form of slight exacerbations or relapses, when the affection, which had almost disap- peared, takes on again all its active features ; or, finally, they may be in the form of a return of the whole disease after an interval of health. These recurrences are usually of a milder type on each occasion. The diagnosis of dermatitis exfoliativa is sometimes made with great difficulty; the diseases which it most closely resembles being ' ' universal " eczema and psori- asis, pityriasis rubra, recurrent scarlatiniform erythema, pemphigus foliaceus, and, in its earlier stages, scarlatina and some of the medicinal eruptions. As regards eczema and psoriasis, these affections can rarely be called strictly universal. There is almost always some patch of skin left unaffected, and also in eczema we are apt to have more or less fluid exudation at one period or another of the disease ; while in psoriasis some points almost always show the imbricated scales characteristic of the disease. The history of the case also goes for much. Pityriasis rubra is so closely analogous to exfoliative dermatitis that the two diseases have been confounded by many writers, and indeed the former is now by some con- sidered as a later stage of the disease under consideration. However, pityriasis rubra presents certain symptoms sui generis. Among these may be mentioned its gradual de- velopment, without any other symptom than an intense and universal redness of the skin without infiltration, and with desquamation in fine, white, slightly adherent scales. There is so little itching that the patient does not scratch himself. The eruption is dry, persistent, and lasts for years, the patient falling into a condition of ca- chexia, with retraction and atrophy of the skin. Finally the hair disappears, ulcers and gangrene of the skin su- pervene, the patient becomes emaciated, marasmic, and finally succumbs to some intercurrent complication, as tuberculosis. On the other hand, dermatitis exfoliativa runs its course usually in four months, commonly terminates favorably; the derma is somewhat infiltrated and not atrophied ; des- quamation takes place in large, white, pearly lamellae, several centimetres in dimensions. The view that pityriasis rubra is a chronic stage or form of dermatitis exfoliativa, is held by several writers on the subject, but the point has not yet been demonstrated, and 409 Dermatitis. Dermatitis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. it has been considered better by the present -writer to con- sider the two diseases separately. Under the name of "Erytheme scarlatiniforme des- quamatif recidivant," Besnier and Fereol have described a peculiar affection beginning with fever like scarlatina, with generalized intense redness of the skin, followed by a lamellar exfoliation of the skin of eight to twelve days' duration, and ending in cure. A relapse commonly takes place, however, after a short interval, similar in all re- spects to the first attack, and numerous subsequent re- lapses of diminishing intensity may take place. There is no loss of hair and nails, but each attack leaves a ridge on the nails. These peculiarities, together with the fact that the desquamation is like that of scarlatina, and that the affection runs a shorter course and presents milder symptoms, will serve to differentiate dermatitis exfolia- tiva from this scarlatiniform erythema. Intermediate cases are met with, however, which are quite puzzling. From pemphigus foliaceus our affection is distinguished by its constant dryness. True pemphigus foliaceus gives a history of bullae at one period or another. From scarla- tina the absence of prodromal manifestations, the usually lower temperature, and the course of the disease, if fol- lowed a few days, will mark the distinction. Medicinal eruptions also may quickly be differentiated by the course which they follow, and in most cases by the history of antecedent administration of drugs. The treatment of dermatitis exfoliativa consists of emol- lient applications, and of frequent inunction with vase- line or one of the bland oils. Starch poultices will also be found useful if crusts accumulate. Oxide of zinc ointment, with a little tar applied to fissures and rhagades, carbolic acid in lotions as in eczema (q. v.), and in severe cases inunction with carron oil, enveloping the body after- ward in cotton-these are the forms of external treatment which give most relief to the patient. Stimulating ap- plications do more harm than good. Baths are to be given with caution for fear of pulmonary complications. Internal treatment is to be directed against the skin affection itself and against the complications which may arise-fever, insomnia, sweats, constipation, weakness, etc. Bitter and ferruginous tonics are called for, also cod-liver oil in some cases. In giving drugs, as atropia against the sweats, and chloral or morphia in insomnia, it must be remembered that they themselves occasionally produce an eruption almost precisely like that from which the patient is suffering, and care must be taken not to ag- gravate the existing eruption. Diet is a matter of much importance. Milk diet is perhaps best in the earlier stages of the disease, and later more sustaining and varied fare, as soups, eggs, etc., may be employed. Alcohol should not be used unless the patient fails perceptibly. The prognosis of dermatitis exfoliativa is on the whole favorable, though cases do occasionally go on to a fatal termination. From the description of the disease above given it is seen that relapses must be looked for, and often a tedious course toward recovery. The prognosis, therefore, in any given case should be guarded. Under the designation of exfoliative dermatitis of infants •at the breast, Ritter von Rittershain describes a disorder of a serious character which makes its appearance from the second to the fifth week of life, with the following symptoms : At first, dryness of the skin with slight des- quamation, and redness of the lower part of the face, with fissures at the angles of the mouth. The mucous mem- brane of the latter becomes hyperaemic and the seat of large irregular erosions covered with a thin grayish layer. Meanwhile the child remains well nourished and shows no elevation of temperature. Later, the redness extends over the whole body, and crusts form on the lower part of the face, under which the skin becomes deeply fissured. The epidermis over the whole body is thickened and lifted up from the cutis by a thin layer of fluid exuda- tion. The epidermis is soon thrown off in large masses, leaving the exposed cutis of a dark red color, presenting an appearance like that of an extensive burn. The hands and feet are particularly affected, and here the epidermis peels off in great flakes. Several varieties of the affec- tion in its early stages have been observed. Sometimes miliary vesicles are seen on the forehead extending to the scalp. In other cases the eruption resembles an eczema , in a third class of cases it is like pemphigus. Dessica- tion takes place sometimes within twenty-four to thirty- six hours. In exceptional cases the skin continues dry throughout the whole course of the disease, becoming fissured and presenting a parchment-like dryness. In these cases the whole surface is not involved. All of these changes take place within a week. Later, slight desquamation occurs, often accompanied by eczema, fu- runcles, and abscesses, with at times extensive phlegmo- nous infiltration, gangrene, and death from intercurrent pneumonia, colliquative diarrhoea, etc. Fifty per cent, of the 274 cases observed by Ritter died. The existence of the disease as an independent affection has been denied, but Caspary has recently corroborated Ritter's state- ments. Bibliography. E. Wilson : Treatise on Diseases of the Skin, 1867. A. J. L. Brocq : These de Paris, 1882. Buchanan Baxter : Brit. Med. Jour., vol. ii., 1879, p. 119. Fdreol : Union M6d., 1876, No. 29. Magee Finny : Dublin Jour. Med. Sei., March, 1876, p. 234. Percheron : These de Paris, 1875. L. D. Graham : Jour. Cutaneous and Venereal Dis., 1883, vol. i., p. 390. Exfoliative Dermatitis of Infants at the Breast. Hitter v. Rittershain : Centralztng. f. Kindrkr., 1878, No. 1. Caspary: Vierteljahrsschr. f. Derm. u. Syph., Jahrg., xi., p. 123. Arthur Van Harlingen. DERMATITIS HERPETIFORMIS. Under this designa- tion the disease described by writers under the name of "impetigo herpetiformis" and "herpes gestationis" is to be understood, as well as numerous cases reported as "pemphigus," "herpes pruriginosus," " hydroa," etc. The name dermatitis herpetiformis, recently given by Duhring, who has published a number of papers bearing upon the subject, seems to the writer to better describe this disease than any other name thus far chosen. Dermatitis herpetiformis may be defined as a chronic multiform skin affection, characterized by successive out- breaks in which the eruption may be at one time her- petiform and vesicular, at another pustular, while in other instances, or at other periods in the history of a given case, wheal-like lesions or bullae may predominate. The lesions tend to assume a circinate arrangement, and se- vere and intolerable itching, with more or less constitu- tional disturbance, is a common accompaniment. In severe cases prodromal symptoms are usually present for several days preceding the cutaneous outbreak ; they consist of malaise, constipation, febrile disturbance, chil- liness, heat, or alternate hot and cold sensations. Itching is also generally present for several days before any sign of efflorescence shows itself. Even in mild cases slight sys- temic disorder may precede or exist with the outbreak. This latter may be gradual or sudden in its advent and development. Not infrequently it is sudden, one or an- other manifestation breaking out over the greater part of the general surface, diffusely or in patches, in the course of a few days, accompanied by severe itching or burning. A single variety, as, for example, the erythematous or the vesicular, may appear, or several forms of lesion may exist simultaneously, constituting what may very properly be designated the multiform variety. The ten- dency is, in almost every instance observed by Duhring, to multiformity, and the experience of the writer coin- cides with this. There is, moreover, in many cases, a distinct disposition for one variety, sooner or later, to pass into some other variety ; thus, for the vesicular or pus- tular to become bullous, and vice versa. This change of type may take place during the course of an attack, or on the occasion of a relapse, or, as is often the case, it may not show itself until months or years afterward. Not only multiformity of lesion, but irregularity in the course of development is, it may be repeated, the rule. Itching, burning, or pricking sensations almost always exist. When the eruption is profuse, they are intense, and cause the greatest suffering. They become more violent before and with each outbreak, abating in a measure only with the laceration or rupture of the lesions. The disease is rare, but of more frequent occurrence than was 410 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dermatitis. Dermatitis. formerly supposed to be the case. Duhring's fifteen cases were adults, including both sexes in about equal propor- tions. The writer has met with several cases, including one in a boy of twelve. The disease process is in almost all instances chronic, and is characterized by more or less distinctly marked exacerbations or relapses, occurring at intervals of weeks or months. The disposition of the eruption to appear in successive crops, sometimes slight, at other times severe, is peculiar. Relapses are the rule, the disease in most cases extending over years, pursuing an obstinate, emphatically chronic course. All regions are liable to invasion, including both flexor and extensor surfaces, the face and scalp, elbows and knees, and palms and soles. Excoriations and pigmentation, diffuse and in localized areas, are in old cases always at hand in a marked degree. The pigmentation is usually of a mottled, dirty yellowish, or brownish hue, and is persistent. Treatment has, as yet, proved of little avail in retard- ing or checking the course of the disease, or modifying it in any way. The general health, which is frequently im- paired, or which, in severe cases, may be broken down by suffering and sleeplessness, is to be improved by tonics, diet, etc. Strychnia with quinine, and with or without the addition of arsenic, in doses of grain (.002 milligr.), has been found useful in this respect. Soothing ointments, as the unguentum diachyli of Hebra, may be employed, or the following : R. Bismuthi oxidi, 3 j. (Gm. 4.00); acidi oleici, § j. (Gm. 32.00); cerae albse, 3 iij. (Gm. 12.00); vaselini, 3 ix. (Gm. 30.00); ol. rosae, Tliij. (centigr. 16). Misce. Washes are usually more grateful to the skin than oint- ments in this disease, and are required to soothe the often severe itching and irritation of the skin. The following is a convenient formula: I). Acid, carbolic., 3 iij. (Gm. 12.00); glycerinae, f § j. (Gm. 40.00); aquae ad Oj. (Gm. 480). The prognosis in dermatitis herpetiformis should be guarded. Some cases appear to get well after months or years, but others persist. Relapses are not uncommon. The form observed in connection with gestation usually gets well more rapidly. That observed abroad by Hebra and Kaposi appears to be malignant, the cases ending fatally, which, it is believed, has never been the result in any of the cases reported in this country. Malignant papillary dermatitis is actually or possibly a carcinoma, and should be treated as such. In the earlier stages destruction by scraping or cauterizing may be practised with some hope of success, but once established the only treatment is complete excision of the part in- volved, or even ablation of the entire gland. Arthur Van Harlingen. DERMATITIS MEDICAMENTOSA. Drug eruptions are those produced by the ingestion of substances ordi- narily used as medicines. These must be taken up into the system to produce the effects here understood. The direct irritative effects caused by the application of drugs to the surface are described under the head of Dermatitis venenata. Some drugs, as iodine and its salts, will produce erup- tions in almost every instance if taken in considerable quantity or for a sufficient length of time ; others, as quinine, only produce an effect in persons having a pecul- iar idiosyncrasy toward the drug. The following drugs have been known to produce eruptions upon the skin as a result of their ingestion: Arsenic, antipyrine, bella- donna and atropia, bitter almonds, bromine, borax, can- nabis indica, chloral, copaiba, cubebs, digitalis, duboisia, hyoscyamus, iodine, iodoform, mercury, opium, pilocar- pine, phosphoric acid, quinine, salicylic acid, santonine, tar and its derivatives and congeners, turpentine, carbolic acid, creasote, rosin, and petroleum. The eruptions produced by these drugs are generally limited to a few pretty well-defined groups, and bear a family resemblance to one another. Erythematous, scarla- tiniform, and urticarial rashes are usually met with. Less frequently, pustular, bullar, purpuric, or nodular erup- tions are encountered. There is nothing about the appear- ance of these eruptions which is so characteristic that the drug causing it can be pointed out in any given case. We are able, however, in most instances, to designate an erup- tion as due to the effect of some drug, because, while re- sembling closely some other eruption in its lesions, the drug, eruption is always different in some well-defined symptom. It may be too profuse, or it may be accom- panied or unaccompanied by fever, contrary to the usual rule, or the lesions may occur in some unusual place and run a peculiar course. These points will be developed further in describing the eruptions produced by the indi- vidual drugs. The eruptions due to iodine and bromine differ so much from the other drug eruptions that they may best be considered separately. There is an erythematous eruption due to bromine which may occur in any part of the body, but is usually confined to the lower extremi- ties ; it is diffuse, and at times painful. A maculo-papular eruption has been described as occurring on the face and neck, the skin having a congested violaceous hue, with a copious eruption of maculo-papules and pustules, with enlargement of the sebaceous ducts and the formation of sebaceous crusts. The skin is flushed, but does not itch. As there is some fever and constitutional disturbance, this eruption may be mistaken for the erythematous syphiloderm, but the sebaceous character of the lesions is characteristic. Wigglesworth has described a bullous eruption due to bromine, and characterized by lesions which were some- what acuminated and varied in size from that of a split pea to the end of the finger. In some instances the bull® ruptured, leaving sometimes a simple fringe of torn epi- dermis, and sometimes an ulcerated surface. Some of the bull® appeared to contain blood. The pustular eruptions due to bromine are better known than any of the other varieties. In their simplest form, resembling acne, they occur sooner or later in almost all persons subjected to a course of the bromides. Oc- casionally a "confluent acne" is observed. Here the smaller lesions are pea-sized, prominent, convex, vesico- pustules, seated on a hard, slightly elevated base, and sur- rounded by a vividly red areola. The larger lesions are flattened elevations, covered by a moist, flaccid cuticle, or thick, light-brown crust, and surrounded by a dark-red areola. The crust or cuticle being removed, the surface Bibliography. Hebra: Atlas der Hautkrankheiten, hfr. ix., taf. 9, v. 10. Wien, 1876. Id.: Wien Med. Wochenschr., No. 48, 1872. Also, Lancet, March 23, 1872. Bulkley: Am. Jour. Obstetrics, February, 1874. Duhring : Jour. American Medical Association, August 30, 1884. Arthur Van Harlingen. DERMATITIS, MALIGNANT PAPILLARY, sometimes called Paget's disease of the nipple, is a malignant disease of the nipple and adjacent structures, at first closely re- sembling eczema. The disease begins with roughness, redness, and scaling about the centre of the nipple, with occasional slight oozing or crusting, and, in some cases, the formation of a fissure. The process goes slowly on, presenting to all appearance the symptoms of eczema with intense itching, in many cases"the nipple becoming retracted and finally melting away. When fully devel- oped a considerable portion of the breast may be covered by the red, infiltrated, weeping patch, which is slightly sunken at the sharply defined edge below the level of the surrounding skin, and presents a peculiar livid crimson, different in tint from the bright red of eczema rubrum. Taken between the fingers the infiltration of the skin does not extend as deeply as would be thought from the appearance of the disease. The points just given, to- gether with the fact that the infiltration is firmer than that observed in eczema, and the surface exudes a serous fluid without much discharge, crusting, vesiculation, etc., will serve to distinguish the disease from eczema of the nipple, with which it is very apt to be confounded. Any eczema of the nipple should be viewed with suspicion, above all if chronic in character, tending to spread slowly and steadily, and with more or less progressive retraction of the nipple. 411 Dermatitis. Dermatol ysis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. beneath presents numerous pin-head sized, yellowish-red protuberances. The secretion is found to be chiefly sebaceous in character. These confluent lesions may be from one-fourth of an inch to several inches in diameter. The peculiarity which chiefly distinguishes this form of bromide eruption from acne is that it may occur in any locality, often being found where acne never occurs, and neglecting entirely the favorite localities of that disease. Occasionally we meet with a bromine eruption which resembles the eruption of erythema nodosum. In the diagnosis of bromine eruptions the dusky rose or violaceous color of the lesions must be taken into ac- count, and also the distribution of the lesions, the f oetor of the breath, and the presence of bromine in the urine must be considered. Of course, the history is of importance. With regard to the amount of the drug necessary to produce these skin eruptions, it can only be said that it varies greatly. While usually it is requisite that bromine or its compounds should be taken in considerable doses, and for some length of time, yet cases are on record in which very small doses have quickly brought out a characteristic eruption. Like the eruptions due to bromine, those due to iodine have, some of them, at least, been familiar for a long time. The eruptions from iodine may be erythematous, papular, vesicular, bullar, pustular, or haemorrhagic. The erythematous form shows itself in large disseminated patches in various parts of the body, sometimes forming a sort of iodic roseola. The forearms are usually attacked. If the use of the iodide is persisted in, the eruption may pass on to the papular form. The papular eruption is characterized by heat of the skin, with reddish patches, on which are situated numerous large papules elevated very slightly above the surrounding skin, sometimes dis- seminated over the surface generally. This form of erup- tion is not unlike urticaria, but has a brighter and less circumscribed coloration. It is rare. Vesicular erup- tions resembling eczema are said to have been caused by the ingestion of iodine or its compounds, and several observers have reported a peculiar bullous eruption sit- uated usually upon the head, neck, or upon the upper extremities; less frequently upon the lower extremities and trunk. The lesions begin as pin-point-sized vesicles, or as shot-like papules, at the apices of which vesiculation subsequently occurs. The lesions are pale yellowish- white and glistening. If the iodine be persisted in, and especially if given in large doses, the bullae change to red and purple, and become filled with sero-pus and even ichor. In a few instances blood has been found in the bullae at an early stage. The pustular eruption due to the ingestion of iodine or its compounds is in almost every respect analogous to that produced by the bromides, only that the confluent form is extremely rare. It is peculiar in its subjective symptoms, itching at first, and later giving rise to severe throbbing pain. This symptom, together with the viola- ceous color of the lesions, and their cheesy, non-purulent contents, serves to distinguish the iodine eruption from syphilis or any other disease with which it is liable to be confounded. A purpuric eruption due to the ingestion of iodine or its compounds is now and then met with. It may be brought on even by minute doses of the drug, the case of an infant having been reported where a fatal result was caused by a single dose of two and a half grains. Usu- ally, however, the eruption is not severe, and is found upon the legs. Now and then other haemorrhages may be caused simultaneously. It is usually produced at an early date from the first exhibition of the drug, but its appearance is occasionally delayed until the drug has been administered for some time. The purpuric erup- tion ceases when the iodine is stopped, but may be repro- duced by even minute doses. Both the iodine and the bromine eruptions may often be prevented by the simultaneous administration of arsenic. As much as ten minims of Fowler's solution may be given in each dose when this is borne by the patient. Paget recommends the administration of aromatic spirits of ammonia with the same view. The other drug eruptions, aside from those due to bro- mine and iodine, may be classed together on the ground that they are almost always of an exanthematous char- acter, resembling scarlatina, measles, roseola, urticaria, etc., and that idiosyncrasy bears a much more important part in their production than in the case of the drug erup- tions described above. Arsenic may produce erythema-form, erysipelatoid, papular, urticaria-form, vesicular (?), pustular, and fu- runcular (?) lesions. Herpes zoster is likewise said to be caused by the ingestion of arsenic, but sufficient proof of this has not yet been brought forward. The same may be said of the supposed production of alopecia areata. At times a bistre tint, similar in character to the blue color caused by the long-continued use of nitrate of silver (see Argyria), is said to be caused by arsenic. Very small doses are sometimes sufficient to bring out arsenical eruptions in persons having the peculiar idio- syncrasy. A case is reported in which a rubeola-like ex- anthem was produced by three drops of Fowler's solution taken daily for three days. The eruption produced by the ingestion of belladonna or atropia is always of an erythematous or scarlatiniform character. It is said to be more common among chil- dren, and often appears after the smallest doses, coming out very soon after the drug has been taken, and disap- pearing a few hours later. It usually invades the face and neck, but may cover the entire surface. It is bright red in color and sharply defined, not presenting exactly the appearance either of erythema or of scarlatina. It is composed of large patches, disappearing under pressure, but reappearing immediately when this is withdrawn. This eruption may or may not be accompanied by burn- ing or itching, and it is not followed .by desquamation. The mucous membranes are apt to be involved at the same time. The belladonna eruption is likely to be confounded with the rash of scarlatina. The previous history, how- ever, the absence of lassitude, of chills, and usually of headache, as well as of febrile reaction and strawberry tongue, the ephemeral character of the eruption, and the accompanying dilatation of the pupil, will suffice to settle the question. The mechanism of the belladonna eruption seems more easily explained than that of some other medicinal erup- tions. It is, to all appearance, a secondary vaso-motor paralysis of a marked character. The chloral eruption is usually of an erythematous type, scarlatiniform, or of a dusky rose color, almost purpuric at times. The lesions are apt to occur in patches, on the face, neck, front of the chest, about the larger joints, and on both surfaces of the hands and feet. It is apt to be accompanied by swelling, heat, and severe itching of the affected parts. It may last from half an hour to several hours, and may end twenty-four hours later in light desquamation ; relapses, even after discontinuance of the medicine, have been reported. Stimulants tend to bring out the eruption. The erythematous eruption, like that of belladonna, appears to be due to vaso-motor pa- ralysis, as also are the palpitations and dyspnoea, which are not unusual concomitant symptoms. Urticaria-form and papular eruptions may also be pro- duced by chloral, and vesicular lesions with oedema have been observed. In rare cases desquamation, with shed- ding of the nails and hair, has followed these symptoms. Purpuric eruptions have been observed in a number of cases as the result of the ingestion of chloral, and some of these cases have been followed by general desquamation, while one has ended fatally. The eruption produced by copaiba, internally adminis- tered, is usually a perfectly characteristic papular ery- thema or roseola, the appearance of which is familiar to most persons who have occasion to prescribe this drug. It appears by preference upon the hands, arms, knees, feet, and abdomen. Sometimes it appears suddenly and covers the entire surface. The patches are usually rose-colored, irregularly rounded, not appreciably elevated, sometimes isolated, sometimes grouped in large patches. If the use of the drug be discontinued the eruption lasts but a few 412 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dermatitis. Derniatolysis. days, but if the administration of the copaiba be perse- vered in, the eruption may extend and take on other forms. Itching is generally present, sometimes to an in- tolerable degree. The eruption disappears without ex- foliation. Miliary, vesicular, and urticaria-form eruptions have been described. These forms of copaiba eruption may sometimes be mistaken for syphilitic erythema, but the onset of the latter is not so sudden, there is no itching, and the places of election-namely, in the case of the copaiba eruption, the upper and lower extremities, especially the backs of the hands, the knees, and around the malleoli and upon the breast, rarely over the whole body-are dif- ferent. The aspect, color, and configuration of the patches are also different. Finally, the disagreeable odor of the skin in the copaiba eruption, owing to the large quantity eliminated by the various glands, is a diagnostic point of value. A case of "pemphagoid" eruption, probably of bullous urticaria-form lesions, with anasarca, but without albuminuria, has been reported. (The urine passed during the use of copaiba furnishes a deposit with nitric acid which may be confounded with albumen.) The eruption produced by mercury is almost invariably of an erythema-form or scarlatiniform character, although cases have been reported in which vesicles, bullae, pustules, and phlegmonous lesions have been observed. The dose of mercury required to bring out the eruption in persons hav- ing an idiosyncrasy toward this drug, is often quite small. Two grains (.14 ctgr.) of calomel in one case, and in an- other a single five-grain blue pill, sufficed to bring out a copious eruption. Engelmann reports the case of a man who took in the course of an afternoon three doses of calo- mel, each a little over two grains (.15 ctgr.). Two hours after the last dose had been taken the patient began to ex- perience a feeling of general discomfort; the skin became dry, and began to itch more and more, the eyes became sensitive to bright light, the mouth and nose dry, and the voice hoarse. The face became puffed up and. red, and this red color soon spread over the entire body, accompa- nied by severe fever, thirst, and sleeplessness. When seen the next morning the patient presented the appearance of a person suffering from severe erysipelas. The face was greatly swollen, particularly the eyelids, so that the latter could scarcely be opened; the skin was drawn, shining, and scarlet red, even in the scalp. The conjunctivae were markedly injected, and the nasal mucous membrane was dry, as was also the mucous membrane of the lips and buc- cal cavity. The tongue was thickly coated, except the tip, which was of a deep purplish red. The red color of the skin appeared to extend over the entire body. The skin was very slightly infiltrated, excepting in the face; it was dry and very hot; temperature 104° F., pulse 120. There was no albumen in the urine. There were gen- eral symptoms of fever ; the skin felt very hot and itchy, particularly on the palms and soles, ears and scalp. There was extreme general malaise. The eruption began to disappear in a day or two, and desquamation took place in large sheets. The general symptoms of malaise continued for a fortnight. It was very difficult to distin- guish the eruption in this case from that of ordinary scar- latina. The history was, of course, of the greatest im- portance. It appeared that the patient had twice previ- ously suffered in a similar manner after taking mercury. The first time he had taken it in pill. The second time he had been exposed in a room to the fumes of the toy known as " Pharaoh's serpents." The eruption brought out by the ingestion of opium or morphia is usually of an erythema-form character, and often resembles closely that of scarlet fever, or in some cases that of measles or of urticaria. It is apt to attack the flexor surfaces, and is accompanied by severe itching. Occasionally complete desquamation of the epidermis takes place over the palms and soles, the epidermis being removable in the form of complete casts of the hands and feet. It is said that the pharynx may be attacked by an erythematous inflammation. In a case reported by Behrend, one-fourth grain (15 milligr.) of opium was given every hour, until ten doses had been taken, or two and a half grains of the drug in all. Within a few hours the patient was seized with severe itching in the skin over the chest, and on the inner sides of the arms, wrists, hands, thighs, knees, and calves. The itching was so severe as to prevent sleep. It was accompanied by a diffuse scarlatiniform eruption, which was made up of minute pin-point efflores- cences, not sharply defined but separate, though at first sight they seemed to be diffuse except over the feet. The tongue was coated, the pharynx normal. The erup- tion faded rapidly when the opium was suspended, but returned again on recommencing the medicine. Des- quamation took place at the end of fourteen days, in large patches, particularly over the backs and palms of the hands, and on the soles of the feet. The quinine eruptions are among the most frequent of all drug eruptions depending on idiosyncrasy, and, next to those produced by bromine and iodine, have been most carefully studied. Morrow has written an excellent monograph on the subject. The prevailing type of quinine eruption is erythema- tous, closely resembling the rash of scarlatina or measles. It first shows itself over the face and neck, but soon be- comes diffused over the whole surface of the body. In exceptional cases it may not become generalized. Some- times on desquamation the epidermis of the hands and feet is shed as a whole. Occasionally the quinine erup- tion may be papular in form, sometimes resembling ery- thema multiforme papulatum, or more frequently urti- caria. In this class of cases there is more or less oedema, with distressing burning, tingling, and itching. The quinine eruption of scarlatinous form may be dis- tinguished from scarlatina by the absence of the scarlatina tongue and sore throat. The pulse is too slow for the initial stage of scarlet fever, and the redness appears sud- denly and without premonitory symptoms. Quinine may also be found in the urine by observing fluorescence (after the chloride of sodium has been precipitated by ni- trate of silver). A special tendency to dermatitis of the scrotum has been noted in some cases of quinine eruption, and finally, a number of cases of purpura-like eruption from quinine have been reported. As regards the other drugs mentioned little need be said, excepting that there is a general resemblance be- tween them as regards their usual effects upon the skin. In eruptions due to the ingestion of drugs, we have in almost every case the imitation of some other eruption, but in an exaggerated form ; the eruption is excessive in some way or another, and usually comes on without any premonitory symptoms such as usher in the eruptions of the exanthemata, for instance. These points should be kept to mind in making a diagnosis in doubtful cases, and the question should at once be put as to what medi- cine, if any, has been taken. Idiosyncrasy is the only word which can be used to explain the cause of eruptions due to the ingestion of drugs, and it may be added that they act through the nervous system. Beyond this our certain knowledge does not extend. Arthur Van Harlingen. DERMATITIS PAPILLARIS CAPILLITII. Under this title has been described an eruption of the skin character- ized by the appearance of pin-head-sized, isolated, or con- fluent elevations of the surface, with interspersed pus- tules, which finally form cicatriciform patches over which the hairs are either clustered in tufts or totally absent. The hairs are atrophied, yet firmly fixed in their follicles, and suffer elongation or fracture before withdrawal. The disease is encountered chiefly upon the nucha, occi- put, and vertex. Papillomatous vegetations, crust-cov- ered, haemorrhagic, and with a foul-smelling secretion, sometimes form, and eventually retract into a sclerotic tissue (Hyde). Some observers consider this affection a form of sycosis non parasitica (Veiel). Arthur Van Harlingen. DERMATOLYSIS. Definition.-A newgrowth or overgrowth of the cutaneous structures, in which the skin hangs in pendulous folds over circumscribed areas. 413 Dermatolysis. Desquamation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Synonyms.-Pachydermatocele, Elephantiasis mollis, E. telangiectodes, Cutis pendula. The disease may be congenital, or first manifest itself at any period of childhood, rarely later, and continue to of the hypoderm. When the tumor has attained large dimensions there is often an excessive formation of one or another tissue, so as to cause a preponderance of the same in the whole or in certain parts of the growth, thus simulating some variety of the well-defined new-growths of the integument. Thus we find that the mass may be composed in parts, or almost wholly, of bands of fibrous tissue, as in ordinary multiple fibromata or neuro-fibro- mata ; or of gelatinous connective tissue, as in elephan- tiasis mollis ; or of dense and rigid bundles of scirrhous hardness ; or that there are large interspaces or cystic cavities filled with a colloid-like fluid ; or that the vas- cular system is disproportionately developed, the vessels being enormously dilated, so as to resemble the spongy or even cavernous tumor (ele- phantiasis telangiectodes) ; or the lymph spaces may possibly be enlarged ; or the adipose tis- sue be enormously developed, as in lipoma. The mass is also often permeated by an abun- dant cedematous infiltration. It will be seen, therefore, that the anatomical changes are far from uniform in all cases. With regard to the causes of the affection little is known. It is in some instances but a continuation, after birth, of some congenital hypertrophy of insignificant dimensions ; thus ntevus pigmentosus is fre- quently its starting- point. It appears as if the skin in some parts had been endowed with an unrestrained hyper- plasy, so as to outgrow the other structures. Prognosis.-There is no limit apparently to the possible extent of the growth. Its effects upon the patient vary according to the seat and size of the tumor. If in a situation where it produces little incon- venience, it may be borne through a long life without harm, but when its weight and po- sition are such as to drag upon the point of at- tachment, it may produce, in addition to the local at- rophy of muscles and bone, exhaustion and cachexia after many years, and a serious impression upon the gen- eral system. Treatment.-The growth, when small, may be easily extirpated by the knife. Enormous ones have also been thus removed when favorably situated. When the tissues are highly vascular the galvano-cautery may be employed. The growth often returns after any operation. James C. White. Fig. 807.-Patient, Aged Thirty. Growths began in childhood, and af- fected, in addition to localities represented, the left lower leg and thigh. They were removed by Dr. R. M. Hodges, at Massachusetts General Hospital. See " Surgical Records," vol. cxxxii., p. 218. This patient's daughter, eighteen years of age, was operated upon in October, 1885, for the same disease upon the legs. increase through life. It occasionally affects several generations in succession, or more than one individual of the same generation. Its most common seat is the side or back of the head, next the back, next the hip and thigh, and less often the shoulder and upper arm. Over some one or more of these localities the skin seems at first to become soft, protuberant, and wrinkled, and the follicular openings are seen to be farther apart than usual, giving a coarse look to the surface. Gradually the skin becomes more loose and baggy, and begins to hang down in pouch form, or, wlien a considerable area is affected, to depend in folds. Eventually, in the course of years it may be, the growth may increase to immense dimensions, surrounding the neck like an enormous convoluted tip- pet ; cover the shoulder and back as with a thick super- imposed garment of extra skin ; hang from the arm along its whole length like the dewlap of a bull ; or form a great attachment of redundant skin dependent from the hip and thigh. Grasped in the hand the mass will be found to be soft and compressible, giving the impression in some cases, or in some parts, as if composed of spongy vascular tissue, in others of a fatty growth. Sometimes the surface is deeply pigmented in parts, and sometimes covered with an excessive growth of hair. Subjectively the symptoms are generally those of inconvenience, due to the weight and bulk of such an appendage. Its develop- ment is generally very slow, but it may increase rapidly and attain large dimensions in a few years. Frequently there are numerous smaller growths in the vicinity of the main tumor, or scattered over large areas, closely resem- bling the appearances presented in multiple fibroma. Erysipelatous or eczematous inflammation occasionally affects the growth, and gangrene of its tissues has been ob- served. It is generally accompanied, after a long time, by atrophy of the muscles of the parts affected, or of the bone even to which it is attached. The recurrent derma- titis which attends the early stages of elephantiasis of the legs does not occur in dermatolysis. Anatomy.-The disease appears to be primarily an overgrowth or hypertrophy of all the structures of the true skin, beginning probably in the deeper fibrous layers Fig. 808.-Arm of same Patient, in de- pendent position. DES CHUTES HOT SPRINGS. Location, in Wasco County, Oregon, east of the Cascade Mountains, in the Des Chutes River Valley. Analysis (L. M. Dornbach and Professor E. N. Horsford).-One pint contains : Grains. Carbonate of soda 4.312 Chloride of potassium 0.250 Chloride of sodium 2.552 Chloride of magnesium 0.152 Sulphate of soda 1.183 Sulphate of lime 0.228 Silicate of soda 1.025 Iron trace Total 9.702 Gas. Cub. in. Carbonic acid 2.82 414 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dermatolj sis. Desquamation. According to Dr. Newberry, the geologist of the Gov- ernment explorations for the Pacific Railroad, numerous hot springs (the above being of the number) issue from the cliffs bounding the Wam-Chuck River, collect in basins, and eventually flow into the river. The tempera- ture of two of them was respectively 143° and 145° F. " The water holds large quantities of silica in solution, but has a bland and pleasant taste." The property is as yet unimproved. G. B. F. DES MOINES. The accompanying chart, representing the climate of the city of Des Moines, Iowa, and ob- tained from the Chief Signal Office in Washington, is here introduced for convenience of reference. A detailed explanation of this and of the other similar charts will be found under the heading Climate ; where also the reader may find suggestions as to the method of using these charts. II. R. Climate of Des Moines, Iowa.-Latitude 41° 35', Longitude 93° 37'.-Period of Observations, August 1, 1878, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, Sid feet. A Mean temperature of months at the hours of Average mean temi>erature de- > duced from column A. > B Mean temperature for period of ob- servation. Average maximum temperature - for period. Average minimum temperature _ for period. | ® 1 E Absolute maximum temperature for period. F Absolute minimum temperature for period. Greatest number of days in any single month on which the tern- perature was below the mean monthly minimum temperature. 1 Greatest number of days in any i single month on which the tern- i m perature was above the mean " 1 monthly maximum temperature. 1 1 January.... February... March April May June July August September.. October November.. December.. Spring Summer.... Autumn.... Winter Year | 7 A.M. Degrees. 15.9 21.0 29.3 41.8 54.4 63.6 67.4 66.8 1 56.3 47.0 32.1 20.8 3 p.M. Degrees. 26.2 32.5 41.7 57.2 69.3 76.6 81.6 82.0 71.6 60.4 43.0 29.1 11 P.M. Degrees. 20.7 26.2 34.9 49.0 60.8 68.2 72.4 72.3 61.6 51.4 36.3 23.6 Degrees. 20.9 26.5 ( 35.3 49.3 61.5 69.4 73.8 73.7 63.1 52.9 37.1 24.5 48.7 72.3 51.0 23.9 49.0 Highest. Degrees. 36.2 36.0 39.6 51.8 67.4 71.5 77.4 78.1 67.6 59.6 42.0 35.0 51.5 74.9 53.3 29.4 49.9 Lowest. Degrees. 8.8 19.1 28.9 1 43.4 54.8 67.5 68.4 69.7 59.4 48.7 27.9 19.8 46.4 69.1 46.1 18.4 46.1 Degrees. 29.4 35.2 44.0 59.7 72.6 80.0 84.7 84.1 73.7 62.6 46.1 31.9 Degrees. 10.2 15.6 26.0 39.5 52.3 60.8 65.3 64.8 54.0 44.5 28.8 16.4 Highest. Degrees. 63.0 68.0 80.0 89.0 93.0 95.5 98.5 103.0 93.0 85.0 71.0 57.0 1 :::::: Lowest. Degrees. 39.0 45.0 52.0 81.0 83.0 90.0 92.0 91.0 81.0 77.0 60.0 49.0 Highest. Degrees. 10.0 1.0 10.0 31.0 44.0 54.0 56.0 63.0 41.0 33.0 21.0 10.0 Lowest. Degrees. -26.0 -23.0 -3.0 11.0 33.0 44.0 52.0 48.0 34.0 15.0 Zero -17.0 . 26 21 20 17 24 18 19 21 23 ' 24 22 18 29 22 20 20 25 19 22 23 18 22 23 29 January.... February .. March April May J K L » N o R S size. In the normal condition the epidermis is continually being rubbed off, washed away, or shed spontaneously. The dried and horny cells thus removed are constantly being renewed from beneath, the source of the epidermic growth being the rete Malpighii. As each cell grows and develops, the chemical and physical qualities of its con- stituents become changed and the cell loses vitality, its nucleus disappears, it becomes dry and lifeless, and is gradually cast off as effete. Under ordinary circum- stances this normal desquamation takes place impercept- ibly in the form of fine powdery scales. In certain pathological conditions of the skin, and in certain grave constitutional disorders, e.g., scarlet fever, recurrent exfoliative, dermatitis, etc., general desquama- tion may take place to a marked degree in large lamellae, the epidermis being thrown off the hands and feet in glove-like casts, occasionally even including the nails. Also in certain abnormal congenital states of the skin, as ichthyosis, which should be described rather as a deformity than a disease occurring in connection with general con- stitutional disturbance, excessive desquamation may take nlace. At other times desauamation mav take nlace in E'g 3ft « £ |j 89.0 91.0 83.0 78.0 60.0 51.5 46.5 55.0 59.0 70.0 71.0 74.0 96.0 59.0 93.0 94.0 129.0 .a aS o 71.1 69.3 67.4 62,6 66.8 L £ >> H'S 22 O 0 11.0 10.4 14.0 11.2 15.0 13.6 14.2 13.1 12.2 11.8 11.3 13.5 40.2 40.9 35.3 34.9 151.3 £ E £ ce o o 11.0 10.0 8.4 9.0 6.2 5.8 10.6 11.0 11.3 10.5 10.7 6.7 23.6 27.4 32.5 27.7 111.2 1 a E O H Ils 22.0 20.4 22.4 20.2 21.2 19.4 24.8 24.1 23.5 22.3 22.0 20.2 63.8 68.3 67.8 62.6 262.5 £ E o g Inches. 1.06 1.69 1.40 2.58 6 54 6 .E ° 'E o £ From N.W. N.W. N. N. S.W. s. S.W. S.W. S.W. s. N.W. N.W. N. S.W. S.W. N.W. S.W. So '5 a G >.S . O'S 3 si'S o ft Miles. 6.3 7.3 8.2 8.4 6.7 6.2 5.1 4.6 5.6 5.9 6.7 6 4 7.8 5.3 6.1 6.7 6.4 June July August .... September. October.... November. December . Spring Summer... Autumn ... Winter Year 1 72.8 71.2 68.9 68.4 69.7 68.3 71.7 65.6 71.0 68.8 70.7 69.0 9.30 3.37 3.69 2.81 4.62 2.82 1.47 10.52 16.36 10.25 4.22 41.35 size. In the normal condition the epidermis is continually being rubbed off, washed away, or shed spontaneously. The dried and horny cells thus removed are constantly being renewed from beneath, the source of the epidermic growth being the rete Malpighii. As each cell grows and develops, the chemical and physical qualities of its con- stituents become changed and the cell loses vitality, its nucleus disappears, it becomes dry and lifeless, and is gradually cast off as effete. Under ordinary circum- stances this normal desquamation takes place impercept- ibly in the form of fine powdery scales. In certain pathological conditions of the skin, and in certain grave constitutional disorders, e.g., scarlet fever, recurrent exfoliative, dermatitis, etc., general desquama- tion may take place to a marked degree in large lamellae, the epidermis being thrown off the hands and feet in glove-like casts, occasionally even including the nails. Also in certain abnormal congenital states of the skin, as ichthyosis, which should be described rather as a deformity than a disease occurring in connection with general con- stitutional disturbance, excessive desquamation may take place. At other times desquamation may take place in the form of bran-like scales. Certain diseases of the skin, as psoriasis, are character- ized by the profuse production of epidermic scales over circumscribed areas, and this symptom constitutes the clinical feature of the disease. In other skin affections, as, for instance, some forms of eczema, desquamation is the final stage in a series of pathological phenomena in- volving the cutaneous envelope. In the scaly diseases, properly so called, epidermic ex- foliation goes on for an indefinite period, during the whole duration of the disease in fact; while in affections where desquamation is a secondary phenomenon, but one exfoliation takes place, healthy skin forming under- neath as the desquamative lamella is in process of separa- tion, as after the blisters of a burn. Arthur Van Harlingen. DE SOTO SPRINGS. Location, De Soto Parish, Lou- isiana ; Post-office, Grand Cane, or Mansfield. Access.-From New Orleans, or Shreveport, via New Orleans Division of the Texas & Pacific Railroad to Grand Cane, three and a half miles from the springs. Analysis.-A superficial analysis, made years ago, shows this to be a sulphur and iron spring, analogous to several others in the immediate neighborhood. The location is healthful. The accommodations are good for a limited number of guests, who, as a rule, are residents of the surrounding counties, and seek the resort for the cure of skin diseases. G. B. F. DESQUAMATION is the exfoliation or separation of the epidermis in the form of scales of a greater or less 415 Detroit. Diabetes Mellitus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. DETROIT. The accompanying chart, representing the climate of the city of Detroit, Mich., and obtained from the Chief Signal Office in Washington, is here intro- duced for convenience of reference. A detailed explana- tion of this and of the other similar charts will be found under the heading Climate ; where also the reader may find suggestions as to the method of using these charts. II. R. Climate of Detroit, Mich.-Latitude 42° 20', Longitude 83° 3'.-Period of Observations, December 1, 1870, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, GOH feet. January ,.. February .. March April AI ay Mean ten at 7 A.M. Degrees. 22.5 23.5 29.2 40.8 53.4 63.3 67.2 A iperature the hours 3 P.M. Degrees. 27.7 31.1 37.4 51.0 64.7 73.8 78.5 if months of 11 P.M. Degrees. 24.2 26.5 32.0 42.1 55.3 64.6 69.1 C Average mean temperature de- i* ®a®o» o duced from column A. > * 5° 1 Mean ten for peri servatio Highest. Degrees. 37.0 39.9 41.1 53.4 64.1 69.3 74.3 74.1 72.3 58.5 44.5 40.2 50.1 71.3 58.1 34.0 51.2 R iperature od of ob- n. Lowest. Degrees. 14.9 12.0 25.6 37.1 53.2 64.7 69.3 tf £ Si 3 81 " S Average maximum temperature - S for period. D | B 1 a II 2 = E Q GJ << Degrees. 18.6 22.2 28.3 38.0 48.8 57.6 63.0 61.6 55.1 46.5 33.0 25.2 or am 1 Absolute tempers period. Highest. Degrees. 65.0 60.0 75.0 78.5 90.5 93.0 100.0 98.8 97.0 85.0 69.0 65.0 omr con E maximum iture for Lowest. Degrees. 37.0 42.0 50.0 64.0 70.5 85.0 86.0 84.0 81.0 72.0 50.0 38.0 stitution [ 1 Absolute tempera period. Highest. Degrees. 19.0 20.0 24.0 35.0 40.0 55.0 60.0 56.0 50.0 37.2 24.0 23.9 al dises F minimum ture for Lowest. Degrees. -15.0 -20.0 -7.0 8.0 29.0 38.0 50.0 45.0 29.8 22.0 Zero -24.0 sps. or - ] Greatest number of days in any » : : : : : w-mjcm-'mwkimnw single month on which the tem- * X ; ! ; ; ; --perature was below the mean a, | monthly minimum temperature. ~ Greatest number of days in any 1 " 7 7 7 7 7 single month on which the tem- m 3 1 1 7 : 7 - oiwao perature was above the mean monthly maximum temperature.' June July 67.2 71.6 August September. October .... November.. December.. Spring Summer ... Autumn ... Winter Year 65 57 47 34 26 4 5 4 9 8 I i £ 7.2 >8.9 7.1 0.8 1.2 L< 68.2 60.4 50.4 36.7 28.3 M 70 62 1 51 37 28 45 69 50 26 47 IV .2 .2 .6 4 7 0 6 4 8 9 O 66.6 58.2 46.1 30.2 18.3 41.8 67.7 46.6 20.0 44.1 S 79.5 71.9 61.8 45.8 36.4 liver Range of temper- ature for period. Mean relative hu- midity. Average number of fair days. 1 Average number | of clear days. Average number of fair and clear days. Average rainfall. Prevailing direc- tion of wind. Average velocity of wind, in miles, per hour. the digestive system, or of alimentation. In the Mortal- ity Statistics of the United States Census of 1880 (p. 46) it is classed among " General Diseases, Group D," along with rheumatism, cancer, consumption, etc. Historical Note.-Celsus was probably the first to clearly describe the disease. Aretaeus (first century) and Galen (131 to 210 a.d.) first describe it under the name "Diabetes." In 1674 Willis first associated the presence of sugar with the disease, which he discovered from the sweet taste of the urine. Subsequent observers succeeded in separating the sugar, and in 1787 Rollo commenced the dietetic treatment of diabetes by withholding vegeta- ble food. In 1823 Gmelin and Tiedemann found that sugar is formed by the digestion of carbohydrates. In 1835 Ambrosiani demonstrated sugar in the blood. In 1848 Claude Bernard began his elaborate researches, which will be discussed below (see Theoretical Causes and Physiological Experiments). Since that date a host of observers in many countries have contributed exten- sively to the knowledge of the disease. Frequency.-Diabetes mellitus is not a very rare dis- January... February.. March April May June July August.... September. October.... November. December.. Spring Summer... Autumn... Winter.... Year 80.0 80.0 82.0 70.5 61.5 55.0 50.0 53.8 67.2 63.0 79.0 89.0 97.5 62.0 97.0 89.0 124.0 78.3 74.9 73.4 64.0 63.0 68.7 70.0 70.9 72.7 70.6 74.0 78.6 66.8 69.9 72.4 77.3 71.6 9.6 11.4 12.0 12.8 13.5 13.3 14.9 12.8 12.9 12.1 10.9 11.6 38 8 41.0 35.9 32.6 147.8 3.8 5.8 5.5 6.9 9.2 8.4 9.8 11.4 9.2 8.5 5.0 2.4 21.6 29.6 22.7 12.0 85.9 13.4 17.2 17.5 19.7 22.7 21.7 24.7 24.2 22.1 20.6 15.9 14.0 59.9 70.6 58.6 44.6 233.7 T X Inches. 2.14 2.41 2.87 2.37 3.72 3.95 4.14 2.93 2.68 2.87 2.55 2.78 8.96 11.02 8.10 7.33 35.41 From S.W. W. N.W. N.E. S.W. S.W. S.W. S.W. S.W. S.W. w. S.W. S.W. S.W. S.W. S.W. S.W. Miles. 8.2 8.6 9.0 8.6 7.9 6.9 6.4 6.1 6.8 7.8 8.3 8.4 8.5 6.5 7.6 8.4 7.8 liver, or among constitutional diseases, or disorders of the digestive system, or of alimentation. In the Mortal- ity Statistics of the United States Census of 1880 (p. 46) it is classed among " General Diseases, Group D," along with rheumatism, cancer, consumption, etc. Historical Note.-Celsus was probably the first to clearly describe the disease. Aretaeus (first century) and Galen (131 to 210 a.d.) first describe it under the name "Diabetes." In 1674 Willis first associated the presence of sugar with the disease, which he discovered from the sweet taste of the urine. Subsequent observers succeeded in separating the sugar, and in 1787 Rollo commenced the dietetic treatment of diabetes by withholding vegeta- ble food. In 1823 Gmelin and Tiedemann found that sugar is formed by the digestion of carbohydrates. In 1835 Ambrosiani demonstrated sugar in the blood. In 1848 Claude Bernard began his elaborate researches, which will be discussed below (see Theoretical Causes and Physiological Experiments). Since that date a host of observers in many countries have contributed exten- sively to the knowledge of the disease. Frequency.-Diabetes mellitus is not a very rare dis- ease. A few cases occur in the experience of almost every general practitioner. It is said to be commoner to- day than thirty or forty years ago. Its discovery may be due to more frequent and careful urinary analyses, or, in those cases which seem to be of neurotic origin, to the fact that diseases of the nervous system have recently very much increased in the United States. In the United States Census for 1880 (p. 46) there are reported 1,443 deaths from diabetes mellitus, or nineteen-hundredths per cent, of deaths from all causes, against 837 deaths, or seventeen-hundredths per cent., in 1870. Diabetes may occur alone, or associated with a variety of diseases, notably those of the liver, pancreas, lungs, and nervous system. Etiology. - Predisposing Causes.-Heredity can be traced as a factor in about one-third of all cases. It does not appear to extend beyond one or two generations. Cli- matic and geographical influences are not marked, but the disease is said to be common in the United States, Eng- land, Germany, Normandy, in France, Ceylon ; rare in Holland, Russia, aud Brazil. DIABETES MELLITUS. Definition.-Diabetes mel- litus is a disease characterized by the passage of a large quantity of urine containing grape-sugar, or glucose, and usually of high specific gravity ; excessive thirst; exces- sive or perverted appetite ; progressive emaciation ; mus- cular weakness, and languor. The disease runs a chronic course, and a majority of cases terminate fatally in two or three years. Synonyms.-Diabetes, mellituria, glycosuria, gluco- suria, diabMe sucre (Fr.), Harnruhr (Ger.). The terms glycosuria, glucosuria, are used by some au- thors to denote the disease diabetes mellitus. Their proper use is in a more restricted sense, to imply merely the ex- istence of saccharine urine, which may be of temporary occurrence. Glycosuria, or glucosuria, is, therefore, a symptom of diabetes mellitus, not the disease itself. Classification.-The etiology of diabetes mellitus is still very obscure. It is, consequently, sometimes classed for convenience among diseases of the kidney, on account of the abnormal urine ; sometimes among diseases of the 416 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Detroit. Diabetes Meilitus. Age. Diabetes may occur at any period from early in- fancy to old age. It is commonest in females between twenty and forty years ; in males between thirty and forty-five years. (Cases reported among the very young : In a suckling, Garnerus, Deutsch. Med. Woch., 1884, 697 ; one-year-old boy, Bosenbach, ibid., 489; child, five years, Thomson, Glas. Med. Jour., 1885, 4th ser., xxiii., 59). Social Condition. It is somewhat more frequent among the wealthy than the poor, because of sedentary habits combined with over-indulgence in eating. Sex. Diabetes is commoner among males in the pro- portion of two and a half or three to one. The develop- ment and exercise of the sexual functions in both sexes seems to increase the liability to the disease (Roberts, "Renal Dis.," p. 256). It is less acute and less fatal in women after the menopause. Race. Extensive statistics are wanting, but the He- brew race seems to be the most susceptible to diabetes, while the negro race is the least so. It is very prevalent among wealthy Jewesses who chance to over-eat and take little exercise. Temperament. Gouty and obese persons, especially those having much omental fat, are more liable to dia- betes than are thin persons who are more active. Determining Causes.-These are often very obscure. Such as have been assigned, however, are : Traumatism, such as shocks to the nervous system, es- pecially concussion of the whole body (railway accidents, etc.), injuries to the head, blows over the liver. Exposure to cold, wet, and fatigue, especially during menstruation. Convalescence from fevers, especially re- lapsing fever. Emotional strain and worry, mental fatigue and anx- iety. Tumors and haemorrhages at the base of the brain, lesions of the floor of the fourth ventricle, cerebral and spinal meningitis, etc. Over-indulgence in food. It is doubtful whether any one article of diet can determine an attack of diabetes, but food of a rich proteid or hydrocarbon nature keeps the liver constantly overtaxed, and excessive indulgence in sweets, new wines, and fruit-must is said to precipi- tate the disease. Malarial congestion was followed by diabetes in six cases reported by Verneuil {Bull, de la Acad, de Med., 48, 1881). Diabetes is often associated with gout, neuralgias, phthi- sis, and hepatic disorders, but the relations of cause and effect in such cases are very imperfectly understood. It is not especially associated with any particular form of hepatic disease. In a case of pyosalpinx, complicated by diabetes, the ovary was removed (Imlach, Brit. Med. Jour., July 11, 1885), and the diabetes disappeared nine days later. Schmitz (Brit. Med. Jour., 1883) gives an analysis of 600 cases of diabetes, in which 248 were hereditary ; 96 came of neuropathic or psychopathic families ; in 183 the exciting cause was acute neurotic disorder, and in 153 there had been excessive indulgence in sweets. In one- third of a large series of cases reported by Ord (Medical Record, New York, p. 230, 1884) there was a history of mental anxiety or overwork, and in one-third of alco- holism. Physiological Experiments ; Theoretical Causes. -Claude Bernard commenced in 1848 a series of experi- ments to determine where the sugar ingested by an ani- mal is destroyed. He fed animals heavily upon sugar, killed them, and examined their blood taken from vari- ous vessels. He found that a good deal of sugar is de- stroyed in the lungs, but he also found it carried by the hepatic vein in large amount, while the portal vein con- tained a trace only. He found that the liver, when ex- cised from the body and washed free of all blood by a stream of water injected through the portal vein, would still yield sugar after standing a while. Thus he demon- strated that the liver is capable of forming sugar by a process which may be continued for some time inde- pendently of its blood-supply. He next searched for the source of the sugar formed by the liver, and discovered the substance, to which he gave the name of " glycogen." Glycogen, or " animal starch," is a normal ingredient, of the liver cells, in which it is stored in the form of amorphous granules around their nuclei (Bock, Hoff- mann, v. Wittich). It is closely allied to inulin, and when treated by diastatic ferments or boiled with dilute min- eral acids it is converted into glucose. Hensen, of Kiel, discovered glycogen independently of Bernard, and at nearly the same time. Bernard also found that the quan- tity of sugar which he could collect from the hepatic vein at any time did not seem to increase when the ani- mal was fed upon a large amount of sugar ; this circum- stance led him to argue that the liver arrests the sugar ingested on its way to the general circulation, and that the liver thus acts as a regulator of the amount of sugar contained in the blood at any time. Bernard also ex- tracted with glycerine a diastatic ferment from the liver and blood, which he supposed had the function of con- verting the glycogen into glucose ; this action he called the " glycogenic " function of the liver. The sugar absorbed from the intestines and arrested by the liver he supposed to be converted into glycogen by the ' ' glycogenic " func- tion of the liver. Glycogen is also formed from peptones. These ex- periments, confirmed by many physiologists, have given rise to three principal theories regarding the origin of glycosuria: 1. It is due to impaired glycogenic func- tion, and the sugar taken as food is at once passed into the circulation. 2. It is due to increased glycogenic function ; there is an overproduction of sugar from the glycogen, the latter being derived both from sugar and peptones. 3. There is a diminished combustion or de- struction of sugar in the general tissues. Either of these conditions will give rise to the presence of an abnormal amount of sugar in the blood (glycohaemia), which is ex- creted by the kidneys (glycosuria). To aid in substantiat- ing these theories it should be proved : 1. That there is a definite relation between the quantity of sugar that leaves the liver and the quantity of glycogen remaining in the liver. 2. That the "glycogenic ferment" re- sembles diastase. 3. That the glucose passing through the hepatic vein is identical with the sugar which can be formed from starch by fermentation. 4. That there is a definite relation between the amount of hydrocarbons (and peptones) entering the liver and the amounts of gly- cogen and glucose subsequently obtained. The experi- ments of Bernard have been in the main confirmed by many physiologists, but there is exception taken to some of them, and his theories are by no means universally accepted. Physiological. Experiments.-If an animal be sud- denly killed, and the liver instantly excised and chemi- cally analyzed, sugar is found in small amount, which Seegen says is from 0.4 to 0.6 percent.; Dalton, 0.2 to 0.4 percent.; Bernard, 0.2 to 0.3 per cent.; Pavy, 0.02 to 0.05 per cent. It is therefore supposed that little, if any, sugar remains in the liver during life, and it is sug- gested by Flint that the sugar formed in the liver dur- ing life is immediately washed out by the blood-current. Some time after death, or when the circulation is checked, the glycogen continues to form sugar, which accumulates in the liver. Pavy obtained so little sugar in blood from the right side of the heart that he thought it must be formed only as a post-mortem change ; but Flint's theory accounts for the removal of the sugar as fast as it is pro- duced by the liver during life, and it circulates so rapidly that it is not found normally in the blood except in small quantities. Glycogen has been found in the muscles and elsewhere, and it has been supposed that sugar might be formed in the vessels, by a ferment carried in the blood, quite independently of the liver; but the hepatogenous origin of the glucose is the view most generally enter- tained at this day. Bernard, Schiff, and others found that the formation of sugar could be increased by irrita- tion or puncture (piqfire, Bernard) of a spot in the floor of the fourth ventricle, midway between the origins of the auditory nerve and par-vagum. This is the diabetic spot or centre, and it is in relation with the sympathetic vaso-motor nerves that control the capacity of the hepatic vessels. In animals in which fatty degeneration of the 417 Diabetes MellUu^ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. liver had been produced by arsenic or phosphorous poisoning, puncture of the diabetic centre failed to pro- duce glycosuria. Bernard also caused glycosuria by the inhalation of irritant vapors in the lungs, and by stimula- tion of the pneumogastric. Schiff produced glycosuria by removal of the spleen, and by tying the secondary vena cava which exists in the frog, thereby causing hepatic hypersemia. He tied off successive portions of the liver from connection with the circulation, and found the amount of sugar proportion- ally decreased. He found no sugar in frog's blood three weeks after extirpation of the liver. If the pneumogastric be divided in the neck, or if the spinal cord be divided above the origin of the branches of the great sympathetic which go to the liver, the formation of sugar is checked. Bernard thought that glycosuria could be cured if it were possible to galvanize the sympathetic nerves, which are weakened by the over-action of their antagonists. Schiff calls the glycosuria produced by irritation of the diabetic centre, which lasts only a few hours or days, " irritative glycosuria," in distinction from permanent " paralytic glycosuria," produced by dividing the anterior columns of the spinal cord at the fourth cervical vertebra. If dilatation of the intestinal vessels be produced in con- junction with hepatic dilatation, glycosuria does not al- ways result. The occurrence of diabetes in connection with inflammations of the liver and passive hepatic con- gestion, secondary to advanced cardiac disease, favors the view that glycosuria may be caused by an increased amount of blood flowing through the liver; for the blood would convey more ferment to the liver, which would be stimulated to a more active conversion of its glycogen into sugar, or else the blood would flow so rapidly through the liver that the sugar brought by the portal vein would not have time to be converted into glycogen, but would pass through the liver unaltered into the general circula- tion. So, whether the glycogenic function is increased or diminished in cases of glycosuria, either hypothesis would demand increased activity of the portal circulation ; and, in the former case, there should also be increased activity of the circulation in the hepatic arteries which convey the glycogenic ferment, as well as the portal vein. Glyco- suria can be further caused by poisons, such as curare, CO2, various narcotics, common salt solution contained in excess in the blood; in cats, by fixation and trache- otomy ; in frogs, with nitrate of uranium, by injecting irritants like ether or ammonia into the vena cava (Har- ley), by direct galvanization of the liver (Schiff) ; in dogs, with phloridzin (v. Mering, Berl. klin. Woch., Oc- tober 19, 1885, p. 682) ; by various disturbances of the circulation, such as obtain in epilepsy, hysteria, etc. Pavy says that oxygenated blood in the portal circula- tion causes super-oxidation in the liver, which is therefore stimulated to greater activity. The glycogenic function of the liver is denied by some competent observers. (See Abeles, Oest. Med. Jahr., 1875, p. 269 ; v. Mering, Arch, fur Anat. u. Phys., 1877, p. 739 ; Bleile, ibid., 1879, p. 50.) Seegen, in an elaborate series of experiments, cover- ing a period of over ten years, supports the main facts stated by Bernard, but discredits his theories. Seegen says that the liver ferment does not act like diastase ; that it works much slower; that the sugar found by Bernard is true glucose, whereas sugar formed by diastase from starch has a slighter reducing power and a greater rotary power with polarized light, and that it is probably iden- tical with maltose (musculos, v. Mering). Seegen and Kratschmer found that the amount of sugar formed by the liver increases from the moment of death for the first twenty-four to forty-eight hours or more ; that the great- est increase is in the first hour ; that, except in rabbits, the glycogen does not diminish as the sugar increases. They therefore argue that the source of the liver sugar is not from glycogen, but from peptones. In dogs fed on peptones alone the liver contains fifty to two hundred per cent, more sugar than usual; if the peptones are in- jected into the portal vein, there is one hundred to three hundred per cent, more sugar found in the liver, and one hundred to one hundred and fifty more in the hepatic veins. If two pieces of liver are pladed, one in a pep- tone solution in blood, and the other in water, the former yields nearly twice as much sugar as the aqueous solu- tion. The amount of carbon ingested by a dog fed on meat alone is sufficient to account for the carbon found in the sugar produced. In favor of the non-conversion of sugar into glyco- gen (glycogenic function) it is urged that sugar injected into the jugular or crural vein reappears in the urine, which it does not do if injected into the mesenteric vein ; that the ingestion of sugar has caused glycosuria where a large amount of the liver was destroyed by cirrhosis, and where the portal circulation was obstructed. Huppert, Pettenkofer, and Voit advance the following theory: Sugar, like urea, is a normal product of the decomposi- tion of albuminous bodies. In health the sugar is oxi- dized ; in diabetes less oxygen than normal is absorbed, owing to destruction of red blood-corpuscles due to mal- nutrition, therefore the sugar accumulates in the blood. The sugar is formed from the albuminous constituents of the body, which undergo too rapid metamorphoses ; this is proved by the amount of urea, which is also found in- creased. Von Mering found sugar in the urine after a twenty-six hours' fast of a diabetic. Quincke has found iron in various novel situations, due to the destruction of the red corpuscles; but he says there is still a normal amount of haemoglobin present, and he discredits the theory of Pettenkofer and Voit (Quincke, Virch. Arch., Bd. 54, s. 542). Another theory is advanced by Porter: That there is not enough sugar present at any time in the blood of diabetics to account for all that the urine contains, and therefore the sugar-forming elements, urea CO2,H2O, are converted into glucose by the renal epithelium. This increased work would, he says, partially account for the enlargement of the renal epithelial cells which is observed in so may autopsies upon diabetics. Brunton cites an interesting case of diabetes consequent upon the presence of a tapeworm, which was cured by removal of the worm. The peripheral irritation of sen- sory sympathetic fibres may have been conveyed to the diabetic centre in the medulla, and reflected to the vaso • motor system of the liver. He thinks that the increased appetite caused by the presence of the worm may also have been instrumental in starting the glycosuria from over-eating. The entire question of the etiology of diabetes is still undergoing discussion, and whatever views are at pres- ent entertained may be modified by future research, but it seems evident that error in the digestion of proteids must be held responsible, in part at least, for the presence of glycosuria. Symptoms.-Clinical features of a typical case. In a typical case of diabetes the first symptom noticed is in- creasing frequency of micturition. A large amount of urine is voided, and the patient must rise at night to mic- turate. At the same time there is loss of flesh and strength, while the appetite remains normal or becomes greatly in- creased. The patient drinks a large amount of water, which very soon passes away by the kidneys. His thirst may become so intense that he will drink his own urine if sufficient water be denied him. The mouth becomes sticky, or dry and acid, and there is often a sweet taste. In the absence of perspiration the skin grows dry and wrinkled, the face looks drawn and pinched, and the eyes are hollow. There may be alopecia. The bowels are costive ; later diarrhoea and constipation may alternate. A peculiar sweetish, sickening odor arises from the skin and expired air, muscular weakness and debility rap- idly supervene to a greater extent than is to be accounted for by the mere loss of flesh. There are restlessness and insomnia ; the sleep is broken by frequent calls to mictu- rate, and to relieve thirst. There are pains in the back and joints, and cramps, especially in the calves. As ema- ciation progresses there is shortness of breath, as in many wasting diseases. The pulse becomes rapid and feeble ; the temperature is reduced ; the patient grows melan- choly, hypochondriacal; the memory fails, and the mind may wander at times ; there is loss of sexual power. If phthisis develops, there is hectic and profuse perspira- 418 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. SiabZtZZ tion. After the disease has existed for some time dyspep- tic symptoms are prominent; a weight or sinking feeling at the epigastrium is complained of; there is a disgust for all kinds of food, while flatus and sour eructations may become very annoying. The emaciation is phenomenal, and bed-sores and excoriations of the genitals from fre- quent passage of irritating, acid, saccharine urine, add to the discomfort. The patient dies, after two or three years, from coma, marasmus, gangrene, or some intercurrent disease. Earliest symptoms vary considerably. Usually the first symptom is frequent micturition. There may be debility before there is loss of flesh ; there may be increasing em- bonpoint at first. Irritation of the glans penis is the first symptom noticed by some patients, or it may be stains upon the linen, or the attraction of flies and bees to the urine if it fall on the ground. Occasionally the first symp- tom is either an enormous appetite, mental depression, moroseness, marked insomnia, or loss of sexual power. Many cases are at first discovered through the presence of sugar in the urine, which has been presented for life-in- surance examination, or which is examined in the course of some acute disease where diabetes was never suspected. Symptoms in Detail.-The urine. The color is usually •clear light amber, or straw. As a rule, the more sugar it contains the paler is the urine. It becomes turbid, after several days, from development of the yeast fungus, torula cerevisice. The quantity varies greatly, and is usually enormously increased. It fluctuates under the influences of treat- ment, perspiration, intercurrent pyrexia, etc. It occa- sionally remains nearly normal, and yet abundant sugar is present; 5,000 to 10,000 c.c. or more may be voided in twenty-four hours. The average is between 3,000 and 4,500 c.c. (The normal average in health is 1,500 c.c.) The quantity of urine voided has been said to exceed the amount of fluid ingested. This may occur for twenty- four hours or so, but obviously not for long. The sediment is usually slight, if present. On evapora- tion a yellowish-white film is left. The urine forms a white froth on top when shaken, which being viscid, persists for some time. The odor may resemble whey, ripe apples, or hay; it is always peculiar and sweetish ; flies or bees may be attracted by it. The taste is very sweet. The reaction is usually quite acid, sometimes neutral, rarely alkaline. The acidity is usually proportional to the amount of sugar. It is increased by carbon-dioxide and acetic acid, products of fermentation. After stand- ing, the urine does not become alkaline, and does not ac- quire an ammoniacal odor, but it undergoes saccharine fermentation. The specific gravity is in the great majority of cases high. It ranges between 1.035 and 1.050, and often goes higher. Bouchardat reports a case with specific gravity 1.074. Occasionally urine containing sugar is found with a specific gravity as low as 1.010 (Pavy). It rarely goes be- low this limit if any sugar is present. A case with specific gravity 1.002 has been reported (Medical Record, New York, vol. xxii., p. 729). As a rule, high specific gravity indicates a severe case, and vice versa ; the quantity of urine must, however, be always taken into account also. The specific gravity depends much more upon the amount of sugar present than upon the other solid constituents, which are not usually lessened. The urea is proportional to the amount of azotic ele- ments ingested. If the diet is largely nitrogenous the urea will be increased. Diabetics often pass more urea than the normal amount (Liebermeister, Reich). The urea is, however, always in small proportion to the total quantity of urine voided. The sugar passed in the urine in twenty-four hours may exceed 500 grammes (Bouchardat). The average pro- portion of sugar to urine is 32 or 35 to 1,000. The influ- ence of a heavy meal in increasing the percentage of sugar is felt after about two hours, and it lasts during several hours. In some cases very little sugar is passed, •and yet the symptoms are very severe ; in other instances a great deal is passed, and the symptoms are not at all severe. As a general rule applying to a majority of cases, the severity of the symptoms increases or dimin- ishes with the amount of sugar passed. After grape- sugar has disappeared during treatment, inosite is some- times found, as in simple polyuria. (For the tests for sugar in the urine, see articles Glucose and Urine, Analysis of.) In addition to the sugar the urine may contain acetone, alcohol, or peptones ; levulose was once found by See- gen (Centralbl. f. d. med. Wissenschft., 1884, xxii., 753- 757). Frequently more or less albumen is present, with hyaline or granular casts, and leucocytes. Micturition is very frequent and copious. Patients may have to urinate every hour, or oftener. There is often a burning sensation in the urethra, and itching about the glans penis and meatus. Digestion, Alimentary Canal, etc.-The saliva is thick, frothy, acid ; it often contains sugar. The mouth may be so dry as to interfere with articulation. The thirst is excessive (polydipsia), and it is not satisfied by drinking. The endosmosis from the dessication of all the tissues supplies fluid to the blood-vessels, and leaving the tissues relatively dry causes thirst (Vogel); moreover, the extra fluid in the vessels is constantly drained away by the kid- neys. The thirst is most intense one or two hours after meals, when sugar formation is most active. Ten or fif- teen quarts of water may be consumed daily. There is a sweet taste in the mouth, said to be due to sugar in the cap- illary circulation which supplies the taste-bulbs (Bernard). The taste is present when there is no sugar in the saliva. The tongue is moist, sticky, coated, and shows large round papillae ; or it is dry, dark red, and fissured. The gums are soft and pale, or red. They bleed readily, and are retracted from the teeth, which latter become carious. The appetite is at first excessive ; it amounts to boulimia (polyphagia). Sometimes it is very capricious or intermittent, and it fails entirely late in the disease, when the digestion may become greatly impaired, with all the symptoms of gastric and intestinal catarrh. At first the food which is eaten does not supply the needs of the body, and there is constant craving for more. Oc- casionally there are nausea and vomiting. The ejecta and faeces contain sugar. The ejecta may also contain acetone; this is said to be a forerunner of coma. The secretion of the bile is lessened. The emaciation is very extreme. It seems to depend somewhat upon the amount of sugar in the urine, increas- ing as the sugar increases, but it is also dependent upon the condition of the digestive system, and general malnu- trition. It is often increased by the presence of phthisis. The Pulmonary System.-The sputa contains glucose. The respirations are at first slow ; later, from exhaustion or phthisis, they become rapid and shallow. In one va- riety of coma they are slow and very deep. Patients lose the power of storing up oxygen at night for use dur- ing the day (Pettenkofer, Voit). The expired air con- tains less CO2 than normal, while less oxygen is inhaled. The breath has a sweet, mawkish odor, resembling hay or ripe apples. The temperature remains normal, or it usually becomes subnormal, and so remains throughout the disease unless there be some inflammatory complication. A large amount of heat-producing material passes from the body unused. The axillary temperature is 95° or 97° F. When pneumonia, or local joint, or visceral inflamma- tions, or fevers of any variety occur as complications, as soon as the temperature rises the amount of sugar in the urine decreases (Ord), and remains at a minimum while such complication lasts. Some observers attribute this fact to increased combustion of sugar in the body during the pyrexial stage. Ord (Medical Record, New York, p. 231, 1884) attributes it to the diversion of the blood to the seat of the local inflammation. Others, like Bernard, think that the pyrexial condition interferes with the liver in its sugar-forming function. The pulse often presents high tension at first; later it may become frequent, feeble, and irritable. An anaemic bruit may be heard over the mitral and pulmonic valves. 419 Diabetes IVIellitus. Diabetes IVIellitus. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The perspiration is often checked, and the insensible transpiration from the skin is less than normal. In about one-third of the cases the perspiration has been increased, owing generally to the presence of phthisis (Flint, Lieber- meister, Reich), and the sweat contains sugar. Cases have been observed in which excessive perspiration alter- nated with excessive diuresis, so that when the perspira- tion became free there was less sugar in the urine by one- half (Griesinger, Niemeyer), and the volume was much diminished. When the skin is very dry, there may be furfuraceous desquamation. The odor of the perspira- tion resembles that of the breath. Nervous System.-There are not infrequently numbness and formication in the extremities, especially along the outer side of the thighs. This is due to loss of vaso- motor control (Pepper). Some patients complain greatly of vertigo, tinnitus aurium, and constant headache. There may be hyperaesthesia, and there are sensations of internal heat, rigors, etc. Paralyses, temporary or permanent, may occur. Kin- nicutt {Medical liecord, New York, vol. xxiv., p. 221) re- ports a case in which there were three successive attacks of facial hemiplegia, each lasting for several days. The patient died in syncope with sudden hemiplegia of the body. Laudesberg mentions a case of paralysis of the abducens. Mental Symptoms.-Patients who have suffered from the disease for some time usually undergo a decided mental change. They become sad, morose, irritable, taciturn, parsimonious. The mind remains clear, but they are listless, drowsy, and apathetic ; they indulge in soliloquy, but care little for external impressions ; not in- frequently they attempt suicide. Hypochondriasis is a common occurrence, especially in those cases where a too rigid diet is enforced, or where the urine is frequently measured. Dementia paralytica may result in extreme instances (Hamilton, New York Med. Jour., xl., 1-5). Impotence almost always occurs after the disease is well developed, although sexual desire may be temporarily increased at first. It has been claimed that the semen, which is saccharine, prevents erotic excitement, and also that the spermatic fluid is dried up. The real cause of impotence, however, is probably the general constitu- tional debility. The occurrence of menstruation lessens the amount of sugar temporarily (Flint). The Eyes.-Cataract, in one or both lenses, occurs as a late symptom in a certain proportion of cases (see article Cataract, vol. i., p. 793; also, Lecorche : "De la Cata- racte Diab.," Arch., Gin. de Med., Mai, 1861). It is of the soft variety. Kunde and Kohnhorn have pro- duced opacity of the lens in frogs by artificially abstract- ing water, and Weir Mitchell by injecting syrup sub- cutaneously ; but the question of the etiology of the cataract in man is still obscure. Sugar occurs in the crystalline lens. Bouchardat describes a condition under the name of "glyco-polyuria," in which he says there is a moderate quantity of sugar, with an increase of the lithic acid in the blood. This condition occurring in persons over fifty years of age is, he says, the cause of cataract, carbuncle, gangrene, softening of the brain, etc. Premature presbyopia occurs. Transient amblyopia occurs once in five cases (Bouchardat). It often becomes permanent, and there may be complete or incomplete amaurosis. Atrophy of the optic discs, retinitis (with al- buminuria), etc., have been noted. Out of 162 cases of diabetes reported by Dufresne, 20 had various ocular affections. Course.-Diabetes usually runs an insidious chronic course. The disease is no doubt often well established long before its symptoms become sufficiently urgent to attract the attention of either patient or physician. The majority of cases terminate fatally in from two to three years. Griesinger reports 225 cases, sixty per cent, of which died in less than three years. Many patients, how- ever, live on comfortably for ten or twelve years, or more. In 1859-60 Prout reported 700 cases, only two of which lived for ten years {Arch. f. Phys. Heilk., 1859- 60); but since that time a much larger percentage of cases have survived. Frerichs reports oue case which he had under treatment for twenty years, and several more where the disease lasted ten to eighteen years. Diabetes acutus and diabetes acutissimus (Senator) are varieties in which the disease becomes very rapidly fatal, and death may oc- cur inside of three weeks. One case is reported (Jones, Lancet, February, 1883) where death from coma occurred five days after the disease first attracted attention, though it had probably existed for a much longer time. Cure.-There is a growing belief that diabetes can be cured, if treated early and faithfully (Frerichs, Cantani, Flint, Jr., and many others). A large number of cases can certainly be restored to a very comfortable condition, the patients gain flesh and stfength, and the sugar disap- pears in great part or entirely, while the quantity and quality of the urine approaches the normal standard. Life may certainly be indefinitely prolonged in many cases, although the liability to relapse is ever present. It has been said that the only chance for a diabetic to be cured is to believe that he never is cured ; that is, to be con- stantly on the alert to avoid all indiscretions in hygienic and dietary matters. Frerichs reports twelve cases of positive cure, and many others are recorded. Prognosis.-The prognosis depends upon the etiology and other factors. The disease runs a much more rapid and fatal course in the young. As a rule, stout middle- aged men have the best chance of recovery or improve- ment. Thin persons withstand the disease less well. When diabetes has already lasted many years the prog- nosis is bad. Rapid emaciation is more to be dreaded than the presence of excessive sugar. The prognosis is favorable if there is no hereditary or phthisical history ; if the disease is treated early; if a strict dietary regimen can be adhered to ; if the sugar disappears readily under treatment, and if it does not return speedily if the treatment be interrupted ; if the amount of urea is large, and the amount of uric acid in the urine small (Coignard). Cases associated with gout usually are relatively light. The prognosis is bad where there is hereditary dia- betes, or where there is disease of the central nervous, system, or phthisis ; when the patient is under thirty years ; if the sugar does not disappear under treatment ; if the disease be of long standing; if the emaciation rapidly increases. The occurrence of cataract, perma- nent amblyopia, or gangrene, is a serious omen. Causes of Death.-Of 250 fatal cases recorded by Frerichs, 18 died of exhaustion, 34 of phthisis, 7 of pneu- monia (4 of these with pulmonary gangrene), 8 of ne- phritis, 7 of carbuncle, 6 of cancer, 3 of other complaints. In all the others, symptoms of cerebral paralysis were present; 10 died from haemorrhage (cerebral), 2 from softening of the brain, 3 from spinal meningitis, and the rest from coma without local lesion. Sometimes patients die of uraemia. Griesinger says that forty-three per cent, died of phthisis in a series of 225 cases. Other causes of death are asthenia, dysentery, and gangrene. Coma, diabetic coma (Kussmaul's coma), is the precur- sor of sudden death in many cases. Frerichs distin- guishes three varieties: 1, accompanied by syncope, col- lapse, cardiac paralysis ; occurs after sudden exertion, etc. ; 2, ushered in by gastric or other local affections, headache, delirium, anxiety, and dyspnoea; 3, coma without dyspnoea, commencing with headache, vertigo, drowsiness, intoxication. The majority of cases of dia- betes occurring under twenty-five years of age result in death by coma (Duffy, Dublin Med. Jour., 1883-84). Vari- ous theories regarding the etiology of diabetic coma are held. That it is due to cerebral oedema or anaemia, or to hyperglycaemia, is not credited by Frerichs and others of experience. Fatty emboli are found in very few cases only (Frerichs, McKenzie, Foster, Saundby), although lipaemia is not infrequent among diabetic cases. Uraemia (Ebstein) has been suggested as a cause, but there is enough urea present in the urine in most cases to exclude this theory (Flint, Sr., Frerichs). The theory which is at present most discussed is that it is due to the presence of acetone in the system (acetouaemia). (See articles Ace- 420 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diabetes Mellitus. Diabetes Mellitus. tone, vol. i., p. 58, and Acetonaemia, vol. i., p. 59). Ace- tone is found in some cases in the expired air, urine, and blood (Petters, Kaulich) of diabetics in considerable amount, but on the other hand, there are many cases of coma in which it is not found, and it does occur in some fevers, gastritis, cancer of the stomach, alcoholic intoxica- tion, after inhalation of chloroform, ether, etc. Kussmaul denies that acetone is the cause of the coma, for he has given it for weeks in doses of 3 j.- 3 iss. for phthisis with- out ill effect. Von Jaksch says that .01 of acetone occurs daily in normal urine and .5 in fevers. Ralfe and Wilks (Trans. Path. Soc., Lond., 82, 83, xxiv., 328-397), sup- port the view that part of the diabetic coma cases are due to acetonaemia, but they doubt that free acetone is found in the urine, though they believe it to contain free aceto- acetic acid, which would explain the increased acidity of the urine in diabetes, and the rapid fatty degeneration which progresses in the comatose stage. Noble, besides acetone, found ethyl-alcohol in the expired air. The oxidation processes of all diabetics are certainly greatly altered, and it is possible that they excrete unaltered al- cohol. Albertoni (Arch, fiir exper. Pathol, u. Ther., vol. xviii., p. 218-241) says that acetone causes death by coma only in very large doses, and then it behaves like acetic acid. He gave fifty cubic centimetres to a man without more serious effect than marked stupor. He says that acetone found in acid diabetic urine is not necessarily formed in the blood, but may be a product of decomposi- tion of acetic acid. The conclusion is that while a few cases of diabetic coma are possibly due to acetonaemia, the cause of the majority is still undecided. Foster and Saundby (Birmingham Med. Bev., 1884, xv., 148-156) conclude that: 1, Diabetic coma is especially liable to occur in severe acute cases in the young ; 2, pre- disposing causes are nervous excitement, cold, constipa- tion, muscular exertion; 3, the discovery of the ferric chloride reaction in the urine is a warning of approaching coma; 4, in some cases the earliest signs are abdominal pain, rapid pulse, deep respirations ; 5, cyanosis may be absent until just before death, despite dyspnoea; 6, con- vulsions may or may not occur; 7, they favor the tox- semic acetone theory. In most varieties of diabetic coma the respirations are peculiarly deep, and the whole chest is rhythmically and deeply expanded. This form of respiration occurs with- out apparent dyspnoea. Pathology.-No constant lesions have been found for diabetes in the liver, kidneys, nervous system, or any- where in the body. The liver in different cases has been found hyperaemic and congested, cirrhotic, enlarged, atrophied, amyloid, filled with abscesses ; thus presenting no uniform lesion. Obliteration of the portal vein has been noticed. Not infrequently there is marked dilatation of the hepatic capillaries (Lecorche), and thickening of their walls, and new connective tissue has been found in the intralobular plexuses (Porter). The veins are not enlarged. There is enlargement and proliferation of the hepatic cells, and they are markedly granular and nucleated. The pancreas in some cases is congested, and it is either hypertrophied or atrophied, anaemic, or the seat of cancer or calculi. These various lesions have been found in about fifty per cent, of reported autopsies, so frequently that some writers have held the pancreas responsible for the diabetes (Duffy: Dublin Jour. Med. Sei., 1884, 3s., Ixxvii., 395-401). Kidneys.-Catarrh of the pelvis of the kidney and ureters has been found, and various stages and varieties of nephritis. The renal arteries and tubules are usually greatly dilated, owing to the extra work thrown upon them. The epithelium of the tubules is swollen, and the interstitial tissue often appears cedematous rather than affected by inflammation. It is said that in cases accom- panied by Bright's disease the amount of albumin is small, because sugar is formed from albumin in the sys-- tem. Frerichs says that hyaline changes in the tubules due to deposit of glycogen are constant. The lungs, where phthisis or chronic pneumonia has complicated the diabetes, are found filled with cavities and caseous deposits. There are sometimes pleuritic ex- udations. Where pneumonia has existed, glycogen is found in the pulmonary tissue. The heart may be fatty or atrophied. There are oc- casionally atheromatous changes in the vessels. The alimentary canal shows evidences of chronic catarrh in many cases. There is thickening of the muscular coat of the stomach and small intestines, with deposition of pigment, tumefaction, and erosions (Porter). The spleen is not usually altered. There may be atrophy of the testes in the young. The blood contains sugar normally in amounts not ex- ceeding one to tw'o and one-third parts per one thousand. When the quantity of sugar exceeds this limit (glyco- haemia) it is found in the urine (glycosuria). Prolonged glycosuria gives rise to diabetes mellitus. The sugar contained in the blood of some diabetics amounts to nine parts per one thousand (Hoppe-Seyler). The blood may also contain fat to such an extent that the serum appears milky (Brunton). Anaemia is usually present. Nervous System.-In the central nervous organs in some cases, small serum-filled spaces have been found around the arterioles of the gray matter of the floor of the fourth ventricle, and the olivary bodies ; and colloid masses, the size of leucocytes and upward, have been discovered in the corpus striatum, optic thalami, and gray matter of the hemispheres. Tumors or infarctions sometimes are seen in the neighborhood of the fourth ventricle. The medulla is sometimes soft, and it may be the seat of a tumor or blood-clot. The cerebral arteries and perivas- cular spaces are dilated (Dickinson). The nerves of the semi-lunar and splanchnic plexuses are said to be thick- ened. Atrophy of the nerve-cells in the solar plexus has been noted. The vagi may be hypertrophied or atro- phied. Complications.-There is always present a great lia- bility to ' ' catching cold, " and to the contraction of acute visceral inflammations. Pregnancy may occur in diabetic women, in which case the foetus is apt to die. Duncan collected twenty-two cases in fifteen women, which pre- sented features of great gravity to both mother and child {Jour. Lond. Obstet. Soc., 1883). Duncan thinks that the rarity of conception among diabetics is due to the early destruction of the sexual energies. Gangrene (idiopathic), which resembles the senile form, affects the extremities, nose, ears, and sometimes the gums. It is most common among cases with cerebral lesions (Schiff). There is alveolar periostitis, so that the teeth loosen and fall out (Magitot). This is said to be due to the formation of free acid in the mouth from decomposi- tion of sugar (Falk). Idiopathic gangrene of the genitals is very rare ; the few reported cases have occurred in males (Fournier). Ulcers of the toes, without gangrene, have been reported (M. Laffon : Lancet, September 26, 1885). Inflammations of tendons and aponeuroses, carbuncles, and 'furunculosis also occur. Genital Organs.-The passage of saccharine urine, and the frequent calls to micturate, are a cause of great irri- tation to the genitals. Eczematous eruptions occur, which may extend from the genitals upward to the um- bilicus, and down the thighs, often with hyperplastic changes. Pruritus, balano-posthitis, and phimosis occur frequently (Fournier). The phimosis is always chronic, insidious, deforming. Sometimes the prepuce becomes like parchment. There may be chronic prepucial lym- phangitis. Vegetations may form in the urethra (A. Mar- tin) from irritation of the mucous surface. They grow large and rapidly, and persistently return after removal. Surgical complications which may arise requiring oper- ative interference, are generally acknowledged to be ex- tremely dangerous, for gangrene or septicaemia are very apt to follow (Marchal, Verneuil, Roser). These latter occurrences should be treated by anti-diabetic as well as antiseptic methods, for antiseptic precautions fail, if em- ployed alone (Muller: AertS. Intell. Bl., No. 41, 1882). Surgical operations should, therefore, always be avoided, excepting in great emergencies. Ulcers and cutaneous abrasions heal slowly, and fractures are slow in uniting 421 Diabetes Mellitus. Diaphoretics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (Verneuil, Bull, de la Acad, de Med., July 29, 1883). Operations for cataract are sometimes successful, although there is always danger of suppuration (Roberts). Patients otherwise robust appear to suffer the most from any form of wounds. In 1863, 133 cases illustra- tive of the dangers of operating upon diabetics were pub- lished by Marchal, who first called attention to the sub- ject ten years before. Fournier says that no patients should be circumcised until the urine has been examined for sugar, for if diabetes exist, gangrene of the genitals is almost sure to follow. If malaria coexist, the malaria is apt to be made worse than the diabetes by any necessary surgical operation (Verneuil, Bull, de la Acad, de Med., No. 48, 1881). Associated Diseases.-The frequent association of gout and diabetes has long been observed (Bernard, Ray er), and in " gouty glycosuria" (Brunton) comparison i^made between the constant hypersemia of the diabetic liver and the acute hyperaemia of the gouty joints. In a large series of cases of diabetes reported by Ord (Med. Rec., New York, p. 230,1884), gout occurred in over one-third, and in some there was rheumatoid arthritis. In these pa- tients not only does the urine contain sugar in excess, but the urea and uric acid are largely increased. It is inter- esting to observe in this connection that the same diet and treatment benefit gouty and diabetic patients, for the gouty live best upon a nitrogenous diet with alkalies. The occurrence of an excess of uric acid in the urine (uricaemia) is a frequent forerunner of diabetes (Coignard, Comillon, Cour. Med., March 4, 1882). Locomotor ataxia, tabes dorsalis, angina pectoris (Ord, Med. Rec., New York, 1884, p. 230), insanity, and hemi- plegia, are all mentioned as occurring in conjunction with diabetes. Pulmonary ph thisis is associated with diabetes in about one-third or more of the cases. It is characterized by the formation of large and numerous cavities, with caseous deposits. Phthisis with glycosuria is sometimes spoken of as " phthisiurea." Neuralgia, etc.-Griesinger regards sciatica as a fre- quent accompaniment of diabetes. Worms, in 1881, was among the first to establish the relation between neural- gias and diabetes (Comillon, Drasche, Rev. de Med., 1883- 84). The neuralgias are distinguished by acuteness and tenacity, and local symmetry. They are more painful than other forms, paroxysmal, and without fever. The chief seats of the pains are in the inferior dental and scia- tic nerves. The best treatment is said to be the salicylate of sodium. Differential Diagnosis.-There are few affections with which diabetes is likely to be confounded. The presence of sugar in the urine is the first fact to establish. Hys- terical patients occasionally put sugar in their urine fop the purposeof deceiving their physicians, but they seldom know the distinctions between cane and grape sugar, and use the former. They can always be found out by draw- ing the urine to be examined with a catheter. Temporary glycosuria occurs under a variety of con- ditions, such as cases of poisoning from amyl nitrite, CO2,H2SO4, mercury, alcohol, etc.; and after anthrax, diphtheria, scarlatina, typhoid fever, etc. ; but it is tran- sient, the urine contains less sugar than in diabetes, and all the severe symptoms of emaciation and extensive tis- sue waste, leading to local disease and usually death, of excessive hunger and thirst, etc., are wanting. In polyuria, or diabetes insipidus, there is no sugar in the urine, and the specific gravity is very low. Primary peptonuric diabetes is described by Quinquard (Trib. Med., August 5, 1883) as a disease presenting the clinical features of mellituria, thirst, marked cachexia, polyuria, etc., etc., but instead of sugar the urine contains peptones; it polarizes light to the left, and it is of low specific gravity. He regards this as a different affection from the secondary peptonuria which occurs sometimes after diabetes mellitus is established. Temporary lactosuria occurs as an almost normal accom- paniment of the puerperal state. Lactose reduces copper like glucose, but it can be distinguished by possessing less rotatory power than glucose. The lactosuria is tran sient, and it does not exhibit the severe symptoms of dia- betes. Treatment.-The treatment of diabetes to-day is much more successful than it was thirty or forty years ago, when every case was regarded as necessarily fatal. The treatment should be prophylactic, hygienic, dietetic, and medicinal. Prophylaxis.-Until more is known of the etiology of diabetes definite prophylactic rules cannot be established ; but in general, where there is distinct heredity to be feared, or when the lithic acid diathesis exists, all over- excitement of the nervous system, mental or physical, as well as over-indulgence in alcohol and sweets should be strenuously avoided. Hygiene.-Every precaution should be taken against "catching cold." If possible, a moderately warm and temperate climate is to be preferred. Fresh air and all the moderate exercise that can be taken without fatigue are extremely important (Brunton Bouchardat). Flan- nels should be worn next the skin, and the clothing should always be warm, for the body has less heat-produc- ing power than normally. The function of perspiration should be stimulated by frequent warm baths, dry rub- bing, etc. Turkish or Russian baths are recommended to be taken occasionally by the more robust, and massage is desirable for feebler patients, when rest in bed may be- come necessary. All muscular, nervous, and mental fa- tigue is very ill-borne. Care should be taken to wash the genitals after micturition, to prevent excoriation. Diet.-Strict regulation of the diet should be faith- fully tried before any medication is resorted to, when the latter frequently becomes superfluous. A placebo may be given if necessary. During the siege of Paris it was observed that a number of diabetics improved greatly, owing to the enforced restrictions in their diet (Bouchardat). There has been much discussion regard- ing the necessity for total exclusion of sugar-producing foods from the diet. It is a difficult thing to do, for the craving of sweets, but especially for bread, becomes so fierce that patients whose veracity is otherwise unim- peachable, will resort to lies or any deception to obtain the coveted articles of food. Cantani advises a prelimi- nary fast of twenty-four hours before commencing the dietetic treatment. The value of this expedient is ques- tionable. The improvement in many cases upon a diet which excludes starches and sugars almost completely, is phenomenal. Upon such diet one of three results will follow : 1. The patient begins to gain flesh and strength ; he sleeps better ; the daily quantity of urine falls perhaps from 300 ounces to 70, and it approaches the normal com- position ; the excessive appetite and thirst diminish ; the digestion improves, and in ten days or twenty the sugar may entirely disappear. 2. The amount of urine is less- ened, but the specific gravity remains high, and the sugar is abundant; prognosis very grave. 3. The patient can- not tolerate the diet, and drugs must be resorted to. Most patients do better when allowed a little starch (bread) and sugar in their diet (Pepper, Trousseau, Fre- richs, Niemeyer), otherwise the craving for it does them positive harm, and a loathing for all food results, or they break from all restraint and injure themselves by over- eating. Bread is the most difficult food to dispense with entirely. It is advisable in any case not to reduce the diet too suddenly. Various artificial breads and rusks are made of gluten, almonds (Pavy), bran flour, etc., some of which are pala- table for a time. Many have been found, however, to contain 60 or 80 per cent, of starch-full as much as wheaten bread-while others contain no nutriment at all. Many elaborate diet tables have been prepared. For those whose means allow the menu is extensive, but for the poor in hospitals and at home, it is difficult to enforce a too restricted regimen. A fair menu is the following (Pepper, Med. Rec., New York, 1884, vol. xxv., p. 11): Breakfast or supper: tea, lemonade (no sugar), soft boiled eggs, broiled chop, beefsteak or any fish, raw tomatoes or onions with vinegar, a very little toasted bread or biscuit, butter, cream (old rum or whiskey). Oysters are objected to by some because their bulky livers contain sugar. 422 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. JJlaJhoreUc"1*"8' Dinner: meat (fat), string-beans, cauliflower, lettuce, game (except their livers), cheese, nuts (except peanuts and chestnuts). Additional articles which belong to a much more lib- eral diet are : chicory, spinach, artichokes, romaine, olives, endives, watercress, dandelion, coleslaw, sorrel, radishes, asparagus, mushrooms, truffles, salsify, cu- cumbers, cabbage, Brussels sprouts, pickles, peppers, broccoli, buttermilk curds, gelatine, ice creams and wine- jelly without sugar, caviar, sour apples, raspberries, blackberries, currants, lemons, oranges, peaches, Brazil- and cocoa-nuts, filberts, walnuts, almonds. Some allow turnips, celery, tomatoes, coffee, while others exclude these articles. To be avoided are sweets of all kinds ; potatoes, peas, beans (except string), rice, sago, tapioca, corn-starch, beats, parsnips, carrots, rhubarb, breads in excess, corn- meal, buckwheat, etc., sweet wines, sweet spirits, li- queurs, malt liquors, champagnes. If alcohol is required a sour claret or Burgundy is best. Hock and dry sherry may be given. It is better to omit alcohol entirely in most cases. Substitutes for cane-sugar that have been tried, are mannite, inosite, levulose, inulin, and glycerine. They are said not to increase the glucose in the urine. Fre- richs regards glycerine as harmful. A reasonable restriction may be placed on the amount of food taken and of fluid drunk. Cracked ice allays the thirst a little sometimes. The articles above enumerated afford considerable choice, and it is to be distinctly understood that only so many of them are to be allowed at a time as may serve to divert the craving of the patient from his chief enemy -concentrated forms of hydrocarbons. The sugar in the urine should be carefully estimated, and some patients will be found who can take any of the above articles with impunity, while others can take but very few, and others again can take certain foods for a short time with- out increasing the sugar elimination, and suddenly they will be found to agree no longer, when some other diet must be at once substituted. A reasonable amount of vegetable food increases the bulk of the faeces, and pre- vents constipation. Skimmed Milk.-An exclusive diet of skimmed milk was tried first by Donkin. At first a gill should be given every two hours, which may soon be increased to half a pint every two or three hours. The small amount of milk-sugar contained in it is said to do no harm (Porteus, Edinb. Med. Jr., xxx., 508-510). Some advise the milk diet as a last resort, others recommend trying it at once. After six weeks a gradual return to a mixed nitrogenous diet may be permitted. But few patients, however, can be found to accustom themselves to this diet, or to endure it over a week. Koumiss has been successfully substi- tuted for the skimmed milk (Pepper). Frerichs and many others disfavor the milk treatment. Medicines.-No one drug seems to be applicable to all cases. If any drug is found to disagree, its use should be at once abandoned. Toleration for some remedies is soon acquired to such an extent as to render them use- less. The medicinal treatment should aim to regulate the digestion and the nervous system, and to regulate the vascular system, so as to maintain the normal amount of arterial tension. The results of medicinal treatment vary greatly, for a strict diet is usually enforced at the same time. For the digestion, tonics such as iron, mineral acids, cod-liver oil, and aromatic bitters are often useful, espe- cially in advanced cases. Iron is also useful for the an- aemia, which is often present. A variety of substances, such as pepsin, yeast (§ss. t. i. d.), rennet, ox-gall, etc., have been used with uncertain result. Vaso-motor tonics, like strychnina (Frick, Wilks, Dick- inson), ergot (Da Costa), are sometimes beneficial. They regulate the arterial tension, reduce the amount of urine, and relieve thirst and appetite. Calcium sulphide is of service (Husted, Flint, Sr.), es- pecially when there is any tendency toward furunculosis. Dilute acid. phos. is given to relieve thirst. 01. phos- phor. (containing phos. gr. ^) is recommended (Travig- not, 1884). Arsenic (Salkowski), acid, salicyl., sodii salicyl. (Yar- row, Therap. Gaz., July 15, 1885), valerian (Lecorche), creosote (Valentini), atropina (Pupier), pilocarpina (Ea- ger), have all been successfully employed in certain cases. The transfusion of blood was tried by Dieulafoy (Bull. Soc. Med. des Hop., 1884, i., 38 to 41). Opium and codeia (Pavy, Frerichs, Flint, Sr., Bris- towe, and many others) relieve restlessness and the crav- ing for food and drink, and lessen the amount of urine and frequency of micturition ; the body weight increases, and sugar diminishes. Diabetics are extremely tolerant of opium and its alkaloids. The opium may be gradu- ally increased until gr. xx. to xxx. (!) are given in twen- ty-four hours, and the codeia may be increased from gr. i up to gr. xv. (Pavy), in urgent cases. Codeia is pre- ferable on account of being less constipating. Potassium bromide is recommended by Frerichs, Feli- zet, and others, to lessen the flow of urine, relieve thirst and restlessness, etc. (Teissier, Lyon Med., 1884, xlv., 221 to 224). Iodoform (gr. viii. in twenty-four hours) has been em- ployed with some success (Jacoby, Moleschott). It is said to lessen arterial tension, and the amount of urine and sugar. It probably acts on the vaso-motor centres (Balp, Brozzolo, Arch. Itai, de Biol., 1883-84). Carbolic acid is used, and it is said to prevent the for- mation of acetone in the stomach. If acetone is detected in the stomach, and symptoms of acetonemia are immi- nent, it has been advised to evacuate the stomach by an emetic or stomach-pump. Alkalies have been employed with benefit for over a century (Willis, Miahle). The alkaline carbonates are es- pecially used (Niemeyer, Seegen, Griesinger). The citrates and acetates are also employed. Trousseau advises the use of sodii bicarb., 3 i. to iv., daily for ten days at a time. The waters of Carlsbad, Neuenahr, Vichy, are useful, six to eight glasses may be drunk daily. They are of less benefit taken at home than at the springs, where hygienic advantages are also secured. Lactic acid is a remedy which has achieved a good reputation in some hands. It is given to the amount of 3 jss. or much more, daily (Cantani, Felton). It is in- structive to note that attacks of rheumatism have been precipitated by the excessive use of this drug for diabetes. Among the drugs recently employed with greatest suc- cess is Clemen's liquor arsenici bromati (brom, arsen.), which is a solution of arsenious acid with bromine in gly- cerine and water. The initial dose is one or two drops, which is rapidly increased to five drops t.i.d. (Bekai, Flint, Jr., Gilliford). Bibliogbaphy. Abraham, P. S.: Concerning Pathol, of D., Dublin Jr. Med. Sci., 1884, 3 s., Ixxvii., 401-404. Bernard, Claude : Logons de Physiol. Experiment, appliquee a la Mede- cine, Paris, 1853; Physiologic Experiment., tome i., p. 302; Revue Sci- entifique, 2 s., tome iv. Bouchardat: Du Diabete Sucrd ou Glycosurie ; son Traitement Hygien- ique, Paris ; De la Glycosurie ou Diabete Sucre. Paris, 1875. Cantani: Le Diabete Sucre; son Traitement dietetique. Paris, 1876. Dickinson : Treatise on Diabetes; also Med. Times and Gaz., March 9, 1870. Flint, A., Jr. : Journ. Amer. Med. Assoc., 1884, iii.. 29-39 (Treatment), v. Frerichs: Ueber den Diabetes. Berlin. 1884. 8o. Fournier: Med. Prakticien, v., 145, 157, 169, 181, 193. Paris, 1884. Marchal (concerning genito-urinary complications, etc.) : Recherches sur les Accidents inflam, et gangreneux diabetiques. Paris, 1864. Pavy, F. W. : Nature and Treat, of D. London, 1864. Philpot, H. J.: Diabetes Mellitus. London, 1884. Porter, W. IL: Pathol, of Diab. Mellitus, N. Y. Med. Jr., April 11, 1884, pp. 409-415. Schiff : Untersuchung fiber Zuckerbildung. Seegen, J.: Der Diabetes Mellitus, Centralbl. fur d. Med. Wissensch., 1875-76: Pfliiger's Arch., vols. xiv., xix., xxii., xxiv., xxv., xxvii., xxxiv. ; Zts. fur Klin. Med., Berlin. 1884, viii., 328-363; Gyoggaszat. Budapest, 1885, xxv., 329-333, 350-353. Tyson : Diab. Mellitus in Pepper's System of Bract. Medicine, 1885, vol. ii., pp. 195-230. William Gilman Thompson. DIAPHORETICS.-Diaphoretics are medicines which promote perspiration. Their therapeutic use is not em- pirical, but strictly physiological, since their action cor- responds directly with the physiological function of the 423 Diaphoretics. Diaphoretics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. skin, which they increase or restore when it has become deficient. The perspiratory secretion consists of certain solid in- gredients which are held in solution in fluid. Two im- portant but distinct functions are thus fulfilled by the skin, the one being the elimination of excrementitious products, and the other the regulation of the tempera- ture of the body by the evaporation at the surface of the fluid elements of the perspiration. The normal solid constituents consist chiefly of chloride of sodium, various fatty acids, neutral fats, and ammonia. In certain con- ditions of disease, lactic acid and urea may be present; whether this last substance is ever found in the perspira- tion in health is still undetermined, but in morbid states of the kidneys, with deficient excretion, it may un- doubtedly be present, and its elimination by the channel of the skin may be increased by the use of diaphoretics. It is difficult to estimate the amount of matter passed away by the skin, as in addition to the water which is in part given off in a vaporous state, there are other volatile substances which are not easily measured. The amount varies under different circumstances, in consequence of the vicarious action of the kidneys with reference to that of the skin, a smaller amount being passed away by the skin when the kidneys are acting freely, and vice versa. This fact has an important bearing on the therapeutic uses of diaphoretics, as they are less likely to produce the desired effect when circumstances favor a free action of the kidneys. As regards the heat-regulating'function of the skin, Helmholtz has estimated that of the whole loss of heat from the body, 77.5 per cent, is accomplished by the skin, though this is not entirely by evaporation, but in part by radiation and conduction. But inasmuch as the loss of heat is largely due to evaporation, the importance of the action of the skin and the value of diaphoretics in the way of lowering temperature are shown. It is thus seen that these medicines may be used to in- crease either one of the functions of the skin, or both of them together. They may be eliminants of those ex- cretory matters which should be discharged at the sur- face, but which in disease are formed in excessive amounts or are retained unduly in consequence of im- perfect action of the skin ; or they may be used to lower the temperature by the increased surface evaporation which they cause ; or, since in the febrile state there are both excessive tissue-waste and elevation of temperature, they may be beneficial in both ways. There are also other purposes of somewhat less impor- tance, but not without value, to which diaphoretics may be directed. Thus they may be employed to lessen drop- sical effusion by the discharge of fluid from the surface that they occasion, thereby rendering the vessels better instruments of absorption; or they may be used as re- vulsives by directing the blood to the skin in the early stage of inflammatory affections of deeper organs. In a large proportion of cases, however, their most important function is that of reducing temperature. Diaphoretics produce their effects in the following dif ferent ways : 1, by increasing the amount of blood in the superficial vessels ; 2, by relaxing these vessels ; 3, by a direct action on the sweat-glands ; 4, by an influence on the nervous apparatus governing the sweat-glands. These different methods need to be considered some- what in detail. 1. The activity of the skin is increased by dilatation of the superficial vessels, from which a small amount of the perspiration may perhaps escape by direct transudation, this amount being increased when these vessels are full. But even the fluid portion is passed away chiefly through the sweat-glands, to which a larger supply of blood is brought, and their activity thus stimulated when the vessels are filled. The action of alcohol as a diaphoretic is partly due to its power of increasing the blood-flow through the skin. External warm applications act also in the same way by dilating the surface vessels. 2. Certain agents seem to act as diaphoretics by relaxing the vessels of the skin. Ipecacuanha and tartar emetic, which are among the most certain and reliable diapho- retics, seem to produce their effects in this way. Their action may be due to a lessening of vaso-motor control, and consequent diminished blood-pressure that they occa- sion. The peculiar activity of Dover's powder as a dia- phoretic is probably due to the fact that at the same time that the blood-vessels are relaxed by the ipecacuanha the rapidity of the blood-current is somewhat increased by the stimulant action of the opium. And so, when the ac- tion of the heart is increased and vascular tension les- sened, a condition exists especially favoring diaphoresis. 3. Some substances would appear to cause perspiration by a direct action on the secreting cells of the sweat- glands, being themselves excreted by these glands, to- gether with an increased amount of water. Illustrations of this mode of operation are seen in certain salts, such as acetate of ammonia and citrate of potassa, which act sometimes on the skin and sometimes on the kidneys, be- ing eliminated by one or the other of these einunctories, and thus proving either diaphoretic or diuretic. 4. Perspiration may be increased by a stimulant influ- ence directed to the sweat-centres, and acting through special nerves regulating the action of the sweat-glands independently of the amount of blood sent to them. The existence of such centres seems well established by patho- logical facts, and also by experiments upon the lower ani- mals, although it is uncertain whether they are situated in the medulla oblongata or are distributed throughout the spinal cord. These centres may apparently be acted upon directly or reflexively. They are believed to be affected directly by pilocarpine, which acts also on the vaso-motor centre, producing rapid dilatation of the arte- rioles, by which perspiration is at the same time pro- moted. A pathological illustration of this direct action is seen in the influence of venous blood on the sweat-centres in cases of dyspnoea, in which increased discharge through the skin often takes place, not only without an increased blood-supply, but with an actual diminution of it and an anaemic condition of the skin. This is witnessed in the colliquative perspiration of phthisis, or that which some- times occurs in the last moments of life, when all the vital powers are failing.1 Warm applications to the skin, besides dilating the su- perficial vessels and thus promoting perspiration, prob- ably act also reflexively on the sweat-centres through an influence conducted by the afferent thermic nerves. So, likewise, it is probable that alcohol acts as a diaphoretic partly by increasing the flow of blood through the sweat- centres. It is thus seen that the perspiratory function is compli- cated, as regards the mechanism which directs and regu- lates it, and in all probability many diaphoretics act in more than one of the ways that have been indicated. Therapeutic Uses.-The following are some of the most important conditions of disease to which diaphoretics are applicable: Fevers.-In all forms of idiopathic fever they may prove serviceable, as has already been seen, through their power of lowering temperature, and this by itself would be a sufficient reason for their use ; but, in addition to this mode of action, they are beneficial by promoting the removal of waste products, which are formed in increased amount in the febrile process. The suggestion afforded by the natural course of certain febrile affections,, which subside or disappear with a critical perspiration, may thus be acted upon, and the natural method of relief antici- pated or promoted by the administration of a diaphoretic. Thus in intermittent and remittent fevers, when the skin is hot and dry, the citrate of potassa, in the form of the neutral mixture or effervescing draught, will often be found valuable and refreshing as a diaphoretic. Inflammations.-In the symptomatic fever dependent upon an inflammatory process diaphoretics may serve several purposes. Given in the early forming stage of a coryza or a bronchial catarrh, they may abort the affection at the outset, and for this purpose a full dose, ten grains, of Dover's powder at bedtime is a time-honored and most effective remedy. And in later periods of these and other 424 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diaphoretic*. Diaphoretics. inflammatory affections of the air-passages, they prove serviceable by lowering temperature ; and through the vicarious action existing between the skin and bronchial mucous membrane, their revulsive effect favors an abate- ment of the hyperaemia in the latter tract. The deferves- cence of pneumonia on one of the critical days of the disease is often attended with free perspiration, which may be aided by the use of a diaphoretic. In such a case one of the more stimulating agents of the class, such as the solution of the acetate of ammonia or the spirit of nitrous ether, is best, in order to counteract the tendency to depression sometimes met with at this stage of the dis- ease. In all febrile and inflammatory diseases, if the action of the skin is imperfect, benefit in greater or less degree may be gotten by restoring its function through the use of diaphoretics. In certain blood diseases, when the symptoms appear with more or less probability to depend on the presence in the blood of some morbific cause, the depurating action of diaphoretics may be invoked. In acute rheumatism profuse perspiration is one of the most prominent symp- toms of the disease, being apparently connected in some way with its essential pathology, and it is often so free that diaphoretics are not required to increase it. It some- times happens, however, that the skin is dry as well as hot in this disease ; its deficient action may then be restored by the use of agents of this class, the best in general being Dover's powder, from its combined ano- dyne and diaphoretic powers. It is noticeable, more- over, that salicylic acid and the salicylates, which very often promptly control rheumatism, are apt to cause free diaphoresis, which may have some share in produc- ing the good effect. Chronic rheumatism, in which the skin is often dry, is in many cases benefited by guaiacum and by sulphur, both of which tend to produce diaphor- esis, and may thus act as eliminatives. In dropsies diaphoretics are sometimes found of signal efficacy. Chronic dropsy is but little benefited by them, because they cannot relieve the organic changes in the heart, the liver, or the kidneys, on which such dropsy de- pends. But in acute nephritis with more or less suppres- sion of urine, and the consequent infiltration of the areo- lar tissue and serous sacs with fluid, the action of some diaphoretics is prompt and admirable, a real deliverance at times to those who are ready to perish. In this disease diaphoretics are effective in accordance with all their modes of action. They are antipyretic, and thus serve to abate the fever accompanying the renal inflammation ; they are eliminative of urea-one of them, pilocarpine, in a very conspicuous degree-and thus save the nervous centres from the injurious action of this excrementi- tious product, retained in consequence of the imperfect action of the kidneys. They act revulsively to the skin in favor of the engorged kidneys, and thus, besides enabling them to resume their function, they aid in restoring their integrity. And, finally, they promote the removal of the dropsical effusion. No therapeutic effects are more strik- ing and brilliant than those which may be gotten from the administration of jaborandi or pilocarpine, or from the use of the hot-air bath or hot-vapor bath, in cases of acute congestive nephritis. In chronic Bright's disease great temporary relief may be afforded by the use of dia- phoretics in such sudden emergencies as the occurrence of ureemic coma or convulsions ; though they have, of course, no power to remove the structural changes in the kidneys. The above are sufficient examples of some of the most important diseases in which diaphoretics may prove ser- viceable as medicines ; and at the same time they are illus- trations of the ways in which these agents produce their beneficial effects. It remains to mention some of the most important medicines and medicinal agents that are used as diapho- retics. The alcoholic stimulants, taken warm and considerably diluted, are promptly diaphoretic, acting partly by filling the superficial vessels, and partly, perhaps, by a direct stimulant effect on the perspiratory centres. They are especially adapted to cases in which the skin is dry and somewhat cool, or in which there has been a recession of the blood from the superficial vessels from exposure to cold, acting in such cases as revulsives. The influence of heat applied to the surface dry, as in the hot-air bath, or moist, as in the vapor-bath, acts partly in the same way by dilating the vessels of the surface, and thus allowing them to receive more blood. The application of hot air may readily be made by setting the flame of an alcohol- lamp at one end of a tin tube by the side of the patient's bed, the other end being carried under the bed-clothes, so that a heated current is introduced and surrounds the pa- tient's body. The hot-vapor bath may be extemporane- ously applied by placing a vessel of hot water beneath a chair on which the patient is seated, enveloped to his neck in a blanket. The temperature may be kept up to the point at which steam is given off, by placing a spirit- lamp beneath the water-vessel. By either one of these measures prompt and powerful diaphoresis may be pro- duced, and they are signally useful in cases of acute dropsy, with failure of the renal function. Tartrate of antimony and potassa, and ipecacuanha, are among the most important of those diaphoretics which act by relaxing the vessels of the surface when it is hot and dry. Tartar emetic is adapted to the febrile state with a hot and dry skin, and not much depression of the pulse. It is contra-indicated when there is an irritable state of the stomach, or inflammation in any part of the alimentary canal, from its tendency to aggravate such conditions ; as also when the heart's action is feeble, from its powerfully sedative effect. It is chiefly used in the early stage of acute inflammatory affections of the respiratory organs, on account of its combined diaphoretic, expectorant, and sedative actions ; but it is by no means so much employed as it formerly was. When given as a diaphoretic, the dose of tartar emetic is from one-sixteenth to one-eighth of a grain. Ipecacuanha resembles tartar emetic in its combination of properties, but it is much less depressing, and, there- fore, entirely safe in many cases in which the latter agent would be objectionable. It is generally employed as a diaphoretic in association with opium in the form of Dover's powder, which is one of the most certain and re- liable medicines in the whole class. It would appear, as before remarked, that the special action of this compound is due to an increased flow of blood in the superficial vessels, which is at once favored by the relaxing effect of the ipecac and aided by the stimulant influence of the opium. It is especially in the forming stages of inflam- matory affections, both of the air-passages and of the bowels, that Dover's powder is found beneficial, serving often to cut short such diseases partly by a restoration of the equilibrium of the circulation and partly, it may be, by eliminating material which has been retained through suppressed action of the skin. It is also advisable when an anodyne or soporific effect is desired in addition to a diaphoretic action. The ordi- nary dose for such purposes is ten grains, containing one grain each of opium and ipecacuanha, for an adult, and from half a grain to five grains for a child, according to age. The solution of the acetate of ammonia or spirit of min- dererus is much used as a diaphoretic. Its action may be caused in part by the stimulant effect on the circu- lation which it has in common with the other prepara- tions of ammonia ; but it is probably due chiefly to the elimination by the sweat-glands of the salt which it holds in solution. It is often given in febrile diseases in the dose of a teaspoonful up to a tablespoonful in water every two or three hours. It is prepared by saturating dilute acetic acid with carbonate of ammonia. The citrate of potassa acts as a diaphoretic in the same why as the acetate of ammonia, and has the advantage of being more agreeable to take than the latter. It is given in the form either of the neutral mixture or the efferves- cing draught. In making either of these preparations it is better to use lemon-juice rather than citric acid, as the fresh juice is more palatable and acceptable to the stom- 425 Diaphoretics. Diaphragm. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ach. The neutral mixture may be made by adding bi- carbonate of potash to lemon-juice until effervescence ceases. Of this a tablespoonful, diluted with as much water, may be taken every two or three hours. The effervescing draught should be prepared at each ad- ministration by adding to a tablespoonful of lemon-juice diluted with the same quantity of water fifteen grains of bicarbonate of potassa dissolved in a tablespoonful of water. This is to be taken while effervescing. In this way it produces diaphoretic and anti-emetic effects, and is especially adapted to febrile affections in which irrita- bility of the stomach exists, such as intermittent and re- mittent fevers. Guaiacum, the wood and the resin of the guaiacum officinale, a tree of the West Indies, has some power of promoting diaphoresis, being eliminated apparently in part by the perspiratory glands. It has been a good deal used in subacute and chronic rheumatism and in sciatica. As it increases the bronchial secretion, it is also used for its combination of expectorant and diaphoretic actions in chronic bronchitis and in gouty bronchitis. It is given chiefly in the form either of the simple tincture, or the ammoniated tincture, in the dose of from half a drachm up to two or three drachms, in mucilage of gum. The most important of those medicines which appear to act upon the respiratory centres or nerves is jaborandi, the pilocarpus pennatifolius, a Brazilian plant, the leaf- lets of which are the medicinal portion. These contain an alkaloid, pilocarpine, which combines with nitric and hydrochloric acids, to form salts that are freely soluble in water, and may be readily administered hypodermi- cally. This remarkable drug may be regarded as the most powerful, and for certain purposes the most valuable, agent in the whole class of diaphoretics, and it is capable of giving relief in conditions of very urgent peril. Whether given in the form of infusion or fluid extract of the leaves, or by hypodermic injection, the pilocar- pine diffuses rapidly into the blood. Flushing of the face and neck occurs in five or ten minutes, spreading rapidly to other parts of the body, and the pulse becomes accelerated. At the same time perspiration begins, in- creasing in degree until the entire body is bathed in fluid. In some cases an abundant flow of saliva takes place, with a flow of mucus from the nasal and bronchial tracts, and occasionally watery diarrhoea occurs. A fall of tempera- ture of one or two degrees is often noticed, and is prob- ably caused by evaporation from the surface. The quickening of the pulse and flushing of the surface are no doubt due to dilatation of the arterioles. But the most important therapeutic action of the drug is the copious diaphoresis that it occasions, and the value of this action is chiefly due, in the cases in which it is most signally beneficial, to the remarkable fact that under its influence urea is eliminated with the perspiration in considerable quantity, sometimes to the amount of fifteen grains or more in a few hours. It thus acts as a direct depurative of the blood, and it is especially in the uraemia of acute congestive nephritis, in that of the puerperal condition, and in chronic Bright's disease, that pilocarpine is most beneficial. The writer has had very satisfactory results from its use in cases of dropsy following scarlet fever, in which pulmonary oedema has occurred, threatening life by interference with respiration. The dose of the fluid extract of jaborandi is from half a drachm to a drachm, and of the salts of the alkaloid from one-eighth to one-sixteenth of a grain hypodermically, to be repeated in half an hour if the first dose fail to act on the skin. In cases of much impairment of heart-power, it should be given with great caution, if at all, and its administration accompanied with a stimulant to counteract any depress- ing action. It is said that a relatively larger quantity of the drug, in either form, is borne by children than by adults. Samuel G. Chew. 1 See Foster's Physiology, third edit., p. 403. agitation of the diaphragm, <ppriv came afterward to sig- nify the mind itself.] This large muscle, whose func- tions are intimately connected with respiration and with the circulation of the blood, is, for that reason, one of the most important in the body. Haller says of it, " Post cor facile princeps," and Spigelius, " Musculus unus, sane omnium fama celeberrimus." In man it appears as an enormous leaf, of which the divided stem, called the crura or pillars, is attached to the spinal column, while the blade is a musculo-tendinous septum, dividing the thoracic from the abdominal cavity, being arched over from behind upward and forward, and attached by its serrated edges around the entire lower circumference of the thoracic cage. This appearance will be evident on inspecting Fig. 809, which represents it as viewed from in front when the body is leaning considerably forward. The septum, which in fishes separates the cavity of the branchiae from the abdomen, appears to be a rudimentary form of this muscle. In birds it is represented by mus- cular slips which pass up from the lower ribs to be at- tached to the pleurae. It is only in mammalia that a com- plete septum is formed. As most mammals have ribs ap- proaching the pelvis more nearly than those of man, the arch of the diaphragm is with them more pronounced. Our knowledge of the development of the diaphragm, though far from complete, indicates that it arises early, as a septum between the heart and the liver. In the so-called Central tendon. Eighth rib. Aorta, cesophagus, and pneumogastric nerve. Right crus. Left crus. Third lumbar vertebra. " descent " of the heart this is carried into the thorax with it, remaining connected with the spine above by means of the sheets which are to form the deep cervical fascia, and which descend to fold around the heart and form the pericardium. Below it gradually extends downward to form the crura along the lumbar vertebrae. Ventrally it becomes connected with the mesoblastic fold raised by the growth of the liver. The lateral portions are the last to close in, and probably the left is later than the right, which partly accounts for the fact that congenital dia- phragmatic hernias occur at least twice as often on that side. The centrifugal development accords with the views of His, Gerbe, Duguet, and Uskow, but Kblliker thinks the development is centripetal from two lateral halves. This great rarity of median diaphragmatic herniae is strong evidence against this view. The more fixed attachments of the diaphragm are there- fore upon the spinal column. Below by the pillars or crura (Figs. 809 and 810), arising from the bodies of the lumbar vertebrae, blending with the anterior common ligament as far down on the right as the disk between the third and fourth lumbar, on the left one vertebra higher. The crura partly cross above like an 8, forming two ori- fices. The posterior one is bounded behind by the spine ; the aorta passes down through it into the abdomen, and the thoracic duct ascends. The Chinese physicians are said to call this opening the door of life. Its edges are Fig. 809.-Antero-superior View of Diaphragm. DIAPHRAGM. [From the Greek Bid<f>payp.a, a partition wall. The older writers (Hippocrates) used the term <bpeves, and this signification is retained in our word phrenic. As emotions of the mind are manifested by 426 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diaphoretics. Diaphragm. tendinous, and afford origin for muscular fibres. Hence the opening is enlarged rather than closed during the ac- tion of the diaphragm. Nevertheless, the pull of the crura upon the aorta is believed to be the reason of the frequent occurrence of aneurism at this point. Through the anterior opening formed by the recrossing of the fibres, and which is on a level with the tenth dorsal verte- bra, the oesophagus and the pneumogastric nerve descend. Being completely encircled by muscular fibres, it is neces- sarily closed whenever the muscle is in action. This explains why a prolonged holding of the breath arrests eructation. Inspiration must be arrested to complete the act of swallowing, and Senac (cited by Hyrtl) reports a case in which the oesophagus was ruptured by swallowing during some irregular action of the muscle. After en- circling the oesophageal opening, the muscular fibres are inserted into an aponeurotic structure called the central tendon. From the sides of the bodies of the first and second lumbar vertebra? to the body of the transverse processes of the same, a tendinous arch stretches over the psoas muscle, called the ligamentum arcuatum internum. Another but weaker arch, called the ligamentum ar- layer of the pericardium, which is, properly speaking, a cone-shaped extension of it. From this pass prolonga- tions upon the great vessels, to the first rib on either side, to the cervical fascia, and to the spine ; forming what Forbes calls the superior tendinous crura of the dia- phragm. The central tendon is so fixed by this attach- ment that it does not descend in inspiration (see Fig. 811). When the diaphragm contracts the pericardial cone be- comes tense, and the expanding lungs are prevented from pressing upon the heart. Forbes has pointed out that the ductus arteriosus of foetal life is closed by the traction of certain muscular fibres of the diaphragm, which ascend upon the left side of the pericardium and pull upon it obliquely. The first act of respiration, therefore, occludes the previously existing channels for blood, so as to neces- sarily propel it into the lungs. The insertion, or more movable attachment, of the dia- phragm is by means of muscular fibres which, radiating from the central tendon, pass to each rib and to the xiphoid appendage, interdigitating with the transversalis abdominis. The insertion upon the xiphoid appendage is by two fascicles, which frequently have a cellular in- terval between them. Here, then, the subperitoneal tis- Inferior vena cava. Middle leaflet. (Esophageal opening. Opening for vena cava.. Right leaflet. Muscular fibres radiat- ing from the pillars. Fibres radiating from pillars. .Left leaflet. Opening for right splanch- nic and azygos. .Aortic opening. Lig. arcuatum internum Opening for left splanchnic nerve. Lig. arcuatum externum Quadratus lumborum Opening for azygos vein. . Arciform fibres. Psoas magnus. Spinal muscles. .Pillars or crura. Fig. 8f0.-The Diaphragm as seen from Below. (From Beaunis and Bouchard.) cuatum externum, is formed by the fascia of the trans- versalis stretching from the transverse process of the first lumbar vertebra to the last rib over the quadratus lum- borum. From both of these muscular fibres arise. The central tendon of the diaphragm is an aponeurotic septum into which the muscular fibres from the crura and the ligamenta arcuata are inserted, and from which others take their origin. It lies at the highest point of the vault, and, from its glistening appearance, has been called after the Dutch anatomist, Van Helmont, the Speculum Hel- montii. It has the shape of a trefoil leaf, the right leaflet being the largest, the left the smallest. Between the right and middle leaflets is the opening for the inferior vena cava, surrounded on all sides by crossing aponeurotic fibres which make it somewhat quadrilateral in shape, and bind it firmly to the lower border of the ninth dorsal vertebra. The edges of the opening being inextensible and continuous with the external coat of the vessel, the vein remains patulous throughout the respiratory act, and the blood is therefore sucked up through the cava into the thorax whenever the diaphragm descends. The central tendon is continuous above with the fibrous sue is continuous with that of the anterior mediastinum, and pus may pass through. Another interval frequently exists between the xiphoid insertion and that to the ribs, by which the peritoneum and pleura are left in contact. Through this hernia may occur, and here Larrey advised that puncture of the pericardium be practised. Besides the openings mentioned, the crura are perfo- rated by foramina for the azygos veins, the splanchnic and the sympathetic nerves. The vena azygos major frequently passes through the aortic opening. The relations of the diaphragm (see Fig. 812) are im- portant, as they determine its functions. The large mass of the liver lies directly under it, and the right lobe being by far the largest causesit to be more highly arched upon that side. The height varies in different individuals and in different conditions, being higher when an enlarged liver, ascites, or abdominal tumors push it up, and lower when depressed by pathological conditions in the thoracic cavity, such as emphysema, pleuritic or pericarditic ef- fusion, hypertrophy of the heart, etc. It also varies with each act of inspiration. Fig. 813 shows how its outline changes. In the cadaver its state is about midway be- 427 Dia ph ragm. Diaphragm. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tween the highest and lowest points, and the top of the vault on the right side is on a level with the sternal end of the fourth costal cartilage. In forced expiration it rises to the third costal cartilage, and in forced inspira- causes pain, and how abscesses of the liver may penetrate the thoracic cavity. Over the greater extent of its surface the liver is sepa- rated from the diaphragm by the peritoneum; but in J^Bib J Jut tus Arteriosus. Pulmonary artery. Pericardium. HfcART Ascending muscular fibres. Suspensory ligament of liver. Central tendon. Fig. 813.-Diagram Showing the Movement of the Diaphragm during Respiration. The upper line shows its outline during forced expira- tion, the lower during forced inspiration. (After Yeo.) Fig. 811.-Diagram of the Heart and Pericardium, showing Position with reference to the Diaphragm. The fibrous portion of the pericardium is shown as continuous with the deep cervical fascia above. From it pass processes, some of which ensheath the great vessels (represented as shaded outlines), and others extend to the first rib. Muscular fibres are shown passing from the diaphragm to the pericardium, and it is by their means that the ductus arteriosus is occluded. (Modified from Forbes.) certain situations this is wanting, and the original condi- tion of firm union between the two persists. This is most marked at the caval opening, where a considerable area of union occurs. A ball penetrating the diaphragm at about the tenth dorsal vertebra might enter the liver without wounding the peritoneum. From the spine, lines of union extend to the right and left between the folds of the coronary ligament, and anteriorly between those of the suspensory ligament. The weight of the liver (about four pounds), is, therefore, mainly hung from the central tendon at its union with the spine. The sus- tion descends to the sternal end of the fifth intercostal .space (Luschka). (See Fig. 814.) On the left side it is one or two ribs lower, varying somewhat with the disten- tion of the stomach. It has been found in the cadaver, in cases of ovarian tumor and ascites, as high as the second rib, and, in cases of pleural effusion, as low as the Diaphragm .Spleen. Fig. 814.-Lateral View of the Thorax, showing the Movements of the Diaphragm. The lower curved and punctate line represents it in a state of active contraction ; the middle curved line shows how it ap- pears during moderate contraction; the upper curved line demon- strates how far upward the diaphragm may extend when pushed up by the action of the abdominal muscles in forced expiration. Fig. 812.-Frontal Section of Thorax and Upper Abdomen, showing Re- lations of Diaphragm. (After Rudinger.) false ribs. It never, however, loses its convexity, this be- ing sustained by the unyielding superior crura. These relations explain why, in acute hepatitis, the movement of the diaphragm over the inflamed viscus pensory ligament probably keeps the diaphragm somewhat tense in a line downward and forward toward the umbil- icus, and causes it to assume the form of a double vault. No doubt this greatly steadies the muscle when in action. 428 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diaphragm. Diaphragm. In persons who have suffered for a long time with dif- ficulty of respiration (emphysema, occlusion of trachea, etc.), the diaphragm becomes hypertrophied and the liver becomes marked by grooves corresponding to the mus- cular bundles (Zahn). If the liver is removed from the abdomen, the lower thoracic aperture contracts when the diaphragm descends. As the contrary is the case in the living body, it appears that the convex surface of the liver is necessary in order to slightly change the direction of the muscular pull, so that tlie ribs may be raised instead of drawn together. Under the left arch the stomach and spleen lie, en- wrapped by the peritoneum. Hence the slight difficulty of breathing which occurs after a hearty meal. It is not infrequent to find, in post-mortem examinations, that the diaphragm has been softened by the digestive action of the gastric juice. Above, the diaphragm is lined by the pleurae on either side, and by the pericardium in the middle. The lungs do not cover the whole of the pleural surface, there being a space on either side into which they do not descend, called the costo-diaphragmatic sinus. A penetrating wound here will pass through both the costal and the diaphragmatic layers of the pleura, penetrate the dia- phragm, and reach the cavity of the abdomen without in- volving the lungs. Over the central tendon lies the right side of the heart, the opening of the vena cava into the right auricle being so close to the diaphragm that the course of that vessel in the thorax is very short. Cardiac impulses are not in- frequently conveyed to the epigastrium when the stom- ach is full, and, on the contrary, any affection of the cardiac end of the stomach (heart-burn) is apt to be re- ferred to the heart. The general effect of the action of the diaphragm is to enlarge the thoracic cavity, and to correspondingly contract the abdominal. Not only is the thorax enlarged from above downward, but also from side to side, because of the elevation of the ribs which occurs as already described. This not only causes air to descend through the trachea, but also the blood to ascend through the caval opening, and lymph through the tho- racic duct. By means of the pressure on the abdominal viscera, which is effected by the descent of the diaphragm, many physiological acts are performed. In efforts of this kind a full inspiration is first taken, and then the glottis is closed in order to hold the diaphragm stationary. The muscles of the abdominal wall then come into action, and the viscera are squeezed between the two surfaces. This mechanism, which was formerly known as the abdominal press (prelum abdominale), is used in defecation, mictu- rition, and parturition. Combined with a spasmodic action of the fibres of the stomach which holds the oesophagus open, it is also used in vomiting. The effort of the diaphragm is most effective when the body is bent forward so that it is on a horizontal plane over the com- pressed viscera. This is the attitude assumed in violent lifting effort, the diaphragm assisting to straighten the spine by pressing downward upon the viscera. It has been known to be ruptured in such cases, and hernia is usually caused thus. The nerves that supply the diaphragm are derived from three different sources. The principal one is the phrenic nerve, which arises mainly from the third and fourth cervical nerves. The original development of the dia- phragm in connection with the heart, directly in front of this region, apparently explains the unusual distance which exists between the origin and termination of this nerve. Its peculiar course downward on the sides of the pericardial cone, and in front of the root of the lungs, also accords with this view, and indicates that the ante- rior part of the diaphragm is the oldest. Division of this nerve paralyzes the muscle on the affected side. The spinal centre corresponding to this nerve appears to be in the so-called respiratory area of the cord, about the level of the third cervical vertebra, near the origin of the nerves which supply other muscles of respiration and phonation. Injuries to the cord at or above this point are also fol- lowed by paralysis of the muscle. Filaments from the sympathetic also pass to the dia- phragm, and some authorities are of the opinion that the circumferential fibres inserted upon the ribs are supplied by intercostal nerves. The muscle is liable to peculiar or disordered action from many causes. As instances of this it is only necessary to mention its share in hiccough, sobbing, yawning, laughing, sneezing, groaning, and sigh- ing. In experiments upon the electric excitation of the phre- nic nerve in animals, Kronecker and Marckwald came to the conclusion that the contraction of the muscle was not like that of the ordinary voluntary muscles, as it lasts much longer. It is rather to be regarded as tetanic in its nature, and can be arrested at any stage under ordinary condi- tions. The fact that the muscle is under the control of the will only within a certain limit probably led to the fanciful ideas of the old physiologists, who considered it as the fanner of the hypochondria, preventing noxious vapors from rising into the thorax. Being a muscle of great activity, its blood-supply must necessarily be large. This comes from the branches of the internal mammary (comes nervi phrenici, musculo- phrenic), oesophageal, and intercostals above, and the in- ferior phrenic and lumbar below. Bibliography. Anger, Benjamin : Nouveaux Elements d'Anatomie Chirurgicale. Paris, 1869. Despres, Armand : Nouveau Dictionnaire de Medecine et de Chirurgie Pratiques, vol. xi., article Diaphragm. Paris, 1869. Forbes: The Diaphragm a Protector of the Heart and Cardiac Vessels, etc., Am. Journ. of Med. Sci., vol. Ixxx., n. s.. 1880, p. 88. Gerhardt, C. : Der Stand des Diaphragma's. Tubingen, 1860. Henocque and Eloy : Dictionnaire Encyclop6dique des Sciences Med- icales, vol. 29, 1st series, article Diaphragm. Hyrtl, Joseph: Handbuch der Topographischen Anatomic, 7th ed. Wien, 1882. Kronecker and Marckwald : Archiv fur Anatomie und Physiologic (Physi- olog. Abthl'g), pp. 592-594. Leipzig, 1879. Milne-Edwards: Comptes-rendus de PAcademic des Sciences. Paris, 1875. Todd's Cyclopaedia of Anatomy and Physiology, article Diaphragm. Zahn, F. W. : Note sur les plis respiratoires du diaphragme, etc., Revue Med. de la Suisse Romande, vol. ii., 1882, p. 19. Frank Baker. DIAPHRAGM, DISEASES AND INJURIES OF. The diaphragm being formed of muscular and fibrous tissues, and covered with serous membrane, is subject to the same diseases which attack these structures in other situations ; and, constituting furthermore the boundary between the abdominal and thoracic cavities, it is affected by diseases of the organs enclosed in these cavities, being at times displaced, involved in disease by continuity, or ruptured and the seat of a hernia. Displacements of the diaphragm in an upward or down- ward direction are caused by a relative increase in the contents of either the abdomen or the thorax. Thus a pleuritic effusion, emphysema, hydropericardium, or in- tra-thoracic aneurism may mechanically depress the dia- phragm, reducing the height of its arch and causing the muscle to assume a more horizontal position. In the same way ascites, pregnancy, enlarged liver or spleen, or intra-abdominal tumors, push the muscle upward and cause an exaggeration of its vault. Displacement is like- wise caused by a relative decrease in bulk of organs con- tained in either of the contiguous cavities. The symptoms of this condition are difficult breathing, a deep inspiration being often impossible, sometimes a short dry cough, and a dragging sensation around the circle of attachments of the diaphragm to the bony framework. When the mus- cle is elevated the false ribs are pulled up and assume a more horizontal direction, and when an intra-thoracic en- largement causes a depression of the septum the false ribs are carried downward and become more vertical. A local displacement may be caused by enlargement of a sin- gle organ, as the liver or heart. In this case the respira- tory and other symptoms are less pronounced in propor- tion as the disturbance of position of the muscular sep- tum is less complete. Atrophy of the liver has been noted as a supposed consequence of downward displace- ment of the diaphragm. The treatment of diaphragmatic displacements is, of course, that of the causal conditions. 429 Diaphragm. Diarrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Adhesions are sometimes formed between the dia- phragm and the neighboring organs from plastic inflam- mation of their peritoneal or pleural covering. The con- necting material is usually fibrous, but may become cal- careous. Unless the adhesions are very extensive, they do not, as a rule, cause any serious disturbance of the respiratory functions. If the heart be adherent to the diaphragm, the condition is often manifested by pulsa- tions visible in the epigastrium. Perforations of the diaphragm may be caused by dis- ease of the muscle itself (abscess, cystic tumor, or fatty degeneration), or by pus coming from an hepatic abscess. Thinning of the muscle and subsequent perforation may result from the presence of an aneurism. Rupture is sometimes caused by a fall or a blow upon the abdomen, although there may be no external wound. This occurs more frequently upon the left side, probably because of the protection afforded by the presence of the liver on the right. The diaphragm is not infrequently involved in penetrating and gunshot wounds of the abdomen or thorax, and may also be torn by the jagged end of a fractured rib. In some cases the aperture is closed by fibrinous effusion, and recovery ensues; but usually, if death does not speedily occur, the opening remains and gives occasion to diaphragmatic hernia. Hernia of the diaphragm is a condition of not very rare occurrence. It may be divided into three varieties, viz., congenital, acquired, and traumatic. In the first variety the protrusion of the abdominal viscera may be through an opening due to deficiency in the muscle, and may be without a sac ; in other cases there is a sac formed of the thinned and yielding diaphragm itself. In the acquired variety the hernia does not exist at birth, but occurs through one of the natural openings of the diaphragm, or through a congenital thinning or deficiency in some por- tion of this septum; the exciting cause being increased intra-abdominal pressure from pregnancy, accumulation of gas in the intestines, etc., or from action of the muscles of the abdomen in the act of straining at stool, lifting heavy weights, and the like. In this variety, also, there may be a sac formed of a part of the diaphragm itself. In traumatic hernia the viscera are forced through an abnorrhal opening formed suddenly by disease or ex- ternal violence. Any one or more of the abdominal vis- cera may be protruded through the opening in the mus- cular septum, but in the vast majority of cases it is one of the hollow organs that is implicated, as the stomach or some part of the intestine. In a case reported by Sir James Alderson the stomach, omentum, spleen, and trans- verse colon were protruded through an aperture in the left side of the diaphragm, displacing the heart to the right. Scholler found a hernia of the kidney, and sev- eral observers have reported cases in which the left lobe of the liver had passed through into the thoracic cavity. The thoracic viscera are displaced more or less according to the extent of the hernia, the lung on the affected side being compressed and flattened against the posterior wall of the chest, while that of the opposite side may be emphysematous. In some cases of very extensive protrusion of the abdominal viscera both lungs have been found more or less reduced in volume. In hernia of the left side the heart is usually displaced to the right. The symptoms of diaphragmatic hernia are not always well marked, and the condition has been discovered at post-mortem, when its existence during life was never so much as suspected. In the congenital or acquired cases of long standing the presence of a thoracic tumor can sometimes be made out, and this tumor, if it be one of the hollow viscera that is implicated, yields a resonant percussion note. The displacement of the heart and lungs may aid in the diagnosis, and it is sometimes possible to note the absence from its usual situation of the abdomi- nal organ involved. Pain is usually present, and is some- times situated deep down, the patient being unable to define its exact location, or may be referred to the pit of the stomach. There is commonly very marked dyspnoea, which is usually constant, but may be broken by in- termissions of comparatively quiet respiration. When strangulation occurs the symptoms of this condition are added to those already pre-existing. In traumatic hernia the signs of shock at first predominate, and it is only after a time, if the patient recover from the immediate effects of the injury, that the presence of a diaphragmatic hernia can be determined. Dr. Wilks first called attention to excessive thirst as a characteristic symptom of diaphrag- matic hernia, and Bryant and others have since confirmed his observations. Sometimes patients become habituated to this condition, and appear to suffer no great incon- venience from it, but death usually results sooner or later from strangulation or from pulmonary disease. Treat- ment is necessarily unsatisfactory, for but little can be done to reduce the hernia or prevent its recurrence. The maintenance of the erect position would bring the force of gravity to bear ; and carminatives might be given to prevent the accumulation of gas within the intestines, and thus reduce intra-abdominal pressure. Laparotomy might be advisable in certain cases, if other means failed, and would often, indeed, offer the only chance of saving the patient's life. Inflammation of the muscular tissue of the diaphragm, occurring as an idiopathic affection, is certainly of ex- treme rarity, and many writers have doubted its exist- ence. But diaphragmatic pleurisy and peritonitis, con- secutive to inflammation of neighboring parts, are not uncommonly met with. There is a painful sense of con- striction at the pit of the stomach, and often also severe pain following the course of the insertion of the muscle into the chest-walls. This pain is increased by pressure on the epigastrium, and by the respiratory movements. Cough, singultus, and rapid labored breathing are often present. There is also an elevation of temperature in cases of any severity. The symptoms, however, are very obscure, and are those chiefly of functional disturb- ance, and it is almost impossible in many cases to make a differential diagnosis between this condition and pleurisy or peritonitis. The indications for treatment are to re- lieve the pain by morphine hypodermically employed, and to combat the other symptoms, as they arise, by the appropriate remedies. Rheumatism sometimes attacks the diaphragm, and may be either acute or chronic. In the acute form there is severe pain in the epigastrium, and following sometimes the course of the diaphragmatic attachments, increased by respiratory movements, but usually unaffected by pressure at the pit of the stomach. Sometimes the pas- sage of food through the oesophageal opening causes great distress. Respiration is feeble and almost wholly costal, the movements being confined chiefly to the upper por- tion of the thorax. Tonic spasm of the muscle may oc- cur during an attack of rheumatism, and the pain becomes then intolerable. In the chronic form there is much less distress, and complaint is made principally of a feeling of tension rather than actual pain along the points of inser- tion of the muscle, of more or less dyspnoea, and a dry, rather painful, cough. Diagnosis is facilitated by the presence of signs of rheumatism in other parts, and by an absence of intra-thoracic disease sufficient to account for the pain and dyspnoea. The treatment is that for ordinary muscular rheumatism, with, in severe cases, the use of opium to quiet respiratory action and relieve pain. Neuralgia may also be seated in the nerves of the dia- phragm (diaphragmodynia, diaphragmalgia). It is mani- fested by severe pain, usually unilateral, in the circle of attachments of the diaphragm, and sometimes radiating thence to neighboring parts. There are also generally functional disturbances, such as dyspnoea and dysphagia. The affection may be idiopathic or associated with hys- teria, anaemia, or lesions of some of the neighboring viscera. It is a rare affection, and is often confounded with pericarditis, angina pectoris, pleurisy, painful affec- tions of the abdominal viscera, etc. The treatment is the same as that for neuralgia in other parts; arsenic, pushed as far as possible, is often of great service here as in other neuralgias. Spasm, tonic or clonic, of the diaphragm is not a rare affection, at least in its milder forms. It occurs in con- nection with general convulsions in hysteria, chorea, tetanus, and strychnia poisoning, or from 'irritation of the 430 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diaphragm. Diarrhoea. phrenic nerves, due to the presence of a tumor, or to di- gestive disturbances. The spasms may be partial or com- plete. The chief symptoms are hiccough and irregularity or difficulty of respiration, though there is usually also, in severe cases of tonic or clonic spasm, pain in one or both hypochondriac regions. In tonic convulsions of the diaphragm the lower portion of the chest appears to be enlarged, the voice is faint, and it seems sometimes as though suffocation were imminent. This form occurs often associated with laryngismus stridulus, the so-called internal convulsions of rachitic children. The treatment which offers the best hope of cure in the grave forms of diaphragmatic spasm is the use of the interrupted cur- rent, the electrodes being placed over the phrenic nerves or over one nerve, and at one of the points of insertion of the diaphragm. The application of cold and pressure over the pit of the stomach may give good results, as may also the exhibition of antispasmodics. Paralysis of the diaphragm may occur in pleurisy, diphtheria, myelitis of the spinal cord, hysteria, lead poisoning, injury of one or both phrenic nerves, and other conditions. It may be complete or partial, involv- ing the entire muscle, or affecting only one lateral half. There is marked difficulty in breathing, which is entirely costal, the abdomen sinking during inspiration and be- coming fuller in expiration, the reverse of what occurs normally. Coughing, talking, straining at stool, and all acts requiring for their performance fixation or contrac- tion of the diaphragm, are rendered difficult or impos- sible. The faradic current, applied with the electrodes over the phrenic nerves, is said to have given good re- sults in paralysis of the diaphragm. The prognosis varies according to the causal condition; but as long as the paralysis continues, the patient is liable to die from any intercurrent pulmonary affection. New growths in the diaphragm are of very rare occur- rence. Sometimes cystic tumors are found post mortem which gave no signs of their presence during life. Per- foration may occur from the rupture of one of these cysts. Cancer of the diaphragm is said to be always a secondary growth, never appearing primarily in this muscle. In scurvy there may be extensive sanguineous effusions into the diaphragm, an occurrence which is generally indicated by a sudden attack of intense dysp- noea. Atrophy of the diaphragm may occur in progressive muscular atrophy, in amyotrophic spinal paralysis, in old age, and in other conditions. There may be a simple wasting of the fibres, or a condition of fatty or calcareous degeneration of the muscle. Diaphragmatic hernia may ensue as a consequence of local atrophy of the septum. Thomas L. Stedman. rhal, or otherwise-whereby it is intolerant of the pres- ence of its contents, and expels them with abnormal force and frequency, or by the presence of abnormal and irri- tating substances that provoke the intestine to expel them with undue haste. And, since the intolerance of the intestine may be caused by many different pathologi- cal states of various degrees, and the irritating influences are numerous, and since various incidental events also may ensue from the conditions named, diarrhoea has multifarious forms and symptomatic behavior. Symptoms.-The discharges are nearly always more or less fluid. Frequently at the beginning of an attack only normal fecal matter is voided, but soon the passages be- come loose and continue so to the end, their character changing as the disorder progresses. Sometimes during a seizure little beside fecal matter is passed, this being made semi-fluid by the admixture of serum and mucus. Occasionally, and more often in chronic than in acute cases, the fecal matter appears in scybalous masses, often hard, and sometimes dark-colored and mingled with semi- fluid, slimy, mucoid or puriform material. In such cases the scybala rarely appear in every passage, but only occa- sionally, while the fluid material originating in the lower colon and rectum may be passed at short intervals. The passages present every degree of fluidity, from that of water to thin paste. The fluid may be opalescent, like milky water, with or without minute light-colored, flaky particles, or it may be yellowish or reddish, black or green, in various shades of coloration. It may be frothy, or mucilaginous in any degree, from that of slippery-elm water to a slimy mass of trembling jelly. Mucus, next to watery serum, is the most common and constant admix- ture with the faeces in diarrhoea. Food, undigested, par- tially digested, and variously changed, is found at times in the dejections. Most common are the skins and seeds of fruits and vegetables, as apples, cucumbers, and pickles, but articles of food of easy digestibility may be unexpect- edly passed. Thus, tender meats and well-cooked and finely-comminuted vegetables are found in the passages of both children and adults in diarrhoea, while curds of milk, often green in color, are common in the passages of infants. Certain persons are unable to digest particular articles of a usual diet, and invariably void such undi- gested. Meat is sometimes voided in a half-digested state, bearing some resemblance to dead intestinal worms, for which it is occasionally mistaken. Blood often ap- pears in the dejections of diarrhoea. It may be either fluid or in clots, bright red or dark and venous, chocolate-col- ored or even black, from long residence or wide journey- ing in the intestinal canal. It may streak the discharges, be mixed intimately with them, or appear independently. Pus is accidentally passed with the stools, either in small quantity and mixed with mucus, or, less often, in large amount and nearly pure. Fat forms a part of the dejec- tions in many diarrhoeas, although usually it would not be discovered by a casual inspection. Membranes and pseudo- membranes are sometimes voided in diarrhoea. False membranes of various sizes and shapes are exfoliated, even at times strips a foot or two in length, while shreds of the superficial layer of the mucous membrane itself may be cast off. Shreds of undigested meat found in the discharges are sometimes mistaken for membrane. For- eign bodies of unexpected character often appear in the dejections of acute diarrhoea, especially in children-for example, strings, sticks, pins, pieces of leather, and small coins. In color the passages vary. Usually yellow, they may have various shades of red, brown, chocolate-color, black or blackish and green, or be opalescent, like milky water. Flatulence is a more or less common symptom in diar- rhoea, and the flatus may be odorless or fetid. In severe diarrhoea the appearance of the patient always betokens illness. The countenance becomes haggard and shrunken if the attack is continued or severe, general weakness and mental despondency may ensue, loss of ap- petite usually takes place, although, for a brief period in certain cases, and continuously in others, the very oppo- site may obtain. In diarrhoea unattended by inflammation fever is a rare DIARRHOEA. This is a general designation for a class of symptoms that is among the most formidable of all the manifestations of sickness. It means the occurrence of evacuations from the bowels, either unusually often or abnormally fluid in character. The term is also used to designate certain pathological states of the intestines, which induce or are supposed to induce it; but it is not applied to such diseases as dysentery and cholera, except to characterize a symptom. In describing diarrhoea, it is customary to divide it into acute and chronic; but the terms are arbitrary, as the disorder varies in duration, from the brief moment of a solitary passage to a continuous stretch of many years. The line is usually drawn, however, at the limit of a few weeks ; cases continuing longer are chronic, those of shorter duration are acute. In degree of severity, diar- rhoea presents all shades of variation. It arises under a great variety of circumstances, and in conjunction with many different diseases. Nor is this surprising when we consider the extensive mucous surface of the alimentary canal, the indispensable functions of the organs which compose it, and the manifold influences on which they depend, and by which they are disturbed. The wonder is rather that it is not more varied and frequent than it is. The occurrence of diarrhoea is made possible by in- creased irritability of the bowels-inflammatory, catar- 431 Diarrhoea. Diarrhoea. REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES. symptom ; it does not occur in all the inflammatory forms, and does occur to a high degree even in some acute attacks without inflammation. Usually in adults-less often in children-in the acute attacks fever is absent, and the temperature may be subnormal, the surface and extremities, particularly, being cold and possibly moist with perspiration. Pain in the abdomen is seldom ab- sent ; it is often experienced in the back, and in bad cases with large, watery stools, painful cramps may occur in the muscles, chiefly of the lower extremities. The pain in the bowels occurs in different localities in the abdomen, and assumes many different forms and relations to the act of defecation. It is seldom constant, usually inter- rupted, and recurs at varying intervals, often as a colicky suffering, and may be quite independent of an evacua- tion. Audible evidence of movements of gas in the in- testines may mark the recurrences of pain. In relation to the movements of the bowels the pain may occur (1) be- fore a movement, the time before varying from a mo- ment to half an hour, the longer the period the higher in the intestinal tract the seat of pain. The pain may occur (2) at the time of the evacuation, being usually in the rec- tum and anus, or (8) after the passage, being located in the anus, rectum, or descending colon, and in tissues deeper than the mucous membrane. It may persist from a few minutes to half an hour after the passage. Pain may be present only in the anus, and that of a burning, scalding character, and mostly after a number of watery passages. The suffering is during and immediately after an evacuation, is confined to the mucous membrane of the anus, the cause being mainly the irritating character of the stools, but partly the rough use of improper closet paper or worse substitutes for it. The abdomen may be tender in'some region, particu- larly over the colon, or throughout, and the patient may bend the body forward in walking or moving, to avoid aggravation of the suffering, or in the recumbent pos- ture the thighs and legs may be flexed to the same end. Tympanites may be present in varying degree, depend- ing on the extent of inflammatory action and of nervous involvement. Pain may occur in the bladder, in the back, deep in the sacral region and in the thighs and legs. There may be tenesmus, an involuntary and irresistible straining at stool, with pain in the rectum if this part is particularly involved, Faintness, nausea, vertigo, or a sense of great prostration, or all together, may occur in diarrhoea, and perspiration, more or less profuse, may break forth at the time of an evacuation in an attack of only moderate severity. These symptoms differ accord- ing to personal idiosyncrasy, and degree of involvement of the tissues of the intestines. Varieties of Diarrhoea.-The most frequent form of diarrhoea is that which occurs in connection with indiges- tion, which, itself, has many shapes and symptoms. Oc- curring suddenly after over-eating it may be associated with vomiting (cholera morbus). One or more free, fec- ulent evacuations are followed by a number that are semi- fluid, and finally, by mucous or watery ones. Diarrhoea occurs after partaking of certain articles of food or drink that, for the occasion, at least, if not habitually, are indi- gestible or disturbing to the bowels. What affects one person may not another, and one is made sick to-day by what he may to-morrow take with impunity. From eat- ing large-seeded berries, salads, nuts, cheese, fruits, and vegetables, drinking lager-beer, and even milk, certain persons experience diarrhoea occasionally or invariably. Eating in a hurry may cause certain foods, usually easily digested, to disagree and bring on diarrhoea, There is a diarrhoea of indigestion in which several loose passages follow each other in rapid succession during the morning and none again, or at most only one or two, till the suc- ceeding morning-this being repeated daily, sometimes for months. The intestinal canal in a condition of atony or catarrh, or nervous irritability or all, and wearied by undigested food and irritating substances, expels them and is quiet; the morning diarrhoea evacuates the noxious refuse of the meals of the previous day and the disturbed organs rest. In temporary debility from any cause, di- arrhoea from indigestion may come on without dietetic irregularities ; it may assume the form just described, or some other. The patient is suddenly liable to derange- ments of the bowels. Discovering that diarrhoea follows a full meal, he cuts down his diet without increasing his meals, till the starvation point is nearly reached, with the result sometimes of aggravating rather than helping the susceptibility. In persons nervously sensitive, diarrhoea, with possibly sick-headache, may arise from indigestion incident to sudden strong emotion. The experience rarely exceeds one or two loose passages, unless the emotional shock is often repeated, when the diarrhoea may become chronic. Cholera morbus, so-called, is still another form of diarrhoea. It occurs most often after some days of bil- iousness, mental dulness, headache, and coated tongue. Sometimes the attack is precipitated by a final error in diet, a chill or an emotion ; sometimes it occurs without any discoverable exciting cause. It is usually brief, last- ing only a few hours or a day, its force being spent by a free evacuation of the bowels. As in other sudden di- arrhoeas, the first passages are feculent, and the later ones, if the seizure is prolonged, are watery and mucoid. Vomiting may or may not attend the diarrhoea. Bad cases are more prolonged and severe (sporadic cholera), and may even reach a fatal termination. In such, the dejections, after the bowel is once evacuated of fecal mat- ter, are copious, watery, and odorless; cramps and col- lapse take place, and the rapid and appalling shrinking of the tissues, the sinking of the eyes, and the cold ex- tremities, the lowering of the body temperature even, the cold perspiration and huskiness of voice as in Asiatic cholera. This form of diarrhoea in infants is true cholera infantum, a term often improperly applied to slowly pro- gressing catarrhal inflammation of the colon and ileum. Choleriform diarrhoea, in the absence of ah epidemic, is usually recovered from promptly by vigorous adults ; less promptly by infants, children, weakly and aged people. Diarrhoea may follow chill of the surface of the body, with or without other influences. This occurs most often on the approach of cold weather, when people are found insufficiently clad, and internal congestions are easily induced. The attacks are sometimes severe; a catarrh of the colon follows the first passive congestion ; blood (bloody flux) and much mucus are voided with tenes- mus. Diarrhoea in epidemic form appears occasionally when it is quite impossible to discover any adequate cause for it. Such epidemics may be general within circum- scribed limits, visiting all ages and conditions of life, and may appear suddenly, and, after a few days, as suddenly disappear. Nearly all forms of diarrhoea may character- ize such epidemics, but the cases are rarely fatal. The so-called winter cholera which has prevailed in the win- ter season in several northern cities is an example of this form of diarrhoea. Another form is that associated with some disturbing emotion, and which occurs without the additional etiological element of indigestion. Fright, fear, timidity, bashfulness, and suspense are capable of causing sudden diarrhoea. Sometimes, however, they induce the opposite condition of constipation. In either case the phenomenon is a purely nervous one. The di- arrhoea of emotion is usually trivial and brief, but in states of prolonged mental and emotional excitement the looseness may be chronic. There are other forms of nervous diarrhoea. Some persons with sensitive abdom- inal nervous organizations must run to stool immediately after eating or drinking. This trouble is to some extent imaginary-the desire can usually be resisted. But iu other cases there is a nervous hyper-peristalsis that results in diarrhoea, and prevents either efficient digestion or ab- sorption. Cases of this kind are liable to be persistent, recurring many times, and from the most trivial causes, but always chiefly from those that affect the nervous sys- tem, and at times of nervous perturbations. In some persons, this form of diarrhoea is substantially constant and persists for years. Cathartic medicines produce diarrhoea in one of three ways or by a combination of them; either by increasing the fluid contents of the intestines, by increasing the peristal- sis without irritation, or by irritation of the mucous mem- 432 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diarrhoea. Diarrhoea. brane. Severe catharsis produces pain, tenesmus, and a catarrh of the intestines which prolongs the diarrhoea sometimes for a number of days, the passages being wa- tery and mucoid ; but moderate catharsis, especially after a period of constipation or biliousness, is followed by I tuoyancy of spirits and a sense of refreshment. Diarrhoea, with or without vomiting, occasionally oc- curs from the poisonous action of certain articles of food usually bland and harmless, but which happen to be out of condition or in a state of fermentation, such as pud- dings, custards, pies, sauces, ice-cream, and canned meats. The symptoms usually come on suddenly, and from one to three hours after eating the offending substance. Vomit- ing is generally simultaneous with the purging, but may cease before the latter. The diarrhoea may continue after the digestive tube is apparently completely evacuated of all fecal matter and food, and may even lead to a fatal termination. In the severe cases the later passages are mucous and watery, with possibly an admixture of blood, and pains, cramps, great prostration, and profuse sweating occur in varying degrees. In mild cases all symptoms cease after the evacuation of the stomach and bowels. In many cases of diarrhoea constipation occurs in alter- nation ; there is a period of constipation of a few days, then a sharp attack of diarrhoea, then the constipation is repeated, and so on indefinitely. Diarrhoea is a prominent symptom of many cases of typhoid fever. The stools are generally yellowish, ochre- colored, and semi-fluid in character, and may contain blood. Frequently not more than one such passage, rarely five or six, occur daily, while sometimes a loose stool may be passed only once in two or three days. In cases in which only a few glands of the intestine are in- flamed or ulcerated, and these confined to the ileum, the colon is tolerant of the products of the ulcers as well as fecal matter, and constipation may exist; but where the glandular involvement extends to the large intestine diar- rhoea is nearly sure to occur. Diarrhoea is a frequent symptom in pulmonary con- sumption. It has most of the characteristics of the diar- rhoea of indigestion, which it mainly is. Food is passed undigested, evidences of fermentation exist, the passages are thin and watery. Several passages may occur in rapid succession, especially after eating heartily. In an ad- vanced stage of phthisis a dejection often follows so closely upon even a small, bland meal, as to suggest the complete intolerance of the whole alimentary canal to the presence of food, as well as its incapacity for digestion and absorp- tion ; moreover, the food is much of it passed with slight evidence of having undergone any digestive change. In a proportion of such cases there is secondary tubercular ulceration of the intestines, but this alone does not neces- sarily nor frequently produce diarrhoea, unless the colon is involved. Numerous tuberculous ulcers of consider- able size may exist in the small intestine without an- nouncing their presence by any symptom during life. A form of diarrhoea results from chronic ulcer of the rectum. It consists in frequent discharges of small quan- tities of a slimy mixture of mucus, pus and blood, with little fecal matter, and this little in the form of scybalous masses which are voided at varying intervals. Tenesmus may be present, but frequently is not, and often there is little or no pain, unless the ulceration reaches the anus, when pain is always present at the time of defecation, and for a few moments afterward. Diarrhoea of constipation is a designation justified by clinical observation. Fecal matter accumulates in the colon, distends it, becomes hard and dry, and finally lights up an irritation at the lowest point, which announces itself by frequent small discharges of mucus, serum, and fragments of the fecal mass, possibly with pain and tenesmus. It is not necessary in these cases to suppose a complete blocking up of the large intestine ; faeces may accumulate and remain for months, and repeatedly allow small soft feculent passages by the side of the indurated mass or through a hole in its centre. After the discharge of a large mass of long retained faeces, the colon is not infrequently left in a condition of catarrh which may prolong a diarrhoea for several days. The same thing is observed after the evacuation of an old accumulation due to constriction of the intestine. In general peritonitis, contrary to a nearly invariable rule, diarrhoea is sometimes present at some stage of the disease. Vomiting nearly always attends it, and not in- frequently hiccough. In metroperitonitis, on the other hand, diarrhoea is frequent, owing presumably to the in- volvement of the lower bowel in the inflammation causing a catarrh of the mucous membrane of this part. Diar- rhoea is an occasional event in several diseases of the kid- neys. In desquamative nephritis the intestinal mucous membrane appears to become oedematous with the rest of the body, and a free effusion of serum brings on oc- casional paroxysms of diarrhoea. In uraemia from any renal disease, urea may be discharged into the intestine and cause diarrhoea, perhaps principally by its conversion into carbonate of ammonium after its entrance into the canal. Diarrhoea is a rare event late in contracting disease of the kidneys, due presumably to uraemia. In amyloid degeneration it is more common, is liable to be irregular, and may be protracted, is occasionally haemorrhagic, and always rebellious to all treatment. Tuberculosis and can- cer of the kidneys may be attended by diarrhoea probably from uraemia, and possibly in the case of the former by the concurrent existence of tuberculosis of the colon. In intussusception diarrhoea is usually present in some degree at some stage of the case. The stools are few in number and composed of mucus and blood to a consider- able extent, and there is frequently tenesmus, especially if the invagination is at the ileo-caecal region or below it. In constriction of the intestine constipation is the rule, but diarrhoea may alternate with it, or be a nearly constant symptom. Two theories of this phenomenon are ad- vanced, one referring it to the increased peristalsis pro- voked by the constriction, the other to ulceration which sometimes supervenes below the point of stricture. Diarrhoea occurs rarely in cancer of the pancreas, and nearly invariably in cirrhosis of this organ. In the former, secondary deposits are sometimes found in the intestinal walls, which may account for the symptoms. In leu- caemic enlargement of the spleen diarrhoea sometimes oc- curs, the motions being bloody and most of them puru- lent ; they may be, however, profuse and watery. Recurring diarrhoea may attend degeneration of the suprarenal capsules, brought on probably to some degree by the debility which characterizes the disease, but also by the disturbance of the semilunar ganglia and sympa- thetic which must ensue from the marked lesion which occurs in them in many cases of Addison's disease. Diarrhoea makes a part of the pathological picture of the teething of infants (see Diarrhoea, Infantile). In cirrhosis and other diseases of the liver constipation is the rule, yet it may be varied by an occasional sharp attack of diarrhoea, which for the time depletes the dis- tended vessels of the portal system. Intestinal catarrh has been charged with producing diarrhoea with some constancy, as though this symptom might result wherever the location of the catarrh. It cannot be doubted that catarrh attacks all the different portions of the alimentary mucous membrane. Of course, catarrh of any part in some measure interferes with digestion, and in this way may indirectly be a cause of diarrhoea. In chronic catarrh of the small intestine con- stipation is almost constant; in the catarrh of the colon, acute or chronic, diarrhoea is rarely absent. The ten- dency to chronicity is particularly noticeable in the diar- rhoea of chronic dysentery, and of general anaemia from any cause, but especially from dyspepsia, phthisis, and other diseases capable of inducing general cachexia. Etiology.-Many of the general causes of diarrhoea have been referred to already. Often, indeed generally, several influences, direct and remote, act together as causes. The remote, the predisposing causes are any and all influences, diseases and disorders that lessen the vital tone of the intestinal canal, and depress the powers of digestion, and that increase the irritability of the nervous apparatus of the intestines. To this class belong the de- pressing influence of hot weather, especially on infants and children ; of cold, overwork, bad ventilation, starva- 433 Diarrhoea. Diarrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tion, worry and grief of mind, and all the long list of de- pressing emotions. The immediate pathological conditions that produce diarrhoea may be named under a few general heads ; the circumstances under which they occur are numerous. The following is believed to be a logical classification of the causative conditions : 1. Solution of Continuity and other Structural Damage to the Intestinal Walls.-Ulceration, and the catarrh in ad- jacent tissue which it entails, as it occurs in the rectum, the colon, as in chronic dysentery, the intestine anywhere, as in tuberculosis, in amyloid and perhaps other degen- erations of the intestinal walls, typhoid fever, intussus- ception and constriction of the intestines, ulcers from extensive scalds and burns of the surface of the body, atrophy of glandular tissue, and cicatrices from old ulcers, embarrassing digestion and absorption. 2. Inflammation, of the colon and rectum mainly : proc- titis, colitis (dysentery), the inflammation of intussuscep- tion and of cholera reaction, of peritonitis and cancer, and tuberculosis of the intestine. 3. Congestion, otherwise catarrh of the mucous mem- brane of the intestine, mainly below the ileum, without inflammation : the catarrh of cholera, cholera morbus, cold-catching, chilling of the surface of the body in whole or in part, invagination, obstruction to the portal circula- tion in cirrhosis of the liver and cardiac disease, perito- nitis, leucaemia, zymotic poisons, the eruptive fevers, a long list of general diseases, and of irritations of foreign bodies, especially drastic drugs. 4. Increased irritability of the intestine with hyperperi- stalsis. This arises from depressing emotions ; debility, systemic or nervous ; bad hygiene in its multiple shapes ; the reflex effect of teething and manifold other influences capable of reflex action in this direction, especially dis- eases in other organs; constriction of the intestine, and personal idiosyncrasy. 5. Irritating Intestinal Contents.-The results of (a) gas- tric dyspepsia, over-eating, improper or improperly mas- ticated foods, whereby alimentary substances with insuf- ficient gastric digestion, or in a condition of fermentation or decomposition, are cast into the intestine. The result of (b) intestinal indigestion, from abnormality of the liver or pancreas, from loss of secreting substance by previous or existing ulceration, from atony, catarrh, or inflammation ; in the catarrh of the intestine, particu- larly in infants, the large amount of mucus produced not only makes digestion and absorption impossible, but its decomposition leads to products that are themselves irri- tating. (c) Cathartics and other irritating substances, either swallowed or developed in the intestines, as ca- thartic medicines, impure or strongly saline drinking- water, various poisons, including foods undergoing fer- mentation, excessive transudation of serum into the canal, as in choleraic disorders and in the colliquative diarrhoea of depressing diseases, pus, blood, or mucus in quantity ; the rinds, hulls, and seeds of fruits, grains, and vegeta- bles ; retained faeces, the entozoa, the entophyta, urea, as in renal affections, and finally the special micro-organ- isms of disease. Microbes characteristic of diarrhoea have been found to be present in the intestine in severe cases of this disorder, and to disappear with its subsid- ence, but whether they are the cause or consequence, is not established. Excess of bile thrown into the duodenum after the removal of an obstruction may cause diarrhoea, but it is not known, as alleged, that so-called vitiated bile is capable of doing it. Diagnosis.-The diagnosis of diarrhoea is easy enough; the important and often difficult thing is to learn the cause and nature of the disorder. The dejections should be inspected by the physician for foreign bodies, undi- gested food, products of fermentation, pus, blood, mucus, etc. As diarrhoea is oftener due to indigestion than to any other one agency, it is important, when this is present, to determine what part of the alimentary canal or what other organ, if any, is at fault. A consideration of the physiological functions of the different parts and the symptoms of the case will usually lead to the discovery of the region or organ involved. It is equally important to learn what articles of food fail of digestion, in what quantities and under what circumstances as to times of eating, methods of preparation, and size of meals. By careful observation and by exclusion this may be done, and so the first step in successful treatment be attained. If the attack is not due to indigestion, irritation, or catarrh, inflammation or ulceration of some part of the alimen- tary canal should be looked for. A considerable degree of inflammation of the mucous membrane may exist without fever, so the absence of this does not exclude in- flammatory action. In a majority of cases caused by the lesions referred to, the trouble is in the rectum or colon ; inflammation, catarrh, indigestion to a moderate degree rarely cause diarrhoea, provided the bowel below the ileo- caecal valve is normal. The seat of the irritation may often be known by the location and characteristics of the pain. Pain in the region of the umbilicus just before and disappearing immediately after a passage and with- out tenesmus or pain in the rectum locates the trouble, with fair accuracy, in the transverse colon. If tenesmus exists, with pain in the region of the rectum, that part is involved. Tenesmus is a reflex effect of irritation of the mucous membrane of the rectum, nature's effort to be re- lieved, a symptom having a very narrow signification. Pain, on the other hand, while it may be purely neuralgic, may indicate inflammation in any of the tissues of the rectum or outside of it in the pelvis. The colicky pain often experienced in diarrhoea is usually in the large in- testine, as in dysentery. Inflammation-even extensive ulceration-of the small intestine is not ordinarily attended with diarrhoea, nor with colicky pains. Pain in the anus in the act of defecation and following it points strongly to haemorrhoids, fissure, or abscess in the adjacent tissues. The significance of blood in the motions differs with its appearance and with other symptoms. Bright, fresh blood indicates a lesion of some part near the extremity of the bowel, the anus (fissure, haemorrhoids), rectum (ulcer, haemorrhoids), or colon (ulceration, or deep conges- tion, or inflammation). When the blood simply streaks the faeces, it comes generally from small vessels inside the sphincter. Fresh clots seldom appear if the blood comes from a point high up in the intestine. In typhoid fever the blood of a haemorrhage is usually fluid and mixed with the fecal matter. Very dark or blackish blood usually comes from the upper portions of the intestine or stomach ; a large bleeding from ulcer of the latter, or from the duo- denum, as in cutaneous burns, may easily produce such an appearance. Dysenteric stools of true dysentery and intussusception, and those of ulcer and haemorrhoidal troubles, often bear a close resemblance to each other; the distinction between them must be made by other symptoms. Intussusception usually announces itself by suddenly-appearing symptoms, of which colicky pains and vomiting are seldom omitted, and after a time the vomiting is apt to be stercoraceous. In dysentery the vomiting is less-often absent-and the colic is less vio- lent, but colicky pains are rarely absent. Ulcerations and haemorrhoidal projections into the rectum do not in- duce colic nor vomiting, nor, at first, much disturbance of the health. The sudden discharge of pus in large quantity indicates the bursting of an abscess, and is rarely unaccompanied by symptoms and signs indicating the character and location of the latter. Small quantities of pus mixed with the faeces points to ulceration in the lower part of the canal. Large watery stools are usually the product of both the large and small intestines. Mucus in the stools always means catarrh somewhere in the bowel; the purer and clearer the mucus the nearer is the catarrh to the anus. Scybala besmeared with mucus or muco-pus point to catarrh, and possibly ulceration in the rectum. Dark, blackish, or chocolate-colored stools suggest the presence of the coloring matter of blood-blood arising from a point high up in the canal and changed by the secre- tions of the stomach and bowels-or the effect of some medicament, as bismuth, haematoxylon, mercury, or iron. Green stools are not always nor usually produced by excess of bile, as is often supposed, but by biliverdin, an oxidation product of bilirubin, and developed in the in- 434 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diarrhoea. Diarrhoea. testinal canal. When diarrhoea arises from disease of the kidneys, liver, spleen, pancreas, suprarenal capsules, or general disease capable of inducing it, the symptoms of the causative disease usually predominate and identify it. But diarrhoea in tuberculosis is not evidence of tubercu- lar deposit in the small intestines, nor proof of its exist- ence in the colon. In chronic diarrhoea the urine should always be examined for evidence of disease of the kid- neys, the urine for twenty-four hours being secured, if possible, and an accurate determination made of the total solids. The diagnosis of lardaceous change in the intes- tines cannot be made from the intestinal symptoms alone. Chronic dysentery and chronic catarrh of the colon of a severe type are indistinguishable by the symptoms, as in many cases they are pathologically identical. Dysentery and proctitis are occasionally mistaken for each other. But the distinction is not difficult usually, since in dysen- tery there are some constitutional symptoms-colicky pains, borborygmi, fever-while in proctitis the symp- toms are confined to the rectum. In typhoid fever of sufficient severity to cause diar- rhoea there are always continued fever, cephalalgia, pain in the back and extremities, or other symptoms that es- tablish with small difficulty the nature of the disease. But an acute catarrh of the upper part of the colon may, at first, be attended with fever and other constitutional symptoms that, by their resemblance to typhoid fever, justify hesitation in adopting a diagnosis. Pathological Anatomy. - In ordinary acute diar- rhoea, however caused, there is probably always primary slight congestion, otherwise simple catarrh of the mucous membrane of the intestinal canal, particularly of the colon and rectum. Mucus is produced in excess, which, if the attack does not mend promptly, appears in the de- jections. This condition of things prolonged is chronic catarrh, a condition mainly confined to the colon, often extending through years, and having all degrees of sever- ity, even to the limit of extensive ulceration. The suc- cus entericus is reduced to a minimum or abolished, and the lining of the canal is covered with mucus, often in a thick layer. The mucus is a product of morbid action of the follicles and of changed epithelium, a condition of things making digestion and absorption impossible. If the congestion is extreme, and the catarrh long-continued, the solitary glands of the colon may suffer ulceration, the membrane become excoriated, and the mesenteric glands enlarged. From this extreme picture chronic dysentery is anatomically indistinguishable. Choleraic diarrhoeas are catarrhal to some extent, yet there is little mucus till the reaction and painful recovery of the mucous membrane. The large quantity of watery serum comes not alone from the follicles, but from the entire mucous surface, through which it transudes with great rapidity. The mucous surface is denuded of its epithelium in various degrees. Cholera morbus involves an acute catarrh of both stom- ach and bowels. The nervous system is concerned in the sudden and rapid development of the symptoms, and in the production of fever, which occurs sometimes, espe- cially in children. In entero-colitis the inflammation is mostly confined to the lower end of the ileum and the sigmoid flexure of the colon. Ulceration occurs in these localities ; in the ileum in about five, and in the colon in about fifteen, per cent, of the cases ending fatally. The ulcers are small, and begin in the solitary glands. In bad cases hyperplasia of the mesenteric glands is found. All appearance of severe congestion may disappear in death ; hence, a failure to dis- cover it post-mortem is not proof of its not having existed. In the lardaceous degeneration of the intestine the change is in the walls of the small arteries and capillaries, and may be demonstrated by the usual tests. The lesion may re- sult in multiple ulceration. In perhaps fifteen per cent, of all cases of amyloid degeneration in the body, the lesion is found in the intestine. Membranous diarrhoea is usually a consequence of chronic inflammation of the colon ; in rare cases the small intestine may be involved also. The pseudo-membrane is composed mainly of mucin, contains a few large, gran- ular, spherical cells, and some epithelium, and has a jelly- like appearance. Its exfoliation exposes an excoriated, red surface. In nervous diarrhoea there is excessive irritability of the nervous supply of the intestine and mesentery. This supply is most plentiful; the canal is provided through- out its whole extent with two close plexuses of nerves, separated by the circular muscular layer. Experimenta- tion shows marked sensitiveness of these nerves to irrita- tions. Stimulation of the outer plexus checks the move- ments of the intestine, or stops them ; normally, during sleep all movements cease. Irritation of the plexus mes- entericus increases peristalsis, even in severe irritation, to the extent of spasm. It is unquestionable that certain degrees of congestion, reflex or direct excitation, mental and emotional excitement, are capable of producing through these nerves excessive peristalsis and diarrhoea. Not only can psychical states influence muscular move- ments of the intestines, but the character and amount of secretion as well; hence sick-headaches and gastric and in- testinal indigestion from mental influences. Treatment.-The proper treatment of diarrhoea includes but a few distinct therapeutic purposes. The indications vary according to the form of the disorder, but a few gen- eral principles are to be kept in view. The rational indica- tions are to remove the cause, lessen pathological changes, and counteract their harmful consequences. The things to be accomplished are : 1. To lessen suffering. 2. To equalize the circulation, taking the excess of blood out of the internal parts of the body. 3. To evacuate the bowels of all irritating things, whether they be cause or result of the diarrhoea. 4. To correct causal vices of di- gestion. 5. If possible, to relieve causal pathological states, inflammatory or otherwise. 6. To reduce abnor- mal intestinal sensitiveness and relaxation. I place first the relief of pain ; for, beyond the fact that this is every- where one of the highest duties of the physician, suffer- ing is to the patient an event of first importance, and the relief of it, with the resulting amelioration of other symptoms and changes, which nearly always attends, if it does not depend upon it, is promptly followed by re- covery in a large proportion of cases. Wherever so simple a measure as this is sufficient, it is worse than folly to an- noy the patient with further medication. The majority of acute diarrhoeas are due to indigestion of some sort, and are of short duration. Their treatment is simple ; they are often corrective and remedial in them- selves, expelling various offending materials from the system and recovering promptly untreated. The restora- tion is more prompt if, after its evacuation, the intestine can have a brief period of rest. Hence, a low diet and fasting are among the best of remedial measures. Abso- lute fasting is not necessary, but till convalescence is es- tablished the diet should be low, and the food such as can be digested mainly in the stomach. Important as this is for slight attacks, it is much more urgent in pro- longed and severe ones, especially in weakly people and in children. Care must be had in the selection and admin- istration of food, that the patient may be nourished by gastric digestion as far as possible, and thus give the intestine rest. Stale bread and light crackers are the best farinaceous foods ; corn-starch, rice, tapioca, and arrow-root are less eligible. Milk is the best fluid food. If fresh, it may be taken raw ; otherwise it is better boiled, although this process lessens its digestibility. Beef-tea is admissible only if largely composed of fine particles of muscular fibre ; beef-tea that is transparent throughout is not good. Beef-juice is highly nutritious and easily assimilated ; scraped raw beef is one of the best possible foods for diarrhoea in any age or condition, and may be eaten almost ad libitum. It is rarely objected to by the patient, and if it is can be easily made pala- table by the addition of sugar, salt, pepper, and spices. Eggs, raw or slightly cooked, are always allowable ; very slight cooking adds to their digestibility. Uncooked white of egg may be mixed with water and taken as a drink, or in any other way agreeable. Six to ten eggs may thus be used by an adult each day. Oysters, slightly cooked, or preferably raw, are digested easily and rapidly by the stomach, as are also tripe and pigs' feet. Liquid 435 Diarrhoea. Diarrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. foods, especially milk, may with great advantage be pep- tonized by the addition of some preparation of the pan- creas with an alkali, whereby their assimilability is much increased. In the case of milk this is most important, since the casein is by this process made incapable of co- agulation, even by concentrated acids. Five grains of a good extract of the pancreas, with fifteen grains of bi- carbonate of sodium, will peptonize a pint of milk or broth, if kept at the temperature of the body forty min- utes. Peptonizing of foods is an excellent procedure in any diarrhoea in child or adult. The time and frequency of eating should be regulated carefully, especially in se- vere and protracted cases. By trial of small portions of food the dose should be found which can be taken without disturbing the intestine, and this should not be exceeded. Next, by trial, the greatest frequency with which this small meal can be repeated without harm is to be determined and adhered to rigidly, whether the daily number be three or ten. A small meal is eaten with impunity ; too much, even if little, lights up the diarrhoea afresh. In the simple cases due to indigestion, beyond the reg- ulation of the diet, rest and warmth of the body, very little treatment is called for. A slight, stomachic stimu- lant or opiate, to check pain and nervous perturbation, may be needed at first, or later if the attack is prolonged. If pain is sharp and purging severe, opiates should be given promptly, and, if vomiting hazards absorption by the stomach, by the hypodermic method. One of the best combinations of opium for internal administration is the camphorated tincture; the deodorized tincture is an ideal fluid opiate, but the best preparation of all is mor- phine. Chloroform, ether, tincture of capsicum, aro- matic spirit of ammonia, and other aromatics are fre- quently used alone, or added to the opiate with happy effect; but the latter alone is nearly or quite as useful, and has the advantage of simplicity. The subnitrate and salicylate of bismuth are good adjuvants to the opiate ; they are antiseptics, lessen nausea, and calm intestinal irritation. Nausea, as an after-effect of morphine, may generally be prevented by a minute quantity of atropine (I part atropine to 25 to 50 parts morphine). For the diarrhoea of indigestion and biliousness, a favor- ite treatment with some practitioners is repeated small doses, or a single large dose, of some laxative, like castor- oil, rhubarb, or the salines, with or followed by a few drops of tincture of opium. There is abundant clinical evidence of the value of this treatment. Much of its good effect is probably due to the free expulsion of offending material, including bacteria and bacilli. For the diar- rhoea of indigestion-especially the more chronic cases- nothing will take the place of measures to improve the digestion. Alcoholic liquors, tobacco, and coffee, as well as stimulating condiments, if they have been used, should be abstained from as far as possible. Tonics are indicated for the general health and for di- gestion, and the patient should rest from labor and have the best of hygienic influences. Of the general tonics most useful are quinine, iron, strychnine, cod-liver oil, malt extract, the hypophosphites, arsenic, and mineral acids. One tonic that deserves to be more employed for diarrhoea than heretofore is the solution of nitrate of iron. Sulphate and phosphate of sodium, ipecacuanha and euonymin exercise a tonic influence upon the digestive function of the intestine, liver, and possibly the pancreas. Diarrhoea produced by fermenting and poisonous food tends to be severe, and treatment should be prompt. It is usually best to give morphine hypodermically, as it is unsafe to trust to slow absorption by the stomach. A dose of one-eighth grain, repeated in thirty minutes if necessary, will usually stop the diarrhoea as well as the vomiting. Rest and warmth to the extremities must be enjoined. Acute diarrhoea in children is usually susceptible of prompt improvement by an early regulation and lowering of the diet. But first the alimentary canal must be thoroughly evacuated of all undigested food and irritants. A slight diarrhoea, even for a day or two, is no proof of such evacuation. A laxative like oil or calomel should be given whenever it is suspected to be necessary. A cathartic has not infrequently removed undigested food taken several days before, with prompt relief of the diar- rhoea. The old domestic remedy of castor-oil with a touch of laudanum is rational. The diet should be promptly reduced to one-third the usual allowance, and this taken in numerous meals ; this course should be pur- sued, and if possible till some improvement takes place in the symptoms, even if it requires a day or two. Then minute quantities of food should be allowed till the safe dose and interval are ascertained. This rule is to be adhered to if possible, however long the intervals and however urgent the hunger. Food in the slightest excess of the powers of digestion is generally harmful and ag- gravates the diarrhoea. If regulation of the regimen is not followed by prompt improvement, or if a catarrh of the bowels supervenes, minute doses of hydrargyrum cum creta, or calomel, often repeated will be efficacious. A tenth of a grain of calomel or an equivalent dose of the other preparation may be given every two hours, till some improvement shows itself in the passages. Next to this in value-perhaps superior to it, for children as well as for adults-is the subnitrate of bismuth, which, if pure, may be taken in large doses. A child of two years may take five to ten grains every two to four hours, al- though smaller doses are valuable. If the diarrhoea persists, in spite of the bismuth, with watery discharges, the milder astringents, in small doses, may be tried, although they are not very useful medicines. The best of them are, perhaps, kino, catechu, and logwood. To check a bloody flux, or a sudden attack of diarrhoea as it occurs in epidemics, the best course is the opiate treatment with fasting. A hypodermic injection of mor- phine is probably the most potent remedy extant for in- ternal bleeding of any kind. Astringents for haemor- rhage from the lower bowel are of little consequence, and the value of ergot is doubtful. Chronic diarrhoea in adults, when apparently due to atony, debility, tuberculosis, or other constitutional disor- ders, and not to demonstrable ulceration, may be treated with mild astringents ; these will do some good, but little in comparison with regimen. Probably a diet of scraped raw beef, or egg, or peptonized milk, in minute portions, promises more than all the astringents combined. But in some of these cases, even after the most careful regulation of the diet, and, to some extent, improvement in the di- gestion, the diarrhoea continues to a slight extent. Such patients sometimes feel better, are more comfortable, and improve faster if they are continually taking mild astrin- gents or astringent tonics in small doses. In chronic- catarrh of the intestines, where ulceration and chronic thickening have taken place, and in chronic dysentery with similar lesions, and where anaemia and great prostration have resulted, it may be necessary to medicate the dis- eased surfaces directly. An eligible method is by large stimulating injections delivered through a long flexible tube passed as far up the bowel as possible. A good so- lution is one of nitrate of silver, one or two grains to the pint of water. This, or some other not less stimulating enema, may be used every day or two. Large injections of simple cold water produce a soothing effect and lessen the tenesmus and suffering. The patient should have every aid of a tonic regimen, rest, invigorating baths, massage, and travel. The body should be warmly clad, with flannels next the skin, and protected against all vicissitudes of weather that can de- press the vital powers or cause internal congestion. In all chronic diarrhoeas, with any possibility of recovery, the use of opium should be avoided. This drug has a palliative effect on diarrhoea due to lardaceous degenera- tion in the intestine, and may be used cautiously. When fermentation occurs in the intestinal contents- where the stools may be frothy and irritating to the anus -anti-fermentatives are indicated. Perhaps the most valuable of these are the salicylates, the sulphites, car- bolic acid, the carbolates, and resorcin. Salicylate of bismuth is the most rational remedy for fermentation with diarrhoea, and it may be taken in doses of five to twenty grains every two to four hours. 436 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diarrhoea. Diarrhoea. Where diarrhoea is due to diseases of other abdominal organs than the intestine, the treatment must be directed to the causative disease as well as to the symptom. For the relief of the dysenteric diarrhoea of colitis or proctitis, a suppository of one-fourth to one-third grain each of morphine and extract of belladonna, with two to four grains of iodoform, has a happy effect. This method of opiate medication is more rational than that by the stomach, and a single dose often suffices to check an at- tack. The diarrhoea which regularly alternates with constipation, without very great depression of the general health, and in which there is doubtless some chronic ca- tarrh of the colon, requires treatment to counteract this condition. The course must be mild and long continued. One of the best is that of saline laxatives, or laxative min- eral waters, in doses sufficient to counteract the constipa- tion without inducing catharsis. Sulphate of sodium, in combination with the bicarbonate, works most happily, and the Carlsbad probably represents the combination better than any other water. The best time to drink the water is half an hour before breakfast, and the patient easily learns the dose required. It is generally not true that the medicine loses its effect or requires to be taken in increasing doses ; the contrary is the fact. Norman Bridge. my experience, give very little water to their infants, fearing it may cause colic or diarrhoea. During the heated term the little one loses much water both by sen- sible and by insensible perspiration; loses more proportion- ally, in fact, than does an adult, because exposing a greater proportionate superficial area. Becoming thirsty, the child cries. The mother offers the breast, which the child takes instinctively, requiring fluid. The sequel is readily understood : The food on enter- ing the stomach is quickly deprived of its water to fill the depleted blood-vessels; the mass remaining is too thick for the feeble powers of infancy to digest perfectly. It ferments, and in the intestines as a fermenting body rapidly excites a diarrhoea, and hence a further drain upon the blood. These points have been well set forth in an article by Dr. Charles Remsen.2 And in both his service and my own, as House Physician at the Nursery and Child's Hospital, the free exhibition of cool water was produc- tive of the best results in the prevention and cure of diarrhoea. Exposure to cold sometimes acts as a direct cause. There is no reason why an infant should not " catch cold" in the bowels as well as "in the head," or in any mucous membrane besides that of the nose. As in coryza, there is free serous discharge ; and the intes- tinal catarrh and inflammation may become serious enough to prove fatal. Nervous Causes.-Among these should be mentioned teething, fright, falls, or other nervous shocks, and the erethitic diarrhoea of violent peristalsis, in which a move- ment succeeds quickly upon the ingestion of food. Dentition should not, I think, take a prominent rank among causes. It undoubtedly can induce diarrhoea, but I think that most cases attributed to this source ought rather to be assigned elsewhere. It must not be forgotten that weaning and the change to artificial food are coin- cident with dentition. Diarrhoea is sometimes secondary to acute diseases, such as rubeola, scarlatina, pneumonia, and typhoid. Entozoa.-I think that the presence of intestinal para- sites is the decided exception, not the rule, as mothers seem to believe. The diagnosis of worms is worms. I rarely give worm-medicine on account of varying and mysterious nervous symptoms, but advise prolonged and careful inspection of the dejecta. As a last resort, I would treat on this hypothesis. The parasites which are least rare are the nematodes. Thrush.-According to Parrot, this vegetation may ex- tend to stomach and intestines, and excite a severe diar- rhoea. This must be extremely uncommon, although nurses often think that the sprue has "gone through" the child. Children in whom sprue is severe are gen- erally of lowered vitality, and readily subject to diar- rhoea from all causes. Intussusception, tuberculosis, rickets (here there is more commonly constipation), and intestinal glandular atrophy are also to be classed as occasional causes. Pathology and Post-mortem Appearances.-Upon this ground I shall barely touch, as it properly belongs, and is fully covered, elsewhere. In general terms, wre find, post mortem, in acute cases either nothing whatever to account for the gravity of the symptoms, or else ileo-colic congestion, or pallor, with swelling of solitary glands and Peyer's patches, and some- times mesenteric glands ; occasionally small ulcers, fol- licular, or from rapid epithelial desquamation. In chronic cases, the varying lesions of a chronic ca- tarrhal inflammation are present: changes in epithelium, stroma, blood-vessels, follicles, their secretion, the soli- tary, Peyer's and mesenteric glands, and possibly ulcers as before. Symptoms.-The symptoms forming the disorder to which the term infant diarrhoea is applied, are largely due to loss of water by the system, caused by the frequent semi-liquid or liquid passages ; later on, also to exhaus- tion, from lack of nourishment. To these must be added inflammatory symptoms, and those simply due to nerve irritation. DIARRHCEA, INFANTILE. Diarrhoea is a symptom, not a disease, of great or lesser gravity according to the cause, season, age and vitality of the infant. Although a symptom, it is customary to employ the term diarrhoea to designate a certain ailment: a group of symptoms, of which only one, though it be the most important, is the frequent and too fluid dejecta. Etiology.-Undoubtedly the most common cause of infant diarrhoea is improper feeding, either in point of (1) quality, (2) quantity, or (3) frequency. 1. Under this head comes artificial feeding. Hand-fed babies furnish the great majority of the cases in ques- tion, and the largest percentage of deaths. Even breast- milk may in certain cases be a cause, as from continu- ance of colostrum, from laxative maternal medicine or food, maternal mental or physical excitement, and (it is alleged) differences in age between nursling and milk of wet-nurse. 2. The daily quantity of breast-milk needed during early infancy is something more than a pint. Professor J. Lewis Smith1 gives the daily average for the first five weeks as 12.41 ounces. Overfeeding is a prolific cause, especially in summer ;-of this I shall speak again. 3. It is almost unnecessary to say that the practice of offering food to an infant whenever it may cry is fol- lowed by pernicious results. The utmost regularity in point of time should be observed. The proper frequency is mentioned under Treatment. The term "summer complaint" would lead one to in- fer that heat is the direct cause of the greater prevalence of diarrhoea at this season. This is not true ; neverthe- less, heat plays an indirect part as causative agent, in four different ways. 1. In hot weather the air is much more apt to bear noxious products of organic decomposition, superinduced by the heat. The dire effect of such an atmosphere upon the sensitive infant is not surprising, and neither is the greater summer mortality in crowded, offensive, tenement districts. Children breathing pure air of the same tem- perature, although suffering from lassitude, rarely ac- quire diarrhoea from this cause alone. If this were not so, how disastrous to infants would be the couveuse with its high temperatures ! Still, by inducing relaxa- tion of the nervous system heat may act (2) as a nervous predisposing cause. 3. Again as an indirect source, heat acts by favoring rapid decomposition of the food, which being fed to the child in incipient fermentation, starts an irritative diar- rhoea. 4. The last factor, and one often overlooked, is this : Many children too young to express their wants by other means than crying, are, in the summer months, insuf- ficiently supplied with water. In fact, most mothers, in 437 Diarrhoea. Diarrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the latter, the simplest form of the complaint, there are, with the loose movements, the pain of flatulent colic, tympanites, perhaps vomiting ; but no marked tenderness and no fever (though sometimes a nervous one). A con- vulsion, of reflex nature, occasionally ushers in the other symptoms. The tongue may or may not be coated. It is hard to say where mere irritation ends and inflam- mation begins ; but when the latter is present, tenderness, pain, and fever become emphasized, there is often tenes- mus, and the child looks more ill. It is frequently im- possible to decide accurately as to the exact region of gut involved. In their symptomatology, acute and chronic cases are only to be differentiated by the degree, not kind, of phenomena. Regarding the stools, they may consist of merely un- digested food, oftenest curdled milk ; or they may appear digested, or be putrid. They are usually not, as they should be, homogeneous. Flatus is often passed with them, somewhat relieving the meteorism. There may be admixture of mucus, or even passages of clear mucus, with actual constipation. The hue is generally greenish (occasionally strikingly so), sometimes brownish, some- times clay-colored, etc. Blood is rarely passed. Regard- ing the cause of the green color mentioned, there have been several explanations, more or less unsatisfactory. It seems most likely that the coloring matter is biliverdine. In human bile bilirubine preponderates, whence the bronze-brown color; but in these cases it is oxidized, probably by contact with lactic or butyric acid, becom- ing thus biliverdine: which, during diarrhoea, is hurried unchanged out of the system. I have tested this point by the addition, to bile practi- cally devoid of biliverdine, of lactic and butyric acids. In the proportion of one part of lactic acid to fifteen of bile, the latter becomes distinctly greenish in about half an hour, and the green color grows steadily more and more predominant. In larger proportions, the acid induces this oxidation more rapidly. Butyric acid is much less powerful as an oxidizing agent. I find that one to fifteen will hardly induce any change of color within twenty- four hours. It is thus proven that lactic fermentation is of itself capable of inducing the green stools ; although there may, perhaps, be present some additional causative agent. And it seems sensible to regard the greenness and acidity of these stools (usually proportionate one to the other) as an indication for treatment by alkalies and antizymotics ; the latter in order to attack the micro-organisms upon which the fermentation depends. The reaction of the stools in infant diarrhoea is generally acid, and the greater the fermentation the more sour and ichorous the stools become. Less commonly, as in nerv- ous diarrhoeas, or in serous purging, they may be alkaline. The consistency is extremely variable. The symptoms due to loss of water are, great thirst (the mother thinks it appetite); fever, dry, hot skin, and some- times tongue ; partial or complete suppression of urine ; emaciation-first noticed, as a rule, on the inner side of the thighs; marked appearance of Jadelot's gastro-en- teric lines, especially the parentheses about the mouth; depression of the anterior fontanelle-the bones of the vertex may even overlap ; and the appearance of hydroce- phaloid phenomena. Certain of the above group are also to be attributed to lack of nourishment; the sunken fontanelle often means a failing heart; the emaciation may be that of starvation. If the heart be very weak, the surface, and particularly that of the extremities, may be cold, while the interior is hyperpyretic. In chronic cases the complexion assumes a dull, earthy hue. Eruptions, such as furuncle, strophulus, and urti- caria, are occasionally present in either the acute or the chronic cases. Erythema about the buttocks and thighs is due to the irritating character of the stools. The passage of thicker stools, even though still of very offensive odor, and the reappearance of the tears, are favorable signs. A temporary constipation finally re- places the diarrhoea. In fatal cases the termination is by exhaustion, con- vulsions, or coma, or by complicating inflammations. Of these last catarrhal pneumonia, beginning in hypostatic congestion, is the most frequent. " Cholera infantum" seems peculiar alone in regard to the free watery purging and vomiting present; its other symptoms being mainly dependent, upon rapid loss of fluid by the blood. Whether there is the alleged lesion of the sympathetic system, whether this alone of infant diar- rhoeas is due to choleraic germs, and whether it really de- serves a separate title, are doubtful points. Treatment.-The treatment of the diarrhoea of in- fancy may, for simplicity of discussion and for brevity, be thus tabulated: I. Dietetic. II. Hygienic. HI. Stimulant. IV. Medicinal: (a) Analgesics and antispasmodics; (b) astringents ; (e) antizymotics ; (d) alkalies ; (e) acids; (/) alteratives ; (//) aids to digestion ; (A) antipyretics. I. Dietetic.-Within the allotted space I can only hope to speak tersely on the salient points of this most impor- tant topic. If, as is generally the case, the patient be hand-fed, we should change, where practicable, to mother's milk, pref- erably of about the same age as the infant. Where this cannot be done, we must use an artificially- prepared food, which should in its composition closely correspond with that intended by nature for a nursling. Practically this indication can best be fulfilled by the employment of cow's milk modified. There are certain important differences in the composi- tion of the two milks. The subjoined table is that given by Professor Leeds2 as representing an average. The cow's milk is "whole," not skim-milk : Woman's milk. (Specific gravity 1.0317.) Water 86.766 Total solids 13.234 Total solids not fat 9.221 Fat 4.013 Milk-sugar 6.997 Albuminoids 2.058 Ash 0.21 Cow's milk. (Specific gravity 1.029.) Water 87.7 Total solids 12.3 Total solids not fat ... 8.48 Fat 3.75 Milk-sugar 4.42 Albuminoids 3.42 Ash 0.64 Assuming that these figures are correct-and they agree practically with those of such recent writers and able ob- servers as Konig3 and Meigs 4-it will be noticed that the thin, bluish, half-translucent appearance of woman's milk is misleading in the inference which we draw therefrom ; since this milk is in reality somewhat richer in fat, in total solids, and of higher specific gravity than cow's milk. This estimate of the relative amount of fat is the re- verse of that generally maintained heretofore. Vernois and Becquerel,5 for example, give 2.6 per cent, in woman's and 3.6 per cent, in cow's. Professor Jacobi6 in 1882 said : " The percentage of fat in cow's milk is larger than in human milk." "The more cow's milk deserves the title of being good, that is fat, the greater is the danger arising from giving it to infants without considerable modification." Possibly a weak emulsion, mainly of oleine, is more translucent than one containing an equivalent amount of fat, mainly in the form of palmitine. Leeds says (op. cit.): " And as to the fat of human milk, no separation into the many oily and fatty bodies of which it is made up has yet been attempted. " The most serious points of divergence in composition between woman's and cow's milk are, the reaction, the percentages of sugar and albuminoids, as well as the char- acter of the latter. Human milk is neutral, as Meigs and Pepper believe, or alkaline ; that of cows, acid or neutral. Lehmann 7 says: "I believe that the jelly-like coagula of woman's milk are more dependent on the alkaline state of the fluid than on any peculiarity in the caseine; at all events, I have found that woman's milk, when acid, yields a much thicker coagulum than when alkaline ; and cows' milk, 438 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diarrhoea. Diarrhoea. when alkaline, a much looser coagulum than when acid-facts of the highest value in relation to dietetics." According to Meigs, human milk contains but about one per cent, of caseine-the only albuminoid mentioned in his tables ; whereas cows' milk averages three per cent. And according to Biedert, human caseine is, "both in its physical and chemical nature, different from that of cows' milk." Nevertheless, if cows' milk be diluted about one-half, the quantity of caseine then approximates to that in human ; and if we supply an alkali-such as lime-water- we modify coagulation as already seen ; or if instead we add gelatine, mucilage, starch, dextrine, or albumen to a simple watery attenuation, we so separate the particles of caseine that the gastric juice causes its coagulation into light flocculi, instead of heavy curds, difficult of penetra- tion-which would be the case with cows' milk not thus modified. By further adding-to our diluted milk-cream and lactose, we bring it up to the proper standard, as to fat and sugar. If we have not used lime-water, some alkali, as soda bicarbonate, should be supplied. Boiled milk, being safer than unboiled, should always be preferred for infant feeding. If, to modify the coagulum, starch-water be chosen, the best is probably that recommended by Prof. Jacobi- barley-water. This is easily and cheaply made, and, if the child be old enough, the starch is digested more rapidly than most others. But while I have employed it with satisfaction during the treatment of diarrhoea, and noted a soothing effect upon irritated surfaces, I do not give it preference in preparing food for infants too young to transform readily the starch into sugar ; since, as ob- served at the N. and C. Hospital, it sometimes in pro- longed use induces diarrhoea, probably because the bowel finally rebels against the constant presence of this indi- gestible substance in the food. Lime-water is a most valuable diluent, and may be freely used. Meigs recommends one-fourth by measure. The actual amount of lime thus introduced is very slight, as liquor calcis contains only about 0.15 per cent, of hy- drate of calcium. The mixture recommended by Meigs is in the propor- tion of two tablespoonfuls of cream, one of milk, two of lime-water, and three of sugar-water ; the latter being made by dissolving in a pint bottle of hot water drachms of milk-sugar. And since analysis shows no material difference between woman's milk two, and the same twelve, months old, Dr. Meigs advises only very gradual concentration of the food. In Dr. Playfair's food (rennet-whey, plus milk, cream, and lactose), the caseine is diminished in amount, but that remaining is unaltered in quality. Hence, the co- agulum is objectionable, if not modified as already de- scribed. In cases in which stimulation is indicated, a sherry-whey may be valuable. As a rule, I employ in my own practice the following : Milk (or milk and cream), Oj. ; water, Oss. ; gelatine, 3 i.-ij. Boil; add lime-water, Oss. Make the mixture faintly sweet by (preferably) milk-sugar ; keep on ice ; heat before using. I have been pleased with the results obtained from the use of this food. The proportions may have to be changed, of course, to suit individual cases. Besides the reason already given regarding the coagulum, the gelatine is of value as a nitrogenous aliment, Although it may not itself be a tissue-former, it certainly has seemed to me to aid nutrition. Dr. Jacobi (op. cit.) quotes Professor Uffelmann's experiments on a healthy child with a gas- tric fistula. " Unmistakable and numerous observations taught him that both Arabic gum and gelatine are not only emollient and soothing, but directly nutritious." Professor Leeds says of an experiment with milk, gelatine, and acid (not gastric juice) : " With gelatine a very remarkable result was obtained. Ten grammes of the same milk were added to 110 c.c. of a solution of 1 part gelatine in 150 parts of water. Although the gelatine was so attenuated, it entirely prevented the precipitation of caseine on the addition of acid, and what is likewise interesting, appeared to arrest decomposition, the white jelly not having altered after a week's standing." In this case the gelatine strength of the mixture was nearly eight per cent. In the food which I have just described it is rather less than one-half to one per cent. Professor Dalton8 states that as low as three per cent, of gelatine will form a jelly on cooling the mixture. Regarding artificial foods on the market, the number is legion. They may be divided into three main groups : (a) farinaceous ; (&) milk foods; (c) foods more or less like Liebig's. The first consist of torrefied cereals, the process result- ing in transformation of starch into dextrine, and render- ing albuminoids more easily digested. The second consist of cooked cereals in combination with condensed or preserved milk. The third, "Liebig's," consist of wheat-flour, barley malt, water, and alkali. A paste is made, and heated. The result is a composition mainly of maltose and dex- trine, with vegetable albuminoids, chiefly gluten, and salts. Gluten is vegetable, not animal, as is the natural food of the nursling; and were maltose or glucose best for the infant, nature would not have supplied the mother's breast with lactose instead. It seems rational, then, to replace gluten by milk albu- minoids (with gelatine for reasons already given), and glucose by lactose. Many infants have enough vitality to thrive on almost any diet. Nevertheless, if a physiological food can be easily prepared at home, it is safest to use this. We can better trust to the conscientious care of the mother than to the uncertain commercial conscience. As Prof. Jacobi (op. cit.) remarks: " To say that when the article offered is not good it will find no market, is deceiving yourselves, experimenting on your baby, relying on the character of a single man or corporation," etc. Or, as Dr. Chambers9 very pertinently puts it, refer- ring to a certain artificial food : " As it is a recent inven- tion it is pure enough at present, but extensive use will probably teach ingenious methods of sophistication." Condensed milk, diluted, is a very commonly employed diet for infants. It has two chief faults : the sugar- forming about fifty per cent, of the whole-is saccharose, not lactose, and the proportion of fat in it when properly diluted is too small. Children undoubtedly fatten easily on this food, as it is customary not to dilute it very greatly. The same rapid fattening may be noticed on a plantation during the sugar-cane harvest. This fat is easily lost again, and such children do not, I think, pos- sess much vital resistance. Condensed milk is less liable to disagree in the early months than later, because it is usual to dilute it more at first. The excess of sugar sometimes induces a fermen- tative diarrhoea. Here I stop all sugar, and instead sweeten the food slightly with glycerin. It is well to add a little cream to the prepared con- densed milk by way of supplying the deficiency in fat. Where other diet is not assimilated, I have seen good results from the use of the juice of beef or mutton, plus a little sugar or salt; also from giving these meats them- selves, raw and finely subdivided. Raw white of egg may also be retained and digested. Eustace Smith some- times gives unboiled yolk of egg. In older babies we may, if deemed advisable, thicken the food somewhat, using either wheat-flour, long boiled in a bag, as recommended by Dr. J. Lewis Smith,10 or else torrefied by baking-or soda biscuit, zwieback, or dried bread, ground up with a rolling-pin. Of course one objection may be urged against all of these last-named substitutes for mother's milk, namely, that they all differ greatly from the composition of human milk. But infants deprived of their natural food, and ailing, are sometimes subject to dietetic idiosyncra- sies. The best we can do is to begin by offering the nearest approach to the normal that we can produce ; this failing to agree, we try something else. The peptonizing of food-often a most valuable measure-will be discussed later. 439 Diarrhoea. Diet. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the case of nursing babies with diarrhoea, it is generally best to continue the mother's milk, but insisting that it be given at regular intervals and not too frequently-about once in two hours at first, and once in three or four hours later in the first twelvemonth. Of course, a sickly infant who takes but a few drachms of fluid at a time may re- quire a shorter interval between meals; but this point should be regulated by the doctor and not by the mother, to whom every cry is apt to seem the cry of hunger. When prepared food is used, it is best given, as a rule, at breast-milk temperature. Do away with the bottle altogether. Even with care it is difficult thoroughly to cleanse it ; and the youngest infant can readily be taught to feed from a spoon. It is important to mention under the heading of dietetic treatment the free use of cool (not cold) water in summer diarrhoea. It should be offered at least every hour, and oftener if the stools are numerous. Another point which I regard as of the utmost moment where but little food is taken, retained, or digested, is the external application of cod-liver oil. Internally it can rarely be given, being laxative; but by its external use I feel sure that I have saved the lives of several sinking in- fants, during the past two summers. My method is as follows: give the baby a soap-and-water bath ; then, the skin being dried, rub in gently and steadily, with the palm, hot cod-liver oil, containing a few drops of oil of wintergreen to cover the offensive odor. Rub every part from heels to neck, except the abdomen; upon the ex- tremities, rub in the direction of the venous flow. Con- tinue until the skin seems free from oil and will not soil linen. In from half an hour to an hour of patient, gentle work, the skin can be made to absorb from half an ounce to an ounce of the hot oil. Finish by repeating the soap- and-water washing, to remove any odor. This routine may be repeated twice or thrice daily. As a rule, the little patient does not object; and I have more than once seen the baby go to sleep during the soothing and tonic massage. I have sometimes added whiskey to the oil, but do not know whether much of it is absorbed. It may be lost by evaporation. To avoid dermic irritation, we should use the light-colored, and not the darker, rancid oil. II. Hygienic.-Although diet is a part of hygiene, I have preferred to discuss that part separately. Next in importance stands the quality of the air con- stantly breathed by the infant. This, as has already been mentioned, is usually worse in summer, and surely worst in crowded apartments. If it seem impure, in spite of ventilation, the baby must at once be removed to a healthy atmosphere. In tenement practice, where our patient must stay in the foul air at least through the night, we should see to it that during much of the remainder of the twenty-four hours he is away, either carried to the parks, or riding in the street-cars to and from the suburbs, or crossing the ferries, etc. I think it not very rare, even in the best quarters of the city, for the house-air to be sewer-contaminated, owing to unsanitary plumbing. It is a common error to suppose that sewer-gas is always malodorous. Even if the air seem pure, the tonic and reviving effect of a great change-as from sea-shore to inland country, or the reverse-is sometimes marvellous, and should be recommended in desperate cases. Proper diet and pure air will often cure mild diarrhoea without aid from medicine. Great cleanliness should be observed. The inflamed and excoriated buttocks and anal region are rarely noticed where diapers are frequently changed, and the parts washed and powdered. III. Stimulant.-This is often a necessary part of the treatment. It has been the lot of most physicians to wit- ness a patient ' ' die cured ; " that is, the diarrhoea-or other objectionable symptom-has been checked, but the patient has not possessed enough vitality and recuperative power to rally from his disease. In cases such as these alcohol is needed, and is as much food as medicine. I use it freely where there is a failing heart and great weakness. Eustace Smith11 says, "Stimulants are al- ways required when the fontanelles become much de- pressed." I use alcohol and water, in preference to brandy or whiskey and water, as being a more exact way of regu- lating the amount introduced ; and, to the infant, it is just as palatable as the latter. Camphor is also a valuable systemic stimulant, and, as seen in " Hope's camphor mixture," of some value in diarrhoea. Digitalis, ammonia preparations, especially the aromatic spirit, and musk, may be added to this list. Under this head should also be included the tonics, such as nux and quinine, given during convalescence. Repeated hot baths are often of the utmost value in sus- taining the vital power. They should be used whenever coldness of the extremities indicates a failing circulation. IV. Medicinal.-The classification which I have made, of remedies having a direct medicinal effect upon diar- rhoea, seems a natural one. Many of the more commonly employed and successful drugs possess, however, more than one property which may be desirable in curing this affection. Thus, bismuth is both astringent and antizy- motic ; the same is true of silver nitrate ; chalk is antacid and astringent ; opium is analgesic, antispasmodic, anti- secretive, etc. In the first group on our list-the anodynes and anti- spasmodics-vis place opium, belladonna, chloroform, Hoffman's anodyne, and all the volatile oils. Camphor being aromatic, also belongs among the " carminatives." Aromatic powder (cinnamon, ginger, cardamom, nutmeg) is one of the best of these. Syrup of ginger, chamomile and peppermint waters are also commonly employed. Opium is generally given in the form of the camphor- ated tincture. In making paregoric it would be well to use the deodorized (denarcotized) tincture, as being less nauseating than laudanum. I think it somewhat unsafe to prescribe Dover's or Tully's powder in treating weak- lings, since one dose of an imperfect trituration might cost a life. If the combination of ipecac with opium be desired, it is best to use thej?«fd Dover's powder (tinct. ipecac, et opii) now officinal. Opium in enemata is fre- quently used with advantage. It has seemed to me that this drug is often given in un- necessary amount, and without taking the precaution to remove, by a gentle purge, all fermenting food and mucus from the intestines. As a result, secretion and peristal- sis (and hence diarrhoea) are checked while the little pa- tient remains deeply under the influence of the opium ; but meanwhile the actual cause of the affection is steadily increasing in violence. Cocaine applied to the gums is of value in quieting the pain of teething, and hence the reflex disturbance of the bowels. The bromides and chloral must not be forgotten as anti- spasmodics. Poultices certainly have an anodyne and soothing in- fluence. The least weighty, such as slippery-elm bark, are best for babies. I often use a light hot-water coil of rubber, held in place by a turn or two of bandage. At- tach the inlet end of the coil to the hot-water faucet, or else use siphonage. Regulate heat by the thickness of cloths (moistened, if desired) between coil and skin. " Spiced " poultices are merely counter-irritant, because of the volatile oils ; a little mustard added to the poultice is equally efficient. Among astringents, I think bismuth (subnitrate or sub- carbonate) deserves first mention. If pure, it may be used freely, as it is practically not absorbed. It is antifermen- tative, as well as the most unirritating of astringents. It is usually given in too small doses. Ten or twenty grains several times a day is not too much for an infant a few months old. The mother should be told that the movements will become very dark under its use. Nitrate of silver in small fractions of a grain administered by the mouth, or in very weak enemata, is valuable. Oxide of zinc, sulphate of copper and of iron, should be added to the metallic list. The last, like liquor ferri nitratis-in drop doses-is tonic as well as astringent, and of value in chronic cases. Among vegetable astringents, kino and krameria are perhaps most often prescribed. I sometimes employ syrup of krameria with chalk mixture. The blackberry brandy 440 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diarrhoea. Diet. of domestic practice is well known, and fulfils several in- dications. Haematdxylon stains the diapers a permanent red, and hence should be avoided. The antizymotics are an important class, inasmuch as fermentation is such a common cause of diarrhoea. Salicin, salicylic acid, carbolic acid, creasote, calomel, resorcin, benzoates, boroglyceride, bismuth, iodoform, silver nitrate, alum, quinine, and many other drugs, be- long to this class ; and each has its firm adherents. Extremely acid dejections point to fermentation-espe- pecially lactic and butyric-as their cause. Here we should exhibit an alkali as well as an antizymotic. I often combine the two by using bismuth or benzoate of soda with prepared chalk. Other commonly employed alkalies are soda bicarbonate, lime-water, chalk mixture. Magnesia, by combining with the acid present in the alimentary canal, becomes laxative : which is an advan- tage, as the fermenting food and mucus should be cleared away ; and the irritative diarrhoea of fermenta- tion is undoubtedly nature's attempt to do this. In serious cases we should always test the reaction of the stools, as giving us an indication for proper treatment. In mild cases, the urine, continuing to be secreted, and passed with the faeces, would invalidate the test; but in •cases with severe purging the urine is passed but seldom. Acids are comparatively seldom of value in treating infant diarrhoea. When, however, there is simple serous purging, as in "cholera infantum," they are among the best remedies at our command ; and aromatic sulphuric, nitrous, and nitric acids are probably the best of these as- tringent tonics. Alteratives is the vague title of a class of drugs with poorly understood physiological actions. Mercury in the form of Hydrarg. c. creta, or as calomel, stands as a type of these. For alterative purposes it is best given in minute doses, such as gr. fa of calomel triturated with lactose. I have not found mercury of marked value in checking the green stools for which it is commonly recommended ; but have sometimes thought it successful in changing to the normal, yellow hue, clay-colored dejecta. 'Certainly, large doses seem no better as alteratives than the small ones. Castor-oil, ipecac, and rhubarb, in fractional doses, may be classed as alteratives in that they seem to pro- mote a normal state of intestinal secretions. The former and latter also possess some astringent action. I con- sider castor-oil of especial value in doses of a few drops. The indication for the employment of digestive aids is the presence of undigested food in the passages, when proper food has been given in proper amounts. To re- lieve the weakling from a portion of its burden of diges- tion, these aids are daily finding greater appreciation. The ferments at our command are pepsin, pancreatic ex- tract, and malt extract. (For stomach-digestion, acids, and for intestinal, alkalies, would, of course, come under this head as auxiliaries.) In predigesting the infant's food, I prefer extract of pancreas. Containing trypsin, amylopsin, and steapsin, it performs three digestive functions at once ; and leaves, as it should find, the food still alkaline. If the digestive action is long continued, a bitter taste results. Some in- fants do not object, but for the majority we must stop short of this. By prolonged predigestion, the gastric juice will find no unpeptonized casein to coagulate. If we do not wait for this stage, and its accompanying bit- terness, still the trypsin-attacked casein will be thrown down in light, easily-managed flakes during stomachic digestion. Extract of malt merely transforms starch into maltose. It is best used in predigesting. For babies nourished by breast-milk, pepsin should be our choice. Among antipyretics the direct abstraction of heat by cold, or evaporation, is the usual method. Sponging with tepid alcohol and water is enough in mild cases. Where there is a dangerous elevation of temperature-such cases occurring chiefly in either water-starvation, or the serous purging of "cholera infantum"-cold packs, baths, or the coil may be needed. It occasionally happens, in patients with a failing cir- culation, that the interior of the body is super-heated, while the exterior is of subnormal temperature. Here a hot bath-up to 90° or 95° F.-will reduce the heat by bringing the hyperpyretic blood to the surface to be cooled. During the past summer I gave antipyrine a few times in these fevers, in one- to five-grain doses, in lieu of cold applications, with good effect. In looking at the question of treatment as a whole, finally, it may be proper to make a few general sugges- tions. For instance, in cases seen early it is good prac- tice to empty the bowels thoroughly by some unirritating purge, in the hope of thus removing the cause of the trouble; and this treatment should be occasionally re- peated. For this purpose I usually prefer either magne- sia, or a mixture-average dose one drachm-composed of aromatic syrup of rhubarb, |; castor oil and glycerine, each i. Here we get the advantageous constipating after- effect of the castor-oil and rhubarb. In mild cases, by attention to diet and air, nothing more will be needed. If pain be present, use opium, aromatics, and a poultice. If there be crying with and after the stools, and the baby seem to strain in passing them, and if the mucus passed be pretty clear, the irritation is probably rather low down in the large gut, and starch and opium enemata will do good service. Unirritating antizymotics are indicated early ; after a few days, not at first, astringents ; among which I strongly prefer bismuth. I combine it frequently with castor-oil, which is given in doses of a few drops suspended in thin mucilage. Where there is much acidity-betokened by the state of stools, vomited matter, and odor of breath- an alkali is added. Bismuth and aromatic powder combined can be em- ployed early in most cases. I have found powders of bismuth and pepsin of great value. Space does not permit a further discussion of the treat- ment. We must, in all cases, choose our weapons ac- cording to the cause or causes of the symptoms, and their severity. Robert II. M. Dawbarn. 1 Diseases of Children, p. 56. 2 New York Med. Jour., September 29, 1883. 2 On Infant Foods. 3 Chemie der mensch. Nahrungs- und Genussmittel. 4 New York Med. Jour., January 19, 1884. 5 Du Lait chez la Femme. 8 Infant Feeding and Infant Foods. 7 Physiological Chemistry, Cavendish Soc. Translation, vol. i., p. 378. 8 Human Physiology, p. 89. 9 Thomas King Chambers : Diet in Health and Disease. 10 Diseases of Children, p. 711. 11 Wasting Diseases of Infants and Children, p. 12. DIET. To fulfil the conditions necessary for a perfect diet there are three physiological requisites demanded of food : (1) That it contain certain constituents ; (2) that these be sufficient in amount; and (3) that the food be in such a condition as to be assimilable by the system. It cannot be forgotten, however, that, while in a gen- eral way all food has to contain certain constituents, and that it has to be supplied to the system in certain amounts, and in a condition in which it can be assimilated, the con- ditions under which mankind live are so varied, as regards climate, occupation, and individual peculiarities, as to make it but little surprising if no hard and fast line can be laid down governing the supply of food either in its constituents or in its amount. It is sufficient to remember that as there are certain conditions of climate, soil, etc., under which each of the different families of plants and animals is developed and maintained in its highest per- fection, so there are, as all history attests, certain climatic and geological conditions, and, coincident therewith, food conditions, which develop and maintain the human race in its highest state of physical perfection. What these food conditions are will now be considered. 1. Constituents of a Standard Diet. - Such a diet must be placed upon the basis of a physiological question of demand and supply, or, in other words, it is necessary that a diet be such as shall supply the materials for making up the loss of tissue which is constantly tak- ing place in the animal body, and which in addition has 441 Diet. Diet. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to supply the energy required for the performance of the work constituting the many acts incident to life. The various emunctories of the body are constantly throwing off compounds whose constituent elements are found to consist mainly of carbon, hydrogen, oxygen, and nitrogen, along with various inorganic substances. These various elements, although not as a rule existing in the secretions in the same combinations as in food, must, nevertheless, be supplied in a diet, which during the processes of diges- tion and assimilation becomes disintegrated, metamor- phosed, and changed into the various tissues of the body, only to be again transformed and eliminated by the bio- logical and chemical processes necessary to the produc- tion of vital energy or work. Milk has long, and with the best of reason, been considered the type of a perfect food, not only on account of the nature of its constit- uents, but also because they exist in a condition requiring the least elaboration before becoming fitted for assimila- tion by the tissues of the growing child. This is further made evident from the fact of the undeveloped character in the child of some of the glands along the alimentary canal, as well as from the shape and size of the stomach, rendering chymification and chylification, as understood in the adult, imperfect and difficult. Of the unorganized ferments of the alimentary canal those of the gastric juice seem the only ones at all abundant in the child, and hence we find that in milk there is present not a starch, requir- ing diastatic action to take place in it before being made diffusible through its conversion into sugar, but the sugar itself. The comparatively large amount of sugar in wo- man's milk is very remarkable, showing how thoroughly it does the work assigned to the starchy foods so largely present in the diet of adults. The following table, given by A. Winter Blythe, F.C.S., shows the differences in the amount of the constituents of various milks : 2. Amount of Food Necessary in a Standard Diet. -Various calculations have been made by eminent chem- ists and physiologists of the amounts of foods necessary, by estimating the number of grains of the various food elements, which are daily eliminated from the body. Ac- cording to Forster and Voit, the following quantities of the various elementary constituents of food are daily re- quired by an average man: Of albuminoids, 118 Gm. (1,820 grs.) ; of fats, 88.4 Gm. (1,364 grs.) ; of carbohy- drates, 392.3 Gm. (6,053 grs.). The amounts of nitrogen and carbon in these foods are : Nitrogen, 18.3 Gm. (282.40 grs.); carbon, 328 Gm. (5,061.00 grs.). The calculation of these amounts is based upon the fact that, one and one-eighth grain of nitrogen is elimi- nated as urea for each pound weight of the human body, in twenty-four hours during rest, with an increased amount according to the duration and violence of the exercise. The amount of carbonaceous food necessary is calculated from the carbonic acid eliminated in twenty-four hours, and by estimating the amount of carbon required to produce an amount of energy, calcu- lated in foot-tons, equivalent to this on this basis. De Chaumont states that the following amounts of food are required daily by a man weighing 150 pounds and doing an average day's work : Of albuminoids, 4.5 oz. ; of fats, 3.75 oz. ; of carbohydrates, 18.00 oz.; of salts (inorganic), 1.12 oz. The food of the British soldier, as the daily ration, consists of : Albuminoids, 3.86 oz. ; fats, 1.30 oz. ; carbohydrates, 17.43 oz. ; salts (inorganic). 0.81 oz. The chief defect in this ration is seen to be fats, the place of which is, however, partially made up by, com- paratively, an excess of starchy food. The generally ac- cepted statement is that some twenty-three ounces of water- dry food are necessary to supply the waste daily going on in the system of an ordinary man. Various attempts have been made, and with much success, to show that the various constituent elements of food may be supplied at very moderate prices by proper combinations of dif- ferent articles of diet. Dr. Cameron, public analyst of Dublin, has stated that the Irish cotter with potatoes and buttermilk was much more cheaply and better fed than many of the artisans of English cities, because in these two articles the hydrocarbonaceous and nitrogenous ele- ments are supplied in better relative amounts. The fol- lowing at ordinary American prices may be given as one of the best examples of how abundant nourishing food may be cheaply supplied, either for the sick or for the well. The articles, with their amounts and prices, are tabu- lated : Constituents. Cow's milk. Ass's milk. Human milk. Goat's milk. Water 86.57 91.17 88.00 87.54 Caseine and albumen 4.65 1.79 2.97 3.62 Milk-fat . 3.50 1.02 2.90 4.20 Milk-sugar 4.28 5.60 5.97 4.08 Ash .70 .42 .16 .56 Milk is thus seen to contain the various constituents which experience and analysis of the body tissues have found necessary to be present in any proper and sufficient diet, and which has led to the classification of foods now everywhere adopted. Thus, we have nitrogenous sub- stances (albuminoids), fatty substances, starchy (sugar) substances, ash (inorganic salts). From the compounds eliminated by the various organs of the body in twenty- four hours we find these materials (De Chaumont) to bear the following relative proportions: Albuminoids, 3.0; fats, 2.5 ; starch (sugar), 12.0 ; ash, 0.75. We see here that the starch compounds are considerably more abundant, in proportion to the other compounds, than is the sugar in milk; but this will in part be ex- plained by the amount of heat developed and necessary to be supplied during exercise in the adult, by the neces- sity for a bulky food being present in the large stomach of an adult, and by the difficulty which exists in supply- ing, by means of milk, enough of solids to make up the daily waste of the body. Black bread, more nearly than any other single food, supplies, in a fairly small bulk, the amount of nitrogen necessary to replace loss through daily elimination from the body, and of carbon required to keep up the body- heat, and to supply physical energy. It cannot be for- gotten, however, and will be found in practice, that there are judicious combinations of various foods which will better supply the two necessaries of tissue-making and heat-forming materials. Thus, for instance, meat with a fair proportion of fat in it, and white bread and various other starchy foods, fulfil not only these physiological requisites, but also give pleasure to the senses by their variety in flavor and taste, and in method of prepara- tion. Article. Weight. Cost. Large shank of beef 15 pounds. $0 30 Potatoes 3^ peck. 0 05 Flour 3 pounds. 0.09 Barley X pound. 0 025 Carrots 1 pound. 0.01 Onions 0.02 Herbs, pepper, salt . 0.015 Bread 4 pounds. 0.09 Total $0.60 These amounts are found amply sufficient for supply- ing dinners for four persons for three days ; each dinner costing five cents. In analyzing the nutritious properties of these materials we may assume, in the first place, that the meat in the above shank weighs ten or twelve pounds, which would furnish about one pound of meat, including nitrogenous and fatty matters, for each person at each meal. Of the lean portion of the meat seventy-five per cent, is water ; hence some three ounces of water-dry albuminoid materials remain. Calculating further the amount of albuminoids in the flour, bread, and barley allowed for each person, we have nearly another ounce of albuminoids, or a total of 4.25 ounces. Thus, in one meal supplied out of these 442 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diet. Diet. materials at an actual cost (in Toronto, Canada, in winter, 188o) of five cents, enough of flesh-making materials has been supplied to support the demands of a full- grown man for twenty-four hours. The other articles in the foregoing list may be considered largely as adjuvants, giving taste and variety of flavor to the food. The fat and starchy foods are present in sufficient amounts to supply the needs of the system in the matter of heat- forming materials. The following methods of utilizing these materials give taste and variety to the food : The nicer part of the shank is first cut off and set aside to be made into a pie, then the shank is cut into small pieces, breaking the bones up as much as possible; it is then placed in a pot with a close-fitting lid and twelve pints of water are added, with condiments and herbs ; this is then kept at a temperature of about 140° F. for six hours, and afterward strained through a colander, the stock being set aside to cool.- The fat is skimmed off, the bones picked out, and the meat and gristle are first chopped fine, and then placed in a bowl with eight or ten ounces of the stock. This is to be served as brawn. The stock, with barley-flour, potatoes, onions, herbs, and condi- ments, is to be made into a soup. The better part of the meat cut from the shank can finally be made into a meat- pie, with potatoes, etc., the fat serving with the flour to make the crust. This summary of cooking details is of value, since a most important factor in the question of practical dietetics is economy of the various materials supplied as food, through proper methods of preparing them. The penny dinners for school children, recently introduced in various cities of Great Britain, are an ad- mirable illustration of this, as is also the economical, yet varied and wholesome cooking of the French factory op- eratives of Massachusetts, as described by different writ- ers on the cost of foods, in works on labor statistics. 3. Digestibility of Food.-While the whole of the food taken into the system is not digested, or even digest- ible, still the two principles already laid down, viz., that food have proper constituents, and that these be sup- plied in proper amounts, point to the inference that di- gestibility is of extreme importance, both from the stand- point of physical well-being and from that of economy. As might be expected, the digestibility of the various ar- ticles of diet varies, both as regards length of time required and proportion of assimilable food. Further variations, as already mentioned, are present in the digestive powers of the same person at different periods of life, and of dif- ferent persons at the same time of life. While this is true, it is matter of remark that other causes, as climate, wealth, social habits, and religious prejudice, have more influence in determining what people shall eat than has the question of its digestibility. Comparing the weight of the excreted materials with that of the food taken is the most exact method of determining how much of it has been digested ; but it does not follow7 that those sub- stances, such as gelatin, which give the largest amount of excreted materials, are those which, when not digested, cause the largest amount of functional disturbance of the digestive organs. Rice, for instance, which as a dried solid has ninety-six per cent, of its wdiole amount in a digestible form, is capable of producing, in weak states of the diges- tive system, and especially in such a case as that in which enteric fever has affected the glands of the intestine, very serious forms of indigestion, through the fermentative changes which so readily take place in it. Among the foods most quickly digested are the albuminoid mate- rials of meat. It appears, however, from the experiments of Dr. Beaumont with Alexis St. Martin, that very great differences exist, either in the texture of the tissue of the meat in the same animal, or in the manner of cooking it, if we are to judge from the length of time required to digest it. Both are without doubt important factors in the digestibility of meat. In degree of digestibility, Beaumont puts boiled pigs' feet (soused) first, as taking only one hour, while roasted pork takes five hours and a quarter. In this case it is probable that in the latter case the roasting had, by coagulating the albumen, ren- dered the tissues of the meat denser and harder, and there- fore more slowly acted on by the gastric juice. Since the time of Beaumont's experiments very much has been learned concerning the enzymes, or unformed ferments contained in the secretions of the different glands of the digestive tract. To the varying amounts of these in per- sons at different ages, and under various conditions of climate, general health, etc., must be ascribed, along with those mental influences due to gustatory and aesthetic dif- ferences affecting the secretions of these glands, those different degrees of digestibility found in different per- sons for different articles of diet. Without referring further to these well-known facts which, however, must always be considered when prescribing diets for invalids and dyspeptics, the various digestive ferments may be re- ferred to in considering the question of what may be called artificial diets. When food is taken into the mouth it is subjected to the process of mastication, during which saliva is secreted in proportion to the time during which it is retained in the mouth, and to the agreeable sensa- tions produced by eating it. It is quite plain, therefore, that the food, taken without much drink while mastica- tion is going on, will be more thoroughly mixed with saliva and with greater amounts of it. By this process the starch globule, if its protoplasmic cell-wall has been burst by cooking, is subjected to the enzyme known as ptyalin or salivary diastase. By it gelatinous starch is made sol- uble. This diastase secreted by the buccal glands is more viscid when it comes from the sublingual and sub- maxillary glands than from the parotid ; that from the submaxillary being connected with gustation more than is that which comes from the other glands. The starchy food now fairly advanced in its change to a dextrin, passes by deglutition into the stomach, where the acid nature of the gastric juice soon prevents its further change by neutralizing the alkaline ptyalin. Here, in what till comparatively recent years was considered the principal digestive organ, the disintegration and pepton- izing of albuminoid substances is effected by means of the pepsin and hydrochloric acid of the gastric juice. They, thus becoming diffusible in large part and capable of passing through animal membranes, and being, more- over, soluble in water and non-coagulable by acids, are in part absorbed, along with the soluble salts and sugar, by the walls of the stomach. Besides this solvent action on nitrogenous foods, the protoplasmic walls of the cells of fat are acted upon, the neutral fats being thereby set free, and a certain amount of emulsionizing goes on, the fatty acids being, to some extent, set free. The fermentative changes set up by the action of bacteria, or formed fer- ments, upon foods in the stomach, doubtless aid to some extent in digestion, by the production of lactic and possi- bly other acids which have a solvent action upon nitro- genous matters. The undigested and unabsorbed materials now passing into the duodenum, are kept in solution by the acid gastric juice. Left now to the secretions that are poured into the intestine, the remaining food is as far as possible digested, the undigested portions passing off as excreta. The large amount of bile poured into the intes- tine aids somewhat in emulsifying the still undigested fat, and in promoting its passage through the intestinal wall into the blood and lacteals. It plays a further important part in preventing, in large degree, the development of those peculiarly putrid odors produced by the putrefac- tion of animal matters, when the supply of bile is lessened or cut off. The prime factor, however, in intestinal di- gestion is the pancreatic fluid, which is remarkable from the fact that while its special functions are to complete the diastatic action set up by salivary diastase upon starch, thereby transforming it into sugar, and to emul- sify fats, it has also, by the ferment contained in its first and more viscid portions, a capacity for digesting nitro- genous substances in what has now become an alkaline medium. The physiological acts of digestion, briefly summarized in the preceding paragraph, teach very important lessons regarding the preparation of foods in such a manner as to make them as digestible as possible, or regarding what is commonly termed cooking. In cooking meat by roast- ing or boiling it is of prime importance, in order that the juices, digestibility, and flavor of the meat be not lost, 443 Diet. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that the pores at the surface of the meat be closed. This is attained by broiling, roasting in an oven hot at first, or by boiling in water at 212° F. for a very few minutes. By then reducing the temperature to 155°-160° F., the inter- nal portion of the meat has its juices remaining largely uncoagulated, tasty, and digestible. The same process is desirable in cooking an egg, since its albumen kept at a temperature of 160° F., will be gelatinous but not solid. The chief point regarding the cooking of starchy foods is, to bake or boil them until the protoplasmic cell-wall is burst, thereby exposing the starch to the action of the diastatic ferments. When starchy foods contain much cellulose much boiling is necessary ; when this is not done the presence of such indigestible matters in the alimen- tary canal frequently causes serious trouble by their irri- tating mechanical action. In those cases in which much debility is present, as during, and in the convalescence from, acute diseases, it is frequently necessary, in order that the system may receive enough of nutriment to support it against the exhausting effects of fever, etc., to make food assimilable by artifi- cially digesting it. The earliest attempts in this direc- tion seem to have been by alcoholic solutions, obtained by macerating the stomach of the calf in a weak alcoholic medium. An advance was made by the preparation of pepsin from the stomach of the pig, which approaches more nearly that of man. Recently, however, the re- searches, especially of Dr. William Roberts, of Manches- ter, have shown that the artificially extracted unformed ferments of the pancreas have not only a diastatic action resulting in the solution of starches, but have also a pro- tealytic action upon albumenoids. By macerating minced pancreas of the pig with a twenty-five per cent, solution of alcohol in pure water for a week, occasionally shaking the mixture, and afterward straining through muslin and filter-paper till clear, peptones are produced which, though lacking somewhat the flavor of the milk, broths, etc., are readily taken into the blood and supply nourishment where the weakened system is unequal to the task of nat- ural digestion. When albumenoids are thus treated, it is especially necessary to add bicarbonate of soda to prevent coagulation, and keep the solution alkaline. The com- mercial preparations, as those of Fairchild & Foster, New York, which are supplied in a solid state, possess the merits of convenience, and when fresh are preferable to such fluid solutions as Benger's Liquor Pancreaticus ; but the practical difficulty encountered by the physician in prescribing both, lies in the fact that they, being ani- mal substances, are peculiarly liable to undergo putrefac- tive changes. So great is this practical difficulty, that the writer has found it almost impossible, out of several preparations in the chemists' shops, to obtain a single bottle which has not, a few days after it has been opened, shown putrefactive changes. It is needless to say that such a preparation soon becomes useless, if not positively injurious, when prescribed. Assuming that either that made as above described, or the commercial article, is fresh, milk and beef-tea may be very readily peptonized as follows: A pint of milk diluted to four-fifths strength with water, is heated and kept at a temperature of from 140° to 150° F. To this ten grains of bicarbonate of soda are added, and as much extract of pancreas as experience of the particular preparation may prove is necessary. The solution thus made is kept at the above temperature until such time as a distinctly bitter taste is developed, at which point the solution is to be raised to boiling, so as to prevent further peptonizing action. The degree to which this acidity is to be carried will be determined to some extent by the taste of the patient. Peptonized milk-gruel is made in much the same manner as the above, the boiled starchy food solution being added to the milk and after- ward peptonized at about the same temperature as the above preparation. Peptonized beef-tea is made by first adding an equal weight of water to minced lean beef, as a pint of water to a pound of beef, and to this adding bi- carbonate of soda at the rate of ten grains to the pint of water. This is allowed to simmer for one or two hours in a glass-capped quart preserve-jar. The fluid is then decanted off, and the solid portion pressed with a spoon or lemon-presser into a pulp, after which both are returned to the jar and mixed with a sufficient amount of extract of pancreas. This is again covered and kept at a tem- perature of 140° F. for about two hours, being occasion- ally shaken. When the acid taste has developed so as to make further peptonizing action undesirable, the whole solution is boiled for two or three minutes. In pepton- ized nitrogenous matters, beef-tea thus made is equal in nutritive value to milk. To make a nutritive jelly from a shank of beef, it would be necessary to allow the broken- up shank to simmer for five or six hours in water ; then the preparation should cool in order that we may skim off the fat, or, better, draw off the stock from below, leaving the fat behind ; and then, having picked out the bones, peptonize the meat with a small amount of stock added, in the same manner as in making beef-tea. After the action of the ferment has been stopped by raising the solution to the boiling-point, the whole may be allowed to gela- tinize, or set, by adding the stock, sufficiently concen- trated, to it. Peter II. Bryce. DIFFERENTIATION. This term stands sometimes f or a state or a condition, and sometimes for the process of de- velopment which results in that condition. For example, when an author states that " groups of cells distinguished from each other at once by the differentiation of structure and by the more or less marked exclusiveness of function, receive the name of ' tissues' " he employs the word to describe a structural condition ; but when, soon after, he says, " in the increasing complexity of forms, the pro- cess of differentiation should be accompanied by a cor- responding integration," he refers to the successive steps by which a condition is reached (M. Foster, "Physiol- ogy," introduction). Clearly, it is the process which is fundamental and important, since the condition is so called only because it manifests the effects of the pro- cess ; nevertheless, both applications are in common use and may sometimes lead to confusion. Thus the phrase "differentiation of the tissues," is used both to express the fact of their adult differences, and to describe that special phase of development which finally results in those differences. The facts of structural differentiation are simple and familiar. The human body, for example, exhibits extra- ordinary differentiation, which arises out of conditions less and less complicated, until we arrive at a single cell, the ovum, comparatively simple, undifferentiated, and homogeneous. It is only when we inquire after the ex- planation of these remarkable facts that we meet with serious difficulty. What, for instance, is the nature of a process which, under favorable circumstances, will con- vert an undifferentiated ovum into the complex body of an adult rabbit ? or which will develop from an apical cell a mass of "indifferent" tissue, and from this the members of a complete vegetal organism ? It is necessary to beware, at the outset, of such expres- sions as "undifferentiated ovum" and "indifferent tis- sue." These terms are in common use, but they are relative only. For it is certain that the so-called un- differentiated ovum is really a highly differentiated body, often, indeed generally, set apart at an early period of the individual history of the female parent, fed in a more or less special manner, and endowed with a reproductive capacity, all at the parent's expense. At length matured, it is made complete, generally speaking, by the inception of a special male element, likewise differentiated from a male parent by special steps, and it is only after all this and much more has been gone through with, that it be- gins the not more remarkable, though more palpable, pro- cess of individual development, of which one feature is differentiation of the tissues. The controlling or direc- tive force which guides it throughout, at any rate, the greater part of the process, is known as heredity, while the process itself involves the phenomena of growth. We may then picture the actual mechanisms at work in individual differentiations as processes of growth directed in great part by heredity. But if we look further, beyond the individual to the race, and inquire whence came the power of differentia- 444 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diet. Digestion. tion originally, and how was this phase of development itself developed, we are confronted with some of the pro- foundest problems of biology. This, however, is certain : that differentiation of struct- ure always goes hand in hand with specialization of function, a coincidence which gives rise to the many wonderful adaptations of organs to their duties. In- stances occur on every side, e.g., the eye and the image- producing function, the ear and stimulation by means of sound-waves, the head, the foot, the heart, etc. More- over, it is observed, that the degree of differentiation cor- responds in a general way with the amount of specializa- tion, and, what is much more important, that changes in the uses to which parts are put, or in the amount of use, lead to changes more or less marked in the structure of those parts. Thus the increased use of particular muscles often leads to their enlargement, disuse to their corre- sponding atrophy, etc. Now if changes of function be the cause of changes of structure, it should not be impossible to formulate in a general way the proximate causes of differentiation. For the first step having been taken, the difficulty has been so far removed, and we have next to inquire, what are the causes of changes in function ? Obviously these may be intrinsic and peculiar to the organism, or extrin- sic and pertaining to the environment. Doubtless the proximate causes are often intrinsic, but if so, we have still to push on toward the ultimate cause, and in the last analysis it will be found that functional changes are brought about by changes in the environment, which must of necessity be met by changes in organic functions ; for, after all, the exercise of functions is but the reaction of the organism upon its environment. Thus changes of food will necessitate changes in the digestive processes, and these in turn in the digestive apparatus ; changes in the relative composition of the atmosphere would neces- sitate extensive changes in the respiratory process, and this in turn would profoundly modify the structure of the respiratory apparatus. In fact the whole matter of differentiation, broadly speaking, is but one of the phenomena of the adjustment of internal relations to external relations-phenomena which in the aggregate, according to Spencer, constitute the characteristics of life itself. As to the precise me- chanical arrangements by which a change in function is in the first place provoked by a change in the environ- ment it is not easy to say, but for the physiologist who is accustomed to witnessing the effects of use and disuse, of stimuli, stress, and tension, of temperature, electrical changes, and other physical and chemical conditions, it is easy to conceive ample possibilities; and upon other considerations of the same sort, to perceive how changes of function must irresistibly lead to changes of struct- ure, i.e., to differentiation. Furthermore, if so much be granted and added to the facts of heredity, we have the outlines of a mechanical arrangement which will result in successive differentia- tions, and in their preservation. But for the details of the latter process, which includes that quick development and condensed history occurring in the early stages of highly differentiated animals and plants, the subject of Heredity must be referred to. See also Growth, Evolution, and Reproduction. William T. Sedgwick. gestive juices produced, and how docs nature use them when they are ready ? The nature of the problem before us will be clearer if w*e take an example for study. When food is introduced into the stomach, the color of its mucous lining changes ; microscopic examination shows that the cells of its glands undergo alterations in appearance ; a secretion is seen to flow from these glands ; and, finally, the organ itself has certain movements of a character which indicates a pur- pose. What, then, are the questions demanding solution in such a case ? The flushing of the inner surface of the organ, due to alterations in the calibre of its blood-vessels, may be owing to changes locally produced, or they may be the result of reflex action, i.e., the contact of food may, for anything we know, prior to examination, have, by almost direct influence on the vessels, the power of causing them to widen ; or, again, it may act in no such way, but the result may be accomplished wholly by in- fluences which at first proceed by nervous tracts to the nervous centre of brain and spinal cord, and there, in some way, give rise to other impulses which find their way along appropriate nervous tracts to the vessels them- selves, which, by influences acting in this roundabout re- flex manner, are changed in size according as more or little blood is required. Again, are the changes seen to take place in the in- dividual cells wholly independent of the nervous system, or are they the direct effect of nervous connection, or partly the one and partly the other ? We know that the microscopic one-celled creature called Amoeba can per- form all the functions of the higher animals without hav- ing, so far as is known, any nervous elements in its whole organism ; so that it is not inconceivable that a digestive cell should elaborate its materials independently of the nervous system. But, again, the cells of a complex body are arranged to accomplish an end not for themselves alone, but for the joint organism, the whole body. We should, therefore, expect that digestive and all other cells would be, in some way more or less direct, controlled by the nervous centres. Further, it may be asked, is the actual pouring out of the secretion due to contact of food directly with the cells, or primarily to nervous influence of the reflex kind referred to when considering the flushing of the mucous membrane ? Then, assuming that the whole apparatus is in working order, it still remains to inquire, first, whether nature has provided any special contrivance by which all the parts of the food shall, in order, be brought in contact with the digestive juices ; whether she has provided any means by which that food, already partially digested, may be moved on to another part of the alimentary canal for further treatment of a chemical kind ; and, finally, whether-di- gestion having already gone as far as is necessary-she has made any provision for the removal of fully prepared products out of the .way, and their addition to the blood, the great source of supply for the needs of every tissue ? It follows, therefore, that the treatment of digestion in its broadest sense includes an examination of the follow- ing subjects : (1) The nervous mechanism regulating the secretion of the digestive juices ; (2) muscular mechan- isms for the movement of the digesting food ; (3) changes in the cells secreting the digestive fluids; (4) the chemical constitution and the action of the digestive secretions ; and, closely related to this, the (5) removal of digested materials. As (4) has been separately dealt with by the present writer, and (5) has also been provided for in another part of the Handbook, this article will be confined chiefly to the first three subjects. 1. The Act of Secretion and its Regulative Nervous Mechanisms.-Within the last few years great progress has been made in what may be called the special- cell physiology of digestion, i.e., the changes in the cells themselves as they are visible under the microscope. With these studies the names of Langley, in England, and Heidenhain, in Germany, are especially associated. Inasmuch as these investigations have been more thor- oughly and successfully carried out for certain parts of the alimentary tract than for others, it will be well to con- DIGESTION. In considering how the animal body pre- pares its food for its own nourishment-in other words, the process of digestion-it is necessary that we should take some account of the coarse structure and the re- lations of the various organs forming the digestive tract, of the fine cell-structures which elaborate the juices that play an important part in the chemistry of digestion, and, finally, of the secretions themselves. The limits of space allotted to this article will not per- mit any description of the coarse anatomy of the organs concerned, unless incidentally ; it being assumed that the reader already possesses this knowledge. It now remains to inquire, how are these powerful di- 445 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sider the subject of cell changes and nervous mechanisms for some one region in considerable detail, and, till the subject has been pushed farther, assume that similar changes and similar nerve influences prevail throughout. We seem now justified in making certain generalizations for the whole tract. These studies in cell physiology are for many reasons among the most interesting of the whole science, inasmuch as they are an attempt to carry investigation to its farthest limits; for, as the cell is the final anatomical element with whose functions we can be- come acquainted, to understand it, is to bring our knowl- edge to completion. Salivary Secretion.-Not only are the salivary glands the first that meet us, but they have been more fruitfully studied than any others. Far back Claude Bernard in- vestigated the nervous mechanism of salivary secretion, and his work has been again and again confirmed, so that it has long ranked among the classical studies of the science. The salivary glands have been divided into serous and mucous, according to the predominant characteristics of the fluids which they secrete ; but a gland belonging to a certain class in one animal may have an opposite character in another. Let us consider the case of the submaxillary gland in the dog, which has been more studied as to nervous mechanism than any other. Inasmuch as our explanations are mostly only of the nature of unproven theories, or hypotheses merely, it will be proper in this ar- ticle that facts and explanations be kept sharply separate. It will be remembered that the chorda-tym- pani nerve is given off from the facial, joins the lingual stem, again leaving it, and, making connection with the submaxillary ganglion, passes for final distribution to the submaxillary gland ; also that sym- pathetic nerve fibres pass along the arteries supplying the gland, and are also finally distributed to the gland tissue proper. Now, if the lingual nerve be stimulated, or if the chorda tympani be stimulated, a copious flow of saliva from the duct of the submaxillary gland fol- lows ; but if the chorda tympani be divided, and the lingual nerve be then stimulated, no flow fol- lows. If, again, the end of the di- vided chorda tympani next the gland be stimulated, a good flow follows. These are facts that can be read- ily confirmed by any experimenter carrying out the necessary steps of the procedure. What is the ex- planation ? When the terminal (in the gland) end of the chorda tympani is stimulated, we must conclude that the nervous impulses pass along this nerve and influence the gland-cells directly. In the case of stimulation of the lingual below the point at which the chorda leaves it, we have an example of reflex action ; the impulses proceeding first to the brain, and thence, after being modified by the peculiar action of the se- creting centre situated in the medulla oblongata, leave the brain for the gland along the facial to the chorda. This view is supported by the fact that if the lingual be divided above the point where the chorda leaves it, stimulation of the tongue (i.e., the lower end of the lingual) does not excite a flow of saliva. The submaxil- lary ganglion does not seem to act as a centre, though this question has been the subject of much controversy. Inasmuch as the whole brain, down to the medulla, may be removed without destroying the power of the gland to secrete under the stimulation of nerves connect- ing with the medulla, while stimulation of the medulla itself gives rise to a flow, it seems clear that the centre governing the flow of saliva is situated in this part of the brain, and probably near the vaso-motor centre. It might still be objected that in the above cases the flow was owing to the still uninjured sympathetic fibres, but this is answered by the consideration that, after division of the sympathetic, stimulation of the tongue (lingual nerve) or chorda causes a flow of saliva. We are justified in concluding, therefore, that in the case of a flow of saliva, when exciting substances, as food, are placed on the tongue, secretion is a reflex act, the centre being situated in the medulla, and the path of the afferent influences being along the lingual nerve, and that of the efferent along the chorda tympani. This will be clearer after an inspection of the subjoined Fig. 815. It is scarcely necessary to add that when a flow of saliva is excited by the thought of food, the impulses must proceed from the cerebrum to the secreting centre in the medulla. To carry the matter one step farther, the question presents itself, How does this nervous influence act ? What more immediately does it bring about ? Another prominent fact meeting us here, and in all glands in action, Fig. 815.-Diagrammatic Representation of the Submaxillary Gland of the Dog, with its Nerves and Blood-vessels. Sm. gid., the submaxillary gland, into the duct (sm. d.) of which a cannula has been tied. The sublingual gland and duct are not shown, n. I., n. I'., the lingual branch nerve ; ch. t., ch. t'., the chorda tympani, proceeding from the facial nerve, becoming conjoined with the lingual at n.V., and afterward diverging and passing to the gland along the duct; sm. gl., the submaxillary gan- glion with its several roots ; n. I., the lingual, proceeding to the tongue; a. car., the carotid artery, two branches of which, a. sm. a. and r. sm. p., pass to the anterior and posterior parts of the gland ; v. sm., the anterior and posterior veins from the gland falling into v.j., the jugular vein ; v. sym.. the conjoined vagus and sympathetic trunks; gl. cer. s., the super-cervical ganglion, two branches of which, forming a plexus (a./.) over the facial artery, are distributed (n. sym. sm.) along the glandu- lar arteries to the anterior and posterior portions of the gland. The arrows indicate the direction taken by the nervous impulses during reflex stimulation of the gland. They ascend to the brain by the lin- gual, and descend by the chorda tympani. (From M. Foster's "Physiology.") is that the amount of blood which they contain during functional exercise is greatly increased ; they look redder, and under the microscope their arterioles may be seen to dilate. Indeed, in the case of the submaxillary gland, the small arterial twigs may be so widened in calibre that a pulse will appear in the veins issuing from the gland, owing to the diminished resistance on the arterial side. Is it, then, the whole function of the nervous apparatus described to furnish the regulative influences for blood- supply, or is there an additional effect wholly indepen- dent of this vaso-motor influence ? Several facts show that the latter is the case. (1) If an animal be rapidly beheaded and the chorda stimulated, saliva will still flow; in this case, in the absence of even a moderate supply of blood to the gland. (2) A cannula may be tied in the duct of the gland and the pressure of the saliva in the duct measured by a ma- nometer, and it will be found that the secretion continues when the pressure in the duct is greater than that of the 446 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. blood, even in the carotid artery, which would, of course, be a condition unfavorable to the passage of nutritive material through the walls of the blood-vessels. (3) If atropin be injected into the blood of the animal, stimulation of the chorda gives rise to no flow of saliva, although the vascular dilatation follows as usual. This latter experiment seems to point clearly to the view that the increased blood-supply is only an accompaniment, though for prolonged glandular work a necessary one, of the essential influence which the nervous system has over the act of secretion proper. One other conclusion seems justifiable from the above experiments, especially the last, viz., that the chorda contains two kinds of fibres ; the one dilating fibres act- ing on the blood-vessels, the other secreting fibres proper which act directly on the gland-cells themselves. Several authors have described and figured nerves as ending in the cells of the gland, but this cannot yet be considered one of the firmly-established facts of anatomy, though it seems to be more certain as regards the so- called salivary glands of some insects than for the higher animals. The chief difference between the results of chorda stimulation and that of the sympathetic is to be found in the quality or character of the secretion, this being, how- ever, very variable for different animals. But stimula- tion of the sympathetic nerves causes generally a constric- tion of the blood-vessels and scanty flow, while ex- citation of the chorda results in the reverse, an abundant flow and dilated blood-vessels. A simi- lar difference holds for other of the salivary glands. Gastric Secretion.-Before discussing the sub- ject attention is asked to the following facts : (1) A small amount of gastric juice can be obtained by mechanical stimulation of the mucous mem- brane of the stomach. (2) Dilute alkalies (saliva) act as powerful stimuli, but food is the most ef- ficient of all. (3) When both vagi, or the sympa- thetic nerves going to the stomach, are divided, a perfectly natural gastric juice can still be se- creted. (4) Secretion of gastric juice cannot be excited by stimulation of any of the nerves sup- plying the stomach. (5) Gastric secretion is asso- ciated with vascular dilatation, as in the case of the salivary glands. It will be borne in mind that the gland-cells of the stomach are exposed to the actual contact of food in a way impossible in the case of the cells of the salivary glands or pancreas. This consideration, taken with what has been mentioned in (2), (3), and (4), gives ground for the belief that secretion in the stomach may be to a greater extent due to a local mechanism than to the influence of the central nervous system. This is further supported by the fact that when the stomach is mechanically stimulated, over a given area of its mucous membrane, the redness caused thereby does not spread. The local mechanism may be nervous or it may be a sort of sympathetic communication from the active sensitive protoplasm of one cell to that of its neighbor. But, on the other hand, these are facts difficult to ex- plain unless we assume that the central nervous system is largely concerned-or at least may be-in the origination and control of the secretory act in the stomach. Thus it has been seen, in cases of gastric fistula, that a copious flow of secretion has followed the sight or smell of food alone, and it is a common experience that digestion may be de- layed or abolished temporarily by powerful emotions, originating, of course, in the cerebrum. The subject of the relations of the nervous system to the digestive organs, except in the case of the salivary glands, requires much more investigation. Bile and Pancreatic Juice.-The nervous mechanism regulating these secretions is still less known to us ; indeed, it is yet an open question whether there is such an ar- rangement at all. The discharge of bile seems to be a reflex act, for when an acid or the acid-contents of the stomach pass into the duodenum, coming in contact with the biliary opening into the gut, a flow of bile follows ; doubtless brought about by contraction of the walls of the gall-bladder and its ducts, the sphincter at the orifice being at the same time relaxed. However, the secretion of bile can be bet- ter studied w'hen a fistula exists. Under such circum- stances, the following facts are established : (1) The flow of bile is continuous; (2) after food is taken there is a sudden increase in the amount secreted ; this is followed by a fall, then again by another rise, but more gradual, succeeded by another fall. While the pressure under which bile is secreted is low, experiments show that it is greater than the pressure of the blood in the mesenteric veins, the tributaries of the portal vein, which feeds the liver itself. But although the pressure is so much lower in the biliary ducts than in those of the salivary glands, still the relations of pressure re- main the same, i.e., in both cases the pressure in the ducts is greater thtm in the capillaries of the organ. From the fact that the liver is heavier, and is increased in bulk during digestion, it seems reasonable to conclude that its contained blood is then greater in amount; though, as is well knowm, its blood-supply is peculiar. Pancreatic Juice.-We know, perhaps, a little more about the nervous conditions under which this secretion is regulated than in the case of the bile. There are some points in common to be noted : thus, in both cases, the Fig. 816.-Diagram Illustrating the Influence of Food on the Secretion of Pan- creatic Juice. (N. O. Bernstein.) The abscissae represent hours after taking food ; the ordinates represent, in c.c., the amount of secretion in ten minutes. A marked rise is seen at B immediately after food was taken, with a secondary rise between the fourth and fifth hours afterward. Where the line is dotted the observation was interrupted. On food being again given, at C, another rise is seen, followed in turn by a depression, and a secondary rise at the fourth hour. A very similar curve would represent the secretion of bile. (From M. Foster's " Physiology.") rises and falls associated with the taking of food and digestion are much the same, and are well indicated to the eye by the above diagram. But there is this great difference, that during fasting, at least in some animals that have been examined, the flow of pancreatic juice may entirely cease, while that of bile is continuous. The pancreatic glands have such a resemblance to the salivary glands in their appearance, in their secretion, and in their digestive action, that they have been called by the Germans the abdominal salivary glands (Bauchspeicheldruse). Like the salivary glands, the latter flush during secretion, from dilatation of their small blood-vessels. A very few facts of a nervous kind are known in regard to the pancreas. Stimulation of the medulla oblongata will start secretion or increase it if already taking place; wfliile stimulation of the central end of the vagus nerve will arrest secretion. In this case the course of the nervous influences toward the gland from the medullary centre are unknown. It seems, however, clear that, as in the case of the salivary 447 Digestion- Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. glands, secretion is under the control of the central nervous system, and probably of some centre situated in the medulla. Succus entericus, the secretion of the intestine, is under the influence of the nervous system, for section of the nerves going to an isolated portion of intestine leads to an abundant flow of intestinal fluid of a kind thinner than usual. While the physiologist has much to learn before he can furnish satisfactory and complete evidence of the char- acter and extent of the influence of the nervous system in digestion, still every practising physician has become aware of many facts which, in a general way, have deeply impressed him with the almost marvellous influence of the nerve-centres on digestion under peculiar circum- stances. We must also remember that the nervous sys- tem may, under exceptional circumstances, exert an in- fluence which it does not habitually exert. Medicine and physiology will by and by unite the knowledge which they each possess to produce greater completeness and harmony in our views of vital processes. We now ask : Do we know anything of the manner in which the nervous system influences the individual cell ? We are, in fact, brought to another division of the subject. 2. The Microscopic Changes in Gland-Cells Con- cerned in Digestion.-It has been seen that increased conditions will be noticed ; the lumen is enlarged and readily seen, the granules have largely disappeared, the individual cells are better defined, the outer zone is larger, and the blood-vessels are dilated. After digestion has ceased the alveolus again returns to the condition first described. Before giving an interpretation to these ap- pearances, let us examine certain cases with much re- semblance to those first described, in order to ascertain what, if anything, there may be in common. We recognize two kinds of salivary glands; serous, having a thin secretion, and mucous, with a secretion con- taining more or less mucin, the essential constituent of mucus. In the dog, in which it is more convenient to experiment, on account of the greater size of the nerves involved (chorda tympani especially), the submaxillary is a mucous gland. Below are figured the appearances in such a gland, both at rest and after active secretion. In the first case (at rest) we find: (a) the nucleus near the outside of the cell toward the basement membrane ; (b) the cell consists of a loose network of fine fibrils, the spaces of which are filled with a transparent substance which does not readily stain with carmine. There is, in addition, the ordinary protoplasm forming the basis of these and most living cells. After the gland has been in prolonged activity, all this, is changed. The cells are now smaller, the transparent mucigen- ous (mucus-forming) substance has almost wholly dis- appeared, consequently the cells stain well with carmine ; the nucleus has become round and distinct. What now is the explanation of these changes ? It will be seen that the essential variations are in the relative quantities of ordinary protoplasm composing this and other cells, and the special product-in this case mu- cinogen, or mucus-forming substance-accompanied, it is true, by a change in the size of the cells, the size and shape of the nucleus, etc. During secretion, then, the mucinogen is used up to form mucin; during rest the protoplasm is replaced (for it had been employed to form mucinogen), and from it is again formed another load of mucinogen to be used when the gland is called into activity. The sequence, then, is protoplasm, mucinogen, mucin, over and over again. To connect this process with what takes place in the pan- creas, it will be necessary to bear in mind a few facts at once peculiar and significant. If the perfectly fresh pancreas of an ox be soaked in water at once after being taken from the recently-killed animal, it will not give an extract that is capable of digest- ing proteids ; but if this same pancreas be kept for say B. Fig. 817.-A Portion of the Pancreas of the Rabbit (Kiihne and Sheridan Lea). A, at rest; B, in a state of activity, a, the inner granular zone, which in A is larger and more closely studded with fine granules than in B, in which the granules are fewer and coarser; b, the outer trans- parent zone, small in .4, larger in B, and in the latter marked with faint striae; c, the lumen, very obvious in B, but indistinct in A; d, an indentation at the junction of two cells, seen in B, but not occur- ring in A. (From M. Foster's •* Physiology.") blood-supply to a gland does not suffice to explain the whole act of secretion. Such is, indeed, only a necessary accompaniment of the act which we now propose to study in the light of the most recent researches. Here, it will be understood, we are dealing again with undoubted facts, confirmed by several independent observers, but the ex- planation of which will probably in future undergo some modification. Not only have the glands, especially the salivary and pancreatic glands, been studied after hardening and by sections, but, what is much more satisfactory, they have been studied when living and in action, as well as at rest. Jviihne and Lea observed under the micro- scope the pancreas of a rabbit when in actual secretion, so that the appearances, as shown in Fig. 817, are most valuable and of extraor- dinary interest. It will be observed that in the pancreas at rest (a) the outlines of the cells are indistinct; (b) there are two zones in the cells, an outer relatively small and clear, an inner larger and filled with highly refractive granules ; (c) the lumen of the alveolus or terminal portion of the gland is much narrowed. It may be added that the small arteries are reduced in calibre, and the capillaries relatively poor in blood-cor- puscles. If, now, an examination be made when the gland is actively secreting during digestion, the reverse Fig. 818.-Section of a " Mucous" Gland. A, in a state of rest; B, after it has been for some time actively secreting. (After Lavdowsky.) a, demilune cells; c, leucocytes lying in the interalveolar spaces. The darker shading in both figures is intended to indicate the amount of staining. (From M. Foster's " Physiology,") eighteen to twenty-four hours, or if it he at once treated with acidulated water or acidulated glycerine, it then be- comes very active. From this it is legitimate to conclude that the keeping or the acid has effected in the gland some essential change ; or, in other words, there was a something which is not of itself efficient, but which may 448 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. give rise to another something which is active to digest albuminous substances. Now, it is convenient to have a generic name for all an- tecedent producers of ferments, as these active digestive substances have been called, and the name suggested for such is zymogen. Thus we should, in the case of the pan- creas, speak of the antecedent producer, or * ' mother-sub- stance," as trypsinogen ; inasmuch as it gives rise to tryp- sin, i.e., trypsinogen is a zymogen; in like manner mucinogen (mucigen), as it gives rise to mucin, is a zymo- gen. In the case of all digestive glands, then, we may con- clude that the work of the formative protoplasm (its con- structive metabolism) is followed by a breaking down of this protoplasm in the formation of something else (a de- structive metabolism). We must suppose this cell-basis of protoplasm built up from the common source, the blood, by what is poured out in the tissue interspaces and known as lymph. But there is in these digestive fluids not alone the specific ferment, but in addition water and salts. Are they a secretion also, and in some way due to the specific activity of the cell, or are they merely filtered off ? One experi- ment will settle the question in favor of the former view. When atropine is injected into an animal's blood, although the blood-vessels of the submaxil- lary gland are as usual dilated on stimulation of the chorda tympani nerve, no saliva flows. In this case, then, there is no lack of material for filtration in abundance, but yet no water escapes-the atropine has mod- ified the activities of the cell. Moreover, different nerves seem to have different influ- ences over the various Constitu- ents of the secretions ; thus the chorda tympani when stim- ulated gives rise to a watery secretion, while similar stimu- lation of the sympathetic causes a more viscid discharge. It is plain, then, that the dis- charge of water is more under the control of the cerebro- spinal nerve, while the solids are more under that of the sympathetic system; in other words, each assists the other, one washing out, so to speak, what the other furnishes of solids. As regards the cells of the glands of the stomach, an an- alogous condition of things seems to obtain. In the examination of the living cells it is found that in the resting condition the cells are throughout granular; but during activity the granules diminish in such a manner as to leave a clear outer zone. In mammals like changes have been demonstrated, though in some, inasmuch as no marked differences can be made out in the gland, whether at rest or in activity, it seems probable that the granules are renewed as rapidly as used. Fig. 819, founded on Langley's studies, will serve to illustrate at once the general character of the cells of the gastric tubule, and also the different zones in each cell, i.e., the inner granular diminishing during activity, and the outer clear one enlarging during the same period. It is not improbable that there is also in the gastric cells a zymogen, i.e., a pepsinogen, as antecedent to pepsin. As regards the function of the several cells to be seen in the figure above, it is pretty well settled that the large ' ' central or principal cells of the glands secrete the pep- sin, and these pepsin-forming glands are confined mostly to the fundus ; that the same cells furnish the rennet ferment, such glands being less closely confined to the fundus ; while it is suspected, though this is not equally well founded, that the large "ovoid" or "border" cells furnish the hydrochloric acid of the gastric juice. The protective mucus of the stomach is secreted by the cells lining the necks of the glands and the spaces between them. The study of cell-changes in the liver during digestion is beset by great difficulties, and much doubt overhangs the nature of the secretory act in this organ. The blood- supply is complicated, and the cells themselves have other functions than the secretion of bile. It would seem not improbable that the liver-cells appropriate certain mate- rials in a partially-prepared state, such as bile-pigments, taurin, glycin, and perhaps cholesterin wholly made, and thus lighten their possibly complex labors as the form- ers of other products, as urea, etc. It is not at all un- likely that some of the bile poured into the intestine during digestion is reabsorbed and utilized again by the liver-cells as ready-made material simply to be separated from the blood. This view is favored by the fact that injection of bile into the intestine leads to increased secre- tion of this fluid, as seen in cases of biliary fistula. 3. The Mechanisms of Digestion, Muscular and other than Nervous.-We must now consider, very briefly, certain me- chanisms by which the food is prepared for the action of the several digestive juices, moved about in order to facilitate the action of these, or carried along to the site of fresh secretion, and its waste or undigested parts finally re- moved from the body. Mastication. - This process is dif- ferently managed in the various classes of animals. In some, as in the dog, the food is scarcely comminuted at all in the mouth, but bolted almost whole, while in the rumi- nants it is subject- ed to the most pro- longed and thorough grinding in the mouth, after being previously softened in one portion of the compound stomach of these ani- mals. The teeth in man belong to none of the types found in any other class of animals, but are somewhat intermediate' between those found in vegetable and those in flesh- feeders, and with a suitability for a mixed diet. During mastication in man, the chief movement is an up-and-down one, combined with a certain amount of lateral and back-and-forward action. The muscles in- volved are: in the elevation of the lower jaw, the tem- poral, masseter, and internal pterygoid ; in the depression of the same, the digastric, the mylo-hyoid, and the genio- hyoid. The lower jaw is thrust forward by the external ptery- goids. The action of one pterygoid will cause the lower jaw to move laterally to the side of action of the muscle. The jaw is retracted by the lower fibres of the temporal muscle. The movements of the food during mastication are Fig. 820.-Muscles of Tongue and Pharynx. 1, 2, 3, muscles from styloid process (&) to the tongue, hyoid bone (d), and pharynx respec- tively ; 4, 5, 6, 7, 8, muscles of tongue ; 9, 10, 11, constrictors of pharynx; 12, oesoph- agus; 13 is placed on larynx (e). (Allen Thomson.) Fig. 819. - Gastric Gland of Mammal (Mole) during Activ- ity (Langley), c, the mouth of the gland, with its cylindri- cal cells; n, the neck, con- taining conspicuous ovoid cells, with their coarse proto- plasmic network : f, the body of the gland. The granules are seen in the central cells to be limited to the inner portions of each cell, the round nucleus of which is conspicuous. (From M. Foster's "Physiology.") 449 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. largely controlled by the buccinator muscles, and espe- cially by those of the tongue itself. Most of the above-mentioned muscles are supplied by the fifth cranial nerve ; the muscles of the tongue by the hypoglossal. Mastication is a purely voluntary act, under the guid- ance of the muscular sense and the ordinary sensations of touch. Deglutition.-This act is one of the most complicated instances of muscular co-ordination known to us, involv- ing a series of movements accomplished with a harmony that is marvellous. The following brief account shows the sequence of the different steps in the act of swallow- ing a morsel of food : The masticated food, collected into a bolus, is pushed backward by the elevation of the tongue by the stylo-glossus and also by its own muscles ; before the bolus reaches the pharynx by passing through the an- terior pillars of the fauces, the soft palate is raised by the levator palati, and thus shuts off the entrance to the nasal chambers, the resistance being increased by the rise of pressure in the air within (condensation); the posterior pillars of the fauces are caused to approach by the pal- ato-pharyngeal muscles, thus cutting off the return to the mouth in great part, while the pharynx is drawn up over the bolus, after the fash- ion of drawing on a glove, by the stylo- pharyngeus and pala- to-pharyngeus. One step more is neces- sary, viz., to protect the opening of the larynx against the entrance of food. Laryngoscopic e x- amination shows that in swallowing the opening of the glottis is closed ; the cushion of the epiglottis covers the rima glot- tidis, and the lid of the epiglottis itself is depressed over the larynx. At the same time the larynx is raised by the thyro- hyoid muscles, which also aids in protecting the opening of the glottis. When once in the pharynx the mass of food is grasped by the various muscles (con- strictors) composing this organ, and is passed on into the oesophagus or gullet, where it is subjected to the influence of the so-called peristaltic movement common to it and to the intestines. It will be observed that in the act of swallowing there are three parts, or stages : (1) Forcing the food through the isthmus faucium, a voluntary act; (2) passage of the bolus through the upper pharynx, which may be either voluntary or involuntary, but may be considered a reflex act upon the whole ; (3) its descent after being grasped by the constrictors of the pharynx, a wholly involuntary and purely reflex act. The fact that food is swallowed when placed on the back of the tongue in an unconscious animal, or in one, in fact, wholly deprived of its brain, excepting the me- dulla, shows that deglutition, as a whole, is a reflex act. Admitting, then, the reflex nature of the act, we must inquire concerning the paths of the afferent influences to the centre, and of the efferent ones from it. The former pass to the centre in the medulla by the glosso-pharyngeal, by branches of the fifth, and by pharyngeal branches of the vagus. The impulses (efferent) pass from the medulla along the hypoglossal, the glosso-pharyngeal, the pharyn- geal plexus of the vagus, the fifth, and the facial nerves. There is evidence that the centre of deglutition lies higher up than the respiratory centre in the medulla, for the former act may be impossible when the latter is in- tact. This subject, like that of the secretion of saliva, has been treated more fully than those which are to follow, and for a similar reason, viz., that it is better understood. It is most interesting on account of the illustration which it furnishes of very complicated muscular co-ordination, effected with the greatest ease by the central nervous system and its messengers, the nerves. Movements of the (Esophagus.-It will be borne in mind that the gullet is a strong muscular organ, containing fibres running lengthwise, and others arranged in a circu- lar fashion ; and that as a result of this arrangement their joint combination leads to a wave-like motion, which mostly begins at the upper end and proceeds toward the lower. It is a singular fact, however, that if the gullet be cut across, say at its middle, stimulation of the pharynx will still in a reflex way give rise to movements in the lower as well as in the upper part; it must follow, then, that the afferent impulses reaching the medulla give rise to efferent ones which pass by different nerve-tracts to the different parts of the organ. This points to a greater de- gree of dependence, on the part of the gullet, on the central nervous system than is the case for the intestines. The nerves concerned in such a case as the above, as conveyers of afferent impulses, are the glosso-pharyngeal, fifth, etc. The efferent impulses from the centre in the medulla travel along the vagus, being distributed by its various branches. The sphincter at the junction of gullet and stomach seems to be in a condition of constant (tonic) contraction, undergoing relaxation only when food is about to pass into the stomach. Movement of the Stomach.-The nature of the muscular contrivances themselves are, in the case of the stomach, much better understood than the nervous mechanisms regulating them. t The movements are substantially peristaltic ones ; they are weak at first, but they grow more powerful as digestion proceeds. They result in the food being carried from the cardiac toward the pyloric end along the greater cur- vature and back along the lesser curvature, while at the same time other currents carry the food from the centre of the mass outward toward the mucous membrane and in the reverse direction. Around the pyloric end strong circular contractions take place, tending to carry the digested food through the sphincter, which relaxes to allow of its passage. The empty stomach is in a some- what contracted but motionless condition. It has been suggested that the movements of the stomach during digestion are induced by the acid reaction of its secretion, for the increase in the force of its movements runs paral- lel with the increase in the acidity of the gastric juice. This view, however, cannot be considered proven. In the present state of our knowledge it is not possible to give a complete and definite account of the nervous regulative mechanism of the stomach. The following may be considered to be the principal facts known on the sub- ject : The nervous branches to the stomach may be traced to the solar plexus of the sympathetic system, and to the pneumogastrics. Division of the vagi is followed by spasmodic contraction of the cardiac orifice, i.e., an aug- mentation of the natural condition of the sphincter ; but the normal gastric movements either cease or become ir- regular, even if food be present. Stimulation of the ends of the vagi nerves toward the stomach gives rise to imperfect movements if food be present. Section or stimulation of the splanclmics is followed by inconstant effects. It is not known how the pyloric sphincter is controlled. It is altogether likely that the vagi and sympathetic nerves have each an important regulative in fluence over the gastric movements. Movements of the Small Intestines.-It must be borne in mind that of the two muscular coats which the intestines possess, the circular is much the stronger, and has the dominant influence in determining the character of their Fig. 821.-Deep Muscles of Cheek, Pharynx, etc. 1, Orbicularis oris; 2, buccinator; 3, superior, 4, middle, and 5, inferior con- strictors of the pharynx ; 6, oesophagus ; 7, styloid muscles cut across; 8, 9, 10, muscles attached to the hyoid bone (d) and thyroid cartilage (e). (Allen Thomson.) 450 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. peculiar movement known as "peristaltic." To this action of the circular coat is due chiefly the conveyance of the contents of the gut along from one part to another. The movements may begin at the pyloric junction, or at other points, but under ordinary circumstances proceed only downward. The action of the longitudinal muscular coat is to produce subordinate swaying movements of the loops into which the gut is arranged. From the fact that movements may take place in a loop of intestine isolated and cut free from all nervous con- nection, we may conclude that at most only the nervous ganglia of the gut itself (Meissner's and Auerbach's plex- uses) are essential. An empty intestine can pass into peristaltic action, though not equally well with a full one ; the presence of food is a modifier of the movement, pos- sibly a stimulus which starts it, but is not indispensable. Distension of the intestine increases its action, as is well shown in cases of obstruction of the bowels, but in such a case we are scarcely at liberty to exclude the influence of a central mechanism and reflex action. But from all that has been said above, and from other facts at present known to us, we may conclude that the movements of the small intestines arc spontaneous, or auto- matic, i.e., they may arise independently of any stimulus from within or without, including in the latter the nervous centres. This, however, is not equivalent to saying that the movements may not be modified or in some cases even originated by stimuli. If an animal just killed be opened, vigorous peristaltic action is to be seen, and this is not ■due to access of air, for if the belly be unopened they may still be felt or perhaps seen. The same may be ex- cited by inducing a condition of asphyxia in a living an- imal ; hence we conclude that accumulation of carbon di- oxide (Co2), or the lack of oxygen, is the exciting cause; or, to put it otherwise, the peristalsis is caused by imperfect- ly aerated blood coming in contact with the intestines. Such movements may be checked by saturating the blood with oxygen. Section of the vagi and splanchnic nerves does not ar- rest the movements ; while stimulation of the splanchnic tends to check them, and of the vagus to increase them. This, as in the case of the stomach, points to a regula- tive influence of these nerves, but exactly how, or to what extent, it is impossible to say. The vagus is prob- ably the path of efferent impulses, starting from the cere- brum, as in the diarrhoea of strong emotion, such as fear, anxiety, etc. It is worthy of note that the peristaltic wave of con- traction, no matter where .it begins, does not extend be- yond the valve at the pylorus or that at the junction of the caecum and ileum. The movements of the large intestines are virtually of the same kind as those of the smaller gut. Defecation : Its Mechanical and Nervous Mechanism.- This is also one of the best-marked cases of complex muscular co-ordination known. The following order of events may be observed during the act of emptying the bowel of faeces: an inspiration is taken, leading to descent of the diaphragm; this is fol- lowed by a straining expiratory effort, in which the ab- dominal muscles are brought into play while the glottic opening is closed, the result of which is pressure of the intestinal contents downward, assisted by harmonious peristaltic movements of the bowels themselves. As the sigmoid flexure of the colon is from its position pro- tected from the pressure of the abdominal muscles, this part furnishes a point of least resistance into which the faeces are passed ; when the latter are pressed against the sphincter ani it relaxes, and thus expulsion is effected. Owing to the experiments of Goltz on the dog, the nervous mechanism is pretty well understood. This physiologist found that in a dog in which the spinal cord had been divided in the dorsal region some time previously, defecation took place in the usual man- ner In this case, then, the influence of the will was cut off from the lumbar portion of the cord, so that it is legitimate to infer that the act may be performed inde- pendently of the will, and that the act is reflex, its centre .being located in the lumbar spinal cord. Usually the will is concerned to some extent, i.e., in initiating the act at least, for we are conscious of this as well as of an inhibitory or preventing power of the will (cerebrum). We may suppose that the sphincter is kept in tonic contraction by the action of the defecating centre in the lumbar spinal cord, but that either reflexly or owing to the command of the cerebrum this influence is for the time relaxed. We are conscious of this power of the will; but it is also known that the bowel may be emptied during unconsciousness (sleep), in disease of the cord and of the brain, in intoxication, etc. In a word, the act may be wholly reflex, or partly voluntary and partly reflex, the latter being the usual case. The stimulus for the reflex act is, of course, the faeces in the rectum. Vomiting.-This act, in many of its details, resembles defecation. As in the latter, there is an inspiratory effort, with descent of the diaphragm, an expiratory act, with closure of the glottis, followed by a sudden opening of the same, and rush of air as the vomited matters pass the larynx ; there is also pressure of the abdominal mus- cles of a sudden and vigorous kind. In the conscious subject vomiting is usually preceded by increased flow of saliva, swallowing, and nausea. These are, however, not essential. The gullet is shortened by the action of its longitudinal muscular fibres ; the cardiac orifice of the stomach is relaxed suddenly, the stomach itself being brought close under the diaphragm ; there are peristaltic movements of both stomach and oesophagus, which must be considered, however, as quite subordinate, the main propulsive force being the action on the stomach, as it lies against the diaphragm, of the powerful abdominal muscles. In the usual course of events the pyloric orifice of the stomach is closed, but (as when bile regurgitates from the duodenum) this is not complete in all cases. The nervous mechanism of vomiting is not perfectly clear in all its details. It is plain that the respiratory centre of the medulla is in action ; it is also pretty certain that the vagi are the paths of the nervous efferent in- fluences as they pass downward from the vomiting centre, which we may consider to be somewhere in the medulla ; for, if the vagi nerves are divided, vomiting is difficult, from imperfect dilatation of the cardiac orifice. The mechanism of the salivary flow is the usual one, and the impulses may be assumed to start from the vomiting centre. It is well known that vomiting may be reflexly excited by titillation of the fauces, by various kinds of in- testinal obstruction, etc. Vomiting in the latter instance may be prevented by section of the mesenteric nerves; hence we may infer that the course of the efferent im- pulses is along these nerves. We must also consider the vomiting of hernia, of renal and biliary calculi, as reflex in character. The vomiting following sights, smells, re- membrances of such, etc., must be considered as due to the action of the cerebrum directly on the centre in the medulla. Some drugs, as tartar emetic, act on the centre itself ; others, as the well-known mustard, in a reflex manner, through irritation of the mucous membrane of the stomach; while in still other cases the cerebrum may be involved. Synoptical Statement of the Digestive Changes. -The changes accomplished in the digestive organs are chemical, effected by certain secretions furnished by glands under the control of the nervous system. The work of transportation of the food from one part of the alimentary tract to another is effected by muscular mechanism, guided by the central nervous system chiefly. In all the digestive juices the essential constituent is in each case a nitrogenous body, small in quantity, and of the nature of an unorganized ferment. These ferments re- quire for their best action a certain chemical reaction, variable for each, and a certain temperature (about that of the body). In the mouth the food is comminuted by the teeth, mixed with the saliva, its starchy parts converted into sugar (mostly maltose), and formed into a bolus; it is swallowed by the joint action of mouth, pharynx, and oesophagus-the whole being a reflex act. The reaction in the mouth is alkaline. Pty aline is the ferment of saliva. 451 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the stomach the food is moved about constantly, subjected to the action of gastric juice, acid in reaction, with pepsin as the ferment, by which albuminous bodies are changed into peptone. In the small intestines the digestive mass is subjected to the action of bile, pancreatic juice, and succus entericus. Of these, pancreatic juice acts on albuminous bodies by its ferment, trypsin, giving rise to peptones; on fats by steapsin, breaking them up into glycerin and free fatty acids; some of these last uniting with alkalies to form soaps, which again assist in the emulsification of fats-the essential point in the digestion of the latter. A third ferment, amylopsin, acts on starch as ptyalin does. The functions of bile and the intestinal juices are less clear. Bile probably assists in emulsifying fats, and hin- ders putrefactive changes in the intestine. Succus en- tericus acts, perhaps on albumins, perhaps on starch. Thus it is seen that proteids, or albumins, are acted upon in the stomach and intestines ; starches, in the mouth and intestines ; the final product, in the case of albumins, is peptone, which is capable of passing through animal membranes, and in that of starches, sugar. Peptone, sugar, water, and salts are largely absorbed by the blood-vessels ; fats, by the lacteals. The stomach, by the relaxation of its sphincters, admits of the ingress and egress of food ; the latter is assisted by the movements of the stomach ; the food is conveyed along the intestinal tract by the peristaltic movements of the gut itself. Owing to bacteria, there is more or less putrefaction in both small and large intestines ; for this reason, and owing to fermentation, a certain quantity of various gases is pres- ent. There is probably no digestion proper in the large in- testines of man. The undigested and indigestible rem- nant of the food constitutes the faeces. Throughout the intestinal tract the digestive secretions are all alkaline ; fermentations may, how'ever, give an acid reaction to the contents. understood than external digestion, and it is probable that its anomalies and disturbances constitute the cause for a large class of the most serious diseases. The pres- ent article will have no reference to this division of the subject, but will be limited to a consideration of the dis- orders of those processes by which, normally, the nutri- tive elements are brought into the interior of the body. Technically, a distinction has been drawn between dys- pepsia and indigestion, the former term applying, as by derivation, to cases of difficult digestion, i.e., where the act is performed, but laboriously and with difficulty; while indigestion would indicate the non-performance of the function. Practically, however, no such distinction need be observed ; each term indicates a greater or less impairment of the digestive function, with similar causes and results varying only with the extent of the disturb- ance. The present article will treat more especially of the so-called functional disorders of digestion; those symptoms dependent on pathological lesions of the ali- mentary tract being more fully considered under the head of the special organs so affected. Disorders of the digestion constitute one of the classes of maladies for which the physician is most often con- sulted. And the importance of a clear understanding and intelligent treatment of such disorders may be real- ized, when it is remembered that the sufferers from such troubles are found in all ages, sexes, and social classes. In infants it has come to be generally held that the man- agement of the function of digestion, the direction of the times and manner of feeding, constitutes the great secret of success in treatment. And in the affections of adult life, feeding often displaces medication as the prime ob- ject of the physician's care. Especially in the continued fevers is it generally true that so long as the alimentation can be sustained, the prognosis is rendered favorable. A natural division of the causes of depraved digestion is into (A) those involved in the character of the food it- self, and (B) those consisting in the imperfections of the process to which it is subjected. A. Under the former head, of improper food, we may have (a) Deficiency of food. This condition is, on the whole, less frequent than its opposite, for overcrowding of the digestive apparatus is a more common fault than insuffi ciency of food. Still, in a certain number of cases, it is doubtless true that not enough of the nutritive principles are furnished for the digestive organs to ■work upon. Many hard-worked women in our larger cities, for in- stance, try to support life on bread and tea, and what might be called a starvation-dyspepsia is the result. The mill does not turn out meal enough, because the grist is too small. The body suffers because it has not enough material for force-production, and the digestive organs themselves are not well nourished. It has been claimed, and with considerable probability, that the decadence of the native Irish population is largely referable to their almost exclusive diet of potatoes, and the deficiency of proteid elements in their food. Moreover, this leads to what will be considered in a moment, excessive ingestion of food, for the amount of potatoes necessary to sustain life, when no other food is taken, is very great, and the digestive organs are encumbered with the bulk of matter thrown upon them, while, at the same time, the organism is, on the whole, underfed. Again, in many cases, habit- ual drinkers suffer from a deficiency in food, partly, in the lower classes, because they spend so much for liquor that they have not enough left to sufficiently feed them- selves, and partly because the vomiting following a de- bauch takes away some of the food they have swallowed. Further, the excessive use of alcohol often tends of itself to diminish the appetite for solid food. For one of these reasons or another, it is frequently observed that the vic- tims of acute or chronic alcoholism are suffering in a greater or less degree from starvation. The indigestion of infants may be in part due to a lack of a sufficient amount of suitable nutriment, though oftener this is com- plicated with what will be alluded to below as impro- prieties of food. (6) Overfeeding is a second and more common fault in Bibliography of Digestion. Mnnculus and v. Mering : Zeit. f. phys. Chemie, ii., 1879. Bidder u. Schmidt: Die Verdauungssafte. Hoppe-Seyler : Physiolog. Chemie. Bernard: Lee. phys. Exp., 1855; Comptes Rendus, 1862, ii.; Robin's Journal de l'Anat.- et de la Physiologie, i. (1864) ; Liquides de i'organ- isme. Briicke : Wien. Sitzungsberichte, xxxvii.; Vorlesungen. Kiihne: Verhandl. Naturhist. Med. Vereins, Heidelb. ; Lehrbuch. Heidenhain: Breslau Studien, 1868; Pfluger's Arch., xix., xvii., etc. Langley: Journal of Physiology. Kiihne and Sheridan Lea: Verhandl. Naturhist. Med. Vereins, Heid., Bd. i„ Heft 5. N. O. Bernstein: Ludwig's Arbeiten, 1869. Schiff : Lefons sur la Physiologie de la Digestion, ii., 1867. Rutherford : Phil. Trans., Edinb., xxvi. (1870); British Med. Journal, 1S78, 1879. Lovdowsky : Arch. f. micros. Anal., xiil. Pavy: Proc. Roy. Soc., xii. ; Food and Digestion. Mosso : Moleschott's Untersuch., xi. Goltz : Pfluger's Arch., vi., viii. Beaumont: Exps. and Obs. on Gastric Juice, 1834. Brieger : Ber. deutsch. Chern. Gesellsch., x. (1877). Engelmann : Prtuger's Arch., iv. Pfliiger : Die Hemmungsnerven des Darms, 1857. Ebstein u. Griitzner : Pfluger's Arch., viii. Eckhard : Beitrage, vii. Maly : Jahresber. d. Thierchemie. Among recent American literature on this subject the elaborate re- searches of Professor Chittenden, of Yale College, deserve special atten- tion. They have just been published in collected form. T. Wesley Mills. DIGESTION, DISORDERS OF. Taken in its fullest sense, digestion comprises all those processes which the food undergoes in passing from its crude form to its ul- timate destination of tissue-building or force-production in the animal economy. These processes may be divided into two classes, those of exterior digestion and those of interstitial digestion. The former comprises the succes- sive steps by which the food-elements are prepared for and gain access to the true interior of the body-for while in the alimentary canal they are still practically ex- terior to the body. Both extremities of that canal are continuous with the outer integument of which it thus becomes a prolongation. Interstitial digestion, whereby the elements once absorbed inside the body are made available for nutrition and force-production, is much less 452 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Digestion. Digestion. alimentation. It is probable that the majority of persons habitually take more food than their systems require, and the excess forms an incubus upon the whole of the diges- tive tract. The various ferments are made ineffective by being mixed with more food than they were designed to convert. Dilatation of the stomach and intestines follows the mechanical stretching to which these organs are sub- jected. One common cause of overeating is insufficient time given to the meals. Normally, when the stomach has received its complement, afferent impulses carried to the nerve-centres cause diminution of the appetite; but when the food is swallowed hastily there is not time enough given for these regulating processes to take place, and the stomach is overloaded before its warning of re- pletion has been received. The science of cooking, whose object should be to render food more digestible, is per- verted to the fostering of gourmandism. The dinner-pills that were in vogue in the last century saved their con- sumers from some of the effects of gluttony, and the old Romans, we are told, employed emetics as well as cathar- tics to avoid the results of taking too much food. (c) Another source of digestive derangements is irregu- lar and improper times of eating. Many business men, especially in early life, have no fixed time for taking their noonday meal. According to the exigencies of their day's work either a light luncheon or a heavy meal is partaken of ; sometimes the repast is cold, sometimes warm. With irregularity goes haste, which, as we shall see hereafter, interferes with the proper performance of the earlier mechanical and chemical portions of the di- gestive process. Like every other bodily organ, those of digestion require periods of rest. If those periods are broken in upon by the ingestion of food at any and every hour of the day, it is evident that the functions will be less perfectly performed than would be the case were their physiological demands complied with. The times of taking food may also be unfavorable by reason of their relation to other bodily states. A hearty meal late in the evening is likely to interfere either with digestion or with sleep, or both. The chief meal of the day should not be allowed to occur just previous to a time when the indi- vidual is to be either mentally or physically busy ; for in this case the activity of function elsewhere will abstract the blood from the alimentary canal, and the secretions will be defective. It will thus be seen that in the treat- ment of dyspepsia special care must be given to the times of eating. The dinner-hour must sometimes be changed from noon to night, sometimes the reverse, according to the patient's habits of work and to other considerations. The view that no food should be in the stomach at the time for sleep is probably erroneous, for in certain cases a light repast, as a glass of milk and a biscuit, shortly be- fore bedtime is well borne and seems to conduce to sleep. As a rule, the heaviest meal should be so adjusted as to be under digestion at a time neither of sleep nor of active exercise. Despite what has been said of the necessity of giving the digestive apparatus rest, it is true that in some cases, where by excess of ingestion the power of the stomach has been impaired, it may be necessary to pre- scribe frequent small meals in order to afford the econ- omy the necessary amount of nutriment, and at the same time to relieve the organs of overwork. Yet even in such cases it is needful to secure a number of consecutive hours daily when the stomach may be exempt from any work. In a word, in treating dyspepsia, it is always necessary to exercise an intelligent supervision over the times of taking food. (d) Improprieties in the character of the ingesta consti- tute another fruitful cause of impaired digestion. And here it must be said at the outset that, to a great extent, each person must be a law unto himself as to what, for him, is proper alimentation. Certain articles, it is true, are known to be less easily digested than others. But men of robust habit and active out-door occupations will often suffer no evident ill effects from a life-long diet of heavy warm bread, underdone and boggy pastry, and fat-soaked pies, to which abominations an average stomach will sooner or later succumb. Even these gastronomic sala- manders, if they change their mode of living, will often fall victims to a dietary which they have before with- stood. Witness many country lads who, transplanted from the farm to the seminary, locum non cibum mutan- tes, can no longer digest the pastry which they once ate with impunity, and perhaps swell the ranks of the cleri- cal dyspeptics. In all cases in which the digestive organs labor, it is proper to reduce the work to a minimum by cutting off the sugars and fats, which are especially liable to undergo abnormal fermentation in the primse vise, as well as pork in every form, and salted meats. Condi- ments, while a useful adjunct in moderate amounts to most persons' diet, are often abused into becoming a cause of indigestion. In some localities this fault is com- moner than in others. European residents of India are liable to contract the habit of taking an excessive amount of spices. Pepper and the stronger spices may overstim- ulate the mucous membrane of the digestive tract, and so lead to its exhaustion. Excessively hot and excessively cold foods require to be only mentioned as causes of im- paired digestion. Dr. Bowman, in his observations on Alexis St. Martin, found that the ingestion of a glass of ice-water during digestion lowered the temperature of the stomach to 70° F., and that it did not regain its nor- mal temperature for nearly half an hour. Many persons drink so much fluid with their meals as to interfere (independently of the warmth or coldness of the liquids) with the process of digestion. The effect is to dilute the ferments of the stomach so as to render them less active. Finally, under this head we must mention as a wide-spread cause of indigestion the excessive use of alcohol. It is a well-known physiological fact that alco- hol precipitates pepsin from its solutions, and while it is likely that in an ordinary meal a glass or two of mild wine does no harm to digestion on account of the lack of concentration both of the alcohol and of the pepsin solu- tion, yet the habitual use of the stronger liquors un- doubtedly seriously impairs the digestive function; structural lesions due to this cause are, of course, for the present left out of account. (e) Faulty cooking of the various articles of food remains to be mentioned as a cause of dyspepsia. The object of cooking of meats should be to soften the con- nective tissue and allow the digestive fluids to act more directly on the nutritive elements, as well as to develop certain savory qualities of the meat. In the case of most vegetables, the starch which composes them is by cook- ing gelatinized, and thus converted into a more digestible form. Egg-albumen is also more quickly acted on by digestive fluids if cooked, while milk and some few other articles are not digested more quickly after cooking. Under varying circumstances boiling, roasting, or broil- ing may be preferred as means of cooking meat, and each if properly done will add to its digestibility. But frying has an opposite effect. The surface of the meat becomes covered with a greasy layer composed chiefly of the fat in which it has been fried, and this resists the action of the digestive fluids. This constitutes a grave objection against all kinds of fried food. This method of cooking is said to be especially an American institution, and to it has been referred, with considerable plausibility, much of the American dyspepsia. Other kinds of cooking are sometimes, by negligence or ignorance, allowed to lapse into what is practically a fry. " French cooking," which is coming more and more into vogue with us, is full of violations of the laws of health ; its object being, not that which has been referred to as the legitimate end of cook- ing, but rather a stimulation of the appetite to taking a greater amount of ingesta than the economy requires. B. We have hitherto considered those causes of de- praved digestion which could be referred to the character of the ingesta themselves. We now turn to examine the sources of failure on the part of the digestive organs themselves to do their work. The two grand factors of the digestive act are (a) the mechanical and (b) the chem- ical, the former comprising those processes to which the food is subjected to bring it into contact with the diges- tive ferments, and the latter the secretion of those fer- ments which are to effect the peptonization of the ali- mentary substances. 453 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. (a) Under the former head of mechanical processes are two classes of acts, those changing the form of the food, and those altering its position, or bringing it into contact with the digestive fluids. The changes in the form of the food, or its trituration, are in the human subject performed by the teeth, its primary and rougher comminution (for which some of the lower animals, notably birds, have a special apparatus) being effected by knives or other utensils before the food is introduced into the body. (1) The proper trituration of the food requires good teeth, and a sufficiently long retention in the mouth of what is eaten to admit of thorough mastication. It may be necessary for the physician to prescribe artificial teeth if the natural ones are incapable of doing their work; and the present state of the dental art makes it possible to supply in a considerable degree natural deficiencies in this regard. Slow eating is the second prerequisite. One disadvantage of rapid eating has been alluded to under the head of overeating, but a still greater one is that just referred to. Only when the food is thoroughly reduced to a pulp is it able to be properly mixed with the diges- tive fluids. (2) The second mechanical process to which the ingesta are subjected is that which brings them into contact with these ferments. Various muscles are concerned in this function ; they comprise all the muscles of the digestive tract, from the voluntary ones of the lips, tongue, and cheeks, through the semi-voluntary ones of the pharynx, the involuntary ones of the oesophagus, stomach, and intestines, to the voluntary sphincter ani. In the stomach these muscles create currents in the contents, which are thus exposed to .the gastric juice for a longer or shorter time, until the pyloric sphincter yields and admits the food to the intestine. Here the muscles act chiefly by forcing the food downward and bringing it into contact with the digestive glands and the absorption apparatus. Any failure of any part of this muscular apparatus evi- dently offers an obstruction to digestion. Of such fail- ures as are caused by structural lesions we shall not here speak, for these cases are treated under diseases of the several organs concerned. But the two opposite condi- tions of paralysis and spasm deserve mention. Paralysis may occur in the labial or buccinator muscles, in those concerned in deglutition, or in any part of the intestinal tract. Sluggishness of the latter muscles is a very im- portant factor in indigestion, from its interference with the normal peristaltic action (constipation). The accu- mulation of the ingesta, accompanied by a chronic relaxa- tion of the muscles, may lead to dilatation of the stomach or other portions of the alimentary canal. Fecal im- paction may ensue, or; if the digestive process is arrested at an earlier stage, the relaxed visceral walls may con- tain flatus (flatulence). On the other hand, spasm of the muscles of the intestine may occur, causing that species of pain familiar to every one under the name of colic. These different anomalies may coexist in the same individual, and he may at once suffer from constipation, flatulence, and colic. All disturbances of muscular func- tion interfere with the proper rate of progress of the food, and hence with its digestion. Of course, in many cases of this sort it is the nervous system which is primarily at fault. These cases are parallel to those in which similar nervous causes lead to deterioration of the digestive fluids-a condition which will be considered below. (&) Failure of the digestive ferments. It is frequently the case that an impairment in efficiency of one of the digestive juices is accompanied by that of others as well; for similar causes operate, to a considerable extent, upon them all. Still, it is possible in. certain cases to locate the failure with some definiteness, and in order to do this it is important to have a clear understanding of what the functions of the different fluids are. The saliva, so far as it has time to act on the food, converts starches into dextrine. The gastric juice changes proteids (nitroge- nous foods, e.g., albumen, fibrin, gluten, caseine, and gel- atine) into peptone, a substance soluble in an acid, alkaline, or neutral menstruum, and not precipitable by heat. The bile has an action on fats, uniting with the acid fats (which in comparison with the neutral ones are much less in amount in our ordinary ingesta) to form soaps, which in turn are absorbed with especial ease in the presence of bile. The more important function of the bile, however, is by its action on the intestinal wall to facilitate the ab- sorption of the neutral fats, whose emulsification is ef- fected by the pancreatic juice, and to promote intestinal peristalsis. It also imparts the color to the faeces. The pancreatic juice converts proteids to peptones, changes starch to sugar and dextrine, emulsifies fats, splits them up, and by means of the alkali which is present converts them into soaps which, especially in the presence of the bile-salts, are readily absorbed. Finally the intestinal juice changes cane-sugar into invert sugar, and probably (though not certainly) has a digestive action on starch and proteids. If, then, in a given case it be found that nitrog- enous food is not digested, it may be supposed that scarcely any of the ferments are in normal activity ; for either the stomach, pancreas, or intestinal glands should have done that work. If the starches are undigested the- fault is chiefly below the pylorus, though a longer masti- cation and admixture with the saliva might in part rem- edy the trouble. If fats appear in the faeces, the liver or the pancreas is to blame, and in the former case there will be also constipation, and colorless, foul-smelling stools. The depraved condition of these various secretions, which may affect their quantity or quality, or both com- bined, is due to different causes which it will next be our task to enumerate. (1) Primary among these in importance and in frequency is abnormal nervous influence. While the digestive tract is chiefly supplied by the sympathetic system from the solar plexus, the communication of that system with the cerebro-spinal, and the direct supply of the stomach from the right and left pneumogastric, make the secretions to be under the influence of cerebral states, as well as de- pendent on the general tone of both the cerebro-spinal and ganglionic systems. It is a fact familiar to all that anxiety, worry, or fear may arrest the digestive process, and the traditions that for all time have made the taking of food the occasion for good-fellowship, and have given to guest-friendship an immunity, at least for the time being, against" plots, stratagems, and spoils," have had their foundation in physiological requirements. The ef- fect of depressed mental conditions on the digestive act may come to have the force of habit if a person is con- stantly under their influence, and in such a case an es- sential part of the treatment may be to provide for the meals being taken at times when the mental strain is as relaxed as possible, arid among congenial friends rather than alone. The state known as neurasthenia is not only an occasional result of indigestion, but is in turn fre- quently a cause of it, on account not only of the depressed psychical states which characterize it, but of the general nervous exhaustion which lowers the tone of all the nerve- cells presiding over secretion. (2) A second cause of impairment in the character of the digestive fluids is disturbance of the blood-supply of the organs secreting them. These are especially noticeable in diseases of the circulatory system. In valvular disease of the heart a passive congestion is often produced, which prevents that constant supply of fresh arterial blood and high tension in the arterial vessels which con- duce to ready secretion. The so-called "gastric-crises" of advanced heart-disease are due to this cause. The passive congestion sometimes is so excessive as to give rise to haemorrhages. The same circulatory derangements may follow in cirrhosis of the liver or other diseases which affect the portal system. The vascular conditions present in chronic interstitial nephritis are also liable to lie productive of derangements in the digestive secretions. (These are probably quite distinct from the digestive dis- turbances which are coincident with so-called uraemic poi- soning, and which have been supposed to be due to an effort to eliminate the morbific substance, urea, or what- ever else it may be, by the gastric mucous membrane.) Besides the direct effect of nervous activity on the se- cretion of the digestive fluids mentioned above, mental work or worry may also operate through the medium of 454 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. the blood-supply. A large amount of blood is deter- mined to the brain, aifd hence the digestive organs be- come anaemic. Violent muscular exercise has the same effect upon them. (3) Structural changes involving the secreting glands of course impair the character of the digestive ferments. These lesions, which are considered in detail under the subject of Diseases of the Stomach, may give rise to various dyspeptic symptoms, but of course should be diagnosticated from cases of merely functional dyspepsia. There is, however, one lesion of the stomach which is so frequently the accompaniment of a type of indigestion that it deserves special mention. This is chronic gastric catarrh. By its effect on the mucous membrane it greatly interferes with the normal function of the glands, and as its aetiology is similar in many respects to that of simple indigestion, it is probably present in many cases which are commonly spoken of under the latter title only. Symptoms of Indigestion.-Having thus considered the varieties and the causes of indigestion, we now turn to its symptoms. The most useful division of them is into (I.) those which are directly referred to the digestive tract, and (II.) those whose seat is external to it. While the significance of the former group is usually not diffi- cult to appreciate, the latter class are often ascribed to other than their true cause by reason of their apparent remoteness from the digestive organs. I. Local Symptovis.-Of these we will mention first those that are objective, then the subjective, including sensory, and finally motor disturbances of the digestive tract. (1) Of objective symptoms perhaps the most striking is the abnormal appearance of the tongue. This most frequently takes the form of a fur or coating. When the febrile state can be excluded, as well as bad teeth, en- larged tonsils, excessive smoking, and all local causes, a furred tongue usually indicates derangement of the stom- ach, bowels, or liver. In such cases the fur is usually somewhat thick, and in color ranging from a yellow to a dark shade. But besides this condition we may find in the dyspepsia of drunkards a tongue which is abnormally clean and very red, with enlarged red papillae about its tip ; this " irritable tongue," it should be said, may occur in tuberculous disease of the primae viae as well as in the form of irritation mentioned. (2) With the foul tongue there is usually to be observed a more or less offensive odor to the breath. This is often less perceptible to the patient himself than to others, but it may become marked subjectively in connection with a bad taste, regurgitation of liquids and gases, etc. (wide infra). The foul odor is due to sulphuretted hydrogen and other related gases set free by decomposition of the alimentary substances. The digestive ferments, which are anti-putrefactive in their normal condition, no longer exercise their influence, and the organic substances un- dergo a decomposition precisely analogous to that which occurs under similar favoring conditions of heat and moisture outside the body. (3) The appetite shows various signs of derangement. Often it is diminished, constituting in extreme cases the condition known as anorexia ; there may be also an unnat- urally ravenous appetite (boulimia), or these two condi- tions may alternate, the desire for food being fitful and capricious, so that the individual will one day eat inordi- nately, and the next will take almost nothing. The so- called "longings," which lead to the ingestion of unusual or even disgusting articles of food, are more characteristic of hysteria and of pregnancy than of simple indigestion. (4) Disagreeable taste after eating. This may or may not be accompanied with nausea. It is due chiefly to the effect on the terminals of the taste-nerves of the gaseous and liquid products of partial digestion, which are brought up from the stomach by an act of regurgitation, as will be more fully described below. The acidity of the mat- ters brought up may be such as fairly to ' ' set the teeth on edge." Again, the taste may be as that of rotten eggs, especially if eggs or any other food rich in sulphur have been ingested. (5) The most uncomfortable feelings due to indigestion are located in the stomach and below ; among the com- monest is a sense of fulness or oppression at the epigas- trium, which often is an indication that too much food has been taken. Instead of the feeling of bien-aiw that should follow a meal, there is a consciousness that the stomach is laboring, and a process which should go on below the domain of consciousness is lifted into an un- comfortable perception. At times this may amount to (6) Gastralgia. Gastralgia is both a symptom of im- paired digestion, and in some instances constitutes a dis- ease of itself. It therefore demands somewhat extended mention. The term, synonymous with gastrodynia or gastric neuralgia, is applied to a painful affection of the stomach without evidence of structural lesion. It is characterized by paroxysmal attacks of pain, usually of considerable severity, not limited to the period of diges- tive activity. In the acuter and severer types of the dis- ease the onset is sudden, the skin cold, the pulse weak ; there are nausea and vomiting, and other symptoms of shock. The attack is sometimes terminated by the vom- iting, and is liable to end as suddenly as it began. In more chronic forms the individual seizures may be less severe, but they are repeated. The term gastralgia is not properly applicable to those digestive pains of which mention has already been made. In the latter there is more constant evidence of dyspeptic trouble, while in the intervals of the purely neuralgic attacks the organs functionate properly. Yet in chronic gastralgia, when the seizures are frequent and protracted, and the pain is of a heavy, grinding, rather than a sharp, cutting charac- ter, it may be somewhat difficult to distinguish the con- dition from one of chronic gastric catarrh. ^Etiology: Among the predisposing causes of this dis- ease may be mentioned (a) the neurotic temperament, as evidenced by susceptibility to neuralgia in other situations ; by asthma, with which the gastralgia sometimes alter- nates ; by hysteria, especially accompanying uterine and ovarian irritation ; and by various other neuroses, (b) Anaemia predisposes to this as to the other neuralgias, (c) Malaria ; in this case the seizures are apt to have a peri- odic character, and yield most readily to antiperiodic treatment, (d) The excessive use of certain nervous stimu- lants, as tea, coffee, and tobacco, (e) Gout, in which dis- ease the common local manifestations sometimes give place to gastric neuralgia. Among immediate causes of gastralgia are (a) exposure to cold, either by draught upon the exterior of the body, or the ingestion of ice-cold substances ; (b) flatulence ; (c) strong emotions ; (d) certain kinds of food against which there is usually an idiosyncrasy on the part of the indi- vidual, as strawberries, lobster, cheese. The disease is one of youth and middle age, rather than of either extreme of life. The time of the seizure has usually no special relation to that of the taking of food, thereby differing from the pain of ulcer and cancer. The situation of the maximum pain is at the epigastrium, but it radiates thence upward over the chest, down upon the abdomen; it may pierce through to the back or shoot up to the shoulders. A peculiarity in its character, often present (but not, as has been claimed by some writers, pathognomonic), is that the pain is not increased, and, indeed, may be relieved, by local pressure. If this be ob- served to be the fact in any case, it may be taken as evi- dence that the disease is gastralgia rather than any struct- ural affection, but its absence is not proof against the neuralgic character of the disease. The ingestion of food in like manner often, but not always, mitigates the pain of gastralgia, contrary to its effect upon the structural affections. Pathologically, the disease under consideration is an irritation of the sensitive nerve-fibres passing in the trunk of the pneumogastric, and possibly, also, of fibres of the sympathetic supplying the stomach. Organic changes in the neurilemma, or tumors pressing on the nerves, are not absolutely to be excluded in any given case, as they would probably give rise to similar symptoms. But in the great majority of cases no post-mortem explanation can be found for the symptoms. Neuralgia of the solar plexus is generally mentioned in connection with gastral- 455 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gia on account of the difficulty of distinguishing between them clinically. In the situation, the causes, and the character of the pain, and, it may be added, in the treat- ment, there is little difference whether the pneumogastric or the solar plexus be implicated, though, with equal de- grees of pain, there will be in the latter case more de- pression and faintness, with perhaps a feeling of impend- ing death. Diagnosis of Gastralgia.-This affection can be dis- tinguished from the inflammatory diseases by the lack of fever. From other neuralgias, as hepatalgia, in that the latter is usually felt more severely in the right hypo- chondrium. Intercostal neuralgia will give evidence of its existence by showing painful points, usually two in number besides that at the epigastrium, viz. : close to the dorsal vertebrae and in the intercostal spaces at the side. Atonic and catarrhal dyspepsia are to be excluded by the evidence of indigestion between the painful seizures. Cancer is rendered improbable by the greater age of its victims, the more continuous character of the pain, its aggravation by eating, by pressure, the character of the vomit, and the presence of cachexia, and often of an epi- gastric tumor ; ulcer, by the relation of pain to food, its increase by pressure, the absence of periodicity in its at- tacks, also by the vomiting of blood. Heart-disease, which is sometimes simulated by gastralgia on account of the sympathetic disturbance of the heart, the irregular and feeble pulse, etc., will give evidence of itself, if pres- ent, by the usual signs in the intervals between the pain- ful seizures ; during the intervals of purely gastralgic at- tacks the heart is normal. The passage of biliary and renal calculi is to be distinguished from gastralgia by the situation of the pain ; by the further evidence of cal- culi, in the one case in the excreta, in the other in the bladder ; and by the fewer number of the attacks than in gastralgia. (7) Heartburn, or cardialgia, is another troublesome symptom of indigestion. It is a peculiar, hot, irritating sensation, produced probably at the cardiac orifice of the stomach and in the resophagus, and due always to acidity. This acidity is not due to an excess of the normal acid of the gastric juice, but to organic acids developed by a proc- ess of fermentation. It is believed that butyric acid is the chief factor of this phenomenon. Greasy foods, especially sausages, mince-pies, etc., will usually cause heartburn, and the symptom can be temporarily overcome by a small quantity of an alkali, as bicarbonate of sodium, which neutralizes the free acid. Coming now to motor disturbances of the alimentary tract, among the most prominent is (8) Vomiting.-This, though not characteristic of in- digestion alone, will, for the sake of convenience, receive a general consideration in this place. The nervous centre presiding over this phenomenon is situated in the medulla near the respiratory centre. From this ganglion efferent impulses are carried to the stomach by the pneumogastric nerve, and it is probable that the afferent impulses travel in the same tract. Ordinarily the act of vomiting is preceded by nausea. Then, with the efferent impulse to the stomach, a motor impression passes by the chorda tympani to the salivary glands, and a quantity of saliva is poured out. This is swallowed together with some air; the cardiac extremity of the stomach dilates, the glottis closes, and the intrinsic mus- cles of the stomach act, causing retching ; this ineffectual endeavor to relieve the organ is soon supplemented by a fixation of the diaphragm and a contraction of the muscles of the abdomen, whereby the contents of the stomach are ejected into the mouth. A closure of the posterior pillars of the pharynx and of the pylorus usually takes place at the same moment, but this is not constant, the failure of the former being induced by the escape of the vomitus in part through the nostrils, and a failure of the latter being shown, when the gall-bladder is full, by the regur- gitation of bile from the duodenum and the occurrence of " bilious vomiting." For medical purposes the causes of vomiting may be divided into three classes: (a) local ; (b) central; (c) re- flex. In one sense class (a) belongs under class (e), as both are produced by an afferent impulse carried to the central ganglion and reflected by an efferent nerve. But in the former case the afferent impulse started from the same locality to which the motor one was reflected, and in the latter the afferent impression proceeded from a point more or less remote from that at which its motor effect ultimately is produced. (a) Local causes. These are mostly in the form of ir- ritants to the gastric mucous membrane. Among such we may mention: gastric catarrh; the presence of un- digested food due to atonic dyspepsia, a condition very likely to eventuate in the foregoing one ; gastric can- cer ; gastric ulcer; various emetics (not including those which, like tartar emetic, act primarily on the central ganglion); poisons. (b) Central causes. Under this head are included all agents which act directly on the centre for vomiting in the medulla, and also such as are transmitted thereto from the higher cells of the cerebrum. It is to this class, as it seems to us, that the term "sympathetic" should be applied, if it is used at all, rather than (as has been done by some writers) to the irritants acting from a distance, and which will come under our third class. Under this heading we may mention : As a most perfect example, lesions of the medulla, whether morbid or traumatic, in- volving directly the central ganglion. Vomiting from cerebral disease; this occurs chiefly in the early stages of inflammatory diseases of the brain, and stops with the development of coma and paralysis. Other than inflam- matory diseases, such as tumors, etc., of the brain, pro- duce this same symptom. It may be said here, as a guide to diagnosis, that cerebral vomiting is especially likely to be aggravated by movements of the head, and is corre- spondingly mitigated by a horizontal position. There is often an absence of premonitory nausea, and there is apt to be less retching than when the cause of the vomiting is situated in the stomach, the process in the former case somewhat simulating regurgitation in infants. When due to brain disease, vomiting is usually accompanied by other symptoms, as, for instance, in cerebral tumor, headache, constipation, giddiness, and, in more advanced stages of the disease, convulsions and blindness. The vomiting of sea-sickness is due to disturbance of the cen- tres of equilibrium in the cerebellum and the semicircular canals. Sensory impressions and emotional causes may produce vomiting by direct cerebral action ; such are foul smells, loathsome sights and tastes ; also the recollec- tion of them. The same result may be produced simply through the imagination. Constitutional causes of vom- iting probably belong in this category. Such are the sur- gical condition known as shock, diseases in which the blood is charged with some toxic matter, as septicaemia, uraemia, and the beginning of the eruptive fevers, as scarlatina. Nervous irritability and neurasthenia may also be men- tioned in this connection, certain types of these diseases being characterized by obstinate and almost uncontrolla- ble emesis. Finally, certain emetics act directly upon the vomiting centre; such are apomorphia, tartrate of antimony, and ipecacuanha. There is some evidence, to be sure, that at least one of these, tartar emetic, has in addition some effect due to its local irritation of the stomachal nerve-endings. For though a solution injected into the veins produced emesis when a pig's bladder was substituted for the stomach, more of the drug was re- quired than under ordinary circumstances. (c.) Keflex causes operating from a distance from the stomach. Most prominent among these is pregnancy. Here the irritation caused by the stretching of the mus- cular fibres of the uterus sets up afferent impulses which are reflected back to the stomach. In the majority of cases this agency ceases to be operative after the first three months or so of pregnancy. Pain is, as is well known, a frequent producer of vomiting. A severe in- jury, as in a wound either of the trunk or of an extremity; the passage of renal and biliary calculi ; inflammatory diseases involving pain in sensitive parts, as peritonitis, hepatitis, ovaritis, compression of the ovary or testicle, all belong to this category. Strangulated hernia causes vomiting not only when there is pain, but when the latter 456 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. symptom is not well marked, the irritation being in such cases set up by the obstruction to the progress of the in- gesta. Tickling of the fauces is a familiar method of exciting emesis ; irritation of the pharynx, larynx, and trachea will give the same result, as may be seen after a violent fit of coughing. The matters vomited vary in their character in differ- ent cases. They may consist of the ingesta returned in an unaltered state ; this happens when the vomiting occurs soon after the food is taken, and, in cases of extreme in- digestion, when there is little or no gastric juice. Usually the vomitus consists of food more or less completely di- gested. The vomiting of curds, for instance, of a sour smell, often mentioned by mothers as a grave matter, is just what is to be expected if the stomach is functionat- ing at all, the gastric juice having coagulated the casein. Blood may be ejected in certain cases more or less acted upon by the gastric juice. In ulcer of the stomach it is sometimes thrown up in large amounts, and if a large vessel has been opened in bright red color. In cancer, and in cases of passive congestion, when the blood es- capes from the vessels more slowly, it is decomposed, and assumes a dark, grumous appearance, sometimes spoken of as the " coffee-ground vomit." The " black vomit" of yellow fever consists also of altered blood. The occur- rence of bile in the vomit is of no special significance, as has been intimated above. It generally means severe retching which has by its mechanical effect forced the bile backward through the partly open pylorus. Fungi may be found in the vomitus, either that of the yeast or the cubical bodies with transverse markings, called, from their resemblance to corded bales of merchandise, sar- cinse. These are recognizable only by the microscope, though the presence of the sarcinse gives rise to a some- what characteristic frothy matter, which should lead the observer to minuter examination. The sarcinse simply indicate long retention of the stomach contents within its cavity, and, for the reason that this state of things is especially apt to occur when there is some mechanical obstruction to the complete emptying of the stomach, sar- cinae have come to be looked upon as somewhat pathog- nomonic of structural disease of this organ. Carcinoma of the pylorus, with dilatation of the stomach, forms one of the most favorable conditions for the development of sarcinae, but can by no means be diagnosticated from their presence. The time of vomiting with reference to the taking of food is of some significance. If it occurs habitually di- rectly after the food is swallowed, we may conjecture that if there is a structural lesion it involves either the oesopha- gus or the cardiac extremity of the stomach. If, on the other hand, the vomiting comes on generally only after three or four hours from the time of eating, we may sup- pose there is an obstructive lesion involving the pylorus, which prevents the chyme from passing into the duo- denum. The gastritis of drunkards is especially apt to cause vomiting on first rising in the morning before any food has been taken. The vomiting of pregnancy is also rather worse in the early part of the day than later, and in such cases is often relieved by a small quantity of food. (9) Flatulency or Tympanites.-These terms, of which the latter refers more particularly to a retained and distending, the former to a moving and escaping, gas, ap- ply to a condition in which gas is present in the stomach and intestines to a degree sufficient to cause disagreeable sensations in the patient, and to give a tympanitic note on percussion. A lesser degree of gas is probably a normal accompaniment of digestion. Practically, no distinction need be maintained between tympanites and flatulency. In this condition, the gas has three possible sources, the swallowing of air, gases arising by diffusion from the blood, and the fermentative decomposition of food. The oxygen from the air swallowed becomes absorbed, and CO2 is the gas chiefly diffused from the blood. Thus the latter gas, with N, is the principal constituent of gastric eructations. In the intestines H enters into the composition of the flatus. It is probably here that the fermentative changes play the largest part in the evolu- tion of gas, the sugars and starches lending themselves most readily to such changes. The H exists not only alone, but in combination with C and S, the H2S being the special cause of the malodorous quality of the gas. The swallowing of air with the food, unavoidable in a small degree, becomes at times a distressing habit. The habit is identical in character with that known in horses as "cribbing." Air thus swallowed is nearly all re- turned by the mouth. The symptoms of tympanites are tolerably familiar to most persons from their own experience. A feeling of distress comes shortly after eating, which quickly gives place to the belching up of mouthfuls of wind, tasteless, or having a sour or unpleasant odor, sometimes as of rotten eggs, accompanied occasionally with a few drops of fluid (pyrosis). Oppression of the breathing results from the extreme distention. As the gas forms in the intestine less of it passes by the mouth, cramps of greater or less severity are felt, due to distention of the intestinal muscles by the gas ; rumblings (borborygmi) are heard, due to a mixture of gas with fluids. These sounds are audible not only to the patient himself, but also to the bystanders, and are often a source of great mortification to female patients who suffer thus. The cramp caused by the flatus is relieved by the passage of flatus per anum, or by its passage into a more extensive portion of the intestine, thus relieving the tension to the square inch. The physical sign of tympanites is a resonant note on percussion over the stomach and bowels indicative of the presence of gas beneath. In extreme cases the abdomi- nal wall is puffed up into a dome-shaped swelling. Besides being symptomatic of indigestion, tympanites occurs in other abdominal diseases, as notably in perito- nitis ; in cases in which the lumen of the canal has been ob- structed, either from cicatrization or from a new growth. It may become chronic after enteritis or peritonitis, or some forms of spinal lesion ; in such cases there is prob- ably atony of the muscular fibres. Hysteria is often ac- companied by enormous tympanites. The latter symp- tom, indeed, has been of value in the diagnosis of hysterical convulsions ; and the withdrawal of the flatus by a rectal tube is sometimes a useful preliminary to the treatment of such conditions. Flatulence is often an annoying attendant upon the " change of life." (10) Constipation. (11) Diarrhcea.-All that it is necessary to say on these subjects has already been said under their respective headings. (12) Another motor disorder characterizing indigestion is Pyrosis, popularly known as " water-brash." A small quantity, usually less than a mouthful of this fluid, is suddenly, without any accompanying nausea or retching, raised into the mouth. The movement is probably ef- fected by the inverted action of the oesophageal muscles, or at most by the intrinsic muscles of the stomach, the diaphragm and abdominal walls being passive. This fluid is usually of an alkaline character, and its source is not certainly known. According to some authorities, it is saliva which has been prevented from passing into the stomach by spasm of the cardiac extremity. Others be- lieve it to be the secretion of glands at the lower end of the oesophagus. The fluid may, however, be acid from admixture with the contents of the stomach, and the re- gurgitation may be synchronous with the sensation of " heartburn." Hence, by many authors the term pyrosis is made to cover heartburn (the true cardialgia) as well as water-brash. II. Sympathetic Disturbances. - These are very fre- quently caused by indigestion, and their seat may be so remote, and their character so different from those here- tofore described, that a wrong interpretation may be put upon them. The vagus nerve is the channel of sensation from the stomach, and an irritation originating in the mucous membrane of that organ may be referred to other terminal branches of a nerve supplying other viscera. Further, an actual disturbance of these other viscera may be set up by reflex influence from the irritation of the stomach. (1) Cardiac irregularities arc among the most frequent of such phenomena. Palpitation, irregidar pulse, pne- cordial pain, all may lead the patient, and possibly the 457 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. physician as well, to the conviction that serious structural disease of the heart is present. The anxiety which is al- ways caused by irregular heart action is reinforced by that state of mental depression which, as we shall soon see, attends digestive disorder. While it is true that functional disturbance if long continued may lead to structural lesions, yet in the majority of cases of pri mary dyspepsia the heart symptoms will entirely disappear as the digestion improves. It is also noticeable that in persons suffering from functional heart symptoms so caused, the exacerbations are found to be nearly coinci- dent with an increase of the coating on the tongue, the cardialgia, the foul breath, or whatever local symptom is in the given case most prominent in the indigestive crises. (2) Other thoracic viscera may be similarly affected. Dyspnoea may be produced by mere mechanical means, a stomach distended by flatus encroaching upon the res- piratory space by interfering with the descent of the dia- phragm ; it may, however, be purely reflex. More fre- quent is the nervous cough, which is observed in chronic indigestion. Accompanied, as it is, by signs of grave general illness and impaired nutrition, amounting in some cases to extreme emaciation, it may in the absence of a careful physical examination be mistaken for the cough of phthisis. This cough, sometimes popularly known as a "liver-cough," is not due to any disease of that organ so much as to a general indigestive condition. Of course, however, the existence of dyspepsia does not prevent the coexistence of a catarrhal condition of the pharynx or bronchi, or even of phthisis. (3) Oxaluria, which is a tolerably frequent attendant upon functional dyspepsia, may give rise to some renal or vesical irritation, and this, taken in connection with pain in the back (digestive pains involving the nerves on the posterior wall of the stomach are apt to be referred to the back), may give rise to the opinion that the malady is one of the kidneys rather than of the digestive apparatus. (4) The cerebral functions, too, suffer by reflex influ- ence from the seat of indigestion, and the phenomena so produced are, perhaps, enhanced by the circulatory dis- turbances which are also found. In many cases during the period when the stomach is laboring the face becomes flushed, and a general determination of blood to the cerebrum is caused in part by the excited action of the heart, and in part by the interference with the centripetal course of the blood. Experience shows, for instance, that one of the exciting causes of cerebral apoplexy is a full meal, (a) Headache is by common observation a symp- tom of indigestion. It is especially marked in those transient, occasionally recurring attacks of subacute gas- tric catarrh known as " bilious attacks," or by some as sick headache. (It should be remembered, however, that the term ' ' sick headache " is also applied to the ner- vous affection known as migraine, in which the vomiting is sympathetic with the neuralgic pain.) (b) Minor dis- turbances of vision are also met with, consisting chiefly of blurring, with, perhaps, floating particles, ' ' muscae volitantes." These are of importance only as combining with other cerebral symptoms to alarm the patient; in- trinsically they are of little account, (c) Sleeplessness, or a rest broken and harassed by dreams may occur, so that the patient arises unrefreshed. (d) Perhaps no one cere- bral symptom of indigestion, however, excites so much alarm, and so thoroughly convinces the patient that some- thing serious is the matter with him as vertigo. And this is not of infrequent occurrence. We know that this symptom is sometimes of serious import in connection with disease of the heart and brain ; moreover, it is not always possible to distinguish the stomachal vertigo in its character from that of graver significance. It is to be taken in connection with the absence of other signs im- plicating those viscera, as, for instance, in the case of the brain, pain, vomiting, disturbances of sensation, motility, and cerebration. Yet some of these symptoms of brain- disease, it will be observed, coincide with those of indi- gestion, which adds to the difficulty of diagnosis. In general, when due to digestive disorder, the vertigo is less constant, being coincident with exacerbations of the stomachal inaction, though there may be in chronic cases a slight giddiness for a long time. Sometimes it is diffi- cult to recognize the fact of indigestion for the reason that the tongue may remain clean ; but usually in a case of vertigo a stomacho laeso, as Trousseau calls this variety of giddiness, careful examination will reveal evidence of some sort that the digestive act is not being perfectly per- formed. This vertigo is never attended with loss of consciousness. Moreover, stomachal vertigo is said to have this peculiarity, by way of distinction from the cere- bral form, that the latter is objective, surrounding objects seeming to move about, while the patient himself remains still; on the other hand, in stomachal vertigo the sensa- tion is subjective, and the movement seems to be in the individual himself. In the cerebral vertigo, therefore, closing the eyes relieves it, whereas in the other .form it does not. Practically it will be found often difficult to persuade a hypochondriacal person of dyspeptic habit that he is not likely to have " softening of the brain," or some other serious cerebral malady when he suffers se- verely from vertigo. To do this a certain diagnosis must be made, and this, as has been seen, is not always per- fectly easy, (0 The influence of indigestion upon the psychical state is one of the most unfortunate and most remarkable of its effects. The whole range of mental ob- liquities, from slight peevishness to downright melan- cholia, may be met with. The whole character of a man, and the prevailing type of his thought may be changed. If, for instance, the sufferer is a religious man, his views of theology may show a dark and sombre hue. If he is in domestic life, his family and friends may be martyrs to his ungracious and splenitive moods. Examples are not wanting of men eminent in the literary world whose writings bear distinct evidence of the depraved state of their stomachs. This depression of spirits and anxiety feeding upon some of the reflex phenomena of indigestion before mentioned, is liable to lead to that pitiable condi- tion known as hypochondriasis, when the individual fancies himself the prey to all imaginable diseases. It remains to mention two general symptoms of indi- gestion, both probably due to the lack of nutritive ele- ments furnished to the economy. (5) The first is emaciation, which may, under some cir- cumstances, become extreme. It of course requires to be differentiated from other recognized causes of wasting. (6) The condition known as nervous exhaustion, or neurasthenia, may owe its origin in part to dyspepsia, as a predisposing if not an exciting cause. Dr. Bartholow, indeed {Boston Medical and Surgical Journal, January 17, 1884), goes so far as to say that there is no symptom in the catalogue of those belonging to neurasthenia which may not be due to merely reflex influences having their seat in the digestive apparatus. Whether this extreme view be accepted or not, it is evident that in a system of organs making a large daily expenditure of force, if the force-producing supply is impaired by any cause, the functional power of the organs must suffer. This effect certainly is produced by indigestion. It will be seen that the foregoing list of symptoms are none of them pathognomonic of functional indigestion. They are such as proceed from a mere failure of the act of digestion to be performed, alike whether that failure is the result of structural lesion or not. When we can find no evidence of organic disease, we speak of the case as dyspepsia. It is possible that in the future we may discover that certain cases now classed as dyspepsia are in reality structural diseases of one or other organ in- cluded in the digestive tract-stomach, liver, pancreas, or intestine. Bilt for the present our clinical is in arrears of our pathological knowledge. For while the latter has differentiated for us a condition which, as having the character of a structural lesion, would not strictly come under the head of dyspepsia, yet this condition is often, clinically, hardly to be distinguished from one in which no such morbid appearances can be found. Gastric ca- tarrh, from the non-fatal character of the disease, can be recognized only when the patient succumbs to some other and graver malady. Yet during a long course of indigestion the catarrhal condition may have been now present, now absent, according to the aggravation or the 458 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion^ Digestion. alleviation of those factors upon which it will be seen to depend. Hence it is thought best to transfer its consid- eration to this connection out from the list of diseases of the stomach. Pathology.-The pathology, then, of dyspepsia, may be said to be twofold. Atony of the stomach, or atonic dyspepsia, is a disease in which it is probable that the ner- vous system is primarily at fault. In a simple case of this kind there would be no morbid anatomical appear- ances. It is presumed in such cases that the amount, possibly also the composition, of the gastric and other di- gestive fluids is impaired. This is the type which is char- acterized clinically by general nervous weakness, husky voice, relaxed throat, flabby, anaemic tongue (perhaps not so coated as in the other form of the disease), clammy skin, cold extremities, impaired memory, and indisposi- tion to intellectual exertion, with horrible mental depres- sion ; in a word, general symptoms predominating over local, though there is usually some flatulence and oppres- sion after eating. This state of things continuing is apt to give rise to the second, the catarrhal form of the dis- ease, as follows : The ingesta not being properly acted upon, owing to the quantitative and perhaps also qualita- tive defects of the gastric juice, accumulate, undergo par- tial decomposition, and form an irritant to the walls of the stomach. The mucus, which is normally present, is poured out in excess, with accompanying inflammation of the mucous coat. Thus we have catarrh. The thick coating of tenacious mucus keeps the food from the ac- tion of what gastric juice is present, and the reaction, in- stead of being acid, as it should be, becomes alkaline ; in such a menstruum pepsin is inert. The continued ca- tarrh may cause, by extension of the inflammation to the submucous coats, an interstitial gastritis. The thicken- ing of the walls may impair the muscular movements, and so the imperfectly-made chyme may be retained to add to the irritation, instead of being passed on into the intestine. If this be the case dilatation of the stomach may be the next step in the pathological process, the food accumulating perhaps for days, until it is discharged by an attack of vomiting, whose results appall the patient. The long retention and fermentation of the ingesta may thus cause the appearance of sarcinae in the vomitus. An extension of the catarrhal process to the intestine is an- other obvious step in the pathological process. This is evidenced clinically by distress coming on or continuing some hours after the ingestion of food, and is sometimes accompanied by diarrhoea ; but, on the other hand, con- stipation may be produced through the impairment of the vermicular movements of the intestines. The symptoms found clinically, then, in such a form of the disease, will be likely to differ from those of a simple atonic dyspep- sia by the greater relative prominence of pain, irritating diarrhoea or constipation, and other phenomena directly referable to the digestive tract. It must not be understood, however, that the above is the only pathogenesis of gastric catarrh. It may occur independently of any antecedent atony. Irritating foods and such as are difficult of digestion ; excessive amounts even of proper articles of food ; substances that are either very cold or very hot; concentrated alcoholic beverages ; articles which have begun to decompose; any of these causes operating once may bring on an attack of acute catarrh, or if continued may develop the chronic condi- tion. The last two causes mentioned are among the most prolific, leading in the one case to the chronic catarrh of drunkards, and in the other, by means of milk which has begun to ferment, to the serious gastro-intes- tinal derangements of infants. The anatomical appearances in gastric catarrh, whether it be secondary to atony or due to some of the irritants above mentioned, are as follows : The walls of the stomach are covered with an abundance of viscid, tough mucus, of a grayish-white color, which is washed off with difficulty. The mucous membrane is seen to be hyper- trophied, and forms numerous elevated folds ; the eleva- tions are bounded by furrows, giving an appearance which has been called mammillated ; this is due to enlargement of the gastric glands. The color of the mucous membrane is a dark brown or slaty gray, due to the transformation of the hsematin deposited by old haemorrhages ; the ves- sels are seen to be enlarged. All the foregoing appear- ances are rather more marked at the pyloric end of the stomach than elsewhere. The muscle may be thickened, owing to an extension of the inflammation to the sub- jacent structures, and the hypertrophy may be such as to cause an encroachment upon the lumen of the pylorus, in which case the whole organ may be dilated behind the stricture. In acuter forms of the disease the color of the mucous membrane is not so dark, the injection is finer, the capillaries not having yet become dilated ; an exces- sive quantity of tough mucus is found usually, although it is to be said that in many cases, particularly of infants, when the symptoms had pointed strongly to the presence of catarrh, little post-mortem evidence of it is to be found. The so-called gastromalacia, which was formerly sup- posed to be the pathological indication of the catarrhal process in children, is now known to be due to post-mor- tem digestion. Accompanying the anatomical evidences, of catarrh already mentioned, w'e may also find an ex- tension of the process into the intestine ; for a fuller de- scription of which, however, the reader is referred to its appropriate heading (see Intestines, Inflammation of). Diagnosis.-In addition to w hat has already been said, it remains to mention in this connection the grounds of discrimination between a dyspepsia, atonic or catarrhal, and those graver chronic structural diseases w7ith which it is oftenest confounded. These are especially gastric ulcer and cancer. The former of these, it should be said, and possibly the latter, may be developed as the result of a long-standing catarrh, so that a diagnosis of this last- mentioned affection at one time does not exclude the presence of an ulcer later. The pain of chronic ulcer is generally more severe than that of gastric catarrh ; it is more aggravated by the ingestion of food, the aggrava- tion often occurring within fifteen minutes after the meal. The localization of the pain is more definite, sometimes a circumscribed spot of tenderness being detectable in front, with another at the spine corresponding to it. Re- missions, or even intermissions, may occur, as with the inflammatory pain, and last for days. In cancer these intermissions are less common; the pain often is of a radiating character. There may be no more tenderness than is found in catarrh. The symptoms of indigestion, notably acidity and fetid breath, are rather more continu- ous in cancer than in catarrh, especially if the diet be properly regulated ; although it is to be said that a care- ful supervision of the character of the ingesta in cancer has frequently led to such relief of the symptoms as to cause the physician to change his diagnosis to catarrh only to find his error after later developments. Vomit- ing, as a rule, is rather less common in catarrh than in either of the other diseases. The vomitus is apt to con- sist of tough, stringy material, composed in part of modi- fied hydro-carbonaceous ingesta and in part of mucus. The food is rarely returned unaltered, as it may be in the case of ulcer or cancer of the cardiac extremity. The presence of sarcinae is of no diagnostic significance. Haemorrhages are exceedingly rare in gastric catarrh, and the presence of blood, whether fresh or altered, in the vomitus is, therefore, suggestive of structural disease. The degree of emaciation in dyspepsia is much less than in the other diseases, and while the face may show im- perfect nutrition it is devoid of that cachexia which is the usual accompaniment of cancerous disease. Finally, in doubtful cases, our diagnosis will be influenced in some measure by the progress of the disease. If the malady have lasted more than two or three years, or if even in a shorter time it has shown no tendency toward becoming progressively worse, it may be considered much more likely to be a dyspepsia than a cancer. Cerebral diseases must also be diagnosticated from in- digestion, especially when the latter disease is accom- panied by great mental depression, vertigo, etc. The diagnosis can usually be made by detecting evidence of long-standing impairment of digestion, even though its subject may not have been especially conscious of it, and by interrogating the functions of the cranial nerves and 459 Digestion. Digestion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the cerebral centres, as well as by ophthalmoscopic examination, etc. Treatment.-(1) Under this heading we may consider first the indicatio causalis. The reader is referred to what has been already said under the aetiology of indigestion. All irrational and unhygienic modes of life must be cor- rected. In cases in which the nervous tone seems primarily at fault remedies must be directed especially toward im- proving it. The abuse of alcohol must be prevented, and when a gastric catarrh seems to have been caused by this agent total abstinence should be inculcated. Passive con- gestion, due to valvular or other disease of the circulatory system, requires that its cause be remedied if possible. In such cases digitalis or other appropriate heart tonics may be indicated. Whenever nephritis is found to be present the treatment should recognize the fact that the indiges- tive crises are probably due to an attempt to eliminate excrementitious products from the blood, and should therefore include the regimen of the kidneys as well as hot-air baths if necessary. (2) Hygiene is of importance. Like other mucous sur- faces, the gastro-intestinal is subject to the influence of sudden temperature changes. Chronic catarrh is apt to be aggravated during the winter and spring months from this cause. Flannels and equable clothing are therefore of importance ; of especial value are frictions of the skin. These may be made to follow salt baths (natural or artifi- cial) or cold sponging. But even in cases in which no bath is taken, the vigorous use of the flesh-brush or the coarse towel is of great value. Great stress should also be laid upon exercise, particularly in those cases in which it is found that the individual has undergone a marked change in his manner of life in the direction of sedentary occu- pation. Gymnasium practice, and, better still, outdoor exercise, should be insisted upon. Horseback riding for an hour or more daily, judiciously timed with reference to the hours for eating, is perhaps, on the whole, the most valuable form of exercise for dyspeptics. Some, for whom a horse is too expensive, have derived benefit from the use of the bicycle or tricycle ; this method of exercis- ing, however, is too dependent on the weather and the state of the roads. Walking is within the reach of nearly ali, and should be enjoined daily, whether the weather be fair or foul. (3) Mechanical treatment is useful in a certain class of cases, particularly those in which a long-continued catarrh has led to the retention of large quantities of partly-digested, fermenting food, which in its turn has produced dilatation. Here great relief is sometimes brought by washing out the stomach at stated intervals, as, for example, once to thrice daily. This may be done by means of the stomach-pump, or by a simple rubber tube operating on the principle of the siphon. The pa- tient can be taught after a little experience to introduce the tube and perform the washing himself. By this manoeuvre the accumulation of fermenting products is stopped, and it is possible that some of the excess of mu- cus is washed off. At all events the ' ' tone " of the gas- tric coats is improved, and it often happens that after a few sittings the stomach acquires the power of passing its contents onward into the duodenum. Relief of pain and immediate improvement in the body-weight have been repeatedly witnessed as the result of this treatment in appropriate cases. The method is, as has been already indicated, chiefly mechanical in its effects, and hence warm water is usually all that is necessary for the fluid ; but according to the symptomatic indications the water can be acidulated, alkalinized, or even carbonated. (4) We now come to the important question of the die- tetic treatment of dyspepsia. Quite recently the doctrine has been advanced by certain high medical authorities, that greater harm may be done from a too narrow restric- tion of the diet than from no limitation at all; that the instinct of the individual should be followed as far as possible, and that he is likely to do better in proportion as he thinks little of what he may or may not eat than when he conforms strictly to a narrow dietary. It is certainly true that flavors and other obscure elements in food which constitute an adaptation to the idiosyncracy of the individual, and which are often indicated by the natural craving, constitute a better measure of the dietetic value of food than any chemical or physiological behavior of the food as studied in the test-tube or through a gastric fistula. Some persons, for instance, have a strong aver- sion to " slops " of all kinds, and an attempt to force them to subsist on liquids would be very unwise. They will thrive much better upon solids. Yet, while the physician is justified in following to a certain extent the cravings of his patient, there are generally some articles which, in accordance with principles already laid down, must be proscribed, and in extreme cases a much wider prohibition is required. Obviously, first we must strike out those substances which are especially prone to un- dergo fermentative changes, as the sugars and fats. In cases of moderate severity we may have in the die- tary the simpler proteids, cooked lightly so as to devel- op their sapid qualities, but not to toughen them. Un- derdone, lean roast-beef is one of the most valuable foods in many cases ; it may be supplemented by raw oysters, lightly-boiled eggs, niilk, Graham crackers, stale home- made bread, and oatmeal, or groats. After a time, as the patient improves, he may take baked apples, and even raw fruits, beginning with those which are least sweet. Starchy foods must often at first be prohibited, along with their congeners, the sugars, but can frequently be resumed before the latter in the course of the patient's progress. At first the more succulent vegetables are only to be allowed, such as celery, lettuce, spinach, cauliflower, and tomatoes, and then we may add, cautiously, those containing a little starch until we get up even to the po- tato. In certain aggravated forms of indigestion the stom- ach of the patient requires, as it were, to be brought back to first principles. An approximation to the diet of in- fancy is therefore sought. The so-called " milk-cure " is based on this indication, and many cases have been re- ported where it has worked well. The fatty portion of the milk, being, as above mentioned, the constituent most trying to an enfeebled stomach, is often removed, and the patient is given either skim-milk or butter-milk. For a period lasting a month or two, or so long as the catarrhal symptoms persist, no aliment is administered but the milk, which is given in four-ounce doses about once in three hours, day and night, except during sleep. Krukenburg's prescription, quoted by Niemeyer, is, "when the patient is hungry, let him eat butter-milk ; when he is thirsty, let him drink butter-milk." The milk-cure is not always well borne, the patient's strength not keeping up well un- der it, in which case it may be supplemented by some of the prepared foods with which the market is sup- plied, and from which the starch has been removed to fit them for infant feeding. The transition from these ali- ments to a more extended dietary is to be managed on the same general principles upon which the similar process is accomplished in the bringing up of an infant. In those aggravated cases in which vomiting is continuous, it may be necessary to suspend all food for a time, and have re- course, until the stomach becomes tolerant, to nutrient rectal enemata. (5) Before passing to the strictly medicinal treatment of indigestion, it is appropriate at this point to speak of the use of artificially-digested foods and of the digestive fer- ments. These ferments, which may readily be extracted from the respective organs which secrete them, will, un- der appropriate conditions, perform their function outside the body. The suggestion is an obvious one, therefore, that they can be utilized in cases of deficiency in the natural fluids. The active principle of the gastric juice, pepsin,ds obtained usually from the stomach of the pig, and in an acid medium (dilute hydrochloric or lactic acid) is of value in certain cases. It acts not simply as a sol- vent, but as a ferment, and if enough dilute acid is sup- plied, will set up in the products of digestion themselves the power to continue the process. Hence ten grains of pepsin, an average dose, will convert many times jts weight of albuminoid matter into peptone. Rennet wine, an analogous substance, consisting of a freshly-prepared stomach digested in sherry wine, is also of use ; for, while alcohol in large quantities destroys the action of 460 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestion. Digestion. pepsin, yet in moderate amounts it does not impair it. Many of the preparations of pepsin in the market are valueless, for the reason that they have been mixed with alkalies. Pepsin is indicated in those cases in which there is lack of gastric juice from atony of the stomach ; but equally good, if not better, results are often obtained from remedies directed to stimulating the stomach to secrete its own gastric juice. Pancreatine, the principal other ferment used medicinally, is operative only in an alkaline menstruum. Much discussion has therefore arisen re- garding the reasonableness of administering it by the mouth, where it will at once pass into acid solution. Claims have been made as to its capacity for performing a certain amount of digestion in the stomach before it be- comes sufficiently acidulated to be rendered inert, and it is also said to have some power over albumins in an acid menstruum ; but the fact is undoubted that in the pres- ence of pepsin pancreatine is itself digested like any other albuminoid substance. Hence the uselessness of giving it in combination with pepsin, as is done in some of the popular digestive powders (e.g., lacto-peptine) and, in fact, of giving it by the mouth at all. If it could be at once introduced to the duodenum without passing through the stomach, it would doubtless be a useful agent. The extractum pancreatis, or the freshly-chopped pan- creas, combined with a little bicarbonate of soda, is a very useful addition to rectal enemata. The same objections which apply to pancreatine given by the mouth are prob- ably equally applicable to ingluvin, an alleged ferment derived from the stomach of the fowl. On account of the obvious limitations to the use of these ferments when administered for the sake of their action in- side the body, the suggestion has been made to accomplish the artificial digestion of the food by their aid before it is swallowed, or, in other words, to use peptones as food. The chief practical objection to this is their disagree- able taste. The by-products of peptic digestion are es- pecially unpleasant. In the last two or three years, how- ever, peptones prepared by the extract of pancreas have been used considerably, and with fair success. The pro- cess is applied especially to milk, milk-gruel, and broths. Exposure of the food for an hour at a temperature of 100° C. (212° F.) to the action of the extractum pancreatis and sodae bicarb, changes it to peptone, the appearance not being altered, but a bitter taste being developed. Dr. William Roberts1 recommends this method, but advises that the digestion be only half-accomplished outside the body, being stopped as soon a» the bitter taste begins to be noticed. He has found the use of these peptones es- pecially valuable in uraemic vomiting ; in gastric catarrh, whether due to alcohol or to cirrhotic diseases ; also, in the indigestive crises of cardiac disease, and in other similar conditions. . (6) Passing now to the drug-treatment, we find many medicines recommended for dyspepsia, some of which are of undoubted efficacy. Emetics are occasionally of value when the stomach is distended with undigested matters, at the beginning of a systematic treatment for dyspepsia, and sometimes in acute indigestion. But a frequent re- sort to them is to be deprecated, inasmuch as the irrita- tion is apt to enhance the catarrh. Cathartic, or prefer- ably laxative, medicines are occasionally called for when there is obstinate constipation, as it is found that the symptoms are liable to become aggravated if the intestine is overloaded. Among the most useful laxatives are the alkaline mineral waters, as Congress Spring, Friedrichs- hall, Pullna, Hunyadi Janos ; these may be taken daily in small amounts before breakfast. When these natural waters are not available, small quantities of Epsom salts in considerable water will serve a good purpose. More agreeable, but also more expensive, are the granular effer- vescing preparations of magnesia. Among the non-saline laxatives the most useful are those which have a special action on the liver, such as mercurials, aloes, and podo- phyllin. The first is indicated when the stools are too light in color, but, of course, in chronic cases a continued use of this drug must be made only with caution. Podophyllin, on the other hand, according to Ringer, is of special advantage when the stools are dark, and may be used in such cases whether there is constipation or not, in the latter case the dose being small, e.g., one-thirtieth to one-twentieth of a grain, morning and night. In chil- dren gray powder and calomel are the most convenient form of mercurials, while in adults blue mass and the bi- chloride may be used; as a rule a mercurial should be followed by some saline. Aloes is most useful in com- bination, either as the compound extract of colocynth or in a pill with nux vomica. The pure bitters, as quassia and columbo, and the alkaloids quinia and strychnia (which in small doses have somewhat the same effect) are often of use in dyspepsia. Strychnia, in conjunction with small doses of ipecac, has been found very useful by Fothergill {Medical Record, September 1, 1883) in atonic cases. The efficacy of the latter drug may be due to its cholagogue action. These bitters do not directly assist digestion ; in fact, their admixture with a digestive ferment diminishes its action. Yet the effect of their contact on the stomach- wall is to give rise to an irritation which is enough like hunger to stimulate a debilitated organ to pour out its secretions. The aromatic bitters, such as chamomile and the spices, pepper, etc., act in a similar way ; a practical point about the latter being that, if a patient has been ac- customed to their use, it will not do to proscribe them at once and entirely. Tincture of nux vomica, in doses of from three to ten drops, three times daily, either alone or in combination with dilute nitric, muriatic, or nitro-muri- atic acid, is of great value in many cases of atonic dyspep- sia and the gastric catarrh of drunkards. The use of the acids and alkalies in dyspepsia is a matter in regard to which there is much confusion, due, perhaps, to insufficient attention to the time of administration. The ingestion of an acid into an empty stomach has the effect of diminishing the amount of the gastric juice, per- haps on the principle that the osmosis of those constituents of the blood which form that acid secretion is thereby hin- dered. On the other hand, the administration of an alkali before meals increases the quantity of the gastric juice. Acids before meals not only diminish the gastric juice, but also that excessive acidity which comes from the abnor- mal fermentation of acids, wdiich especially gives rise to the symptom known as "sour stomach." This last in- dication can also be met by the use of an alkali after meals, which is, however, only a palliative, requiring to be re- peated always, pro re nata, and not correcting the morbid condition so satisfactorily as acids before meals. Acids taken after meals do not, as when before meals, diminish the secretion of gastric juice, for that secretion has already been made. They do, however, possess the power of in- creasing the digestive capacity of a moderate or insuffi- cient supply of gastric juice. This may be observed in artificial digestion conducted in a test-tube, where, after a given quantity of pepsin has done all it can, the addition of more acid will accomplish more digestion. In a word, acids before meals diminish the supply of gastric juice ; after meals they impart to a scanty supply greater effi- ciency. If pyrosis is a marked symptom in any given case, it is well to test the reaction of the fluid regurgitated. If the fluid is alkaline, relief may be often gained by neu- tralizing it with an acid, that is, an acid after the meal. If the fluid raised, however, is acid, obviously the injec- tion of more acid will simply intensify the symptom, and the acid must, in such cases, be given before meals. Hy- drochloric acid is usually the best form of acid, and liquor potassae, bicarbonate of soda, and lime-water are the best varieties of alkalies in dyspepsia. Phosphate of soda is recommended by Bartholow where there is any biliary derangement. Certain individual symptoms connected with indiges- tion frequently demand direct treatment. Prominent among these is Vomiting.-In vomiting due to central and peripheral conditions an attempt should be made, if possible, to re- move the cause. If this can be done little local treatment will be required. When the vomiting is due to conditions existent in the stomach, the following measures will be found more or less effective. They may also be employed in obstinate cases of peripheral origin, but in some of the 461 Digestive Secretions. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. latter, as in pregnancy, it may be necessary to try many remedies before relief is obtained. Of primary impor- tance is regulation of the ingesta, which should be made as bland and unirritating as possible. In acute cases of vomiting it may be well to suspend all food for a time, but of course this cannot be continued for more than a day or two. If absolute intolerance of food lasts a longer time than this, nutritive enemata should be employed, and the stomach allowed a period of rest to regain its power. Before resorting to rectal feeding, trial should be made of the blandest foods. Of these milk is usually the best. It should be given in very small quantities at frequent intervals, say a teaspoonful every fifteen min- utes. With this it is well to combine an alkali, as bicar- bonate of potassa or soda. Nothing is better, however, than lime-water, in the proportion of one-fourth to one- third the bulk of the mixture. In the rare cases in which milk disagrees, beef-tea may be substituted for it; or scraped beef or egg-albumen. From these beginnings the diet can be gradually extended as the stomach regains its tone, the important principle being to give the food in small quantities frequently repeated. Cracked ice, to be swallowed in small morsels, is of use. Carbonated waters, as Apollinaris, Seltzer, Vichy, and other efferves- cent natural waters, as well as " siphon soda," are often of great service. Counter-irritation over the stomach by sinapisms may be made. Among the drugs used prefer- ence is to be given to those of' small bulk and feeble taste. Such are dilute hydrocyanic acid, in doses of .06 to .25 c.c. (1 to 4 minims), repeated hourly ; wine of ipe- cac, .06 c.c. (1 minim), every hour; calomel, 3 milligr. 6/u grain), in powder, laid on the tongue every hour • Fowler's solution, .06 Gm. (1 minim), before each of the principal meals. This is especially useful when there is reason to suspect some degree of catarrh, as in the vomiting of drunkards. Creosote or carbolic acid may be given in drop doses, or a drop of a mixture of equal parts of carbolic acid and tincture of iodine. Minute doses of morphia may be indicated when there is great irritability of the stomach, but the constipating and nauseating effect of this drug should always be borne in mind, and its use discontinued as soon as possible. Other medicines whose dose is larger may occasionally be of use, but for the reason already indicated the foregoing are to be preferred. Among others we will mention oxalate of cerium, .30 Gm. (5 grains) ; bismuth subnitrate, .06 Gm. (10 grains), and bicarbonate of soda in similar doses. Constipation.-The treatment of this condition is given in the article entitled Constipation. Flatulence.-Here special supervision of the diet is im- portant. The leguminous vegetables, as beans and peas, are well known as causers of flatulence; cabbage should never be allowed._ In extreme cases sugars and starches should be proscribed ; tea is apt to increase flatulence. In general it should be enjoined to drink little fluid with the meals, and but little-at once at any time. If the flat- ulence is accompanied with acidity, acids should be ad- ministered before meals. Among drugs we have the car- minatives or aromatics. These may be given in the form of powder, as in the pulvis aromaticus (containing cinnamon, ginger, cardamom, and nutmeg); as essential oils, of cloves, cardamom, cajeput, etc.; as tinctures of ginger, capsicum, etc. ; or, finally, as waters, as of mint, cinnamon, etc. The number of these carminatives is large. Charcoal, animal or vegetable, is of value in doses of 0.5 Gm. (5 to 10 grains), either before meals or after, according as the flatulence is worst immediately after eat- ing or after an interval. It may often be combined with bismuth, 1 Gin. (15 grains), to advantage. Chloroform in drop doses, tincture of asafoetida, 5 Gm. (3 j.); carbolic acid in drop doses ; sulpho-carbolate of soda, 1 Gm. (15 grains), are also of value. Among external applications nothing is better than turpentine stupes over the abdo- men. Gastralgia.-The treatment of this condition is, in gen- eral, the same as for neuralgias elsewhere. When a cause can be found, as anaemia or malaria, it should be removed. Iron in the former case, quinine in the latter, are the most useful drugs. For the ordinary cases of nervous origin nothing is better than arsenic, in the form of Fowler's solution, in small doses, one or two drops, three times a day. Under these circumstances it may be given be- fore meals (contrary to the general rule for administer- ing arsenic). The diet must be made as simple, and at the same time as nourishing, as possible, and general measures of hygiene inculcated. During the paroxysm the pain often demands a narcotic. The hypodermic injection of morphia is especially appropriate, on ac- count of the promptness of its action. In chronic cases care must be taken against the formation of a morphia habit. We now come to the question of alcohol in dyspepsia. Though, as has already been said, this agent checks the activity of pepsin in experiments in the test-tube, yet in the admixture which a weak solution of it, as a mild wine, forms in the stomach, it is probably not deleterious to the digestion. Moreover, its stimulating effect on the gastric tubules is very likely an advantage. Wine may also supply the acidity which, in some cases, is so desir- able. The distilled liquors had best be avoided by dys- peptics, but wines having ten per cent, or less of alcohol, and rather dry, may be prescribed at meal-time. It must' however, be borne in mind that alcoholic remedies in chronic diseases are always to be used with caution, and in no class of cases is this truer than in atonic nervous affections. Having come to depend upon the sustaining power of his daily dram, the patient may never feel the physical or moral strength to discontinue it, and may go on increasing its quantity long after the physician has disclaimed responsibility for it. For these reasons it is, in the opinion of the writer, rarely well to employ alco- hol in the treatment of dyspepsia. The same considera- tions will apply to the use of opium, which is recom- mended by some authorities, though there is less to be said at the best for opium than for alcohol. General tonic medicines are indicated in a certain num- ber of cases, in addition to the drugs heretofore men- tioned ; notably in cases of dyspepsia due to depression of the whole system. Iron is among the most valuable of such remedies, but great care should be taken that it be administered in such a way as not to interfere with the already enfeebled digestion. The salts of the vegetable acids, as the lactate, citrate, tartrate, etc., are usually to be preferred to the stronger preparations, as among other advantages they are less liable to constipate. Chalybeate waters are also to be recorfimended. The salt-water baths, already mentioned under the head of the hygienic man- agement of the disease, are supposed by some to owe a considerable part of their good effect to the absorption of iodine in such a manner as to secure its tonic effect. Charles Francis Withington. 1 Lumleian Lectures, 1880. On the Digestive Ferments and the Use of Artificially Digested Food. By William Roberts, M.D., F.R.S. DIGESTIVE SECRETIONS AND DIGESTION, CHEM ISTRY OF. Saliva.-Mixed Saliva and its Constituents. -It consists of the secretions of the various salivary glands and the glands of the mucous membrane of the mouth. It may be obtained in various ways, but easily by simply forbearing to swallow and holding the mouth open over a ves-el to receive the fluid. It is colorless, somewhat turbid, without smell, and contains salivary corpuscles, epithelium, etc. The reaction is alkaline, and the sp. gr. .1.002 to 1.006. The reaction may become strongly acid in digestive disturbances, diabetes, and other pathological processes. It contains the usual inor- ganic salts, certain gases, and, of organic bodies, mucin, traces of albuminous bodies, and so-called extractives. As peculiar to saliva are the diastatic ferment and sul- phocyanate of potassium. (a) Sulphocyanic acid (CNSH) is not regularly found in saliva, and never but in small quantities. It occurs mostly as the potassium salt, and is probably derived from albuminous matters (N and S). (Ji) The salivary ferment has not been completely iso- lated, so that its chemical constitution is imperfectly 462 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. SJfeZtlve Secretions. known. It is a nitrogenous body, and bears the name Ptyalin. The following tables give the composition of mixed saliva. The divergences to be noted in the analyses of several observers are due to variations in the saliva of different persons, and to inaccuracies necessarily associ- ated with any attempt to determine quantitatively the mucin, epithelium, etc. renders it turbid, as does also the addition of hydrochlo ricor nitric acid. The sp. gr. is 1.0026 to 1.0033. It has the amylolytic ferment; but observers are not agreed as to whether it contains sulphocyanic acid or not. The following table gives the analysis of the submaxil- lary saliva of the dog, by Bidder and Schmidt: 1. 2. Water 991.45 996.04 Remnant 8.55 3.96 Organic 2.89 1.51 Constituents. (In 1,000 Parts.) Water Saliva of Man. Of THE Doo. CO 'o E <D ft 992.9 7.1 1.4 3.8 ' 1.9 1 5 S3 8 995.1 4.84 1.62 1.34 0.06 1.82 QQ A 1 £ 994.1 5.9 2.13 1.42 0.10 2.19 ; ; ; ; Tiedemann and : : ; : Gmelin. o w 994.7 5.3 3.27 p: w ; PP Schmidt. -7 • or • 00 * GO Solids Mucus and epithe- lium 3.48-8.4* 0.064-0.09 Soluble organic matters Sulphocyan. pot... Inorganic salts.... Alkaline chlorides 4.50 Earthy carbonates and phosphates 1.16 2.45 Analysis of the submaxillary saliva of the cow, by Las- saigne: Water 991.14 Mucus and organic matter 3.53 Alkaline carbonates 0.10 Alkaline chlorides 5.02 Alkaline phosphates 0.15 Calcium phosphates 0.06 3. Saliva of the Sublingual Gland. It is strongly alka- line and very viscous ; contains much mucus, formed elements, and sulphocyanic acid (Longet). Changes Effected in Starch by Acids, Diastase, and Saliva. -The ferment of the saliva, denominated sugar-forming, amylolytic, diastatic, etc., is probably identical with that of similar action found in the pancreatic and intestinal secretions ; but this has not been demonstrated. It was formerly thought that the ferment changed the starch to dextrine, and this later to sugar ; but, in 1860, Musculus and v. Mering suggested that both were formed contem- poraneously, and they would represent the reaction some- what thus : 3C6H10O5+H2O Starch. * In filtered saliva. Jacubowitsch found in 1,000 parts of saliva : Sal ts Man. 1.82 Dog. 6 79 Phosphoric acid 0.51 | 0 R? a 0.43 f 0.03 i Magnesia 0.01 f 0.15 Alkaline chlorides 0.84 5.82 = C6H12O6 Dextrose. + 2C0H10O6 Dextrine. The Secretion of Individual Salivary Glands.-The chief differences in the secretion of the three glands are physi cal; that of the parotid being thin and watery, while that of the other two is viscous and rich in mucus. 1. The Saliva of the Parotid Gland. It may be ob- tained pure by the insertion of a canula into its duct. It contains no solid forms except epithelium ; its reaction is mostly alkaline, but may be neutral or acid ; its sp. gr. 1.006 to 1.008; contains a little albuminous matter ; changes starch-paste into sugar-which power is lost at 60° C. (140° F.), or on the addition of a mineral acid. This ac- tion also is demonstrable in the parotid saliva of the new- born. In the dog the ferment is not present, or but to a slight degree. The secretion of the gland in the horse is rich in lime (Lehmann). Sulphocyanic acid is found in the parotid saliva of man (Oehl). The following table gives analyses of parotid saliva in the cases of man, the dog, and the horse : Others would prefer the following: 2C6H10O5+H2O = C6H12O6 + CeHloO6 It was also suggested as probable that a part of the starch was changed into a dextrine which could not be acted on by the ferment, for it was found that only half the quantity of sugar was obtained by the prolonged ac- tion of saliva as by the action of dilute acids (long-con- tinued boiling). It was also found that there were at least two kinds of dextrine: one that was colored by iodine, and another that remained unaffected by that re- agent. Though grape-sugar is found as the result of salivary digestion, it is not the chief product, which is maltose, C12H22O11+H2O. The latter is distinguished by its smaller reducing capacity for solution of copper sulphate, and by its angle of rotation: a = + 150°. It is now dem- onstrated that the secretions from all the glands have the action characteristic of saliva. The saliva of man is in general stronger in its action than that of other animals. Ostaschewsky arranged, according to the activity of the saliva, the following animals in a diminishing series : The rat, rabbit, cat, dog, sheep, and goat. It is now known that the saliva of the new-born is amylolytic. Agents Affecting the Action of Saliva.-Slight changes in the reaction of saliva do not much affect its working, but alkalies and acids both affect it when in other than the minutest quantities, and, when of any appreciable strength, are apt to totally suspend its action ; however, it is now known definitely that salivary digestion does proceed in the stomach. Temperature. When saliva is heated to 100° C. (212° F.), it loses the power to change starch to sugar, and with very low temperatures the action is reduced to a minimum; 39° C. (102° F.) is the most favorable. Pas- chutin observed that the amylolytic action increased with the rise of the temperature (up to 39° C.), the duration of the action, and the dilution of the solution of ferments. The same observations hold good of malt diastase. Car- bolic acid is found to be injurious only when it reaches a strength of ten per cent. ; free salicylic acid, when of one per cent, solution, is injurious, while arsenious acid and quinine seem to have no such influence. Raw starch is very slowly affected indeed. or: ggg&S ■ : : : 3 o: : 985.4-983.7 14.6-16.3 9.0 0.3 5.0 C. G. Mitscherlich. Of Min. 993.16 6.84 3.44 .:.. 3.40 Hoppe-Seyler. 995.3 4.7 1 * U.i ' 1.2 C. Schmidt and Jacubowitsch. Of the Dog. 993.849 6.151 Herter. 991.527 8.473 1.536 6.251 6'688 Herter. 991.928 8.072 Herter. 990.0 10.0 2.06-6.0 4.80-8.73 Lehmann. Of the Horse. 2. The Secretion of the Submaxillary Gland. It is poured into the mouth by Wharton's duct. Directly after its secretion it is clear, like water, and thin ; but later it becomes thicker. It is always alkaline. Boiling 463 Dteeslive Secretions' REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. A very active preparation for the purposes of artificial digestion may be made as follows: Mince the glands of some animal known to have an active secretion; treat with alcohol to remove water ; evaporate the alcohol that cannot be poured off or pressed out, at a gentle heat, and then digest in glycerine. Pathological Conditions.-The tartar of the teeth, also salivary concretions occasionally found in the ducts of the glands, consist of calcium carbonate, and calcium phosphate, with mucus, epithelium, leptothrix, a smaller quantity of alkaline salts, and magnesia. The saliva of salivation from iodine and mercury con- tains more albuminous matters and salts. In icterus the saliva remains mostly free from bile-coloring matters. In diabetes sugar is never present, but the reaction is often acid. The acid reaction is often present in disturb- ances of digestion and febrile conditions. The Secretion of the Stomach ; Gastric Diges- tion.-The Characteristics of Gastric Juice and its Con- stituents.-Pure gastric juice is clear, like water, transpar- ent, of sp. gr. 1.0022 to 1.0024, with slightly acid, salty taste. The reaction is uniformly acid, though less so among herbivora than among flesh-feeders. It gives no precipi- tate by boiling with acids, nor by the addition of alum, chloride of iron, copper sulphate, or potassic ferrocyanide. Alkaline reagents produce turbidity or a flocky precipi- tate. Corrosive sublimate precipitates an organic sub- stance. Silver nitrate and nitric acid precipitate silver chloride ; alcohol and lead acetate a rich flocky precipi- tate, which consists largely of the characteristic ferments. On distillation of the secretion, toward the end of the process acid vapors pass over ; the solid remnant does not reach two per cent. Gastric secretion is the only one among those of the higher animals in which it is possible to demonstrate directly the presence of the free acid. The following table of C. Schmidt gives the analysis of gastric secretion in man, the dog, and the sheep. acid of the stomach, Selmi and Heintz called attention to the fact that with a perfectly neutral reaction the gastric juice, or the mucous membrane of the stomach, produced the same result; this pointed strongly to a special fer- ment as the cause of the phenomenon, and to this Ham- marsten gave the name Rennet. The evidence for such a view may be briefly stated as follows: 1. Fresh cow's milk, with a neutral infusion of mucous membrane of the stomach, clots at 36° to 38° C. (97° to 101° F.), in from four to ten minutes perfectly, and the reaction does not change either during or directly after the clotting. 2. A solution of casein, free from milk-sugar, in which the supposition of the formation of lactic acid is excluded, clots when mixed with rennet infusion. 3. Hammarsten has prepared a ferment which produces no effect on milk-sugar, but acts on milk or solutions of casein free from sugar. A simple method for the prepa- ration of rennet is to digest the mucous membrane of the calf's stomach with glycerine, and precipitate the pepsin with solution of magnesium carbonate or acetate of lead. Neither pepsin nor rennet is known as a distinct ' ' chem- ical entity." A third ferment, capable of changing milk-sugar into lactic acid, seems to exist, for both pepsin and rennet can be destroyed by dilute solution of caustic potash, and the resulting fluid can still act on milk-sugar. The. Free Acid of the Gastric Juice.-As far back as 1824 Prout estimated the amount of free HC1 in gastric secre- tion. C. Schmidt had shown that pure gastric secretion, after eighteen to twenty hours' fasting, in carnivora con- tained only free HC1, and no trace of lactic or acetic acid ; while in that of herbivora there were small traces of lac- tic acid. Other acids are produced either by HC1 or by fermen- tation, e.g., lactic and butyric acids, which could thus arise from the carbohydrates of the food. Origin of Free Hydrochloric Acid in the Organism.-In some animals it can be shown that acid is produced with- in the glands of the stomach ; in others this does not seem possible. Various theories have been proposed to account for the HC1 of the gastric secretion. Maly thinks it may arise as expressed in the following equation : 3CaCla + 2Na2H PO4 = Ca3 (PO4)2 + 4 NaCl + 2 HC1. The members of the left side of this equation occur in serum, and acids diffuse themselves much more rapidly than alkalies or neutral bodies ; these two facts, taken together, lend probability to the theory that the HC1 is formed by the action of the sodium phosphate on calcium chloride, but the matter is not at all settled. The relative value of various acids for the purposes of digestion, as tested by an artificial digestive fluid, may be set down as follows : Hydrochloric, nitric, lactic, phos- phoric, sulphuric, acetic, oxalic, tartaric. Digestive or Pepsin Tests.-A qualitative test for the presence of pepsin in a fluid may be made by shaking up a small piece of boiled fibrin in a test-tube with some of the pepsin-containing fluid. It will gradually disappear. Quantitative tests may be made by determining either (1) how much of an excess of albumen is dissolved in a definite time, or (2) in what time a definite quantity of albumen is dissolved. Griitzner's method is the follow- ing : Finely-divided fibrin is soaked for twenty hours in dilute solution of ammonium carminate, washed out, and allowed to swell up in hydrochloric acid. It then has a uniform rose tint. A scale for comparison is then made with ten grades by adding ammonium carminate solution in definite proportion to glycerine. A fragment of col- ored fibrin thrown into an active juice gives up its color- ing matter as rapidly as digested, and if the same quantity of fibrin be used in a series of experiments, the tint of the fluid acting on it may be taken as a gauge of its digestive power. The fibrin as above prepared for use may be preserved in ether for a lengthened period. The Action of Pepsin as Studied on Fibrin and Albumen. -The action of the gastric secretion or a solution of pepsin may be studied either on fibrin or on the albumen of the white of hen's egg. Each has its advantages. Constituents. Man. Dog. Sheep. Containing saliva. Free from saliva. Water Organic matters (ferments. 994.404 971.171 973.062 986.143 etc.) 3.195 17.336 17.127 4.055 HCl 0.200 2.337 3.050 1.234 CaCl2 0.061 1.661 0.624 0.114 NaCl 1.465 3.147 2.507 4.369 KC1 0.550 1.073 1.125 1.518 NH4C1 0.537 0.468 0.473 Ca3 (PO4)2 2.294 1.729 1.182 Mg3 (PO4j2 ' 0 125 0 323 0.226 0.577 FePO4 ,.'.T 0.121 0.082 0.331 The Ferment of Gastric Secretion ; Pepsin.-Pepsin will not diffuse itself through parchment paper; though v. Wittich thought if dilute hydrochloric acid were used in- stead of water it would ; but this Hammarsten could not confirm. Artificial gastric fluid may be obtained by any of the three following methods: 1. Mince the mucous membrane of a pig's stomach finely; rub up in a mortar witii pounded glass ; extract with water, filter, and add HC1 till two- tenths per cent, is reached. This contains but little of the products of digestion, and is very active. 2. Mince up finely as before the mucous membrane, etc. Add a large quantity of dilute HC1 of two-tenths per cent, strength, and let the mass digest at blood heat, decant, and filter. This preparation will contain more of the products of digestion than the former. 3. After preparing the mucous membrane in a finely- divided condition as before, remove water as much as possible by blotting-paper or absolute alcohol; then place in concentrated glycerine. This preparation is exceed- ingly potent and almost wholly free from products of di- gestion. It must, of course, when being used, be added to an acid solution of the proper strength (two-tenths per cent.). Cheese-forming Ferment, or Rennet.-In opposition to the view that the curdling of milk was due wholly to the 464 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sec^tionZ* Rapidity of digestion depends on: (1) the swelling capacity of the albumen ; (2) its condition as to aggrega- tion ; (3) proportion of pepsin in the fluid ; (4) the quan- tity and quality of the acid present; (5) the prevailing temperature ; (6) degree of the dilution. The tempera- ture at which peptic digestion proceeds ranges from 35° to 50° C. (95° to 122° F.). A pepsin solution may, how- ever, be kept for hours at -5° C. (23° F.), and, when the temperature is raised duly, still prove active; 60° to 70° C. (140° to 158° F.) may be reached before the activity is lost. These remarks upon temperature do not apply to cold- blooded animals. Hoppe-Seyler found that an artificial digestive fluid from the pike was strongest at 20° C. (68° F. j, and more active at 15° C. (59° F.) than at 40° C. (104° F.). The order of digestibility of the following substances is : Casein, fibrin, coagulated albumen of hen's egg, ani- mal albumen, vegetable albumen. The difference de- pends largely on the relative swelling capacity. Briicke has expressed in the following table the di- gestive capacity with a constant acidity but a variable pepsin quantity, expressed as x, 2x, etc. : there is, however, no proof. It may be a splitting up of larger proteid molecules. Peptone closely resembling that of digestion may be produced in different ways : (1) By the action of strong acids ; (2) by the prolonged action of dilute acids at high temperatures; (3) by the action of super-heated water in a Papin's digestor. All true proteids are capable of conversion into pep- tone. Of other nitrogenous bodies, not truly proteid, mucin, nuclein, and the chemical basis of horny tissues, are wholly unaffected; gelatinous tissues are dissolved, and their proper gelatinous characters lost. The Products of the Gastric Digestion of Albumen and Fibrin.-Digestion must be considered as a chemical proc- ess, and not a mere solution. The first result of peptic digestion is parapeptone (acid albumin, syntonin). It re- mains longer in a fluid form in pepsin, but is ultimately all changed to peptone. Parapeptone is, in the main, like acid albumin, or syntonin resulting from the action of acids in albuminous bodies. This diagram represents graphically the changes referred to : Albumen or Fibrin. Glass. Pepsin proportion. Action. 1 0 No digestion. 2 X | After 7 hours, in 3, a little; in 2, a greater undi- 3 2x f gested remnant ; after 20 hours, all dissolved. 4 4x Digested in 7 hours. 5 8x Digested in 3X hours. 6 16x Digested in 3 hours. 7 32x Digested in % hour. Acid Albumin (=; Parapeptone). Peptone. Peptone is known rather by its negative than by its posi- tive qualities. We endeavor to obtain it pure by the re- moval of other bodies with which it is mixed. From a solution containing it, it is thrown down by alcohol as a white, flocculent, amorphous precipitate. It is very hy- groscopic, and very easily soluble in water. ' ' In concen- trated solutions all differences between albumen and pep- tone disappear up to the non-precipitation by boiling " (Adamkiewicz). It gives the following color reactions : 1. The Biuret reaction. 2. With strong HNO3 and heat, a dull-yellow color. 8. Adamkiewicz's reaction. 4, Millon's reaction. The distinguishing test is the Biuret reaction. A dilute solution of peptone, if treated with caustic potash or soda (a few drops) and a drop of very dilute solution of copper sulphate, gives a rose-red color. Al- buminous bodies similarly heated give a violet color. Digestion of other Food Stuffs.-Casein gives the usual products of gastric digestion. According to Meissner, from these there is separated by soda solution a part that is fully digestible ; and another part, which is free from phosphorus, possesses the general properties of albumin- ous bodies, and is not further digestible (dyspepton). The digestible portion thus separated contains phosphorus (nuclein). Syntonin behaves like albumen in the presence of di- gestive fluids. Oxyhaemoglobin is changed to acid albumin and haema- tin ; the former becomes peptone, the latter is indigestible. These changes explain the dark-brown color of blood poured out in the stomach (Hoppe-Scyler). Plant albumin behaves as animal albumin. Tendons and bones undergo a change equivalent to digestion. Epidermoidal tissues, amyloid, nuclein, starch, gum arabic, fat, wax, etc., are not altered. Digestion in the Living Stomach.-How far does the di- gestion of albuminous matters go in the stomach ? We are probably justified in saying that it does not proceed to the point of the complete transformation of all such matters into peptone, or even into acid albumin. The time requisite for the digestion of different kinds of food in the stomach is variable even in the same individual, and still more so in different persons. G. Weber investigated the digestive process in dogs by feeding them on flesh, and killing them after definite periods. Uffermann observed the process in a gastroto- mized boy ; and Dr. Beaumont's experiments on St. Mar- tin, who had a permanent fistula in the stomach in con- sequence of a gunshot wound, are well known. Among Fate of the Pepsin.-There is good reason to suppose that the pepsin is not used up or decomposed, but that it is in part precipitated in the undigested remnant. A por- tion is certainly absorbed, for it can be detected as pepsin in the urine. A digestive fluid may become so concentrated that di- gestion will cease ; but the action may be renewed by simple dilution with an acid solution of 0.2 per cent. Whether a given quantity of pepsin placed under favor- able conditions can digest an unlimited quantity of pro- teid material is uncertain, but it is known that it can di- gest a very large quantity. The Source of the Pepsin.-Ebstein, Griitzner, and others hold that the pepsin found in the part of the stomach where mucous glands abound is produced by certain cells of these glands. They believe the pyloric glands are pepsin-forming ; while Friedinger, Wittich, and others consider the pepsin in the parts of the stomach free from rennet glands (Labdrusen) as infiltrated and mechanically related to that part. The rennet ferment is probably manufactured by the same glands as produce pepsin-i.e., by the principal cells of the glands of the fundus chiefly, but also by the pyloric glands. A view is now rapidly gaining ground that all the digestive ferments (pepsin, rennet ferment, etc.) are derived from an antecedent organic material (zymogen) prepared by the cells concerned, from which material the pepsin, etc., is derived. It has been suggested that the "border," or "ovoid," cells secrete the acid of the gastric juice, but this has not been demonstrated any more than has the true chemical source of the HOI (see article on Digestion). The important work of Heidenhain, Langley, and others has, so far as it bears on digestion, been treated at length in another part of this work, by the present writer. In certain young animals, for days after birth, there is no pepsin in the stomach. In new-born children there is pepsin in the mucous membrane in not inconsiderable quantity, and such infants have the power to change casein into peptone, according to their size and general bodily condition (Hammarsten, Zweifel). Rennet is also found in the stomach of the infant. The Chemical Nature of the Gastric Digestive Action.- It has been suggested that this action partakes of the nature of the action of saliva on starch, i.e., a hydration. Of this 465 Digestive SecJetioi"^ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. other points observed were the following : That flesh swells, becomes pale or yellowish, gelatinous looking ; that muscle breaks up into its components ; that raw flesh is digested more slowly than when cooked ; that when it is cut fine or scraped, digestion proceeds much faster than when the meat is in larger pieces; that fat flesh is more difficult of digestion than lean, etc. Milk is observed to clot, its casein is dissolved, and its fat forms into drops. Biedert thinks the casein of cow's milk qualitatively different from that of human milk. Self-digestion of the Stomach.-It had been frequently observed that animals suddenly killed during the progress of digestion, gave evidence of self-digestion of the stom- ach, often very extensive. The question then arises, Why does the stomach not digest itself during life ? 1. Kuhne suggests that the superficial parts of the glands-their cells-are again and again dissolved away and renewed. 2. Schiff supposes that the mucus constantly covering the mucous membrane, and especially during fasting, is a protection. 8. Schiff and Pavy found that if the epithelial lining were scratched away from any part of the stomach of a dog (with a fistula) that that part suffered digestion to some degree. 4. The alkalinity of the blood has by most authorities been advanced as the chief preventive cause. Bernard found that if a portion of the stomach were so ligatured that no blood could find access to it, such part showed signs of having been digested ; and his experiment of placing the leg of a living frog through the fistula of a dog's stomach, and noting that it was digested, he explains upon the ground that the alkalinity of the blood in the frog's leg is insufficient to neutralize the acidity of the gastric juice of the stomach. The Carbohydrates in Gastric Digestion.-There is no doubt that the digestion of starch, as begun by the saliva, can proceed in the stomach, but the process may be modi- fied. Briicke found soluble starch and erythrodextrine much more abundant than sugar. Further, lactic acid may arise by the action of a ferment on the sugar. The lactic acid normally arising in the stomach should be at- tributed to a ferment, and not to the agency of bacteria ; but in cases of dyspepsia it is probably largely due to the latter. Of other substances, cane-sugar is not changed in the stomach ; gum and cellulose remain unchanged; inulin behaves like starch. Pathological.-There is likely to be an excess of acid in the stomach after the use of beer, wine, fruit, very sweet and very fat food. The acids thus arising are : lactic, acetic, and probably fatty acids, especially butyric. In febrile conditions the normal acid is deficient; in uraemic conditions there may be found in the stomach urea and ammonium carbonate. (For the chemistry of bile, see under Bile.) Pancreatic Secretion and Pancreatic Digestion. -This form of digestion is the most complicated and per- fect chemical process of all those accomplished in the di- gestive tract. The Pancreatic Secretion.-It is a perfectly clear viscid fluid, which foams on shaking, has a weakly salty taste, and on standing undergoes a true clotting, a change which is hindered by alkalies. Alcohol throws down a white flocculent precipitate, which may be in part redis- solved in water. The specific gravity of the secretion ob- tained from a recent fistula was 1.08. It is eminently liable to putrefaction. During pancreatic digestion a substance is formed in the alimentary canal which, with chlorine-water, gives a red color, and later the contents become stinking and thin. Crude nitric acid gives the contents a red color, due to the presence of indol. Components and Quantitative Estimation of Pancreatic Secretion.-1. Albuminous bodies, among which is prob- ably alkali albuminate. 2. Fat and soaps. 8. The usual salts, among which those of sodium prevail. 4. Fer- ments : (a) A starch-digesting, amylolytic, or diastatic ferment; (b) a ferment that changes albuminous matters in an alkaline medium into peptone and amido-acids ; (c) a ferment splitting up fat into glycerine and free fatty acids. The following tables give the analyses of pancreatic secretion taken from fistulae. In 1,000 parts of pancreatic juice from the dog : 1. Directly after the operation. (C. Schmidt.) 2. From a permanent fistula. (C. Schmidt.) a. ft. a. b. c. Water 900.8 884.4 976.8 979.9 984.6 Solids 99.2 115.6 23.2 20.1 15.4 Organic matters . 90.4 16.4 12.4 9.2 Ash 8.8 7.5 6.1 The ash from 1,000 parts secretion : After operation from Mean of three a permanent fistula. analyses. Soda 0.58 3.31 Sodium chloride 7.35 2.50 Potassium chloride 0.02 0.93 Earthy phosphate, with traces of iron 0.53 0.08 Na3PO4 0.01 Lime and magnesia .... 0.32 0.01 The ferments of the pancreas have been studied and obtained, more or less pure, by Cohnheim, Danilewski, Paschutin, Heidenhain, and Kuhne. Pancreatic Digestion.-Action on carbohydrates. The action is, in general, like that of saliva on starch. This ferment is robbed of its active powers by boiling, and by the addition of large quantities of mineral acids and al- kalies, corrosive sublimate, sulphurous acid, potash, and ammonia. The addition of alkaloids, urea, ether, prussic acid, bile, and gastric juice do not appreciably influence it. Its action is much more rapid than that of saliva, and is most effective at 87° to 40° C. A large quantity of starch-paste, subjected to an infu- sion of pancreas for ten hours at 15° C., after being pri- marily heated up to 40° C., showed the presence of dex- trin, maltose, and a little grape-sugar. The long-continued action of pancreatic infusion will also lead to the lac- tic-acid fermentation. Glycogen behaves like starch, but inulin and cane-sugar remain unchanged. The diastatic action is wanting in the new-born ; it ap- pears first at the end of the second month, and is moderately strong at the end of the third (Karowin and Zweifel). Action on the glycerides or fats. Pancreatic secretion forms, at 85° to 40° C., an emulsion with fats, which is hastened by shaking, and remains for fifteen to eighteen hours, thus contrasting strongly with the feeble and transient emulsion of bile. The chemical splitting up of the glyceride or fat mole- cule is due to a special ferment. In an artificial digestion the presence of both free glycerine and free fatty acids may be demonstrated, and the latter give to the fluid the acid reaction which it assumes under such circumstances. It may be expressed as follows : c3h6 OCOCnH2n+l OCOC„H2„+i OCOCn Han 4-1 +3H2O = CSHS- OH OH OH +3 (HOOC.C„Han+1) Action on albuminous bodies. It, like gastric juice, splits up albuminous bodies, but its action is in this re- spect, according to Corvisart, three times more rapid than that of the secretion of the stomach. Boiled tibrine, exposed for from half an hour to three hours at 40° C. to the action of the fresh juice, gave no trace of putrescence, but in the case of the infusion of the gland, and with the increase of the alkalinity of the fluid, there was a stronger tendency in this direction (Corvisart). The addition of an acid in any strength, and of an alkali beyond one per cent., was unfavorable to digestion (Corvisart and Kuhne). Strong acids and alka- lies stopped the action wholly, as did also boiling. Products of the Pancreatic Digestion of Albuminous Bodies.-After complete digestion, the products are not precipitated by boiling, indicating the production of pep- tone, but digestion proceeds much further than in the 466 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestive Secretions. Digestive Secretions. corresponding case in the stomach ; for, in addition to peptone and alkali albuminate, there are produced leucin, tyrosin, traces of aspartic acid, xanthin bodies, one aro- matic acid, and many bodies of unknown composition, etc. The peptone of pancreatic digestion, if not in all, is certainly in most respects like that produced by gas- tric action. The most elaborate investigation of pancreatic diges- tion has been made by Kiihne, whose views, some of which must be regarded as hypotheses as yet, may be expressed in the following table, extracted from the latest (fourth) edition of Foster's ' ' Physiology" (appendix). The diagram also shows how close is the correspond- ence in the results of the decomposition of albumin by the digestive fluids and by the action of acids : of leucin in the digestive processes, does not, like the for- mer, occur in fresh, healthy organs. It is found abun- dantly in the urine, together with leucin, in acute atrophy of the spleen and liver, in variola and typhoid fever, in the skin in certain of its affections, in the sputum of many bronchial affections, in certain cysts, etc. The cochineal insect is rich in tyrosin, and it has also been found like leucin in plants. It must, in all cases, be regarded as a product of albuminous decomposition. It may be obtained pure in very fine, white needles ; also with the appearance of tufts and sheaves, in which form it is sometimes found in the urine. It is easily solu- ble in water, in alcohol, and in ether. In chemical constitution it may be regarded as 2EthyL amidoparaoxybenzoic acid, C6H3 (NHC2H6) Oil. COOH (v. Barth), or, according to v. Barth himself, Beilstein and Kuhlberg, an Oxyphenylamidopropionic acid, C6H4. OH ,C2H3 (NH2). COOH. The Destiny of Tyrosin.-In a dog fed with tyrosin, the latter appeared in the urine and faeces (v. Nencki, et al.). After doses of considerable size, von Brieger could find it in neither the urine nor the faeces of man ; but there was an increase of the so-called paired sulphuric acids, and more than the normal quantity of phenol in the urine. Aspartic acid, C4II7NO4, and glutamic acid, C5H9NO4, were found in the digested product of blood-fibrin by Radziejewski and Salkowski. Salomon found under simi- lar circumstances hypoxanthin and xanthin. Pancreatic Secretion in the Intestinal Tract; Pancreatic Putrefaction.-It has been observed that a mixture of pancreatic and gastric secretions is not equally effective as each singly, so far as can be judged by the total re- sults, which Kiihne explained by supposing that the pep- sin interfered with the trypsin. As mentioned under gastric digestion, the bile causes the chyme of the stomach to undergo precipitation, and the precipitate thus formed may be dissolved in an excess of bile ; further, the emulsifying power of the pancreatic fluid must be largely increased by the assistance of the bile ; all of which would seem to show that the latter secretion facilitates the work of the pancreas. Putrefaction owing to pancreatic digestion does take place in the alimentary canal, but in very varying degree, according to circumstances. The following substances are known to arise : Indol, ammonia, carbon-dioxide, sulphu- retted hydrogen, marsh gas, hydrogen, phenol, leucin, ty- rosin, butyric, valerianic, and acetic acids, etc. ; and, by decomposition of mucus, glycocoll. The process is re- markable not alone by the variety of the products of de- composition, but by the energy of the process, and the rapidity with which it goes on. Absorption taking place along so extensive a surface must, however, be a hindrance to the process. The decomposition process is more extensive in the herbivora, on account of the great length of the alimen- tary tract, evidence of which is found in the fact that twenty-three times as much indigo-forming substance (indican) is found in their urine as in that of man. There seems to be no reason to doubt that indican is derived from the indol of the alimentary canal. Micro-organisms are always found during the progress of the putrefactive changes, and are probably essential. Valerianic, butyric, etc., acids, are derived from leucin. Tyrosin disappears after the first few hours. The sul- phur from which the sulphuretted hydrogen and the sul- phuric acid are derived, may be traced to that of the albu- men itself. Indol, which gives the smell to the contents of the lower bowel, occurs, when pure, in thin, glistening leaves. It may be distilled over with steam, is soluble in boiling water, and easily so in alcohol and ether. Its destiny seems plainly to be that of undergoing ab- sorption and oxidation into indican, which appears in the urine. When the small intestines of a dog were ligatured below so that the contents could not pass on, the indican of the urine was greatly increased, and the same increase has been observed in man in pathological obstructions of the intestines. The same remark applies to phenol. Phenol unlike indol, increases with the duration of the Decomposition of Pboteids by Digestion. Antipeptone Action of Pepsin. Antialbuinose Antipeptone Albumin Hemipeptone Leucin, etc. Tyrosin, etc. Special action of Trypsin. Hemialbumose Hemipeptone Leucin, etc. Tyrosin, etc. Decomposition by Acids. 1. By .25 per cent. HC1 at 40° C. Antial bumate. Antialbumid. Albumin Hemialbumose Hemipeptone. Hemipeptone. 2. By 3 to 5 per cent. H2SO4 at 100° C. Antialbumid. Albumin Leucin, etc. Tyrosin, etc. Hemialbumose Hemipeptone Hemipeptone Leucin, etc. Tyrosin, etc. "The several products (antipeptone, etc.) are given in duplicate, on the hypothesis (which, though not proved, is probable) that the changes of digestion are essentially hy- drolytic changes, accompanied by a reduplication; that just as a molecule of starch splits up into at least two molecules of dextrose, or as a molecule of cane-sugar splits up into a molecule of dextrose and a molecule of levulose, so a molecule of antialbumose, for instance, splits up into two molecules of antipeptone, and so on " (Foster's "Physiology," 4th English ed., appendix, p. 719). Leucin, C6Hi3NO2, and the sister substance, tyrosin, occur mostly together, but in the digestive process there is always more of the former. Leucin is always present in normal pancreatic secretion. It is interesting as an ex- ample of a crystalline substance formed during digestion from a non-crystalline. It is found in the pancreas, lymphatic glands, salivary glands, thymus, brain, lungs, in pathological conditions in the urine, in pus, in leukje- mic blood, etc. It may be made from a variety of sub- stances by chemical treatment, tyrosin generally arising at the same time. The pure leucin occurs in snow-white, pearly, light crystalline leaves, with a fatty feel; it is soluble in water at 20° C., more so in hot water and in al- cohol, especially warm alcohol ; but it is not soluble in ether. It melts at 170° C. to a woolly mass. In its chemical constitution it is probably an isomer of amidocaproic acid. Its formula may be written : H2 N-ch2-CH2-CH2-CH2-CH3-COOH. Its destiny in the organism is obscure, but it is absorbed, and probably is represented in part, at least, by urea in the urine. Tyrosin, C8ILiNO3, though so constant a companion 467 Diplltll^ria?Cre**OnS, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. time of decomposition; not appearing so early as indol (Odermatt), but a small quantity is to be found in the in- testines. Its destiny is also clear; some of it passing through with the faeces, but another portion going to the urine, in which it appears as phenol-sulphuric acid. The Intestines, Processes Therein ; Excrement, Gases.-Intestinal Secretions and their Ferments.-Budge and Krolow, separating Brunner's glands in the pig, pre- pared a watery infusion of them which changed starch into dextrine and sugar, and dissolved fibrin at 35° C., but did not affect coagulated albumen of the hen's egg. Costa found that the crypts of Lieberkuhn had a similar action. Succus entericus as described by Thiry, is a clear, wine- yellow fluid of sp. gr. 1.01, and strongly alkaline; con- taining albuminous matters but not mucin. Thiry found that it produced no effect on starch ; that raw fibrin was dissolved by it; that the minced albumen of the hen's egg was not in the least affected, nor was muscular tissue ; that the digestive power was destroyed by neutralization and acidity. The action of this secre- tion, therefore, is more like that of the pancreas than like that of the stomach. The peptone was not essentially different from the peptone of pancreatic or peptic di- gestion ; cane-sugar was inverted, but no change in fat could be observed. Thiry's juice was obtained from an isolated loop of intestine, whose blood-supply was main- tained in the normal way. Paschutin believed a ferment might be obtained from the whole length of the small intestine which could change cane-sugar into grape-sugar. Intestinal Secretion acting within the Intestines.-It may be said the results under such circumstances agree, in the main, with what had been observed of its action outside these organs. A case reported by Busch is very remark- able, and would seem to show that intestinal digestion, whatever be its importance under normal conditions, may assume great importance under exceptional circum- stances. A woman had been so gored by a steer that the food, partially digested, passed through a fistulous open- ing in the upper part of the small intestine, the result being that the patient was reduced to a very emaciated condition. Busch gave her food rich in albuminous matters. She gained in flesh and strength, daily, in a manner that was surprising and very puzzling, in view of all that was previously known of the digestive capacity of the intestinal secretions. It has been suggested that the digestion ensuing in this case was largely brought about by the putrefactive decomposition of albuminous matters which was favored by the free inlet for bacteria afforded by the wound (Maly). It may be, however, that the contact of food with the intestinal wall itself may have an important influence, or that the mucus lying on its surface may contain an active ferment. The subject of digestion as effected by the intestines per se must still be considered as somewhat obscure. The Large Intestines.-A glycerine extract of their mucous membrane was found without digestive action. Investigations made on a preternatural anus in the sigmoid flexure lead to the conclusion that the large intestines possess no real digestive power. Digestive changes do proceed, no doubt, normally in this tract, but they are plainly such as are due solely to putrefaction. Intestinal Contents.-The reaction of the contents of the intestines is mostly alkaline against the wall, but acid within the mass. As they proceed along their course the contents become more finely divided, more deeply tinged with pigment, passing from a light-yellow to a yellowish- brown, and increasing in consistence, especially in the lower part of the tract. An examination reveals suspended in them swollen muscle-fibres, swollen connective tissue, cartilage, gelati- nous tissue, elastic fibres, epithelium, fat-drops, chloro- phyll, precipitated fatty and bile acids, soaps, cholesterin, ferments, and the various products of digestion to be recognized chiefly by chemical tests. The following may be enumerated as substances to be easily obtained from a watery extract of the contents: albuminous bodies, peptone, gelatin, sugars, dextrine, alkaline soaps, lactates, chlorides, salts of cholic and gly- cocholic acids, • taurin, bile pigments, hydrobilirubin, salts of carbonic, acetic, and butyric acid, compounds of ammonia, the products of pancreatic digestion and of putrefactive decomposition. The changes, as the contents pass along the intestinal surfaces, may be stated as chiefly greater consistence, less fat, increase of the alkaline reac- tion, and increase in putrefactive changes, with a corre- sponding increase in the fecal smell. It is probable that a lactic acid ferment is present along the whole course of the intestinal canal. Reduc- tion processes doubtless take place, examples of which are the formation of sulphuretted hydrogen, the sulphides from the sulphates, and hydrobilirubin from bilirubin. In the intestinal tract of the new-born, in which there are no gases, hydrobilirubin is absent. One source of the nascent hydrogen is the butyric acid fermentation which may be considered a later stage of the lactic acid fermen- tation. The Excrement is, with a mixed diet, yellowish-brown ;. with a flesh diet, much darker ; with a milk diet, yellow. The smell of the faeces is due to the presence of sul- phuretted hydrogen, ammonia and volatile bases, indol, and skatol. The mean weight of the faeces for twenty-four hours is one hundred and thirty grammes (a little over four ounces). The principal chemical constituents of the faeces are : Mucin, albumin, soluble organic and inorganic salts, taurin, excretin, coloring matters, fat, cholesterin, and indol. The stercorin of Flint is probably only cholesterin (Maly). If lecithin occurs it is only in traces. The earthy salts of the fatty acids occur, but bile-acids are not usually found in a watery extract of human faeces. Albumin is seldom present (Hoppe-Seyler). The volatile elements of faeces are isobutyric acid, indol, and skatol. Chlorophyl may be demonstrated by its characteristic spectrum. The inorganic salts consist largely of ammonio-mag- nesium-phosphate. The reaction of the excrement is variable, but often acid. The cholesterin of the faeces is in part derived from the bile and in part from the food. The faeces of infants at the breast, according to Weg- scheider, are acid, contain little peptone, no albumen, oleic and solid fatty acids, unchanged bile-coloring mat- ters, hydrobilirubin, and cholalic acid. The acid reaction is probably dependent upon lactic acid and volatile fatty acids. Skatol may be obtained from faeces in snow-white crys- tals, as also from putrescent fibrin. It is known to be nitrogenous, and its formula has been given as CSH9N. It is distinguished from indol in being less soluble in water, in not being colored by chlorine water, and in giv- ing no red precipitate with fuming nitric acid, but simply a white turbidity. Excretin occurs in little leaves or tufts mixed with needles, insoluble in cold or hot water, soluble in hot alcohol and in ether. The reaction is neutral. Its origin is unknown, and its constitution but imperfectly known. Meconium differs from faeces in its larger proportion of unchanged bile matters. Bile acids and bile pigments, c g., taurocholic acid, bilirubin, biliverdin, and sometimes cholesterin are found in it. Hydrobilirubin is wanting. The following table shows the results of the analyses of faeces. The small quantity of soluble salts is note- worthy. Porter. Fleitmann. Per cent. Per cent. Potash 6.10 18 49 Soda 5.07 0.75 Lime 26.46 21.36 Magnesia 10.54 10.67 Iron oxide 2.50 2 09 ( Phosphoric acid 36.03 30.98 As anhydrons.-J Sulphuric acid 3.13 1.13 ( Carbonic acid 5.07 1.05 Sodium chloride 4.33 0.58 Silicic acid 1.44 Sapd 7.39 468 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Digestive Secretions. Diphtheria. Pathological.-In cholera-stools there is an increase in the soluble salts (sodium chloride and alkalies), a variable quantity of albumen, abundance of epithelium ; and they are colored red by nitric acid. In diarrhoea there is always an increase of epithelium. The stools of typhoid fever contain much crystallized ammonio-magnesium phosphate. Many drugs color the stools, as is "well known. Intestinal Concretions. - Though occurring in man, they are much more frequent in the horse, in which they often acquire a great size, and consist mostly of ammon. mag. phosphate. In concretions from man, calcium phosphate, plant-cells, and fat have been found in addi- tion. The Gases of the Digestive Tract.-The gases in question are derived from swallowing air, from fermentative pro- cesses, and from putrefaction. Oxygen diminishes along the length of the canal, but CO2 and combustible gases increase. The following tables constructed by Ruge, from analy- ses of the gases collected by a method on which great reli- ance may be placed, give, I., the results with a mixed diet, in the same person but on different days ; and II., with a varying diet as indicated. a broad membranous border. It has a brown color, the membranous border being paler. The half fruits, or mericarps, are usually distinct in the fruits of commerce. Odor and taste agreeably aromatic." Dill contains an agreeable essential oil, composed of a hydrocarbon and carvol (Nietzki). Its action and use are exactly those of anise, caraway, and the other um- belliferous carminatives, from which it differs only in taste and odor. Allied Plants and Allied Drugs.-See Anise. W. P. Bolles. DIPHTHERIA. Synonyms: Ulcus Syriacum; Garo- tillo ; Morbus Suffocans ; Angina Maligna ; Ulcere Gan- greneux; Bynanche; Diphtheritic (bi^epa tr-qs = quick skin) (Bretonneau); Diphtheric (Trousseau). There are many other names for the disease, but those given are the best known. History.-D'Hauvanture, an Indian physician contem- porary with Pythagoras, describes an affection suggestive of diphtheria. Asclepiades is said to have performed laryngotomy, but Aretseus, of Cappadocia, gives the first good description of the disease, under the name of " Syriac Ulcer." Most of the ancient writers upon medi- cine give more or less accurate accounts of it, but it is im- possible to find an accurate description of the disease dur- ing the middle ages. Petrus Forestius (1557), Von Woerd (in Holland), Joannes Wierus (in Dantzic, Cologne, and Augsburg, 1565), and Ballonius (in Paris, 1576), all de- scribe epidemics of what was probably diphtheria-the last named being the first writer to speak of the false membrane. The first mention of an epidemic in Spain is in 1583, and the best account of the disease among Spanish writers is that given by Juan de Villa Real (1611). In Italy the first good account of an epidemic is that of 1618, and Wedel speaks of the disease in Germany in 1718. The first reference to this affection in New England, or, in fact, in America, may very probably be found in Sibley's " Harv. Grad.," vol. i., p. 94, where a number of children are said to have died from "bladders in the windpipe " in 1659. At various periods, after this, refer- ences to the disease are found, with some imperfect de- scriptions, as occurring in various parts of New England. The first Swiss epidemic occurred in 1752, Dutch in 1747, and Swedish in 1755. Of the writers of the last half of the eighteenth century there are two deserving of especial mention, i.e., Home, a Scotchman, -who wrote in 1765, and Bard, an American, whose papers appeared in 1789. The modern history of diphtheria begins with the ap- pearance of Bretonneau's first paper in 1821. He asserted the identity of angina maligna (diphtheria) with membra- nous laryngitis (croup). He spoke of the continuity of the false membrane of the nose, pharynx, and respiratory tract; of its identity with some morbid processes of the skin ; and asserted that diphtheria was a specific disease, and not to be confounded with catarrhal or scarlatinal inflammation. He claimed also that it was a purely local disease-an opinion which he afterward modified. His completed monograph appeared in 1826. From this time on, the literature of the disease becomes more and more voluminous year by year, and the task of selecting -what is worthy of preservation would be an enormous one. Hardly a writer upon medicine, or an in- vestigator of the etiology of disease, but has had more or less matter for publication. The points in dispute are, many of them, discussed to-day as vigorously as ever. The question of the identity of the two processes, croup and diphtheria, from a pathological standpoint, may be considered to be settled in the affirmative, so far as to jus- tify the assertion that true croup-membranous laryngitis -is one form of diphtheria. The etiology of the disease -whether it is produced by bacteria or other more ob- scure agencies-is still in doubt. The question is engag- ing the attention of many workers, however, and a solu- tion of the problem may be looked for in the not distant future. Since Bretonneau. the principal contributions to the Table I. Mixed Diet. 1. 2. 3. 4. co2 14.9 40.5 21.8 12.8 N. .*. 45.3 17.5 44.4 43.1 CH4 39.7 19.8 32.9 44.1 H .' 22.2 0.8 Table II. Milk. Leguminous food. Flesh. 1. 2. 1. 2. 3. 4. 5. 1. 2. 3. ■co2 16.8 9.1 34.0 38.4 21.0 35.4 17.6 13.6 12.5 8.4 N 38.4 36.7 19.1 10.7 19.0 21.8 32.2 46.0 57.9 64.4 CH4 0.9 44.5 49.4 56.0 42.8 50.2 37 4 27.6 26 4 H.? 43.9 54.2 2.3 1.6 4.0 3.0 2.1 0.7 Pathological.-Eructations from those suffering from stomachic affections, in analyses by Ewald, give hydro- gen, carbon dioxide, air, and marsh gas. The vomit in these cases contained sarcime, mycoderms, butyric and lactic acids. Source of the Normal Gases of the Intestines.-CO3 is, in part, an oxidation product and, in part, derived from fer- mentation and putrefaction. N is in greater part derived from the air by the removal of oxygen. H is derived from both the butyric acid fermentation, and the putre- faction of albuminous matters. Kunkel, by the decomposition of fibrin by the pan- creas, obtained the following as the results of the analy- sis of the gases produced. 1. 2. h2s 1.9 0 7 co2 68 4 59.5 h/ 28.5 38 5 €H< 1.5 1.1 T. Wesley Mills. DILL FRUIT (Anethi Fructus, Br. Ph. ; Aneth, Codex Med.), the fruit of Peucedanum graveolens Hiem. Ane- thum graveolens Linn.); Order, Umbelliferoe, a European annual, with a slender, low, branching stem and dissected leaves. Flowers and fruits in compound non-involucrate umbels. Dill is raised in gardens as a household aro- matic, and is official in Great Britain as the source of Aqua Anethi and Oleum Anethi of that Pharmacopoeia. The description of its fruit is as follows : " Broadly oval, about one-sixth of an inch long, flat, and surrounded by 469 Diphtheria. Diphtheria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. history of the disease have been by Trousseau, Bour- geoise, Baumgarten, Rilliet and Barthez, and Virchow. In 1847 the latter first made the distinction between the catarrhal, croupous, and necrobiotic varieties of laryngeal affection. After him, the writers upon the subject be- come enormous in number. Among them are to be espe- cially distinguished West, Sanderson, Billroth, Eberth, Klebs, and Oertel. Description.-Symptoms in General.-The symptoms may vary from those of the slightest sore throat to those of the most serious and malignant disease. For convenience these may be separated into several forms, according to the severity of the symptoms. These are : I. The typical form ; II. The catarrhal or mild form ; III. The malignant form ; IV. (rare) The chronic form. I. The Typical Form.-A typical case of diphtheria presents about the following phenomena : After a gen- eral feeling of " malaise," or loss of tone, lasting for from two to five days, the attack commences with a definite constitutional disturbance. The first stage presents a rapid rise of temperature (often 103° to 105° F.), a feeling of chilliness, anorexia, nausea, and occasionally vomiting and diarrhoea. The throat early becomes dry and hot, with pain upon deglutition, and the neck is swollen, stiff, and tender. The tonsils, pillars of the fauces, uvula, and back of the pharynx are red, swollen, and turgid. The appearance of the false membrane is not until the arrival of the Second Stage. In this, a viscid yellowish secretion will be seen gradually forming in the depressions of one or both tonsils. Later, certain points of the superficial mu- cous tissue become infiltrated with a yellowish material, these points being something elevated above the general surface. These points, at first more or less translucent, become opaque and grayish-white. They extend and co- alesce, and thus a considerable surface of the fauces and pharynx may become covered with a pseudo-membrane, which is constantly being re-enforced with additions to its under surface. Portions of the membrane may be torn off, and occasionally a perfect cast of the place from which it is removed may be obtained. The neck is swol- len from the enlargement of the parotid and submaxil- lary glands, which are frequently hard and very tender. Ftever is generally lessened with the appearance of the exudation, exceptionally, however, it may remain as high or even rise higher than at first. Swallowing is per- formed with difficulty, and the breath is fetid from the decomposition of the morbid secretions. The pulse is weak and compressible, and is either very rapid or very slow. The first sound of the heart is weakened. Albu- minuria is a frequent symptom in the earlier stages of an attack, and the urine is apt to be scanty and high-colored. Hyaline casts are not uncommon, but the occurrence of granular or epithelial casts is not constant. The morbid process may spread downward and invade the larynx and trachea-this usually occurring in from three to four days after the invasion, and making itself manifest by unmistakable signs. These are hoarse, muf- fled voice, stridulous breathing, constant dry cough at first; later dyspnoea, increasing cyanosis, swelling of the face, and drowsiness passing into coma. The nasal cavities may be involved primarily, or by the extension of the disease from the fauces. This is indi- cated by the discharge from the nose of a fetid, dark- colored, watery fluid, with the formation of false mem- brane in the nasal cavities. There is often, also, repeated and sometimes fatal epistaxis, and occasionally there occurs a blocking of the lachrymal duct, or the disease may extend by this channel to the . eye. The morbid process may also pass through the Eustachian tube, with a resulting perforation of the membrana tympani and a subsequent purulent discharge from the ear. If the larynx be not attacked, The third stage is reached, and the disease slowly disap- pears or death occurs very rapidly. If the result is to be favorable, a marked improvement takes place in all the symptoms by the end of the first or the beginning of the second week. The temperature becomes normal, the pulse regains its strength and regularity, anorexia disap- pears. The congestion of the fauces diminishes, the ex- udation ceases to extend, and portions of it become de- tached. The patient feels very well, but the danger is not passed, for a relapse may occur, which may be more severe than the initial attack. Another danger to be feared at this time is syncope from failure of the action of the heart. If the termination of the attack be un- favorable, death may occur from a secondary blood- poisoning, with typhoid symptoms or coma, or, more frequently, from cardiac embolism or syncope. II. The Mild Form.-In such a case the symptoms are often so slight that the diagnosis must be exceedingly doubtful; they are those of an ordinary catarrhal sore throat. The constitutional disturbance is very slight, the elevation in temperature being but one or two degrees, the pulse being but little affected. There may be slight pain and dryness in the throat, and some difficulty in deglutition. The submaxillary glands may be swollen and tender, the tonsils, soft palate, and pharynx red and swollen, and in a day or two minute yellowish spots, the size of a pin's head, make their appearance; these are easily removable. The symptoms improve on the third or fourth day, and often the presence of persistent and general weakness is the only definite sign that the case has been one of diphtheria. This form is often, how- ever, introductory to an acute attack, which bursts out in a few days in full force. III. Malignant Form.-In a case of this kind there are at once rigors, headache, vomiting, and not infrequently epistaxis. The throat symptoms are not always very severe, but decomposition of the secretions and the re- sulting fetor is very great. The temperature is not neces- sarily high, the pulse is small, rapid, and wavy. The patient becomes drowsy, the skin is cold and clammy, the face pale, the tongue dry, brown, and tremulous, the mucous surfaces bleed easily, and petechiae under the skin are often present. All the symptoms of a typical case crowd on, and the patient dies comatose or in syn- cope. IV. Chronic Diphtheria is rare. Mackenzie (" Diph- theria," p. 31) quotes a case in which the membrane per- sisted in re-forming for three months. Other cases are reported by Barthez (Bull, de la Soc. Med. des Hop., 1858), Isambert (Lorain et Lepine, " Nouv. Diet.," 1869), and Hybre (These de Paris, 1875, No. 462). Symptoms in Detail.-Prodromes.-In the majority of cases there is a prodromic stage lasting for a day or two. The patient feels indisposed to exertion, is slightly feverish, and is apt to have some difficulty in deglutition. There is headache with occasional vomiting. Pharynx and Soft Palate. - The pharynx and soft palate are the principal seats of the local diphtheritic disturbance. Larger or smaller deposits are found there, loose, or deeply embedded, according to the location. Sometimes there is but one spot, but usually more, and in a short time (twelve to twenty-four hours) they coalesce to form a membrane. On the uvula, soft palate, and posterior wrall of the pharynx the membrane is super- ficial and may sometimes be easily removed. It is more firmly attached upon the tonsils and sometimes extends into the deeper tissues. There is occasionally no actual membranous formation, and in such cases the tissues are swollen, the surrounding portions more or less reddened, and the infiltration into the tissues gives a more or less grayish-white discoloration. When the uvula is in- volved the swelling is usually more marked than when the rest of the fauces alone are affected. Jacobi speaks of three distinct processes in the throat: 1, A membrane lying on the mucous membrane and which can be separated without much, if any, injury to the subjacent epithelium ; 2, a membrane, implicating the upper layers of the mucous membrane; 3, a whitish or grayish infiltration of the surface and deeper tissues, winch may occasion necrotic destruction. When the symptoms are of long duration and deep infiltration oc- curs, haemorrhages from the affected parts are not un- common. They may be slight, but occasionally large vessels are opened and death may result. Gangrene 470 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diphtheria. Diphtheria. sometimes occurs after extensive infiltration, and a de- cided loss of substance is revealed after the falling off of the membrane, this process more usually taking place upon the tonsils. Nasal Cavities.-The morbid process often passes into the nasal cavities from the posterior aspects of the soft palate or pharynx, especially when the uvula is affected. The disease may occur primarily in the nose, and this happens more often after an acute catarrh ; the secretion is very profuse, slightly flocculent, and frequently very offensive. The first certain indication of nasal diphtheria is the occurrence of tumefaction of the cervical glands, be- fore this it is often impossible to diagnosticate the disease. This adenitis is oftentimes very persistent, a permanent induration sometimes remaining. Chronic nasal catarrh, with elongated uvula and enlarged tonsils, are frequent results of the disease. Eye.-The eye is frequently affected by extension of the process from the nose through the nasal duct, al- though it may also be the seat of primary infection. Diphtheritic conjunctivitis is an exceedingly grave affec- tion, as regards the safety of the eye ; the cornea is fre- quently destroyed by pressure from diphtheritic keratitis in twenty-four hours. Von Graefe first studied diph- theria of the eye in 1854. It is not a frequent affection. Sometimes a single eyelid is the seat of the disease ; the process may first appear on the conjunctiva bulbi, and pass thence to the conjunctiva palpebrarum. The cornea becomes hazy very early, and ulceration occurs-perfora- tion is to be feared, with possible prolapse of the iris and consequent destruction of the eye or, at least, loss of sight. Ear.-The ear may become affected through the Eus- tachian tube and otitis interna and media, with per- foration of the membrana tympani, and even caries of the mastoid bone may be a result. Epiglottis, Larynx, Trachea.-It is not rare to find patches of membrane in the depressions at either side of the base of the epiglottis, which is then swollen, with hard and reddened edges. The most of the diphtheritic process occurs upon the upper surface of it. Dyspnoea and hoarseness are only occasional, and only when there is accompanying oedema at the entrance of the larynx ; this oedema produces a functional paralysis of the vocal chords with marked dyspnoea upon inspiration. Larynx. When membranes form in the larynx in- spiration and expiration are both interfered with. Fever and pain are not necessarily prominent, but as the pro- cess goes on, respiration becomes more difficult, complete aphonia comes on, and the hoarse, croupy cough becomes more and more suppressed. If the affection progresses, all the symptoms of suffocation and poisoning by carbonic acid gas come on. The supra-clavicular and intercostal regions are retracted with each inspiration, sometimes also the ensiform cartilage. Usually a number of days elapse between the first laryngeal symptoms and death ; at times, however, a fatal result occurs in a few hours. Trachea. Jacobi and a few others claim that the trachea and bronchi may be the original seats of the dis- ease, and that the diphtheritic process may spread upward to the larynx and into the fauces. This is denied, how- ever, by Henoch ("Charite Annalen," Berlin, 1876), Oertel, and Steiner (" Ziemssen's Handbuch," Bd. XIV., I. Th., S. 236). Cases of genuine cicatrization between the arytenoid cartilages (Michael, Deutsch. Arch. f. klin. Med., 1879, xxiv., p. 618), with a resulting paralysis of the internal thyro-arytenoid muscles, have been occasion- ally reported. Lungs.-Lobular pneumonia is the occasional result of the inhalation of pieces of false membrane into the small- est bronchi. Fibrinous pneumonia is also known to occur. Broncho-pneumonia frequently appears after tracheotomy, and is a common cause of death after this operation . In all forms the diagnosis is exceedingly dif- ficult, if the larynx be affected, because of the noisy res- piration which interferes with the recognition of the signs upon auscultation ; if the trachea is opened this difficulty is done away with. Mouth.-Primary infection of the mouth is not com- mon ; diphtheria often occurs in this situation, however, in association with the same affection in the nose and fauces. The morbid changes occur on the cheeks, tongue, angles of the mouth, gums, and lips ; appearing here, as in other places, by preference where there has been a solution of continuity in the mucous membrane. Diphtheria of the mouth is an indication of a probable long duration of the disease, with the danger of septic poisoning to follow. (Esophagus and Cardiac Orifice of the Stomach.-The occurrence of genuine diphtheria of these parts is asserted by Rokitansky and Jacobi, while Zenker and von Ziems- sen say that the formation of membrane ceases at the upper portion of the oesophagus. Intestinal diphtheria occurs, but is rare in the human subject, although not uncommon in cows., Wounds of all kinds are easily and rapidly infected, and quickly become covered with the false membrane. Death occurs by general infection from such a source, and may come as well from diphtheritic infection of abra- sions of the skin, as from that of amputations or other re- sults of surgical interference. Skin.-At the beginning of an attack, sometimes not for two or three days, a more or less general erythema may appear upon the skin. Its principal seat is over the shoulders, chest, or back, and it is very similar to, and often indistinguishable from the eruption of scarlatina. Erysipelas also often occurs, and is a complication much to be dreaded. Genito-urinary Organs.-The diphtheritic process may occur in these organs secondarily, but not often ; some- times it is primary in this locality. The disease has oc- curred in the vulva, vagina, bladder, placenta, and in circumcision wounds. Kidneys.-These are the most actively involved of any of the internal organs during the progress of diphtheria. Wade (Mid. Quart. Journ. Med. Science, April, 1858) first spoke of albuminuria in this disease, and was followed some months later by Germain See (Union Medicate, 1858, p. 407). The presence of albumen is not of such great significance as was at first supposed. It occurs in large quantities in mild cases, and in small amount or not at all in severe attacks. It appears before or after trache- otomy. It is often unaccompanied by any other signs of renal disease, but may be accompanied by various kinds of casts and epithelial cells. Heart and Blood.-There may be weakness of the car- diac muscles, sluggish circulation, dyspnoea, and muffled heart-sounds, cool and pale skin, feeble and frequent, sometimes slow, pulse. Occasionally there is actual en- docarditis affecting the valves, more especially the mitral. This is characterized by high fever, precordial pain, syn- cope, and a systolic murmur. The Nervous System.-This is often affected and fre- quently very seriously. The influence exerted was sup- posed for a long time to be localized in certain nerves or groups of nerves, and that the first point attacked was always the arches of the soft palate. This is not true, however, nor is the assertion that severe paralyses follow severe local manifestations, for the opposite^s very often the case, that a very mild attack of diphtheria may be followed by a very severe form of paralysis. Many theories of the method of production of the paresis are put forward, such as that they are produced by fatty or granular degeneration of the muscular fibres, or by capil- lary haemorrhages, or amyloid degeneration, or by cede- matous infiltration of the part and consequent pressure. All of these, however, are more speculative than based upon actual facts observed. The most frequent paralysis is that of the soft palate, appearing, as a rule, in the second week, although often earlier and sometimes later. A paralysis of the con- strictor muscles of the pharynx also may occur, and these two produce imperfect speech and difficult deglutition, with frequent regurgitation of fluids through the nose. Sometimes life is only to be sustained by the use of the oesophageal tube. Paralysis of the power of accommodation is next in fre- quency. Paralyses of the lower and upper extremities come next in order. They rarely occur suddenly, and 471 Diphtheria. Diphtheria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. usually involve one set of muscles at the same time. Complete fatty degeneration, although rare, may occur. The muscles of the neck are sometimes affected, produc- ing inability to hold the head erect. The fingers alone may be paralyzed. The bladder and sphincters may be affected, but not commonly. Sometimes the muscles of respiration are affected, and such cases are extremely dangerous to life. Such are the motor paralyses, but affections of the sensory apparatus may also occur. Amesthesia of the entire upper part of the body has been seen. Sometimes the two are combined and loco- motor ataxia is the result. Diphtheritic paralyses are irregular in regard to the place of appearance, their severity, their duration, and their response to treatment. They may last from six weeks to six months, may re- cover with treatment and w'ithout it, and may prove re- fractory to anything that can be done to remove them. Etiology.-Diphtheria is pre-eminently a disease of early life, the proportionate number of cases diminishing very rapidly as the age increases. Of five hundred deaths in Vienna, from this disease, in 1868, but one case had reached the age of sixty years. Sex seems to exert no special influence. It occurs mostly in children. The predisposition at this age is explained by the softer condition of the mucous membrane of the mouth and pharynx, and by the nar- rowness of the pharynx, the protuberant condition of the tonsils, the large number and size of the lymphatics and the greater communicability between them and the sys- tem at large (S. L. Schenck, "Mittheil. aus dem Embryo- log. Instit.," 1,1877), all of which aid in the development of the disease. On the other hand, the free acid secre- tions of the mouth after the third month tend to hinder its occurrence after this period. There seem to be families in which there is a predispo- sition to the disease. Climatic and Atmospheric Conditions.-The disease is most common in temperate climates, but it occurs almost everywhere. It is probable that moisture favors the de- velopment of the poison, and also that it can lie dormant for a long time, and until some special agency calls it into activity. The disease prevails more extensively during the winter months, apparently at the time when catarrhal conditions are most common and the mucous membrane is in a receptive condition. Social position offers no safeguard against an attack during an epidemic, although sporadic cases seem to es- pecially attack those living under bad hygienic surround- ings. Exhalations from sewers and filthy personal habits are also said to produce the disease. The weight of evidence, however, seems to be against their possessing any specific action. Nature of the Diphtheritic Poison.-Investigations of this point have occupied the attention of observers for years past, and the discussion is as vigorous as ever. In 1840 Henle expressed his belief in a " contagium vivum," and Buhl first found schizomycetes in the diphtheritic membrane, expressing, however, no opinion as to their special import. Oertel, Klebs, Orth, Eberth, Curtis and Satterthwaite, Burdon-Sanderson, Weisgerber, and Peris, with a host of others, took part in the discussion. Most of the work was done before the recent advances in my- cology had been made, and before the present methods of precision were employed, imperfect as they still are. The two recent contributions to the subject, of especial importance, are those of Wood and Formad (" Rep. Nat. Bd. Health, 1882," Memoir on Diphtheria, Appendix A), and Loeffler (" Mitt. a. d. Kais. Gesund.," ii., 1884). The latter is of the greater value because the experiments were under the supervision and after the methods of Koch, than whom there is no greater living mycologist. The experiments were made upon various animals, and investigations were carried out upon the human race. The results are as follows : Two kinds of organisms were found, one a micrococcus, the inoculation of which pro- duced lesions similar to erysipelas, and a bacillus, situated in the deeper tissues, growing well at 20° C. (68° F.) on a culture-medium of blood-serum, meat-broth, peptone, and grape-sugar. The conclusions of this important paper are summed up as follows: 1. The organisms were not dis- covered in every case, but this may be explained by suppos- ing their elimination during the course of the disease, as occurs in the case of other pathogenic bacteria. 2. The arrangement in the pseudo-membranes of rabbits and chickens (produced by inoculation) was not as typical as in cases of human diphtheria. 3. The application of the organism to the healthy mucous membrane gave no re- sult ; but it is not known whether a minute lesion is not necessary for the production of the disease in the human subject, and besides, there is no tonsil with crypts and recesses favoring vegetation in these animals. 4. None of the surviving animals ever had post-diphtheritic pa- ralysis ; but this is not surprising, for its occurrence in man is rare, also, when compared with the number of cases of the disease which occur. 5. The mucous membrane of twenty healthy children was examined, with the re- sult of finding the bacteria once. It is not impossible, however, that they may constantly lodge upon these sur- faces without growing. The article concludes with some observations upon a diphtheria-like process in pigeons and calves, accompanied by organisms differing from those in man. Taken as a whole, the paper is a very im- portant step in the investigation of the etiology of the disease, and will be of great assistance in future work upon the subject. Wood and Formad, after a series of culture and inoc- ulation experiments, reached the conclusion that the dis- ease " is a putrid sore throat, with or without a secondary septicaemia," which leaves the matter about as it was be- fore. Loeffler's results, therefore, seem to agree with those of Klebs (Int. Med. Cong., 1883) in ascribing a probable specific action to the bacillus found in this dis- ease. At the same time it is to be said that the work is not yet complete, and that it is not yet certain that the specific organism of diphtheria has been demon- strated. Manner of Infection.-Whether diphtheria be a local disease with constitutional sequelae, or whether it be a general disease, making its most marked appearance at certain points, has been much discussed. If, however, as seems probable, it is excited by some form of bacterium, the question is settled that the local manifestations are the signs of the place of entrance, and the constitutional disturbances the evidence of the general distribution of the poison. The contagiousness of diphtheria is undoubted ; the con- tagious material may be communicated directly by the patient ; it seems to cling to solid bodies, and may be transported in this way to a distance-how far is as yet undetermined. The methods of transmission that appear to offer the most usual channels for the spread of the disease are: bad drainage, polluted water-supply, milk of diseased cows (Power, Brit. Med. Journ., February 1, 1879 ; Bol- linger, Zeit. f Thier. Med. u. Very. Path., 1879, vi., p. 7), and infected animals (Dennuau, Zeit. f. Thier. u. Verg. Path., 1876, p. 1; Blazekovic, Ibid., 1878, p. 64 ; Brignion, Ibid., p. 87 ; Bollinger, Ibid., 1878, p. 253; Friedberger, Ibid., 1879, p. 161 ; Aicate, Rev. d'Hygieneetde Police San., 1879, p. 3 ; Trastol, "De la Trans, de la Dip. des Animaux al'Homme," Gaz. Heb., April 5,1879). All these research- es, with many others, make it certain that the disease does occur among domesticated animals. This question being determined in the affirmative furnishes a probable ex- planation of the origin of many cases in human beings in which the source of infection has been obscure. Pathological Anatomy.-The most important part of the diphtheritic process is the false membrane : it is the most prominent characteristic as well as the most fre- quently met with. It is tough, dry, yellowish, or gray- ish white, firm and elastic. It swells upon the addition of acetic acid, and becomes more or less transparent. It is soluble in caustic alkalies, insoluble in water, and yields neither gelatine nor albumen. It varies in appear- ance from a thin, transparent pellicle to a skin of con- siderable thickness. On separation, if the attack has been a mild one, the subjacent mucous membrane is 472 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diphtheria. Diphtheria. smooth and paler than normal; if the attack has been severe, more or less ulceration is left behind. It consists, first, in great part, of fibrin, the result of epi- thelial changes, or coming directly from the exuded blood-serum. It contains also epithelium, more or less degenerated blood, mucus, and bacteria. Its method of formation is something as follows. The pavement epi- thelium becomes cloudy, swollen, and dentated, and dis- solves into a network. It becomes later the recipient of newly formed cells. There is a considerable infiltration of the mucous membrane, with pus-cells and granules ; the cellular tissue is studded with granules also, its de- composition resulting in a fine granular deposit and ne- crosis, a process considered by Virchow to be an impor- tant element in severe forms of diphtheria. The clinical differences between the membrane of croup and that of diphtheria are not borne out by the microscopical exami- nation, which shows that there is no essential difference at all. In this connection it is of interest to record the opinion of Weigert (Virch. Arch., v., 1870), that the mem- brane arises from parts deeper than the epithelial layer, and that a division into croup, pseudo-croup, and diph- theria may be made. Thus, when there are but few leu- cocytes, the deposit is a network of fibrillae, which is croup ; when there are numerous leucocytes, the masses are more solid and voluminous, and this is pseudo-croup or pseudo-diphtheria ; when the tissue is hard like coag- ulated fibrin, when it does not occur on the surface, but is deeply embedded in the mucous membrane, the process is diphtheria. Heart.-1This organ is often found to be perfectly healthy. It may present numerous thrombi, however, and there is often fatty degeneration of the muscular tis- sue, or parenchymatous inflammation or haemorrhages may occur. Endocarditis is found affecting the mitral more often than the tricuspid or pulmonary valves. Per- foration of the septum of the right auricle and of the aorta has been seen. Lungs.-These organs present various inflammatory or congestive appearances-oedema, broncho-pneumonia, atelectasis, emphysema, ecchymoses, and infarction are all found at various times. They may also be entirely unaffected. The spleen is often increased in size, congested, and may be friable, with more or less extensive infarctions. The kidneys may be normal, simply congested, or the seat of parenchymatous or interstitial nephritis. In the muscles are sometimes found ecchymoses, myo- sitis, gray degeneration, or atrophy. The lymphatic glands are often swollen and inflamed. They may be hard or yielding to pressure ; abscesses are not common. The tissue about the glands is often in- volved in the inflammatory process also. Intestinal Canal.-Unless the actual seat of the disease, this tract presents no peculiar appearance. Virchow con- siders that diphtheria of the intestinal canal is character- ized by fibrinous deposits on the surface and in the tissues of the intestines, with a subsequent granular degenera- tion of the tissues ; and Rajewsky claims that his experi- ments prove that bacteria are important factors in the production of the diphtheritic membrane after previous inflammation has taken place in the intestine. Brain.-If death has occurred from asphyxia, the brain presents a venous engorgement of the membranes and cerebral substance, with minute extravasations of blood. Pus and lymph have also been found on the arachnoid membrane in cases in which septicaemia has been very marked. In very many cases, however, there are no per- ceptible alterations in the cranial cavity. Diagnosis.-The characteristic sign of diphtheria is the presence of a circumscribed membrane, with more or less congestion of the surrounding parts. The fever is not always a prominent symptom, and but little importance can be attached to it. High fever at the beginning of the disease should make the diagnosis doubtful for the time. Swelling of the glands of the neck, especially about the angles of the jaw, is an important aid in the diagnosis ; the absence of this sign is, however, of no weight as neg- ative evidence ; it is of especial value when the seat of the process is in the nose, and its exact location cannot be readily examined. Diphtheria of the vagina, conjunctiva, and of wounds can only be confounded with a simple purulent coating where ocular examination alone is at command, and con- fusion between the two processes can very seldom occur. The eruption, when it is present, occurs about the chest, neck, and abdomen, and is to be distinguished from that of scarlatina, according to Jacobi, in that this latter first appears about the hips and extremities. Not infrequently, however, the differential diagnosis is extremely difficult, and can be made only after sufficient time for observa- tion of the efflorescence has passed. Albuminuria, if present in the first few days of an at- tack, is an indication of diphtheria; if it appears later, of scarlatina. The diagnosis of diphtheritic paralysis presents no difficulties if the case has been watched from the beginning, and the diagnosis of the primary disease has been satisfactorily made. The settlement of the question as to whether a paresis is a sequel of diphtheria or not, is often impossible if the previous history be ob- scure. The special characteristics of the diphtheritic paralysis are, that it very frequently starts from the pharynx, that its course is exceedingly irregular, that it is mostly peripheral in character, and generally motor, but sometimes sensory. Differential Diagnosis.-Diphtheria may be con- founded with scarlet fever, confluent herpes of the throat, acute tonsilitis, and acute laryngitis. In addition to the points already touched upon, the following aids to diag- nosis may be mentioned. The disease may be differen- tiated from scarlet fever by the constitutional symptoms being less, as a rule. There is less anorexia and more prostration, the throat is less uniformly reddened in scar- let fever, the membrane, if any exists at all, is more easily detached in the latter disease. The larynx is almost never attacked in scarlet fever, and haematuria is common, while it is rare in diphtheria. The rash is different; in diphtheria it is not common, appears at irregular periods, is partial, appears suddenly in patches, and is of an uni- form erythematous redness, without the punctated ap- pearance peculiar to the scarlatinal eruption (Meigs and Pepper). It is very often impossible to differentiate acute tonsillitis from diphtheria at first. If this be the disease, however, rather than diphtheria, the inflammation either subsides or suppuration occurs, which makes the diagnosis plain very soon. Confluent herpes has the peculiarities of a rapid rise in temperature followed by an equally rapid fall. The pain in the throat is of a peculiar smarting character, and there is no tendency to spread. The presence of herpes of the lips is oftentimes of very great help in making out the diagnosis. Catarrhal laryngitis of a severe form is oftentimes im- possible to differentiate from diphtheria, especially in the early stages. When the disease is fully developed it is easier to distinguish it, for catarrhal laryngitis nearly al- ways ends in recovery and without the severe sequelae of diphtheria. Prognosis.-The prognosis in each individual case should be very guarded; to consider that recovery is probable before the disease has run its course is exceed- ingly unsafe, and even then relapses may occur and the result be once more placed in doubt. The general course of an epidemic may have some influence upon prognosis, but that influence is exceedingly small, for it is the mild cases that are the most deceptive. Speaking very gener- ally, the prognosis is favorable where the local manifes- tation of the disease is of small extent, and is situated on a part that has but little communication by the lymph- atics with the rest of the system. An indication of slug- gishness in the course of the disease-as diphtheria of wounds or of the angles of the mouth-is unfavorable, as also is the extension of the disease to the larynx. The septic or gangrenous forms of diphtheria are es- pecially dangerous, but the height of the fever has no especial bearing upon the result. A rapid, small, and ir- regular pulse is a sign of failure of the heart, but is not 473 Diphtheria. Diplopia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a very unfavorable sign so long as there is an approxi- mately normal relation to the rate of respiration. Every complication adds to the gravity of the prognosis. During convalescence the extension of the paralysis to the muscles of respiration is a very alarming sign. The indications of immediate danger are croupy symptoms, arising from the extension of the membrane into the larynx, a brown or black appearance of the false mem- brane, haemorrhage from the nose or throat, bronchi or intestines, purpura, copious discharge from the nostrils, intense albuminuria, great swelling of the cervical glands, marked diminution of temperature, nausea or diarrhoea at an advanced period of the disease. Any one of these symptoms indicates a severe case, two or more together show that the patient is in imminent danger of a fatal ter- mination (Mackenzie: "Diphtheria," 1879). Treatment. - There is no specific for diphtheria. Treatment is to be based, first, upon general principles, and, second, upon local applications. Measures to sustain the general health are of the great- est importance, and should receive special attention. The temperature of the room should be from 62° to 65° F.; there should be a sunny exposure and an open fire. The diet should be as nutritious as possible, consisting of beef-tea, milk, and the like, given regularly in small quantities and at short intervals, especially during the night, for it is then that the vital powers are in their least resistant state. If signs of failure of the heart ap- pear, the patient's head should be kept as low as possible. High fever should be treated with sponge-baths of tepid water; quinine and salicylate of sodium are also recom- mended. Collapse should be met with the free exhibi- tion of stimulants, and severe vomiting or diarrhoea should be checked at once. The means and the methods of employing them must be left to the judgment of the physician. As complete isolation of the case as is possible should be practised. The sick-room should be kept cool; the temperature spoken of above is the best, and plenty of fresh air should be admitted. The nurses should keep the mouth closed when over the patient; any caressing or fondling should be absolutely prohibited. It is also a good plan to wear cotton in the nostrils as a filter. The general treatment should be begun early, as there is no typical course to the disease, and, therefore, delay is dangerous. There is small chance of giving too much stimulant, and a tonic never does harm, whereas its omission may be irreparable. An exceedingly important measure is disinfection, which may be attained by the use of roll-sulphur (two pounds to every 1,728 cubic feet of space) for fumigation of the rooms, and copperas solution (one and a half pound to a gallon of water) for everything that can be placed in it. Better than this is a solution of corrosive sublimate (one part to ten thousand of water), which should be freely used in all drains, privies, etc., and for soaking all soiled linen or clothing. The instructions given for disinfection by the National Board of Health (Bulletin No. 10, September 6,1879) are simple and effective-substituting the corrosive ■sublimate solution for the other agents mentioned. Special Treatment.-The first indications are to employ those remedies which have or seem to have an effect in softening or destroying the false membrane. The principal among these are steam inhalations, which have been employed in various ways, as from the nozzle of a kettle and by dropping hot bricks into water. The best method of employment is by means of the atomizer, used very frequently in conjunction with some thera- peutic agent, as carbolic acid, salicylic acid, salt, or chlo- rate of potassium. Chlorate of Potash. This remedy is one very widely employed, and of especial benefit, not however as a spe- cific against the disease. Its beneficial effects arise from its alleviating the laryngitis and stomatitis accompanying the disease, and from its placing the surrounding parts in such a condition that the false membrane rarely spreads. It should be given freely, that is, in small doses and fre- quently. One of the best methods of application is by the steam atomizer. Using the spray for five or ten minutes every hour has been followed by the happiest re- sults. The strength of the solution to be used is that of saturation, a sufficient dilution for safety being effected by the steam. For children the solution should be weak- ened so that a child of three years will not get more than two grammes (30 grains) in the twenty-four hours. Serious results, as acute nephritis, have been recorded from over- doses of this drug; but properly employed its great value is unquestionable. It does not have any marked effect in dissolving the diphtheritic membrane, as has been sup- posed. Steam is of value only in those cases in which the mem- brane is upon the surface, and in all cases a good supply of fresh air must be introduced, avoiding all overloading of the atmosphere-in other words, its use must be sus- pended if it proves annoying. Water to promote the secretions is of value, either given alone, three to six ounces every hour, or combined in hot drinks of various kinds. Cold water and cold applications, in the form of ice-bags, are useful in many ways in easing the discomfort of the swollen and sore throat. Cracked ice, swallowed occa- sionally, water-ices, and ice-cream give relief. Sponging with tepid water in high fever and when the surface is hot gives great comfort to the patient. The use of this remedy is contraindicated, however, if the feet are cold, or if there is any other sign of a weakened cir- culation. Lime-water, either alone or in combination with glyce- rine, applied locally to the throat by means of spray, sponges, or gargles, has been very highly thought of as exerting some solvent effect upon the membranes ; this action is so slow, however, that the good results ob- tained are probably due-as suggested when speaking of chlorate of potash-in this case, as well as in that of acetic acid and other well-known remedies, more to their cleansing effect than to any specific action. Neurin is highly spoken of by Winiwarter as an alka- line anti-ferment, thus requiring no change of reaction before entering the circulation. Turpentine. Inhalations of the oil of turpentine are recommended, ten to fifteen minims every hour. A bet- ter method of employment is by boiling some water con- taining half an ounce of the spirits or oil of turpentine in the room. This should be kept going continuously. Chloride of ammonium seems to be of use occasionally ; dose, internally, from one to two grains every two or three hours for a child of two years, or half a drachm burned over a flame in the room. Mercury has been extensively used, but has nothing to recommend it. Astringents, as alum, tannin, nitrate of silver, have al- most entirely passed out of use, their employment seem- ing to retard rather than to favor the exudative process. Chloride of iron, introduced by Gigot in France in 1848, has been used very extensively and beneficially, if given freely and often. As much as from five to ten drops of the tincture every half hour may be given. Carbolic acid is helpful merely as a cleansing agent, and perhaps not even for that. Salicylic acid has been highly praised, but its merits seem to depend more upon its power as a destroyer of the foul odor than upon anything else. Quinine is of little or no value, except, rarely, in cases of high fever. Potassa fusa and other deliquescent salts, as well as chromic acid, are dangerous because of the difficulty of limiting their action. Bromine, six to twelve drops every one, two, or three hours, in sweetened water, is very highly recommended by W. H. Thomson (Jacobi: " Diphtheria," p. 201), but its wider employment does not appear to justify his encomi- ums. Ozone has been recommended with no very great re- sults from its employment. It is to be inhaled every one or two hours for from three to five minutes. Boric acid (one to thirty), used as a gargle, and benzoate of sodium (one to eighteen), given so that a child of one to three years shall have from one to two drachms in 474 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diphtheria. Diplopia. twenty-four hours, are among the many other remedies that have been proposed. Sulphur, inhaled, and the use of cubebs and copaiba, nearly complete the list of remedies that have been em- ployed by the most distinguished men. As will be seen, none of them offer a prospect of universal success. Gargles, sprays, and local applications of watery solu- tions of corrosive sublimate, in strength of from one part to three thousand and upward, are the latest means employed against the local manifestations of the disease. The re- sults are as yet too few to enable any estimate of their value to be made. Mechanical removal of the membranes must not be prac- tised. When they can be detached without the use of force they will come off of themselves, and this time should be patiently awaited. Swelling of the lymphatic glands in diphtheria must be treated as if an idiopathic affection, by applications of cold water or ice, poultices, and, if absolutely necessary, by incision. Nasal diphtheria must be combated with constant hourly douches of some of the remedies spoken of above. Laryngeal diphtheria is occasionally helped by the em- ployment of emetics. It is when the symptoms become urgent in this form of the disease that tracheotomy is re- sorted to-the indications for the operation being the danger of suffocation from stenosis of the larynx. The mortality after the operation increases in proportion to the delay in its performance. Diphtheritic paralysis may in many cases be treated simply by rest, good food, stimulants, tonics-as iron and quinine, and sometimes by electricity. Strychnia is recommended, but its usefulness is very doubtful. Diphtheritic conjunctivitis must be attacked at once and vigorously, with ice applied locally, and boric acid (in concentrated watery solution) every hour. The un- affected eye must be carefully protected from inoculation, and this is best done by covering it with lint and collo- dion, or with lint, cotton, and adhesive plaster. axes fulfil this condition, and the doubling is really per- ceived ; although, as a result of unconscious education of the sense of vision, it is recognized not as double vision, but as the expression of a difference in the distance of the several objects from the observer (stereoscopic vision). In the case of near objects seen against a distant back- ground, the minuter details of the background are in a great measure effaced in consequence of inaccurate ac- commodation, and so come easily to be disregarded ; the same thing is true also in the case of objects much nearer to the observer than the point of fixation, as when we look out into the street, or at a landscape, through a wire-gauze window-screen. In fact, we learn to concentrate the atten- tion upon such objects as lie at or near the point for which the eyes are accommodated, and upon which their axes are directed, and to disregard the comparatively ill-de- fined and incongruous images of much nearer and of much more distant objects. The fact of the formation of incongruous retinal images under normal conditions of accommodation and convergence may be demonstrated experimentally by directing the gaze upon a small ob- ject, like a pencil, held vertically in the hand at the dis- tance of about a foot from the face, and at the same dis- tance from a vertical bar of the window-sash. If we look with the two eyes at the pencil, it will be seen single, between two parallel images of the sash-bar, or if we look at the sash-bar it will be seen single, between two parallel images of the pencil. Diplopia may be evoked artificially by altering the di- rection in which the rays of light from any object enter one of the eyes. If, while looking at an object of mod- erate size, we hold a thin prism in front of one of the eyes, the rays which pass through the prism will be bent out of their course, and will enter the eye as if emanating from a second object situated to the side of the actual ob- ject, corresponding to the direction of the edge of the prism, and the object will be seen doubled. If the edge of the prism is turned toward the temple, the second image will correspond to that of an object situated to the same side of the median plane of the body (homonymous diplopia); and if the edge of the prism is turned toward the nose, the position of the second image will correspond to that of an object situated to the other side of the median plane (crossed diplopia). If the edge of the prism is turned upward or downward, the second image will, similarly, be displaced upward or downward (vertical diplopia); and if the edge is turned in any direction inter- mediate between the horizontal and the vertical, the dis- placement of the second image will be in the same direc- tion, and the diplopia will be oblique. Diplopia, as an anomaly of vision, may result from any deviation from the normal relative direction of the axes of the two eyes. If, while looking at any small object, we press lightly through the lids upon one of the eye- balls, so as slightly to change the direction of its axis, a second image will be perceived upon the side of the ob- ject opposite to that toward which the axis of the eye has been turned. Displacement of one of the eyeballs by an orbital tumor, or as the result of a fracture of the orbital wall impairing the lateral support of the globe, or from swelling of the orbital tissues by which the free move- ments of the eyeball are impeded, may thus give rise to diplopia. Such causes may be either temporary or per- manent in their action, but even when they are perma- nent the ocular muscles may adapt themselves to the new conditions, and thus re-establish and maintain single vision with the two eyes. In other cases, in which the movements of the eyeball are impeded only in their ex- treme range, or in certain directions, the patient may learn to avoid such movements of the eyes as are attended with double vision, and to substitute for them a move- ment of the entire head. Diplopia is sometimes the predominating symptom in cases of slight preponderance of either the recti-interni or recti-externi muscles over their antagonists, and it is then either homonymous or crossed. As the normal range of convergence of the optic axes is somewhat in- creased when the eyes are directed downward, and dimin- ished when they are directed upward, a person suffering Bard : Trans. Am. Philosophical Soc., Phila., vol. i., pp. 288-404. Bretonneau : Des inflam, speciales du Tissu Muqueux et en particulier de la Diphthdrite. Paris, 1826. Addition supplementaire au traite de la Diphtherite. Paris, 1827. Buhl: Ueber Diphtherie. Zeitsch. f. Biol., iii. Cheyne, John : Essays on Diseases of Childhood, with Cases and Dissec- tions. Edinburgh, 1801, Curtis and Satterthwaite : Report New York City Board of Health. 1877. Eberth : Berl. Klin. Woch., 1864 and 1865. Ueber bact. Mycose. Leip- zig, 1872. Virch. Arch., Ivii. Gay : Tracheotomy in Croup and Diphtheria. Trans. Am. Surg. Ass., 1884. Greenhow, E. H. : On Diphtheria. 1861. Gubler and See : Ueber die Paralysie nach Diphtherie. Gaz. des Hopi- taux, 1860. Hirsch : Pathologie, Bd. ii., S. 152. Home : Inquiry into the Nature, Cause, and Cure of Croup. Edin- burgh, 1765. Hueter: Allgemeine Chirurgie, S. 205. Hueter and Tommasi-Crudeli: Cent. f. d. Med. Wissenschaften, 1868. Jacobi : Treatise on Diphtheria. New York, 1880. Klebs: Verhandlungen des Congresses f. Univer. Medicin., II. Ab- theilung, S. 143. Wiesbaden, 1883. Letzerich: Ueber Diphtherie, Berlin Klin. Woch., No. 16, 1871 ; Diph- therites u. Diphtherie, Virch. Arch., Bd. 45,46, 47. 52, 58, 61, 68; Arch, f. exp. Path. u. Pharm., 1880 ; Die Diphtherie, Berlin, 1880. Loeffler: Untersuchungen liber die Bedeutung der Mikro-organismus fiir die Entstehung der Diphtherie beim Menschen, etc., Mittheilungcn a. d. Kais. Gesund., Bd. ii. 1884. Mackenzie : Diphtheria. London, 1879. Oertel: Aerzliches Intelligenzblatt, 1868. Exper. untersuch. ii. Diph., Leipzig, 1871. Zur Aetiologie der Infectious Krankheiten, etc., Vor- trag gehalten in den Sitzungen des Aerzlichen Vereins zu Munchen im Jahre 1880. Ziemssen's Cyclopaedia, vol. i. Munchen, 1881. Trendelenburg : Ueber Contag. u. loc. nat. d. Diphtherie., Arch. f. Klin. Chir., x., 720. 1869. Virchow : Hand, der spec. Path. u. Ther., and many articles in Archives. Von Recklinghausen: Cent. f. d. Med. Wissenschaften, S. 713. 1873. Literature. DIPLOPIA, or double vision (from 8nr\oo$, double, and dty. eye), is a result of the formation of the two images upon non-corresponding parts of the retinae of the two eyes. Strictly speaking, in every act of binocular vision, the retinal images of all objects which lie either nearer or more remote than the point of intersection of the visual Harold C. Ernst. 475 Diplopia. Direction. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from slight insufficiency of the interni may sometimes correct the tendency to crossed diplopia by habitually carrying the head high or tipped a little backward ; and, similarly, in the case of slight insufficiency of the ex- ternl, he may correct the tendency to homonymous dip- lopia by habitually bowing the head. In such cases the wearing of prismatic spectacles, with the bases of the prisms turned inward or outward according as the interni or the externi are in need of assistance, may afford per- fect relief, and enable the patient to carry his head in the normal position. So, also, a slight deviation of one of the optic axes upward or downward may give rise to a ver- tical diplopia, which may be corrected by wearing a pair of spectacles of which one of the glasses is a prism, set with its base turned downward or upward as may be in- dicated ; or a pair of prisms may be given, with their bases turned in opposite directions, so as to divide the correction between the two eyes (see Spectacles). In every case of deviation of one of the optic axes from its normal direction, the retinal image in the devi- ated eye is necessarily formed upon an eccentric portion of the retina, where the visual acuteness, as regards per- ception of form, is less acute than at the fovea centralis ; and the greater the deviation the more peripheral will be the image, and the less vivid the perception. Hence, in the higher degrees of deviation, the perception of one of the retinal images may be so reduced in vividness as to make it easy to disregard it altogether, and the diplopia may then give place to single vision with a single eye. This is, in fact, ordinarily the case in strabismus, in which affection the relative deviation of the crossed eye, and the consequent displacement of its retinal image, are both considerable and nearly constant. In confirmed strabismus diplopia is accordingly but seldom remarked by the patient, although it may be evoked in the greater number of cases by displacing one or both of the retinal images by means of prisms, or by making them appear of different colors by directing the patient to look at a bright object, such as a candle-flame, through a colored glass held before one of the eyes. Diplopia is also often developed, as a transient phenomenon, after the partial correction of the deviation by tenotomy (see Strabismus). In paralysis or paresis of one or more of the external muscles of the eyeball, from suspended or impaired func- tion of one of the motor nerves (third, fourth, or sixth), diplopia is from the beginning a prominent symptom, and it may also persist for a very long time. This is ex- plained by the fact that in simple paralysis (or paresis) of a single muscle the faulty direction of the axis occurs only in those positions of the eyeball in which the af- fected muscle fails to do its appropriate work, while in looking in other directions the normal relative direction of the two eyes is preserved. Binocular vision is, there- fore, only occasionally disturbed by the perception of double images, and the diplopia, when it is evoked by an unsuccessful attempt to turn the eye in the direction of the paralyzed muscle, is easily corrected by turning the head in the same direction, and so fusing again the mo- mentarily separated images. Moreover, the distance by which the two images are seen separated from each other is dependent wholly upon the direction in which the eyes are turned, and is, therefore, a varying quantity ; so that the false image, which is projected at different times upon different portions of the retina of the deviated eye, is constantly asserting itself in a new position, and is, therefore, less easily disregarded than in the case (as in strabismus) in which the relation of the two images to each other is nearly, or quite, constant. In a later stage of the affection, however, the unopposed antagonist of the paralyzed muscle usually becomes shortened, so that some degree of doubling may occur even in the most favorable positions of the two eyes; but even then the diplopia remains variable in degree, and so is apt to per- sist as an ever-recurring source of visual disturbance. In diplopia, whether dependent on an impediment to the free mobility of one of the eyes, or upon perverted ac- tion of one of the ocular muscles, it is ordinarily the af- fected eye which deviates ; exceptional cases occur, how- ever, in which this eye is so much the better eye, as re- gards acuteness of vision, that it continues to be used, and is consequently accurately directed upon the object, while the deviation is transferred to the eye whose mo- tility remains unimpaired. Hence, it is sometimes quite possible to fall into the error of attributing the defect in motility to the wrong eye, as, for instance, in a case of vertical diplopia, in which it may be very difficult to de- cide whether one of the eyes is turned a little upward or the other a little downward, or, in a case of homonymous or crossed diplopia, where we may be in doubt whether the excessive or insufficient convergence has its seat in one of the eyes or in both. From a practical stand- point, however, these nicer points of diagnosis are ordi- narily of minor importance, for the reason that, if the deviation is of such a nature and degree as to bring it within the power of prisms to correct it, the prisms must usually be applied to both eyes in order to obtain a suf- ficient refractive effect with a minimum disturbance from dispersion; and, similarly, in a large proportion of the cases of deviation of higher grade, for which tenot- omy may be the appropriate remedy, the requisite cor- rection is best attained by operating upon both eyes. We have thus far considered diplopia as simply a doubling of the visual impression ; but, in fact, the axis of the deviated eye is very often not only misdirected, but is also more or less rotated or twisted. Of the six muscles which move the eyeball in different directions, only two, the rectus-internus and the rectus-externus, effect a simple change in its direction. The other four muscles, viz., the rectus-superior, the rectus-inferior, the obliquus-superior, and the obliquus-inferior, when they act singly, cause also some degree of rotation of the axis of the eyeball, and thus give rise not only to a dis- placement, but also to a notable rotation of the image. Under normal conditions, the tendency to rotation from the action of the superior rectus is neutralized by an equal tendency to rotation in the opposite direction from the action of the inferior oblique ; and, similarly, the ro- tating effect of the inferior rectus is neutralized by the opposite rotating action of the superior oblique. But when any one of these muscles is paralyzed, this correct- ing power is lost, and the correlated muscle is left free to exert its function of rotation. This rotation of the false image is best studied by directing the patient to look at a foot-rule, or at a yard-stick, held vertically or horizon- tally at a distance of a foot or several feet from the face, and moving it upward or downward, or from side to side, until the two images appear. The false image will then be seen to be turned in a direction oblique to the direction in which the rule is held, and to that of its im- age as seen by the non-deviated eye. Diplopia with ro- tation of the false image is a source of especial visual dis- turbance, for the reason that the rotation is not corrected by wearing prisms, and an operation on the weakened muscle (advancement of its insertion), or the division of the tendon of the muscle which is the immediate cause of the rotation, would generally be ineffective, or even prejudicial, by giving rise to further limitation of the movements of the eyeball. The special consideration of the different positions and directions which the false im- age may assume belongs to the subject of the disorders of the motor apparatus of the eyes (see Strabismus). Diplopia is generally defined as the seeing of one and the same object doubled, but it may also appear under the phase of seeing two different objects at the same time. A strongly illuminated object placed amid relatively in- conspicuous surroundings, as, for instance, a lighted candle, a street-lamp, or the moon, is ordinarily seen doubled, and the same is generally true of objects not in themselves especially conspicuous, but upon which the patient is compelled to fix his attention, as a door-step, etc. At other times, while in the act of looking at any object the phantom of some other object upon which the deviated eye may happen to be directed is seen in- truding itself upon the scene, to the possible great con- fusion of the picture. In most cases, however, the brain becomes educated, sooner or later, to an appreciation of the new conditions, and, by discriminating between the true and the false image, learns to concentrate the atten- 476 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diplopia. Direction. tion upon the former to the exclusion of the latter. Thus the disturbing illusions are suppressed, and vision be- comes practically uniocular. In somewhat rare instances, however, this process of education appears to take an- other course, as in certain cases of strabismus, in which it would seem that the brain may continue in some sort to take cognizance of the displaced image, and to refer it correctly to the object.* Diplopia monophthalmica, or double vision in a single eye, may be a result of the formation of two images upon different parts of the same retina. This may occur in an ametropic eye in which a supernumerary pupil has been formed in consequence of an injury (iridodialysis), or from the accidental perforation of the iris in an operation for closure of the pupil following cataract extraction. The mode of formation of the two images, and their fusion in a single image when the ametropia is corrected, may be seen from an inspection of Fig. 340 in vol. i. of this Handbook. (See also Polyopia Monophthalmica, vol. i., p. 404.) John Green. the external meatus, then the relative intensity of the sen- sation in the two ears has an influence. It is probably due to the latter cause that noises in which, as a rule, high resonating overtones exist, are more exactly local- ized than simple notes. It is possible that certain mus- cular and tactile sensations should also be here included. Ed. Weber conjectured that the tympanum felt its own vibrations. It better accords with the results of other experiments, however, to consider that the action of the tensor tympani muscle, by its involuntary accommoda- tion to sounds of different intensities, thus accompanies auditory impressions with motor sensations of varying strengths. Light.-Sight is the sense through which the chief judgments of direction are made. In all cases the direc- tion of an object is represented by a line joining the body with the object, and objects on that line or its continua- tion are considered to have identical directions. The phenomena are first to be considered for one eye alone, the field of vision being stationary. When the image falls on a part of the retina other than the fovea, the eye must be turned in order to bring the image on that point, and for this purpose it must be moved by its muscles. In performing such a muscular movement there are three sensations which may be recognized : the innervation feeling ; the tension of the muscles ; the result of the ex- ertion. When the eyeball is pulled to one side by the hand, objects in the field of vision appear to move, and the eye to remain quiet; at the same time, pulling the eye changes the tension of the muscles; nevertheless, neither the movement of the eye by a means other than the contraction of its own muscles, nor the tension of the muscles due to the same cause, is recognized as a motion of the eye, and so objects appear to move in a direction opposite to that in w'hich the eye is pulled. In patients having the musculi recti paralyzed, an at- tempt to contract a rectus is followed by an apparent motion of objects in a direction opposite to that in which it is willed to move the eye. In this case there is present neither the contraction of the muscle nor any result of the exertion, but merely the innervation feeling; yet, from this arises a subjective sensation of motion. Since the in- nervation feeling can produce this result, it is argued that our judgment of the direction of an object seen is based on the remembrance of the innervation feeling necessary to bring the eye into such a position that the image shall fall on the fovea. The only result of the innervation impulse which we plainly recognize in the eye is the altered position of objects in the field of vision. This alteration, bringing with it a variation in the position of the image, can be shown to act as a control on innervation efforts. If a prism be put before the eye so as to cause the rays from a given object to fall on a new part of the retina- the object having thus been apparently moved to the left- for example, and then the eyes being closed, if the hand is stretched in the supposed direction, it will fail to touch the object, passing by it to the left. On touching the object, however, with the eyes open, and associating thus the new position of the image with fresh tactile sen- sations, a new combination is developed by which it can be inferred from the position of the retinal image where the hand must be placed to touch the object. When two eyes are used the conditions are somewhat complicated, for one eye influences the judgments de- rived from the other. Helmholtz gives the following illustration : When one eye is closed, both axes being kept parallel, and first a distant then a very near object is fixated, both having identical directions, no change oc- curs in their apparent position in the field so long as the eye is simply focussed from one to the other. If, how- ever, the near object be fixated and the closed eye be now converged so as to occupy the position necessary to fix- ate it if it were open, a marked apparent motion takes place in the distant object in such a way that, if we con- sider the left eye as the one open during the experiment, the distant object moves from right to left. On again making the axes parallel, it resumes its former position. The sense of direction, as derived from one eye, must ac- DIPPEL'S ANIMAL OIL (Animal Oil; Ethereal Ani- mal Oil). By the dry distillation of bone, horn, and ani- mal substances generally, an oily liquid is produced, which was formerly used in medicine under the common name of Dippel's Oil or Dippel's Animal Oil. The oil, when purified, is a thin, colorless, or yellowish fluid, of a pungent, ethereal, and smoky flavor. It is a very com- posite body, containing among other things quite a num- ber of organic bases. Physiologically it is neurotic and irritant, and has proved fatally poisonous in doses of a tablespoonful. It was formerly prescribed internally in doses of a few drops, or used externally as an irritant embrocation, clear or as an ingredient of composite lini- ments. Eduard Curtis. DIRECTION, JUDGMENT OF. It is>proposed to con- sider here the judgment of direction of such objects only as are outside the body and not in contact with it. Heat.-Heat and cold are sensations produced by ob- jects at certain temperatures, when the heat-waves are allowed to act on the skin. The direction of an object capable of producing either of these sensations can be roughly estimated by inference from the part of the skin affected, but the judgments thus made are of little im- portance. Sound.-Sound-waves also offer some data for judging direction. The following account of the phenomena is taken from Wundt. The concha acts as a condenser, spe- cially collecting those waves which come from in front. The same sound is therefore heard more intensely when coming from that direction. This fact is brought out by an experiment where the conchas are bound down and some apparatus representing them is attached to the sides of the head, with the concavity directed backward. By this device the natural conditions are reversed, and sounds coming from behind are thus heard more dis- tinctly and are then wrongly judged to come from in front. It has been suggested that the tactile sensibility of the concha, re-enforced by the hairs on it, may, in the case of loud sounds, be a means of indicating the direc- tion. But this explanation is not sufficient, for in the case of faint sounds discriminations between "right" and "left" can be more easily made than between "in front " and " behind," while with sounds coming from in front it is possible, to a certain extent, to determine the angle formed by the line of the sound-waves with the median vertical plane of the body. Since the closing of one ear destroys this localization of direction, the latter must be considered as a function of binaural audition. When certain partial tones are intensified by the resonance in * The writer has met with a few cases of convergent strabismus in which, after tenotomy of one or both of the interni, crossed diplopia was evoked by tests made with prisms and colored glasses, notwithstanding the fact that a portion of the convergence of the optic axes remained un- corrected, as was evident from inspection of the eyes and from the change in direction in alternate fixation of a candle-flame. In no one of these cases was it possible to keep the patient long enough under ob- servation to admit of a thorough study of this phenomenon. 477 Direction. Disinfectants. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cordingly be considered modifiable by the other eye, even though the latter remains closed. In an analogous way the judgment of horizontal and vertical lines is found to be influenced by the motions of the closed eye. For instance, with the axes parallel, one eye being closed, a thread forming the diameter of a short cir- cular tube, when judged to be vertical or horizon- tal, is found to be really so, though by putting the head in different positions during the experiment the retinal horizon of the observing eye may, in certain of these positions, make an angle of even ten degrees with the true horizon. When, however, the previously par- allel axes are converged, and the individual fixates a point on the thread, the line which was previously hori- zontal is now seen to undergo apparent rotation of such a nature that it corresponds with the rotation of the ret- inal horizon of the closed eye. Suppose in this case the right eye to be open, then on converging the left (closed) eye the right end of the thread apparently sinks while the left rises. Under this head of judgment of direction Helmholtz treats of a number of cases in which the objects viewed are in motion, for example, falling water. One who has watched a waterfall for a time notices, on looking at the bank, that objects there appear to move in a direction op- posite to that of the water. The explanation offered by Helmholtz is that the eye, in order to view the falling water, continued to follow it downward for a time, then twitched up only to again follow it down, and so on. On now directing the gaze to the bank, the objects there apparently move in the opposite direction because the observer is unconsciously still continuing the same move- ments of the eyes as when gazing at the waterfall, and because this motion is unconscious the objects on the bank are consequently judged to move. The objection to this explanation of these illusions of motion is that they can be obtained in the after-image with the eyes closed, and, further, that two opposite motions can be simultaneously produced in the same retina. These facts, which with others were brought out by Bowditch and Hall, conclusively show that the explanation of Helm- holtz will not apply in these cases. No other explana- tion of the phenomena is, however, at present formulated. In considering the centre to which these lines of direc- tion are referred, E. Hering drew attention to the fact that we perceive the direction of objects seen as if both eyes were fused into one, and that one was located in the median plane of the head. This cyclopean eye is consid- ered as so constructed that the retinal images are pro- jected outward in the line of vision of that eye. The habit of thus attending only to the mean direction of the lines of sight is considered by Helmholtz to de- pend on the fact that the median vertical plane of the body is the one to which all objects are referred, so that an object neither right nor left lies in that plane, which also passes midway between the two eyes. Further, an object may lie to the right or left of this plane and bear the reverse relation to the vertical plane (parallel to the median vertical plane) of the homonymous eye. In practice, we thus fuse the directions of both the optic axes and refer the lines of sight to a point in the head midway between the two eyes. That this process results from habit is indicated by the fact that variations occur in the location of the cyclopean eye, and that fixation of the attention on the impressions from one eye alone serves to make that for the time being the reference point. Other observations indicate the same conclusion. The above statements are mainly from Helmholtz's Physiologische Optik, where they are elaborated. les mauvaises odeurs. " This is the popular sense in which the word is used in this country and in Europe. Vallin, in his " Traite des Desinfectants et de la Disinfection," says that it is impossible to accept this definition, for the reason that it is not sufficiently comprehensive. He says: "We may say with reason that every bad odor renders disinfection necessary, but it does not follow that disinfection is useless when there is no emanation appre- ciable to the sense of smell " (loc. cit., p. 3). After dis- cussing the subject at some length, Vallin gives the following definition as that preferred by him : "Disin- fectants are substances capable of neutralizing morbific principles, virus, germs, miasms, or of decomposing the fetid particles and gases which are disengaged by or- ganic matter undergoing putrefaction" (foe. cit., p. 6). On another page (2) Vallin admits that it is, perhaps, unsci- entific "to introduce into the idea of disinfection the suppression of odors which offend the sense of smell; " for, he says, "the bad odor is not injurious in itself ; it is an epiphenomenon which does not necessarily give the measure of the injurious properties of the air, or of any substance whatever." Nevertheless the popular sense in which the word is used is included in his definition, because, as he says, " it is necessary to avoid doing vio- lence to the ordinary sense of words " (p. 2). When the ordinary sense in which a word is used leads to confusion, we think it better to insist upon its being used in a more limited and scientific sense, and to in- struct the public as to the exact meaning which we would attach to it. We, therefore, prefer the definition which has been given by the Committee on Disinfectants of the American Public Health Association : " The Committee would define a disinfectant as an agent capable of de- stroying the infective power of infectious material." This does not commit us to any theory as to the exact nature of the agent which gives to infectious material its infecting power, but it draws a line between the morbific agents which produce that class of diseases known as infectious-which it is the object of disinfectants to de- stroy-and other substances which may injuriously affect man, such as the gases of putrefaction and other toxic agents. From our point of view we do not disinfect a privy-vault by destroying the sulphuretted hydrogen given off from its contents, any more than we would disinfect the atmosphere of a laboratory by neutralizing the fumes of chlorine or of sulphur dioxide given off during an experiment. To make our position entirely clear we can- not do better than to quote further from the "Prelim- inary Report of the Committee on Disinfectants : " " The object of disinfection is to prevent the extension of infectious diseases by destroying the specific infectious material which gives rise to them. This is accomplished by the use of disinfectants. " There can be no partial disinfection of such material; either its infecting power is destroyed or it is not. In the latter case there is a failure to disinfect. Nor can there be any disinfection in the absence of infectious material. " Popularly, the term disinfection is used in a much broader sense. Any chemical agent which destroys or masks bad odors, or which arrests putrefactive decompo- sition, is spoken of as a disinfectant. And in the absence of any infectious disease it is common to speak of disin- fecting a foul cesspool, or bad-smelling stable, or privy- vault. " This popular use of the term has led to much misap- prehension, and the agents which have been found to de- stroy bad odors-deodorizers-or to arrest putrefactive decomposition-antiseptics-have been confidently recom- mended and extensively used for the destruction of disease-germs in the excreta of patients with cholera, typhoid fever, etc. " The injurious consequences which are likely to result from such misapprehension and misuse of the word dis- infectant will be appreciated when it is known that : " Recent researches have demonstrated that many of the agents which have been found useful as deodorizers, or as antiseptics, are entirely without value for the de- struction of disease-germs." References. Grundzuge der Physiologischen Psychologie. Wundt, 1880. Handbuch der Physiologischen Optik. Helmholtz, 1867. Journal of Physiology, vol. lit, p. 297, 1880-82. Optical Illusions of Motion. By H. P. Bowditch, M.D., and G. Stanley Hall, Ph.D. Henry Herbert Donaldson. DISINFECTANTS. Littre, in his "Dictionary of the French Language," defines disinfectants as follows: "Disinfectants, substances qui detruisent chimiquement 478 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Direction. Disinfectants. If it were demonstrated that every kind of infectious material owes its specific infecting power to the presence of micro-organisms, we might bring this article to a close by referring the reader to the title Germicides, under which a full account will be found of the present state of knowledge with reference to the germicide power of the chemical agents known as disinfectants, as determined by biological tests. But this is not yet demonstrated, and our knowledge relating to the comparative value of disinfectants is to a considerable extent empirical, being based upon the prac- tical experience of sanitarians. This experience, how- ever, is not in conflict with the view that the infectious agent in those diseases which have not been proved to be germ-diseases-small-pox, yellow fever, scarlet fever, etc.-is in truth a living organism. On the other hand, the disinfectants which, independently of theory, have gained the confidence of sanitarians, are for the most part potent germicides, e.g., chlorine, sulphur dioxide, etc. ; or they are at least antiseptics of greater or less value, e.g., the metallic chlorides and sulphates. The same is true as regards the disinfectants which have been tested experimentally upon various kinds of infec- tious material, such as vaccine virus, anthrax blood, sep- ticajmic blood, etc., without reference to the nature of the infectious agent contained in the material disinfected, the test of disinfection being made by inoculation into susceptible animals. The writer, in 1881, made an ex- tended series of experiments of this kind, in which the blood of a rabbit just dead from an infectious form of septicaemia was the material to be disinfected. The com- parative value, as disinfectants, of the agents tested cor- responded, in general, with the germicide power of the same agents as subsequently determined in another series of experiments (1883). In the last-mentioned experiments the destruction of the test-organisms in culture solutions was demonstrated by the failure of these organisms to grow in a suitable medium after having been exposed for a given time to the action of the germicide agent in a certain proportion. As the infectious character of the septicaemic blood in the first series of experiments had been demonstrated to be due to the presence of a micro- coccus, this correspondence in the results obtained by the two methods was, d priori, to have been expected. In the experiments which have been made upon vaccine virus, results have also been obtained which, in the main, correspond with the germicide value of the agents tested, as established by the biological method. As we have no direct evidence that in this case disinfection consists in the destruction of germs, a brief account of these experiments, and of others made directly upon different kinds of virus, will be given in the present article. For the experimental data relating to the germicidal power of various chemical agents, the reader is referred to the article under the title Germicides. Heat.-As long ago as 1831, Dr. Henry, of Manchester, tested the action of dry heat upon vaccine virus, and found that the virus no longer produced any result upon inoculation when it had been exposed to a temperature of 60° C. (140° F.) for four hours. In similar experi- ments made by Baxter (1875), in which the time of ex- posure was reduced to twenty-five minutes, it was found that a temperature of 90° to 95° C. (194° to 203° F.) was required to insure complete destruction of infecting power of virus dried upon ivory points. The virulence of fresh vaccine virus is destroyed at a considerably lower temperature. In a report made to the Congress of Am- sterdam in 1879, Carsten and Coert, as the result of a large number of experiments, arrived at the conclusion that " animal vaccine heated to 64.5° C. (148.1° F.) for thirty minutes loses its virulence." Sulphur Dioxide.-The power of sulphurous acid gas to destroy the virulence of vaccine virus has been demonstrated by several experimenters. Ten minutes exposure in an atmosphere " saturated with sulphurous vapor " was found, both by Dougall and by Baxter, to neutralize the virulence of vaccine dried upon ivory points (Vallin). In these experiments the exact amount of sulphur dioxide in the air of the disinfection chamber is not stated. Experiments made by the writer in 1878 showed that liquid vaccine is rendered inactive by expos- ure for four hours to sulphur dioxide in the proportion of five volumes per one thousand of air. In experiments with dried virus upon ivory points, made in 1880, it was found that virulence was destroyed by six hours' exposure in an atmosphere containing one per cent, of this gas. Baxter and Vallin have tested the disinfecting power of sulphur dioxide upon the virus of glanders. The first- named experimenter found that four parts to one thou- sand by weight, in solution, destroyed the virulence of material obtained from nodules (rubbed up in water) from the lung of an animal with glanders. Vallin experi- mented with virulent pus from an abscess, obtained from a patient with glanders in the hospital of Vai de Grace. This pus was proved by inoculations into guinea-pigs and other animals to produce the characteristic lesions of glanders. Some of this pus placed in a watch-glass was exposed for twelve hours to sulphur dioxide, generated by burning two grammes of sulphur in a box having a capacity of one hundred litres (=14 volumes of SO2 to 1,000 volumes of air). Disinfection was complete, as proved by inoculation. Chlorine.-Experiments made by Dougall, and by Baxter, upon liquid vaccine show that to insure the dis- infection of this material, chlorine must be absorbed in sufficient quantity to give the liquid virus an acid reac- tion. Baxter found that 0.14 of one per cent, was insuf- ficient, while the presence of 0.163 per cent, of chlorine in the lymph neutralized its virulence. In experiments with dried vaccine upon ivory points, Baxter found that exposure for thirty minutes in an atmosphere ' ' saturated with chlorine " was necessary in order to accomplish dis- infection. In experiments made by the writer in 1880, it was found that the virulence of dried virus upon ivory points was destroyed by exposure for six hours in an at- mosphere containing one volume per cent, of chlorine gas. Carbolic Acid.-The power of carbolic acid to de- stroy the virulence of vaccine virus has been established by the experiments of Braidwood and Vacher, of Baxter, and of Hoppe-Seyler. But to accomplish this result, the pure acid must be mixed with the lymph in a proportion of two per cent., and a certain time must be allowed for its disinfecting action. Both Hoppe-Seyler and Baxter found that two per cent, destroys the virulence of liquid vaccine, while one per cent, failed to do so. On the other hand, in Braidwood and Vacher's experiments 2.5 per cent, failed when vaccination was practised immedi- ately after mixing the disinfectant with the liquid virus. Baxter has also experimented upon the virus of glan- ders, and found that two per cent, was successful in de- stroying its infecting power, while 0.5 per cent, failed to act as a disinfectant (Smart). In the writer's experi- ments (1881), with the blood of septicsemic rabbits, in- fective virulence was destroyed by 1.25 per cent, while 0.5 per cent failed. It is impossible in an article of this character to give a complete account of the experimental evidence on record relating to the comparative value of disinfectants. But a careful consideration of this evidence, as obtained in practice by sanitarians, and in laboratory experiments made directly upon infectious material (test by inocula- tion), or upon pure cultures of various micro-organisms (test by cultivation), shows that many agents commonly used are quite unreliable, as used, and that for practical purposes the agents which can be safely recommended as disinfectants are few in number. The following list embraces those which we believe to be the most generally useful and available for disinfect- ing purposes : Dry and moist heat; sulphur dioxide ; the hypochlorites of lime, and of soda (chloride of lime, and Labarraque's solution); mercuric chloride; cupric sul- phate ; carbolic acid. We shall briefly indicate the special purposes for which one or the other of the agents named seems best adapted. Disinfection of Excreta, etc.-Success in restrict- ing the extension of infectious diseases will depend largely upon the proper use of disinfectants in the sick-room. 479 Disinfectants. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. For the disinfection of excreta the most available chemi- cal agents are: 1. Chiaride of lime. Dissolve in water, in the proportion of four ounces to the gallon of water (Standard Solution No. 1 of the Committee on Disinfect- ants of the A. P. H. A.); use one quart of this solution for the disinfection of each liquid discharge in cholera or in typhoid fever. For solid fecal matter a stronger solu- tion or a larger quantity will be required, and it will be prudent to use a larger quantity of the standard solution recommended for a very copious liquid discharge. 2. Mercuric chloride in solution in water, in the proportion of 1 to 500. The addition of an equal quantity of potas- sium permanganate is to be recommended; this consti- tutes Standard Solution No. 2 of the Committee on Disin- fectants. Use a quart of the solution, and leave in contact with material to be disinfected for at least four hours. 3. Carbolic acid, a five per cent, solution to be used in quan- tity at least equal to the amount of material to be disin- fected. 4. Cupric sulphate, a four per cent, solution. Chloride of lime and mercuric chloride may be relied upon for the destruction of spore-containing infectious material, but the last-mentioned agents-carbolic acid, and cupric sulphate-can only be used in the absence of spores (see article under the title Germicides). Disinfection of the Person.-The hands of those who wait upon persons sick with infectious diseases should be washed in an aqueous solution of mercuric chlo- ride of the strength of 1 to 1,000 ; or of carbolic acid, 1 to 50; or of chloride of lime, 1 to 100 ; or of Labarraque's solution, 1 to 10. The same solutions may be used for washing soiled surfaces upon the body of the patient, and for instruments and utensils which have been ex- posed in the sick-room. For a complete bath carbolic acid, 1 to 100 ; mercuric chloride, 1 to 5,000 ; or, Labarraque's solution, 1 to 20, may be used. The dead should be wrapped in a sheet saturated with a solution of mercuric chloride of 1 to 500 ; or of carbolic acid, 1 to 20; or of chloride of lime, 1 to 25. Disinfection of Clothing.-" Boiling for half an hour will destroy the vitality of all known disease-germs, and there is no better way of disinfecting clothing which can be washed than to put it through the ordinary opera- tions of the laundry" (" Prelim. Rep. of Com. on Disinfect- ants"). Clothing may be disinfected by immersion for two hours in a solution of mercuric chloride of the strength of 1 to 1,000 ; or of cupric sulphate, 1 to 100 ; or of car- bolic acid, 1 to 50 ; or of chloride of lime, 1 to 100 (the bleaching properties of chloride of lime must be remem- bered). Clothing which would be injured by washing or immersion in a disinfecting solution may be disinfected by dry heat, in a properly-constructed " oven." In the ab- sence of spores, a temperature of 230° F., maintained for three hours, will be sufficient. The clothing must be freely exposed, for the penetrating power of dry heat is very slight. The spores of bacilli require a temperature of 284° F., maintained for three hours, for their complete destruction. This temperature injures woollen fabrics (Koch). Fumigation with sulphur dioxide has been largely re- lied upon for the disinfection of clothing. To be effect- ual, the articles to be disinfected must be freely exposed to its action, in a well-closed chamber, for a period of at least twelve hours. Burn three pounds of sulphur for each thousand cubic feet of air-space in the room. Disinfection of the Sick-room.-" In the sick-room no disinfectant can take the place of free ventilation and cleanliness. It is an axiom in sanitary science that it is impracticable to disinfect an occupied apartment " ' Prelim. Rep. of Com. on Disinfectants"). The most reliable gase- ous disinfectants are sulphur dioxide and chlorine. The first-named agent is the best from a practical point of view, and is commonly relied upon. The room to be dis- infected should be carefully closed, and three pounds of sulphur burned in it for every thousand cubic feet of air- space. At least twelve hours should be allowed for the action of the disinfectant. " The object of disinfection in the sick-room is, mainly, the destruction of infectious material attached to surfaces or deposited as dust upon window-ledges, in crevices, etc. If the room has been properly cleansed and ventilated while still occupied by the sick person, and especially if it was stripped of carpets and unnecessary furniture at the outset of his attack, the difficulties of disinfection will be greatly reduced " (" Prelim. Rep. of Com. on Disinfect- ants '). All surfaces should be thoroughly washed with a solution of mercuric chloride of the strength of one part to one thousand ; or with a two per cent, solution of carbolic acid ; or with a one per cent, solution of chloride of lime; or with a one per cent, solution of cupric sul- phate. Disinfection of Privy-vaults, Cesspools, etc.- "Use one pound of corrosive sublimate for every five hundred pounds, estimated, of the contents of the vault " ("Prelim. Rep. of Com. on Disinfectants "). The mercuric chloride should be dissolved in a large quantity of water, and gradually added to the material in the vault. When it is certain that the infectious nature of the material to be disinfected is independent of the presence of spores, a solution of carbolic acid (five per cent.), or of sulphate of copper (five per cent.), may be used. " To keep a privy-vault disinfected during the progress of an epidemic, sprinkle chloride of lime freely over the surface of its contents daily" (loc. tit.). Disinfection of Ships.-Sulphur dioxide is the most useful of the gaseous disinfectants, and the only one which has received the approval of practical sanitarians for the disinfection of ships. It should be used in the quantity recommended for the sick-room-three pounds of sulphur to one thousand cubic feet of air-space-and the ship should have at least twelve hours' exposure to the sul- phurous acid gas generated by burning this in the hold ; or a corresponding amount of the gas should be injected into the hold by means of a suitable apparatus. Surfaces should be washed with a solution of mercuric chloride, 1 to 1,000; or carbolic acid, 1 to 50 ; or chloride of lime, 1 to 100. The bilge should be treated with a liberal supply of mercuric chloride in solution. George M. Sternberg. DISLOCATIONS. The term dislocation, as well as its synonym, luxation, is one that surgeons apply to those injuries of the joints that result in the separation of the articulating surfaces in a manner more or less complete. Extraordinary violence, suddenly applied, is the usual cause. This may, however, find its counterpart in a moderate but long-continued force, as is shown in the production of spontaneous luxations. To these may be added disease of the joints, and, as in some congenital luxations, their malformation. It is evident that injuries may be of every degree of violence, from those only sufficient to produce partial separation of the surfaces concerned in the formation of the joint to a total sever- ance of all tissues that restrain these surfaces in their normal relation. Ligaments and muscles, utterly torn from their attachments, would allow the dislocated bone to take any position that the accidental direction of force or the position of the patient might determine. This we often witness as the result of the tremendous violence of railway injuries. But it is convenient to make divisions of the subject under consideration, both because they conduce to a better understanding of the etiology and pathology, and also because they lead to a clearer appre- ciation of our therapeutics and prognosis. Such divisions have a very natural nomenclature, ordinary words being charged with a technical signification. Thus the first thought of the surgeon is to ascertain if the integuments are entire or not, and, if a wound exists, whether it com- municates with the joint. The dislocation is styled sim- ple if there is no such injury as last described, and com- pound if there is. The importance of these divisions is of the utmost consequence, the treatment being entirely different in each of them. But there may be injuries of a very grave character, and, indeed, so destructive as to require removal of the limb, and yet the integuments may not be broken ; but the whole tissue may be so con- tused that its vitality cannot be preserved. Arteries and veins and nerves may be torn across or bruised so as to impair or destroy their function. The bones constituting 480 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Disinfectants. Dislocations. the joints may be broken or comminuted. Such a lux- ation is named complicated, a term that applies to any form of injury of the part that "complicates" the case. There are also divisions that are styled regular and ir- regular. When the forces that produce the dislocation have separated the joint surfaces, there is a mobility which usually yields sufficiently at the moment of accident to save a great destruction of the muscular and tendonous apparatus concerned in the injury. This leads to the lodging of the bones into special positions. The dislo- cated bones are brought into their abnormal position in obedience to certain definite forces, compounded of blow or pressure and the action of muscles, as well as of the remaining integrity of the ligaments. They are also re- tained there in obedience to such forces, now com- pounded of the action of muscles, ligaments, and the form of the long surfaces in their abnormal positions. The uniformity of these positions in the so-called regular luxations gives the surgeon his opportunities for study- ing the forces which oppose the restoration of the bones, and constitutes the basis of treatises upon the topic of dis- locations. When a further destruction of tissues results in making the relations of the bone other than those re- garded as regular, the surgeon becomes, for the time, an original investigator ; as, for instance, when the head of the femur has been lodged in the perineum or in other unusual places. The restoration of luxations is most easily accomplished immediately after their occurrence, but there comes a time when this becomes impossible, arising chiefly from the firm adhesions which nature establishes between the parts in their new relations. This gives rise to a division of the topic into those that are recent, and those that are ancient. This, however, only gives us a general state- ment, for some joints become irreducible much earlier than others. The terms complete and incomplete have refer- ence to the fact of the separation of the articulating sur- faces only. Sometimes the bone rests on the edge of its articulating surface, and is retained by some definite con- dition, which causes it to be termed an incomplete luxation. Children are born with luxated joints, and such disloca- tions are termed congenital. As might be inferred, the luxations in different joints differ very much in their character; some are difficult of restoration, but easy of retention, as in the case of luxations of the femur from the acetabulum ; others are easily restored, but can scarce- ly be retained in the proper position, as luxations of the clavicle. A bone may be dislocated, passed to a certain spot, and afterward shifted to another. When it remains in the place to which it is sent as the primary effect of the accident, the luxation is called primitive, and when it has changed its position, consecutive. If, after the parts have been restored to their normal positions, the dislo- cated bone leaves its place for the one into which it was luxated, the luxation is denominated recurring. Spon- taneous luxations are those that occur as the results of gradual force applied by the steady contractions of mus- cles, often aided by a change in the integrity of the cap- sules, the result of disease. The causes that lead to a separation of joint surfaces are of two kinds : those that produce it, and those that pre- dispose to it. Among the predisposing we may regard the form of the joints themselves. Some, as the hip, have the protection of a deep cavity, while the analogue of this joint, the shoulder, has a very shallow one for the articulation of the humerus, and, as might be in- ferred, has for this reason a great facility of luxation. We have also the conditions incident to age modifying results. Disease, by softening the capsules and liga- ments, will allow the muscles to displace the articulating surfaces. This has abundant exemplification where the flexor muscles are very much stronger than the ex- tensors. The relaxation of the ligaments constitutes a cause of luxation in joints that have once been dislocated. This applies to all joints, and is one of the conditions against which surgeons attempt to provide in their treat- ment of a case after the restoration of the luxation. The ligaments may, however, have a congenital re- laxation, and a similar one may be cultivated by a con- stant stretching, commenced in childhood. This has often been done for the purposes of public exhibition. In such cases the pretended luxations are of an incom- plete character, the bone being held in the enlarged cap- sule upon the edge of the articulation. But, besides these changes, we have certain deficiencies of formation, not recognizable during life, which render the joints in such people more easily displaced than in others. Direct Causes.-The direct causes of luxation are, how- ever, to be found in violence, whether external or inter- nal. In most cases these are compound, being partly the result of a blow or crushing force, and partly of mus- cular action. But they are produced by either of the causes uncombined. For instance, the patella is usually pushed from its position by a blow while the knee is semiflexed and the quadriceps on the stretch, but it is also thrown out by a sharp blow when the muscles are relaxed, and also by mere muscular exertion in walking. Symptoms.-The symptoms that especially characterize luxations are deformity and the loss of function in the joint. There are others, but they are subordinate and in- constant. In diagnosis we are to keep these two condi- tions in view, and it unfortunately happens that they are sometimes masked. Thus, an inordinate swelling of the soft parts so covers up the joints as to render palpation difficult. This is not an infrequent cause of error in di- agnosticating luxation of the shoulder, inasmuch as the sliding of the scapula on the thorax gives an appearance of motion of the joint which does not exist. An epiph- yseal fracture of the humerus at the elbow will allow the forces to result in a deformity precisely similar to that of luxation of the ulna and radius backward, and is often mistaken for it. Deformity is, however, a very palpable symptom, and becomes a matter of especial de- scription in each case. There is, as may be anticipated, a great tendency to shortening of the limb after luxa- tion, but this is not always the case. Immobility is also seldom mistaken if proper care is used. But we fre- quently experience difficulty in making a diagnosis be- tween luxation of a joint and a fracture in its proximity. It is true that if we apply the test of immobility or mo- bility thoroughly, it will be found very reliable in estab- lishing the proper diagnosis. But we must not be deceived by allowing the pain on motion, which exists where fract- ure occurs, to produce an appearance of immobility which is not real. It is true that genuine crepitus is pathognomonic of fracture, and may thus establish the diagnosis. But there are fractures in which we fail to get crepitus, and these are especially found in the neighbor- hood of joints. Epiphyseal fractures usually have a muf- fled crepitus, and the epiphyses are so close to the joint that the position of a regular luxation is often assumed. Besides all these complications which add to the difficulty of making a diagnosis, we find a peculiar kind of crepi- tus from the friction of the dislocated bones, which differs but little from that produced in epiphyseal fractures. The diagnosis is still further rendered difficult by the fact that small particles of bone are torn from their beds by the ligaments, which may be said to rupture, in this pecu- liar way, when the luxation takes place. In the experi- ments which the writer has made upon the cadaver for the purpose of producing luxations, he nearly always found a rough surface produced at some point, due to the cause above mentioned. To illustrate : In producing a disloca- tion of the knee he found one of the crucial ligaments pulling a piece from the tibia in which it was inserted. I think that the separation of the malleolus internus in luxa- tion at the ankle outward is caused by the greater strength of the ligament that connects it with the foot. Moreover, we have genuine fractures of the bone occurring in con- nection with perfect dislocations. It need hardly be added that we have swelling of the soft parts, primarily the result of rupture of blood-vessels and effusion of blood, and sub- sequently from the pouring out of serum. Separation of joint surfaces cannot occur without rupture of tissues in conditions that are normal; nerves will be pressed on or strained, producing violent pain or numbness. In recent luxations, the result of sudden force, the capsular liga- ments are always torn sufficiently to allow the displace- 481 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ment which we term complete. Subsidiary ligaments, lateral and others, are also more or less torn; muscles also, and their tendons, sometimes give away. The ex- ception to this rule is to be found in what are called spon- taneous luxations, where' long-continued pressure by muscular action causes a dilatation of the capsule. In- flammation of the joint may also stretch the capsule so as to facilitate luxation, without producing its rupture. Ancient Luxations.-In process of time nature es- tablishes around the disarticulated surfaces new tissues. For the head of the bone she moulds upon the part a newly-formed surface, and if the head rests upon the periosteum the new tissue becomes the seat of osseous deposit; and if the luxation occurs in childhood, there is often a marvellous construction of a new socket. On the other hand, the true socket usually becomes filled up, partly with remnants of the capsule and partly with any other soft parts that happen to lie in contact with it; all being glued together by newly formed tissue. In persons advanced in age the head of the bone is more likely to be covered by a newly-formed osseous crust, white and hard, resembling ivory. This process is called by pathologists eburnation. Disuse of the limb in these ancient luxa- tions produces a striking atrophy of the muscles, and a less marked atophy of the bone itself. This condition of the bone is one which presents a difficulty that con- fronts the surgeon when he undertakes the reduction of these luxations. He finds that the newly formed tissue has acquired enormous strength, while the original struc- tures have been growing weaker day by day. Treatment.-The reduction of a luxation is more easily effected immediately after it has been produced than at any other time. The muscles, as has been said, seem to be in a state of surprise ; they offer no resistance ; and even in luxations so difficult of restoration by the process of extension as that of the hip, it has been found that it is usually not difficult to restore them. But when a few hours have elapsed, and the peculiar shock arising from injury has passed away, it will be found that, in accord- ance with the general law which regulates the contraction of muscles by reflex action, which is intensified where pain is produced, they will offer most powerful resist- ance. Of course this difficulty increases as the hours go on, and at the end of a few weeks the material thrown out by the blood will have undergone organization, gluing tissues together in abnormal positions, and offering, in addition to muscular action, difficulties which at length are found to be insuperable. The attempt to restore dislocated joints must ever be connected with a knowledge of the special anatomy of the parts.' It will be found that in some of them the chief obstruction to restoration will arise from the capsule or the ligaments, while in others the resisting muscles are the m'ost important conditions to overcome; and in still others the formation of the joints themselves will offer a serious obstacle to restoration. That the muscles con- stitute, as a rule, the most serious difficulty in the way of restoration there can be no question. The very fact that reduction is so easy at first, and so difficult after- ward, is in itself sufficient proof of the correctness of this opinion. Before the discovery of our modern meth- ods of anaesthesia, the surgeon was in the habit, when he met with any great obstacle to the reduction by the ordinary methods applicable to each special luxation, to diminish the power of the muscles by various agents. His custom was to draw blood ad deliquium animi, and then, taking advantage of the faintness incident to this procedure, to resort at once to his manipulations. Fail- ing in this, he would induce further relaxation by the use of a hot bath, carrying it so far as to produce faintness a second time. Still failing, he would employ doses of tar- tarized antimony to produce the well-known muscular re- laxation incident to profound nausea ; or he might even administer a tobacco enema, in order to still further in- crease the relaxation. All these methods have been hap- pily replaced by the use of our modern anaesthetics, which produce a more perfect relaxation than all of these methods combined, and also relieve the unfortunate pa- tient of the pain incidental to the manipulations. The difficulties arising from entangled ligaments or capsules must, be overcome in the first place, by obtaining relaxa- tion, by position, and also by gentle rotation, or by a to-and-fro motion, which may relieve them when caught upon some projecting edge, such as would be found at the neck of a bone. If we fail in this, these obstruct- ing ligaments or capsules must be torn by a force ex- erted for the especial purpose. This may be illustrated in the attempts to reduce luxations of the hip by manipu- lation, and also in the luxation of the proximal phalanx from the metacarpal bone of the thumb. The obsta- cles presented by bone must be overcome by well-di- rected and special movements at the expense of such soft parts as ligaments or muscles which stand in the way. This is illustrated in the reduction of the luxation of the femur on the dorsum by extension, when it is often found necessary to lift the bone over the edge of the acetabulum ; also by the manipulation for reduction of dislocation of the jaw, which is especially directed to the necessity of stretching the muscle in order to conduct the condyle over the articular eminence. But perhaps there are few joints that illustrate the difficulty of restoration from the irregularity of the bony surfaces better than the disloca- tion of the forearm backward from the humerus. Be- sides the obstructions of the kind spoken of, we sometimes have others which are presented by the muscles or their tendons. This is well illustrated in the dislocation of the first phalanx of the thumb, where the head of the meta- carpal bone passes forward so as to lie under the skin, while the muscle of the short flexor is carried behind it. In order to overcome all these difficulties, after relaxation has been obtained, as above explained, a great variety of manipulations must be employed incidental to the nu- merous mal-positions. But extension and counter-exten- sion constitute the most common forms which become necessary in the application of force. Sometimes a mere touch, as it were, accompanied by a proper change in posi- tion, will subserve the purpose. Thus, dislocation of the clavicle is usually reduced by drawing the shoulders back and making slight pressure upon the bone ; and in cases in which the laceration of the ligaments and muscles is ex- treme, a very slight traction may be sufficient to slip the bone back into its place. The methods by manipulation are sufficiently explained by the word itself, the hands of the surgeon being the only agent that it is found necessary to employ. If, however, extension and counter-extension are to be used, it is often the case that the strength of the surgeon is entirely inadequate. This is especially true when any considerable time has elapsed-days or weeks, and even before that- complete change of organization which characterizes an ancient luxation has taken place. When extension and counter-extension are made, it is understood that the force is to be applied to the limb so as to draw it in the direction of the joint. This is done by the surgeon himself when he seizes the arm at the wrist, and places his heel in the axilla ; he makes exten- sion with one and counter-extension with the other, to reduce a luxation of the shoulder-joint. It is often the case that a more powerful method is required. A counter- extension must then be made by broad bands that will withstand a great force, while extension is to be executed by multiplying the hands of assistants ; or, what is better, by the aid of pullies or twisted ropes, or any other steady power that can be controlled. Indeed, it is better that the extension should be entirely under the influence of one will, than that it should be executed by various persons attempting to act together. It is almost impossible for the assistants to control their muscles so as to avoid sudden and excessive traction. The extension, when it is to be powerful, should also be slow, and the muscles must be made to stretch by the steady but unyielding traction. In- asmuch as anaesthetics are almost always employed, the re- cumbent posture is one to which we must conform our arrangements for executing extension and counter-exten- sion. If, on the other hand, an anaesthetic is not em- ployed, it will frequently be found that other postures are to be preferred. The particular point at which the ex- tending bands are to be applied is a matter in which surgeons are not entirely agreed. But it is usually, and 482 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. as I think correctly, thought to be best to apply it to the bone which is dislocated, at some point lower down than the normal situation of the joint. For instance, if a shoulder luxation is to be reduced, the band for exten- sion should be applied above the elbow; if one of the hip, above the knee. The application of an extending band, inasmuch as great force is to be employed, must be made in such a manner as not to injure the integuments. If we are not careful in this respect, the skin may be ab- solutely stripped from the limb. Tins will be found es- pecially true of the thumb, where the counter-extending band must be necessarily small and cord-like, in order to hold its grasp. For this purpose we find it necessary to cover the thumb with a bandage thick and firm, a piece of soft leather being preferred, over which the extending band is to be applied. The writer has known a case in which the pressure of the extending band has so crushed the vessels as to produce gangrene of the thumb. When pressure is to be applied to the larger surfaces we simply rely upon a moistened band- age, wrapped around the limb, over winch a band is secured by a proper pad, or by the clove hitch. For the purpose of attaining the requisite amount of force surgical pulleys are extremely conven- ient, but they are not always at hand. An excellent substitute is found in a simple contrivance devised by Dr. Fahnestock, which consists of a strong rope, of numerous separate strands, which is fastened to a fixed point, and then shortened by twisting with a lever thrust between them. It is obvious that such a method will produce a very great power, and is usually accessible. An instrument known as Jarvis' adjuster has been em- ployed by surgeons during the last forty years: it possesses in itself very great power, and has one merit which those above alluded to do not possess. In order to obtain the benefit of the surgical pulleys, or the Scam- num Hippocratis, it is necessary to place the patient in a fixed position. By the use of Jarvis' adjuster we have, in addition to the power that is requisite, the ability to move the limb, so that we can alter its position during the time of ex- tension. Still, it is a pleasure to know that all of these powerful agencies are seldom employed, if we compare their use at present with that which was deemed necessary twenty years ago. The methods by manipulation have largely displaced those by ex- tension and counter-extension, and especially in the luxations which were formerly thought to require them more than any others. In the case of luxations of the thigh, exten- sion is now seldom employed. Coun- ter-extension, in cases where much force is to be used, is usually secured by folded pieces of cloth strong enough to resist the traction. For this purpose a sheet is almost always at hand, and can hardly be improved upon by any form of bandage. For instance, when it is required for luxa- tion of the shoulder, it should be carried across the chest, below the axilla, and, although the scapula is apt to roll, it is usu- ally found to be the most convenient and comfortable method yet. devised. The button-hole through a firm piece of cloth, like canvas, just large enough to allow the arm to pass through, so that its upper border may catch upon the acromion process, which was recommended by Sir Astley Cooper, is seldom employed. It almost uni- formly fails in its object-that of holding firmly upon the end of the acromion process. If Jarvis' adjuster is em- ployed, it has its own special arrangement for the pur- pose of counter-extension. In order to aid the processes already detailed, modern surgery has resorted to subcutaneous tenotomy and my- otomy more frequently than formerly. By this method we may secure reduction when otherwise it would be im- possible. This is especially applicable to luxations of the thumb and elbow, though its use is by no means con- fined to these joints. In the reduction of ancient luxations we are governed by the same rules that control those that are recent. But we must be prepared for the use of the greatest amount of power that the bone is capable of sus- taining. The process of atrophy has proceeded in it as well as in the soft parts. Fracture of the bone is a not uncommon result. Moreover, we can- not expect to succeed until the newly formed tissues are ruptured-a condi- tion precedent to the direct manipula- tions necessary for re- duction. Hence vio- lent movements of the limb, employing it as a lever to break up the unnatural adhesions, is the first step of the process. But it un- fortunately happens that these adhesions tie down not only the bone but the blood- vessels and nerves. Rupture of these are dangers more to be feared than any that can happen to the bone. Tenotomy and myotomy are far oftener required to assist the reduction of ancient than recent dislocations. After-treatment.-This is usually very simple, and yet a matter of the highest importance, for "if it is neglected, even in those joints that are the best protected against subsequent luxation by their conformation, it will be found that luxation is apt to recur far more easily than at first. Little else is required than to keep the joints perfectly still and in such a position as would not bring the normal capsule or ligaments into a condition of ex- Fig. 822.-Clove Hitch. Fig. 824.-Clove Hitch as applied to the humerus, with bandage underneath. Fig. 823.-Surgical Pulleys. Fig. 825.-Jarvis' Adjuster. tension. If this is not done, and especially if the patient is allowed to move the joint, the torn surfaces will be separated from each other, and instead of uniting edge to edge, as we hope to have them unite, they will become attached to connective tissue or fascia, and thus the joint will lose its natural restraint, and even in a joint as deep as that of the hip, luxation may recur with great facility. Indeed, in the case of the shoulder-joint, where the glenoid fossa is little more than a slightly curved surface against which the head of the bone plays, it is found, even 483 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with the utmost care, that we cannot secure so close a union of the capsule as to prevent recurring luxation. Besides this, we may be under the necessity of treatment proper for the reduction of the inflammatory process ; but of this no details need be given. There are, however, some luxations, of which the clavicle is an illustration, in which there is nothing in the natural conformation of the parts that assists in the retention, and we are under the necessity of relying upon apparatus to keep the sur- faces in proper position, so that the ligaments can unite. The repair of the ligaments and capsule in simple luxa- tions is rapid. It is seldom necessary to keep the parts quiet more than one or two weeks. Compound Dislocations.-These are defined to be those that have the soft parts so lacerated that the wound extends from the joint to the skin. The number of com- pound dislocations of the long bones, when compared with the simple ones, is very small. We find that where the bones are broken, the relation of simple to compound fractures is that of a large preponderance in favor of the former. In dislocations this relation is a great deal more striking. Dr. Hamilton reports Norris' cases of ninety- four dislocations received into the Pennsylvania Hospital for the ten years ending 1840, of which only two were compound. He also states that, of one hundred and sixty- six dislocations that came under his own observations, only eight were compound. The relative frequency of com- pound and simple luxations varies very greatly in differ- ent joints. The shoulder- and the hip-joints are rarely luxated in a compound manner. This is obviously due to the deep burial of the head of the bone in the soft parts. On the other hand, the joints at the extremities, as near the wrist and in the ankle, from the greater exposure as well as superficial position of the bones, are more liable to this accident. A force sufficiently great to break away the attachments between the foot and the tibia and fibula, is apt to have, after this has occurred, some that is unex- pended, capable of tearing the skin. Dislocation of the lower end of the ulna is, after the one just described, one of the most common of compound luxations, occurring in the long bones. I have known one case, and have collected the reports of three others in the practice of my friends. Of course all such statements exclude the con- sideration of the joints of the phalanges. The hand is so much exposed to danger that its numerous articulations are, unfortunately, more often opened than any other. Symptoms.-It is hardly worth while to take any more note of the symptoms of compound luxations, inasmuch as there is a wound-opening upon the surface through which the end of the bone will obtrude, or so large that a probe, or perhaps even the finger, can be thrust through it, to determine the conditions incident to the injury. It is hardly possible for so severe an injury as that of com- pound luxation to occur without others which may com- plicate the case. Still, such do occur. These complica- tions will consist of traumatism of the blood-vessels and nerves, and perhaps of tendons which slough easily upon exposure to the air, or extensive bruising of the skin, rendering it gangrenous. When comparing the dangers incident to compound luxations with those of simple ones, we naturally contrast them with the same relations when existing in fractures.. But the difference in the two classes of conditions is very wide. A simple luxation of a bone once brought back into its normal position usually requires but a short period of time for the repair necessary to restore the limb to its usefulness. The dangers surrounding the condition of dislocation are by no means insignificant, even while the skin is unbroken, if there is considerable extravasation of blood. Nevertheless, the repair is ordinarily sure and complete. But when luxations are compound, although at times they can, like compound fractures, be converted into the condition known as simple, such favorable results are rare, and can be seldom made the basis of treatment. The causes of danger have always been attributed to the inflammatory process as the essential condition. Some surgeons insist that when the bones are restored to their normal position danger arises from the fact of the great strain upon the tendons and muscles, which, having become more or less injured, thereby increase the sum total of the irritation and inflammation. That the in- flammatory process is, primarily, the chief cause of the danger, there can be no question, but it does not ex- plain it entirely. There is a peculiar shock to the nervous system when a large joint is torn open which seems to depress the powers of life at once. When there- is violence sufficiently great to tear open the knee-joint, even if the vessels and nerves are entirely intact, reaction from this depressed condition is slow, and even ampu- tation will seldom save the life. In compound luxa- tion of the ankle-joint, the shock of the injury is se- vere, and the danger is vastly greater than in a compound fracture of the tibia immediately above it. After the in- flammatory process has become established we have in -the synovial membrane an absorbing surface of great activity, which will rapidly undermine the powers of life by the septic process, if the fluids are allowed to re- main in contact with it. The power of absorption seems to be far greater than from the surfaces of the lacerated tissues which constitute an essential feature of compound fractures, and the capacity to endure this dangerous con- dition also seems to be less. Treatment.-This leads us at once to the consideration of the treatment which should be pursued for the relief of the dangers arising from compound luxations. In a general way I may state that resection should be the rule. I do not propose to follow the elaborate discussions that have been made in connection with this topic, but will specify, in each particular luxation, the course that seems proper to pursue. I would, therefore, not lay down this plan of resection as an absolute rule. It is sometimes best to follow the practice, to which there is seldom an exception in the treatment of fractures, namely, that of converting the compound condition into that which is simple by bringing the edges of the wound in the skin and other soft parts into close apposition, in the hope of thus obtaining union by first intention. The com- plications incident to a compound luxation are, as before stated, usually greater in their severity than in the case of fractures, and this fact must be constantly considered in the management of a particular case. If the joint, when luxated, should be barely opened through the skin, the condition of the tissues and of the end of the articulation might, very possibly, be such as to enable the surgeon to convert the compound into a simple luxation. The syno- vial membrane may not have been injured by contact with a foreign body, and the skin, though torn, may yet be capable of union by adhesion. In such a case the reduc- tion of the bone to its proper condition should be under- taken, although we may be so unfortunate as to have sup- puration follow. In proceeding with such a case, the first consideration is to exclude the air. For this purpose it would be wise to carry hare-lip pins deep into the integu- ments, and in sufficient numbers to prevent access of air during the necessary manipulations; after reduction, careful closure must be maintained, although I think the pins should be removed in from thirty-six to forty-eight hours. But such a fortunate combination of circum- stances is rare, and we are under the necessity of meet- ing not only the dangers already alluded to, but also the question of the future utility of the limb. It is the com- mon result, when a compound luxation occurs, that the synovial membrane becomes covered with foreign bodies. The end of the bone, if not buried in the soil, will almost surely come in contact with clothing. The synovial membrane, covered with its glutinous secretion, will re- tain in contact with itself minute particles abstracted from anything with which it comes in contact. But many cases are reported in which, by a thorough cleansing with tepid wrater, carefully poured over the surface, the sur- geon has been able to restore the bone to its proper place, with a completely successful result. These, nevertheless, are exceptions. I must not, however, fail to report the experience of Mr. Lister, who insists that even in a com- pound luxation of the ankle-joint, in which the granu- lating process must almost necessarily take place, we may look for favorable results, provided his method of treat- ment be followed. This consists in first securing a thor- 484 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocatlons. Dislocations. ough cleansing of the parts, and then injecting into the joint a five per cent, solution of carbolic acid in water, for the purpose of removing the principal cause of inflamma- tion, namely, the destructive power of germs. This should be followed by the closure of the wound, after his method. He has reported four luxations successfully treated in this manner. But the profession has not yet become satisfied that it is the safe and proper plan of treating these conditions ; they are still fearful of septicae- mia. It sometimes happens, though rarely, that the re- duction cannot be easily made through the rent in the soft parts, but if such be the case, there should be no hesitation in using the probe-pointed bistoury to relieve the stricture. The question, then, that is before us, in view of the very imminent danger of suppuration in all cases of compound luxation, is to determine the degree of utility which the limb is likely to possess if we succeed in saving it. There are cases in which we must amputate. This has been the rule of some distinguished surgeons in treating compound luxations of the ankle-joint, while others prefer resection of the end of the tibia or fibula, or of the astragalus. If the nerves and blood-vessels are very much lacerated, and the skin extensively bruised, no surgeon will doubt the propriety of amputation ; and in the case of the knee-joint our hesitation to amputate would be still less. But in re- gard to these points, specific statements will be made when we come to speak of the special luxations. I will restate the broad rule, that resection is the plan to be pursued. Sometimes, however, it is best to allow the suppurative process to obliterate the joint rather than attempt a resec- tion. When there is a prospect of saving the limb, this would be by far the best method where the knee-joint is concerned. The treatment of spontaneous luxations does not require a special consideration. The attempt to se- cure permanent reduction usually fails. Congenital Dislocations. - These are very rare, although they have always been recognized. But in the early part of this century a great deal of interest was ex- cited with reference to them, and they especially attracted the attention of the French surgeons, though the main in- terest in the subject was by no means confined to them. This was maintained until within a few years. The causes for such luxations have naturally induced a good deal of speculation, the number being too few to render our knowledge of the etiology very exact. Hippocrates believed that uterine contractions were a sufficient and common cause. The writer has known a fracture of the thigh to occur as the result of violence on the part of the accoucheur in the delivery in a case of breech presenta- tion, and therefore he can readily believe that the same unskilful manipulation might result in luxation. Dr. Hamilton has very well formulated the different opinions on this subject. He regards them as susceptible of ar- rangement under the three following divisions : First, the physiological doctrines, according to which congenital dislocations are due to an original defect in the germ, or to an arrest of development. Second, the pathological doctrines, which refer them to some supposed lesion of the nervous centres; to con- traction or paralysis of the muscles ; to a laxity of the ligaments ; to hydrarthrosis, or to some other diseased condition of the articulating apparatus. Third, the mechanical doctrines, which recognize no intra-uterine dislocations except those which are strictly traumatic ; the causes being understood to be the pecul- iar position of the foetus in utero, violent contractions or the constant pressure of the walls of the uterus, falls and blows upon the abdomen, and unskilful manipula- tion of the child in delivery. Broca states that Parice dissected the hip in three hun- dred and thirty-two cases in the foundling hospital, and found three instances of congenital dislocation among them. He also states, that the proportion of congenital luxations in female children is that of four to one in the male. Treatment.-If the dislocation be discovered immedi- ately after birth, there can be no question of the propriety of making attempts at reduction, and of their probable success, especially if the luxation was produced at the time of delivery. Even in cases of abnormal formation, the retention of the bone in its proper position for a consider- able period of time would be likely to improve the condi- tion. But there is too little known of this to justify the expression of a decided opinion. In the years extending from 1830 to 1860, much interest was exhibited by some French specialists with reference to the treatment of this class of cases after the children had arrived at years of adolescence. A long controversy was maintained on behalf of Pravas by Humbert and Jacquier, who assev- erated his and their success, which, however, was stren- uously and persistently denied by Bouvier. The cases that were especially insisted upon as being relieved were supposed to be congenital luxations of the hip. These were treated by extension, continued through a period of several months. That an improvement might occur in the position of these limbs by this long-continued exten- sion is not improbable, but the writer cannot help be- lieving, in the absence of any personal experience in the matter, that Bouvier is probably correct in his persistent asseverations that restoration of such luxations can never occur. The following statistics of dislocations (Amer. Jour. Med. Sei., October, 1842) are so complete that we make no apology for introducing them here. From an examination of the register of the Hotel Dieu of Paris, M. Malgaigne found that, during a period of six- teen years, 530 dislocations were admitted into that insti- tution, of which there were, Below 5 years old 1 Case. Between 5 and 10 4 Cases. " 10 " 15 8 " " 15 " 20 29 " " 20 " 25 32 " " 25 " 30 40 " " 30 " 35 48 " " 35 " 40 38 " " 40 " 45 45 " " 45 " 50 52 " " 50 " 55 52 " " 55 " 60 51 " " 60 " 65 51 " " 65 " 70 42 " " 70 " 75 19 " " 75 " 80 13 " " 80 " 90 4 " At 90 1 Case. Of these 530 cases, 395 occurred in males, and 135 in females. Of 491 cases in which the seat of injury was particularized, there were', of the humerus, 321 ; clavicle, 33 ; elbow, 26 ; radius, 4 ; wrist, 13 ; thumb, 17 ; fingers, 7 ; femur, 34; knee, 6 ; patella, 2 ; foot, 20 ; jaw, 7; spine, 7. The frequency of luxations of the shoulder in elderly persons is well shown by the fact that of 164 dislocations observed in patients above the age of sixty, where the seat of injury was mentioned, 131 occurred at this part. The dislocations of the clavicle were principally con- fined to adult life, those of the elbow, on the contrary, were mostly in young persons ; one-third of all cases ob- served being in subjects between the ages of ten and twenty ; beyond fifty-four years no example of it was met with. Of the 34 dislocations of the femur, 26 were in males and 8 in females. Dislocations of the Spine.-These luxations seldom occur without fracture, and surgeons of the very largest experience have regarded them as impossible among all the vertebrae below the neck. Those in the cervical re- gion have the processes so much less pronounced than those below them, that the distinct uncomplicated separa- tion of the joint-surfaces in this region can be more easily produced than is possible for those of the dorsal and lum- bar portions of the spine. The difficulty of making a diag- nosis between an uncomplicated luxation and one that is complicated with fracture is not, perhaps, a matter of very great moment from a practical point of view. There are now a few cases in which the autopsy has shown that dislocation, unconnected with fracture, can 485 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. occur at any point along the spine. Of the cervical region it may be said that perhaps the greatest danger is experienced with the dislocations near the skull. Those that concern the occipito-atlantoid articulation are almost necessarily fatal, although a case has been found in which the separation was partial. In this instance, death hav- ing occurred from another cause, an autopsy led to the discovery of the dislocation. Of the atlas it is known that the sliding surfaces of its lower part, articulating with the axis, can be separated in various ways and without a fatal result. The luxation may occur forward, in which case the head will become fixed with the chin on the sternum. It may occur back- ward with the chin in the air, and the occiput on the spine. It may be twisted laterally, with one or both sides dis- placed, and the head fixed in a twisted position. The wide space that is provided for the spinal cord at this point enables these displacements to occur sometimes without a fatal termination. But injuries here are usu- ally those that are accompanied with fracture, which allows of so much mobility that pressure on the chord produces a fatal result. Even when there is no rupture of the chord, there is a suspension of function that cannot be long endured. Traction of the head has reduced such cases successfully. Even if the manipulation should pro- mote a fatal termination, it must be undertaken. In the cases reported pretty strong extension was called for. The cervical articulations below those that have al- ready been spoken of are subject to luxations in all direc- tions ; they can occur backward, forward, and laterally. When luxation occurs backward, the throat seems to pro- trude and the head is turned back in a fixed position ; the reverse is true when the dislocation is forward. One side of the articulation may separate, or both may drop, and the head become moved laterally, or twisted so that the patient's head is fixed with his face looking over his shoulder. The attempt at reduction should be made by extension, but is accompanied with much danger to the chord by stretching it. Causes.-Direct blows on the head, forcing it either backward or forward, will produce the corresponding luxation, but blows on the neck seem to be the chief cause of separation of the surfaces laterally. A case of unilateral dislocation of the fifth cervical vertebra, reported by Professor Reyburn, demonstrates so well the doctrine laid down as to require quotation. While two men were wrestling, one threw the other with great force across the right side of the patient's neck. Slight hemiplegia of the right side resulted. The paral- ysis increased until it was complete in the right upper extremity, and partial in the lower. Professor Reyburn regarded it as a specimen of Malgaigne's unilateral dislo- cation of the fifth cervical vertebra. Nine weeks and two days after the receipt of the injury firm and steady extension was made upon the head, in the direct line of the body, while the shoulders and trunk were counter-ex- tended. The neck was firmly grasped on the outside. After applying the extension about three minutes, the head was rotated toward the right side, while pressure was made on the spinous process, to turn the vertebra to its normal position, to which it returned with an audible snap. This fortunate result, however, did not save the patient's life. The injury done to the spinal marrow resulted fatally, but the post-mortem examination demon- strated the fact of a luxation forward of the articulating process of the right side, uncomplicated with fracture. Dislocations of the Dorsal Vertebra.-A few of these cases have been proved by autopsy, but the separation was moderate. Moreover, there are no diag- nostic marks by which we may recognize an uncompli- cated luxation. The injuries are a mixture of fracture and luxation. Treatment.-This should be made in any case by ex- tension, and it is proper to maintain this extension by weights to the limbs, not only for the purpose of retain- ing the bones in place, and thus removing the pressure on the cord, but also in order to favor repair of the liga- ments. The relief of pain afforded by a removal of the pressure on the nerves emerging at the points of displace- ment, should compel such a course. If, however, this is not sufficient, the use of a plaster-of-Paris bandage is demanded. Dislocations of the Lumbar Vertebra.-These are almost necessarily complicated with fracture. What has been said above upon the management of the dorsal vertebra when injured will apply to the lumbar. Dislocation of the Ribs.-Dislocation of the ribs may take place both from the vertebrae and from the sternum. As is well known, the articulation with the vertebrae is mostly double. Dislocations from these two points can, of course, occur, but the diagnosis is difficult to make, and, perhaps, impossible, fracture being far more common than dislocation. The head of the rib has been found displaced inward. In consequence of the dif- ficulty of diagnosis no attempts at reduction upon any scientific principle have thus far been made. The treat- ment should be the same as for fractitre, which consists in obtaining as much quiescence of the bone as possible, consistent with the functions of respiration. Hence a snug bandage is almost always found to relieve the pain incident to the displacement. But it is probable that this pain will not be sq entirely relieved as in a fracture. Dis- locations of the sternal end have been frequently reported, but they seldom occur except in the young, and when they do occur, they exhibit a displacement of the bone forward. The reduction is to be obtained by throwing the shoulders well back in deep inspiration, and making pressure upon the projecting point. The part then is to be retained by compress and bandage. But I may add also that, although this compress may be reinforced by something firm, like pasteboard or even wood, it is pretty apt to be readily displaced. A few cases of the separation of the sixth, seventh, and eighth ribs, where the cartilages ar- ticulate with each other, have been reported. The treat- ment for such cases is like that just described. Dislocations of the Jaw.-1. The lower jaw is pro- vided with two joints that are symmetrical, and, from its peculiar construction, both are usually dislocated when this condition occurs at all. There are, however, in- stances of luxation of one side alone. The formation of the articulatory surface of the temporal bone for the re- ception of the condyles of the lower jaw, is such that the luxation backward is not possible. But the prominence at its anterior part becomes well developed in the adult, and when the condyles are carried forward over its high- est point they are retained in their abnormal position by the tension of the temporal and • the masseter muscles. This position is constant, and accompanied, of course, with definite symptoms. These are very well defined. The chin projects, the mouth stands open, the saliva flows over the lips, and a tumor appears on each cheek in consequence of the forward displacement of the ramus of the jaw, which position also produces a depression be- hind it. An effort to close the mouth produces pain and fails in its object. Deglutition and phonation are also interfered with. Causes.-This luxation illustrates the fact of the ex- istence of the two causes so common in the production of a dislocation, namely, external force and muscular ac- tion. A blow upon the chin is alone competent to produce it. Muscular action, also, can alone be the cause, for dis- location'has often been produced by a prolonged yawn. The rationale of the luxation from a blow hardly needs explanation. The great force, by driving the chin back, wrenches the condyles out of their sockets, the jaw act- ing as a lever, the posterior part of the articulation as a fulcrum, and the neck of the jaw making the short arm. Such a power causes the condyles to rise up toward the top of the eminence in front, with but a slight portion of its force. If, however, the force is great, the capsule gives way and the condyles pass over the eminence. The tem- poral and masseter muscles at once contract and hold the jaw in its abnormal position. But, as before stated, there is no need of a blow to carry the condyles into the same place. The muscles unaided possess the power if the conditions are favorable. The yawn is an extreme con- traction of the muscles that open the mouth. Such ac- tion brings the condyles high upon the eminence in front 486 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. After-treatment.-This is simple. It is almost im- possible to maintain absolute quiescence of the jaw, but for a period of a week or ten days a bandage should be worn, carried around the chin and over the top of the head so as to hold the two jaws together. The patient should be fed on liquid food, the act of mastication being very sure to produce an enlargement of the capsule and so to favor reluxation. Recurrence is almost, if not quite, impossible, provided the precautions just given are maintained. But a reluxa- tion due to the same causes that first produced the disloca- tion, is very apt to occur. Congenital Luxation.-Professor R. W. Smith has re- ported very elaborately a case of this kind affecting one side of the jaw. The details require too much space for insertion here. Compound Luxation.-This can hardly happen, but if it should occur, resection would be the proper resource. Anchylosis must follow a suppurating joint, and this would be prevented by resection. Subluxation of the Jaw.-1This term has been applied to cases of a folding of the inter-articular cartilage in such a manner that the condyle lies on its anterior surface and produces the symptoms described as characteristic of true luxation, but in a very limited degree. No autopsy has proved this, so far as I know. Still, one can hardly come to any other conclusion. The treatment is to be con- ducted in the same manner as for true luxation. There is, however, a constant tendency to reproduction. The writer has never seen a report of a case in which the condyle seemed to be lodged behind the inter-articular cartilage. He has seen a case in which the left temporo-maxillary articulation has several times had its function impaired in the following manner : The teeth could not be brought together ; the attempt to close the mouth was very pain- ful; the chin was twisted awry and toward the left side ; the teeth of the upper overhung those of the lower jaw to an unusual degree. The reduction of this posterior sub- luxation was effected by carrying a lever between the teeth as far back as possible. Then, while the chin was firmly held by an assistant with both hands, which pressed the jaws together, the lever was used to draw down and thus stretch the apparatus of the joint. This downward traction was kept up for half a minute for the purpose of drawing out any fold that might be present in the inter- articular cartilage. At the end of this time a swaying movement of the lever toward the chin was made, to carry the condyle forward while it was still strained down. These procedures proved entirely satisfactory, and afforded complete relief. The space between the lower and upper teeth, measured horizontally, had dimin- ished a quarter of an inch. No return of the displace- ment has occurred since. Dislocations of the Hyoid Bone.-Dislocation of this bone is exceedingly rare, and but little is known in regard to it; I will, therefore, quote directly from " Holmes' Surgery:" " Gibb has recorded in the following words a case of dislocation of the hyoid bone in a patient under his care. The patient, a man aged forty-five, would feel a sudden click in the left side of his neck, which produced a sensa- tion as if something was sticking in his throat. On ex- amination, this appeared to me to depend upon a dis- placement of the left horn of the hyoid bone, and was generally reduced by throwing the head backward, to- ward the right side, so as to stretch the muscles of the neck, and then suddenly depressing the lower jaw, and so putting the depressors of the hyoid bone into opera- tion. He died, some years after, of pulmonary consump- tion. On examining his throat after death, I found a sort of pouch, which answered the purpose of a synovial cap- sule, embracing the horns of the left thyro-hyoid articu- lation [?]. It was filled with a clear fluid, had a com- paratively large rhomboid sesamoid bone developed in its outer wall, and permitted an extraordinary amount of motion." This was the fourth case of the kind which had come under the notice of Gibb. All the patients were males. He subsequently met with a fifth case in which the patient was a female. of the articulation, and at the same time, when the separa- tion between the jaws is extreme, there will be produced a tension of the masseter and temporal muscles, which at this supreme moment they are very apt to resent by a sudden and violent contraction. The oblique position of the ramus, maintained for the moment by the lower mus- cles, enables the superior ones to drag the condyles for- ward, at the same time rupturing the capsule. But it is undoubtedly true that most cases of this luxation are the result of a blow, aided by muscular action. The force of the blow, perhaps not sufficient to effect the luxation alone, is still competent to place the condyles in the posi- tion of extreme displacement already described as ante- Fig. 826.-Luxation of Lower Jaw. cedent to rupture, which the muscles at this moment complete. As in other luxations, preternatural laxity of the ligaments permits the easy passage of the condyles toward the summit of the eminence, thus rendering the rupture and luxation more easy. There are cases of unilateral luxation, though of rare occurrence. The symptoms are similar to those already described ; the condition is marked by the peculiarity that the chin, instead of being carried directly forward, is drawn toward the unaffected side, thus giving the face a wry appearance. Treatment.-Reduction is brought about by a force which will depress the condyles sufficiently to allow each of them to pass back over the eminentia articularis into the glenoid cavity. The tension of the muscles is sufficient to draw the articulating surfaces together, and usually with a sharp snap. The rent in the capsule does not often present an obstruction to the return of the condyle. The method which the common experience of surgeons has confirmed as the one most easy of ap- plication, and also very efficient, consists in the use of the thumbs as fulcra, while the jaw itself furnishes a lever, the force being applied below the chin. The patient should take a low seat, even on the floor, if the convenience of the surgeon requires it, and the latter should place himself in front, while a support is afforded to the back of the patient's head by a rest on the chair, or by an assistant who presses it against his own per- son. The surgeon having protected his thumbs by wrap- ping them with buckskin, or several layers of cloth, in- troduces them into the patient's mouth and carries them back to the ramus. With the fingers carried under the chin, and with the thumbs in the condition described, the surgeon is able to press the posterior part of the jaw downward while its anterior part is held up. By this manoeuvre he will rarely fail to depress the condyle suf- ficiently far to enable it to pass over the eminence. He may, however, fail, and measures that will secure greater power then become necessary. A lever-for instance, a case-knife, with its handle carried between the teeth- may be employed to produce the requisite depression, while an assistant, locking his hands under the chin of the patient, draws his head firmly against his own chest, thus holding the anterior part so firm that the lever can depress the posterior part of the jaw without forcing open the mouth. 487 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Reference is made in the work quoted to a paper, read in 1848 before the Parisian Medical Society, by Dr. Rip- ley, of South Carolina, on "Dislocation of the Os Hyoides, especially Illustrated in His own Person, and the Manner of Reducing them." The latter process consisted " in throwing the head backward as far as possible, so as to place the muscles of the neck on the stretch, then relaxing the lower jaw, at the same time gently pressing or rubbing over the dis- placed part, when the displacement becomes reduced, after a few attempts, with a click." The writer reports a case of a young man who is liable to constantly recurring luxation of the right horn of the hyoid by a sudden twist of the head to the left, the face being turned to the left and the head carried back. It becomes restored by bending the head forward and to the right, at the same time rubbing the part. This can be repeated at any time by a slight effort. But like other luxations it was on one occasion not restored in this man- ner. He was intently watching a race, and although con- scious of the displacement, was indifferent to the fact that the stretch of the neck was extreme. The head was also suddenly turned back to the right, when it was found that no rubbing or motion that had always reduced the dislocation before would restore the displacement. An entirely opposite plan was now resorted to. The ap- paratus which is used for suspension when applying a plaster-of-Paris jacket was used to the extent of straining the neck enough to bring the patient on "tiptoe." This caused it to snap into place. Luxation of the Body of the Sternum.-Luxa- tions of the body of the sternum are not common, but nevertheless do oc- cur, and may be of two varieties : that of separation of the manubrium from the gladiolus, backward or forward. It is true that ossification of this joint occurs at some period of life, but usually not until old age, and even then in some cases not at all. The causes are, almost without exception, injuries from broad substan- ces, like a mass of earth falling upon a man, or a fall upon the shoulders so as to produce a force bend- ing the body, anal- ogous to breaking a stick by seizing both ends. In many of the cases death occurs from the violence done to the spine. It is to be recollected that the second rib ar- ticulates at the junc- tion of the two bones and has a facet for the manubrium and gladiolus, and it is found that in the separation the second rib usually remains attached to the manubrium. The difficulty is easily recognized in consequence of the superficial position of the bone. There is also a certain creaking sound, during respiratory movement, and pal- pable deformity from the projection of the head of the gladiolus. The manubrium is almost uniformly carried backward. Indeed, a direct blow upon the gladiolus would seem to be the only possible cause for a luxation of the manubrium forward. Symptoms.-In addition to the palpable deformity pro- duced by the passing of the two bones, there is a peculiar expression, which is exhibited by the cut taken from a photograph of such an injury in a young man of twenty years of age. The head is obviously drawn forward and downward by the shooting of the manubrium behind the gladiolus. This carries the head forward, throwing out the chin, through the attachment of the muscles, notably the sterno-cleido-mastoid. Treatment.-This is usually unsatisfactory. However, the case reported by Dr. Foster, of Thorndale, of a young man who fell from the height of sixteen feet, striking be- tween his shoulders, illustrates a successful method. The gladiolus had parted from the manubrium, which was shot behind the first-named bone, there being a depres- sion of half an inch at the place of junction. A ban- dage to retain the shoulders backward was applied without effect, but when he was placed upon a hard bed with a pillow between his shoulders, with the head fall- ing back, it was found reduced on the next day. Deep inspirations accompanied with pressure at first entirely failed to restore it, but while the patient kept this posture it remained in place, and in three weeks he was entirely cured. Dislocations of the Clavicle.-This condition is somewhat rare, the bone usually breaking under the ap- plication of sufficient force, for the ligaments that hold the articulating bones are usually strong. The causes that produce these luxations are blows on the shoulder, usually by a fall. If received in the axis of the bone, and without much tension of the muscles, the retentive ap- paratus of the joint gives way. But such a condition is uncommon. The tension of powerful muscles is almost surely present, and fracture is the rule and luxation the exception. The joints themselves, both at the internal and external extremi- ties, present the pe- culiarity of flattened surfaces, in which there is a slight cup formed by the interar- ticular cartilage that is very constant at the sternal end, but either imperfect or absent at the acro- mial end. When the rupture of the liga- ments has occurred so as to allow of com- plete separation of the articulating sur- faces, it will be found that, although they are easily replaced, the absence of a cup-like formation prevents their retention in their proper position. In order to their restoration, all that is necessary is to seize the humerus at its upper part, and draw the shoulder back- ward. This will reduce the luxation if it be either at the sternal or acromial extremity, in nearly every case, al- though there are cases which it is impossible to restore. The articulating surfaces are at once brought into con- tact, but the moment the grasp of the surgeon is relaxed, the weight of the shoulder and the action of the muscles cause a reluxation. This is easy to comprehend when we recollect that the function of the clavicle is that of a passive antagonist to the action of several powerful mus- cles. Symptoms.-The sternal end of the clavicle is regarded as being thrown, after luxation, into three different posi- tions, which can be definitely stated. These are denom- inated forward, backward, and upward luxations. The forward one is far more common than the other two. The backward one comes next in frequency. Dr. Hamilton, in 57 dislocations of the clavicle, records 13 as belonging to the sternal end, and 44 to the acromial ; and of those belonging to the sternal end 11 were those of dislocation forward, and 2 were thrown upward. In dislocations forward the diagnosis is easy, for the end of the clavicle can be felt in front of the sternum, while the shoulder drops and is carried in toward the thorax. The end of the bone is usually carried downward as well as forward, but this is not uniform, for it is sometimes carried up- Fig. 828.-Luxation of Sternal Extremity of the Clavicle. Fig. 827.-Dislocation of Sternum. (Traced from a photograph.) 488 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Dislocations. Dislocations. ward a little, so as to be in line with the clavicle on the opposite side. In dislocations upward and backward, the end of the clavicle passed behind the sternal fibres of the sterno-cleido-mastoid muscle. In dislocations upward, the end of the bone is brought in front of the trachea, and does not rest upon the end of the sternum. The scapular end of the clavicle may also be thrown from its natural position in three different directions : up- ward, above the acro- mion process, which is the one that com- monly occurs ; down- ward, beneath this process ; and also, finally, beneath the coracoid process ;-the latter two vari- eties however, are extremely rare. In the dislocation up- ward the end of the bone is to be seen overlapping the acromion process, and forming a small tumor, easily felt under the skin. The limb hangs close along the trunk, drawn thereby the action of powerful muscles, and the patient is unable to raise his hand to his mouth, or to carry his arm out at right angles to the body without pain. Treatment.-The treatment of luxation of the clavicle is usu- ally summed up by most authors by recommending the use of the apparatus employed in the treatment of frac- tured clavicle. But this is also coupled with the ac- knowledgment that it usu- ally fails in accomplishing the purpose of retaining the parts in proper apposition. Some have superadded rigid fixtures, such as the plaster- nf.Pari« bondage, with the belief that they aid in approx- imating the joint surfaces; but by the com- mon consent of writers upon this subject, perfect apposi- tion is not to be looked for. From this conclusion the author of this article absolutely dissents. It is his ob- servation, founded upon his own experience and that of his surgical friends who have employed the method about to be described, that a complete cure, as perfect, indeed, as that which obtains in the shoulder or hip-joint, is the rule and not the exception. Of course, this state- ment applies to cases that have recently occurred. When a few weeks of time shall have inter- vened, and adhesions have formed, which will be likely to interfere with the replacement of the sur- faces, a failure in perfect adaptation is to be ex- pected. But where the luxation is recent the res- toration is almost abso- lutely certain ; so that at the end of a short period of time, when the swelling has entirely disappeared, no deformity will be found to exist. This statement is founded on the results of sixteen cases, occurring in my own practice and that of my surgical friends ; only two of which, however, apply to dislocation at the ster- nal extremity, while fourteen are at the acromial end of the clavicle. Before resorting to the measure about to be described, I had failed in producing any satisfactory result by any clavicle apparatus that I had applied. The plan consists in retaining the arm in the position which it is sure to assume when we seize the humerus to make the traction which restores the parts to their proper place so constantly. If the elbow be carried backward and pressed toward the side, this felicitous result will trans- pire. And if, in addition to this, some pressure is made upon the superior surface of the clavicle, its retention in its proper position may be relied upon. A variety of appliances can be resorted to to attain this end, but I have found that the simple bandage which is here illus- trated subserves the purpose with great assurance of suc- cess. This, as will be shown by the cuts, consists of the application of a shawl, or what is better, a piece of com- mon cotton cloth, about two and one-fourth yards in length, and a yard or so in width, folded like a cravat until it is about eight inches in breadth at the centre. The application of this bandage is conducted in the fol- lowing manner : Place this bandage, thus prepared, upon the palm of the outstretched hand, with the finger and thumb in the line of its length and at its centre. This enables the surgeon, while placing it under the elbow of the patient on the affected side, to grasp it firmly, and so adjust it that the border reaches about two inches up on the humerus, and about six inches down upon the fore- arm. The grasp of the surgeon's hand retains the ban- dage in position dur- ing the succeeding manipulations. The first movement is to place the inner tail up over the shoulder, smoothing it out over its rounded surface, and then committing it to an assistant. The outer tail is now carried over the fore- arm, up behind the back to the top of the opposite shoul- der. Traction is now made upon this tail so as to draw the el- bow backward and toward the thorax, after which its end is brought over the shoulder and under the axilla of the un- affected side. The other tail is now seized, and when made tense draws the shoulder backward. This is carried under the armpit, and over the point of the unaffected shoulder. The two ends are now secured by pins at the points where they overlap the bandage. This, as will be observed, produces the peculiar form upon the unaffected side known as the figure-of-eight bandage. The special twist around the elbow of the affected side is similar in form, although one end runs up over the shoulder. For these reasons the writer has called the bandage " the fig- ure-of-eight from the elbow." The bandage, however, is not complete without a sling to hold the forearm slightly above the horizontal position while the patient is erect. If the forearm droop, the bandage becomes disengaged from the elbow, and the arm has a tendency to swing for- ward. But if it be placed in the position already indicated, its weight has a tendency to carry it backward. This sling is best constructed by placing a strip of cotton cloth, three or four inches wide, around the wrist, and pinning the two ends together upon the larger bandage as it passes over the shoulder. It is desirable, also, to fold the end that projects behind the elbow and secure it with a pin, so as to make a sort of cup which will hold the elbow in its place. This bandage is usually worn with great comfort to the patient, the points most complained of being the axillary border of the unaffected side and Fig. 829.-Luxation of Acro- mial Extremity of the Clavicle. Fig. 830.-Dislocation of Clavicle, Acromial End. (Traced from photograph.) Fig. 832.-Figure-of-eight from the Elbow. Side View. Fig. 831.-Side View of Same. 489 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the extremities of the olecranon and condyles of the elbow held by the bandage. Protection against this pressure can be afforded by little compresses, placed alongside of the suffering points, and can be left entirely to the management of the pa- tient. It is wise, however, to watch him daily for the period of a week, loosening the tails of the bandage and then tightening them a little. At the end of this time formed by a roller crossed upon the back, or by collars, or by the sap-yoke. As is well known, the bandage which em- ploys the axillary pad, and is usually designated as Des- sault's bandage, is expected to throw the shoulder out so as to attain the full length of the clavicle, by using the hu- merus as a lever, and the axillary pad as a fulcrum, while the lower end of the arm is carried toward the side, which would cause the shoulder to move outward. We supple- ment also this motion by a force which lifts at the end of the humerus, so as to carry the shoulder upward and backward. But, no matter how firmly we may draw the humerus toward the side, it will still be found that we shall fail in carrying the shoulder out sufficiently far to allow the dislocated end of the clavicle to come into its place. It is obvious that the slightest shortening of the space between the acromion and the sternum, even that of the eighth of an inch, will displace the clavicle when luxated at either end ; for the flat surfaces will not retain the end of the bones in place, in virtue of their forma- tion and of the weight of the arm, and traction of the mus- cles is a constant source of recurring luxation. Hence the necessity of a retentive apparatus. The chief element of our power to restore the bone to its normal position is to be found in our ability to throw the acromion outward sufficiently far to bring the end of the clavicle into its proper place. When the elbow is carried backward and then drawn toward the side, the scapula is moved nearer to the spine than when the arm is hanging perpendicularly. Inasmuch as the scapula in moving backward also slides around the thorax, which is cylindrical in form, it will be found as the result of this motion that space for the full length of the clavicle can easily be obtained by carrying the scapula a little more than an inch nearer the spine than the opposite one when allowed to hang at ease. By carrying the elbow backward we render tense all the muscular fibres that are attached to the an- terior edge of the clavicle, namely, the clavicular fibres of the great pectoral, and those of the internal half of the deltoid. A moment's inspection of these muscles in this position renders this plain. The humerus, which swings from the centre of the head of the bone, has the clavicular fibres of the great pectoral inserted at the lower end of the bicipital groove, while those of the del- toid are attached still lower down. Any movement that carries the humerus back from the perpendicular line necessarily draws upon both of these. Thus we have fur- nished us, with the arm in this position, the firmest kind of bands extending throughout the entire length of the clavicle, drawing down and holding it in the space which has been afforded it by the extended acromion. It has always been known by surgeons that, if patients would take the recumbent posture, and maintain it constantly, the best results, both in fractures and dislocations of the clavicle, were likely to be obtained. This expedient, however, is one to which patients will seldom submit, and, inasmuch as it is necessary that they should not turn upon the side, but constantly maintain the recum- bent position, it is easy to understand that it is a method seldom employed. The rationale offered for the success of this latter plan is to be found in the statement that we thereby avoid the displacement arising from the weight of the shoulder, and also restrain the freedom of motion of the scapula by the weight of the body which holds it upon the bed. I cannot but believe that the position acts chiefly by the accident that the elbow falls upon the bed, and thus the same effect is obtained as by the bandage known as the figure-of-eight from the elbow. Absolute rest upon the back is well-nigh impossible, and if the bones are displaced frequently by the alteration of posi- tion, close union of the torn capsule and ligaments will be necessarily prevented. It is true that surgeons usu- ally supplement the method by some apparatus ; but, if this contains in itself the conditions of displacement, posi- tion alone will not relieve the patient. Ao plan of treat- ment that leaves the humerus perpendicular can make the clavicular fibres tense. The apparatus of retention should be kept in place for two weeks, a longer time than is usually required after most luxations. Fig. 833.-Figure-of-eight from the Elbow. Front View. the capacity of stretching in the cloth will have ceased. A statement of results obtained by these measures, so contradictory to those obtained by any other apparatus, demands an explanation of its rationale. Of the sixteen cases heretofore mentioned but one can be considered as a failure in any degree, and that case was seen two weeks after the accident had occurred ; and even in that one the approximation of the surfaces to each other was close. It would be idle for me to attempt a criticism of the nu- Fig. 834.-Figure-of-eight from the Elbow. View from behind. merous appliances brought forward to rectify fractures and luxations of the clavicle ; but I may offer some upon the two great forms which constantly reappear in prin- ciple, though having numerous modifications. I refer to those which rely upon the use of the humerus as a lever, carried ovex' a fulcrum placed at the border of the axilla, and also to the well-known figure-of-eight bandage, whether 490 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. Dislocations of the Shoulder.-Dislocations of the shoulder, when assuming a regular form, are described as occupying three different positions, with some subdi- visions of these, as when the head of the humerus is per- fectly removed from the glenoid cavity, and there is a complete rupture of the capsule. A fourth variety is also recognized by some sur- geons, though its existence has been disputed by many; it is denominated a subluxa- tion. This last consists of a displacement against the coracoid, thus carrying the head of the humerus for- ward and allowing it to rest upon the edge of the glenoid cavity. The other varieties, which are universally recognized, consist of the removal of the head of the humerus into the axilla-subglenoid disloca- tion ; backward upon the dorsum of the scapula-subspinous dislocation ; and another forward under the clavicle -subclavicular dislocation. The dis- locations downward into the axilla are more common than those of all other joints added together. This may be easily understood by observing the anatomical conditions. The junction of the head of the humerus with the glenoid cavity is recognized as constituting a ball-and-socket joint; but while there is an admirable ball, the almost plane flat surface of the glenoid fossa can only be considered a cavity or socket by courtesy. Its formation presents but little obstruction to the separation of the two surfaces of the two bones. This formation is necessary to allow the extraordinary range of motion which the human arm possesses. But nature has supplemented the passive security of a deep cup by These luxations very frequently illustrate the statement before made, in the paragraph on the general causes of dislocations, that muscular action alone is competent to rupture the capsule and produce complete luxation. The writer has known a luxation of the head of the humerus into the axilla to occur in the case of a powerful man, who, in falling between the joists of an unfinished building, dislocated the joint in this manner by seizing the top of the joists to arrest his fall. The arm was extended directly upward, and the whole weight of the person was sustained by the muscles of the shoulder attached to the humerus. But such was their power that, although there was no blow, they were able to draw the head of the humerus downward into the axilla. The writer has also known a case in which both shoulders were luxated during an epileptic seizure, and in which there was no blow of any kind whatsoever. Nevertheless the most common cause of these luxations is a combination of a blow and muscular action ; the force being exerted upon the arm while it is carried out from the body, thus giving the large muscles which control the movements of the humerus upon the scapula their greatest power, and at the same time rendering them tense. The moment when the blow is received is also, usually, that of the greatest muscular action. The slightly depressed surface Fig. 835.-Subluxation of head of Humerus. Fig. 837.-Dislocation, Subglenoid. of the glenoid cavity offers little or no obstruction. Blows upon the arm may be produced by a mere fall upon the hand while it is extended, or upon the elbow, or upon the shaft of the humerus ; lienee falls upon the shoulder, which are such a prolific cause of injury to the scapula and clavicle, frequently furnish the force which is necessary to produce luxation of the humerus. In- deed, a blow impinged upon the upper part of the arm from an unexpected quarter, and while the muscles are perfectly quiescent, may still be competent to produce a luxation of the humerus from the glenoid cavity. In addition to the causes already enumerated, the pecu- liar twist, or spiral motion, which has been alluded to in speaking of general causes, and which is admirably illus- trated by the luxations of the shoulder, calls for a more ex- tended notice. The following experiments which the writer has made upon this joint upon the cadaver con- firm his views in regard to it. Experiment 1. All the muscles around the joint hav- ing been removed, the capsule only remaining, a lever was applied to the lower end of the humerus, so as to ex- ert its power directly in the line of its shaft. The scap- ula was firmly fixed to a block by staples, while the humerus was carried upward beyond a horizontal line drawn through the clavicles ; this step being taken in order that a luxation might be produced while the arm was in the position, which is undoubtedly a common one, when the body is thrown down and the arm thrown out Fig. 836.-Dislocation, Subglenoid. (Traced from a photograph taken twenty-three hours after the injury had been received.) the substitution therefor of four muscles surrounding the joint, which, by their tension, hold the head of the hu- merus against the glenoid surface, while their tendons, being incorporated in the capsule of the joint, enable them to draw the latter away from the danger of compression during its motions. But these are mere substitutes for a true bony socket, which is a far better security against the danger of luxation. Moreover, the arm is more exposed to accident than any other portion of the body. It is for- ever instinctively ready to guard us against our dangers. Causes.-These are blows, twists, and muscular action. 491 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. for protection. The lever was made of an iron bar four feet long, the short arm being six inches in length. Thus the power of eight men wras brought steadily to bear at the end of the humerus at the elbow. But no force of this amount steadily applied would cause the head of the humerus to leave the glenoid cavity. But when a rope was passed around the upper end of the humerus, through which a sudden force was exerted in imitation of the ac- tion of the pectoralis major, the teres major, and latissi- mus dorsi muscles, it at once left the socket, rupturing the capsule at the inferior border, and passed into the axilla. Experiment 2. In this subject also the muscles were re- moved, and all the apparatus adjusted as before ; but the direction of the humerus was now changed so as to bring it out from the perpendicular position half way toward the horizontal position, assuming the subject to be in the erect posture at an angle of forty-five degrees. The force applied as before was sufficient to tear the capsule both from its inferior and from its superior border. The head of the bone passed upward between the coracoid and acromion processes, producing a slight fracture of the edge of the former, thus making a complete luxation upward. Experiment 3. The arm, with all the tissues, even the skin, untouched, was grasped above the elbow, while the forearm was held at right angles to it with the other hand. The arm being now carried outward, and a little above a horizontal line as drawn through the clavicles, was now twisted, being rotated outward, the forearm act- ing as a lever, and, of course, carried upward. There was no difficulty, by the mere power of the hands of the surgeon, moderately exerted, in throwing the head of the bone into the axilla, tearing its way through the capsule at the inferior border, which was at once revealed by the removal of the integuments and muscles. It is altogether probable that this twisting motion, as de- scribed in Experiment 3, is a prolific cause of luxation of the head of the bone into the axilla. In the case of sub- spinous luxation alluded to above, the subject was seized by a friend at the forearm, at a moment when his muscles were in great tension during an angry scuffle, for the purpose of separating him and his antagonist, and the arm received a twist of rotation inward, precisely op- posite to that described in Experiment 3. Symptoms.-Dislocations of the Head of the Bone into the Axilla. These are described as a flattening of the shoulder, and the position of the head of the bone itself in the axilla. We also find a lengthening of the arm of from half an inch to an inch. Besides these symptoms, there are those of minor moment and less characteristic. We usually find the elbow carried out a short distance from the body, with an inability, on the part of the pa- tient, to move the arm freely, and especially to carry the humerus up to a right angle with the body. There is also a great difficulty in carrying the hand up against the side of the neck corresponding with the uninjured shoulder. Occasionally there is a false crepitus upon at- tempting to move the arm, which may mislead the inex- perienced. Altered sensations in the arm are also present in various degrees. Sometimes the pain is very severe and of a neuralgic form, at other times it is dull and aching, but usually there is a feeling of numbness ; all this being incident to the fact of pressure upon the axillary nerves. These symptoms, when presented to the experienced surgeon, seldom fail to enable him to make a correct diagnosis. But the writer has seen so many errors committed in the diagnosis that he calls especial attention to it. The condi- tion becomes plain enough after a certain period of time, which may be necessary for the removal of the swelling and to allow the muscles to draw the head closer to the thorax. But immediately after an accident, when the blood is poured out under the deltoid, and the patient is somewhat faint, the flattening of the shoulder is not very apparent, and becomes less so if he be loaded with adi- pose tissue. In precisely such subjects, also, there is a difficulty in recognizing the head of the humerus in the axilla, and also in defining accurately the points necessary for measurement. In this, as in most other luxations, immobility is one of the prominent symptoms ; and yet, even this one may be misunderstood in consequence of the sliding of the scapula upon the thorax, this motion being misinterpreted, while in reality the two articular surfaces move together and without any motion upon each other. The inability to carry the arm out from the body may also be attributed merely to the injury done to the soft parts of the shoulder. The numbness and pain incident to pressure upon the axillary nerves are some- times very slight. Treatment.-The reduction of the humerus, in its ab- normal positions in the axilla, is usually effected with ease, provided the patient is seen soon after the accident, be- fore the muscles have recovered, as it were, from their surprise, and especially if the patient be faint. But this is not always so. Even at this stage the rent in the cap- sule may be barely sufficient to allow the head to emerge, and therefore the edge which separates it from the neck may be so caught as not to permit of the replacement of the bone without laceration of the capsule, which the efforts of the surgeon may find it difficult to produce. Still, such cases are rare. Certain methods have been followed by the profession, and if one fails another is tried. It is an undoubted fact that this change from one plan to another becomes necessary within the experience of the same surgeon. One of the conditions, which seems to be indispensable for the reduction of all luxations, is the fix- ation of that portion of the limb or body from which the part has been separated ; but in this particular case we find it difficult, and, indeed, sometimes impossible, to se- cure any reliable fixation of the scapula. It is so mova- ble upon the thorax, and so imbedded in muscles, that we have no opportunity to make pressure directly upon it, except at the acromion, and this is so situated in relation to the deltoid as to render it a very uncertain point for pressure. The head of the bone is caught against the ex- ternal border of the glenoid fossa, and here it is held by some muscles that are very powerful, and by one that is very tense. The latissimus dorsi, the teres major, the pectoralis major, all draw the head of the bone in toward the thorax, and, from their great size and powrer, are for- midable obstacles to the reduction. But, besides these, the lengthening of the limb has rendered 'the supra- spinatus tense. This tension and the power of all these muscles seem to be increased after the lapse of a little time, and, while they offer but small resistance immedi- ately after the accident, they soon begin to contract, and in twenty-four hours the difficulties are very much in- creased. Besides, the swelling, which distends the tissues, adds another source of trouble. Sir Astley Cooper, whose favorite methods have been so generally followed in this country, was in the habit of obtaining an extension by seizing the wrist of the dislo- cated arm and procuring counter-extension by placing his heel in the corresponding axilla. It is obvious that traction by this method must render the muscles which are tense a little more so, in order to disentangle the head from behind the edge of the glenoid cavity. If there be no obstruction offered by the capsule, the mo- ment that this is done the muscles themselves, by a little spasm of contraction, will draw the head of the humerus into the glenoid fossa, producing at the same time an audible snap,or rather a dull thud, which is peculiar and easily recognized when once heard or felt. But, with the heel in the axilla, we possess rather more than the mere convenience of extension. The size of the heel and the space of the axilla are so related to each other that virtually a wedge is introduced between the head of the bone and the thorax, and by means of it, at the moment of extreme tension, the humerus is thrown outward. It has been objected that the foot could not be used in this manner without making such press- ure on the border of the axilla as to counteract the benefits above described. But, however this may be, the method is so convenient, and usually so successful, that it seems to be almost universally adopted as the plan first to be tried. The extension of the forearm from the wrist has, however, one objection, which may not be of great moment; still it has its weight. The biceps, by 492 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations* Disiocations. its attachment to the scapula, is rendered tense during luxation. The forearm hangs from the arm at an angle of about one hundred and thirty-five degrees. Extension, therefore, to a straight line, or one hundred and eighty degrees, increases the tension of one of the powerful forces which retains the head of the bone in its abnormal posi- tion. Another of the numerous methods is to raise the hu- merus out at right angles to the body, and then, placing the knee close to the border of the axilla, so as to use it as a fulcrum, the arm is seized by the surgeon, who bears down upon it, thus employing it as a lever to pry the bone upward. The merit of this plan, as compared with the use of the heel in the axilla, consists in the fact that the elevation of the arm produces some relaxation of the supra-spinatus and biceps muscles, and it also avoids any pressure on the borders of the axilla. An ingenious method of making extension with the semi-flexed fore- arm and the humerus at right angles to the body, is to place the patient upon a table, and then the surgeon, standing with his thigh against the side of the patient's thorax and wrapping his arm around his own pelvis, ro- tates his body so as to draw the bone outward. The plan of Dr. Nathan Smith consists in making counter-extension from the arm of the unaffected side, while the wrist of the affected side is seized and extension is made at right angles. But, if these methods fail, we may now resort to what may be termed the natural one, and that is the drawing of the two surfaces directly toward each other. The sur- geon, by placing the hollow of his foot directly upon the top of the acromion, obtains his counter-extension, while hq can make traction either from the elbow or from the wrist. This method gives a better assurance of restraining the scapuMthan any other. There is^ill another plan, though not new, "which has found more favor in the minds of surgeons recently than ever before. Indeed, the writer has come to employ it as his first method instead of the last. This has been aptly termed reduction by manipulation. No violence is em- ployed. The arm is gently moved in certain ways, and seems almost to be coaxed into its place. The forearm is flexed upon the arm ; the surgeon grasping the wrist for this purpose with one hand, and the elbow with the other, gently carries it forward and upward, close to the thorax, and when it is drawn around so as to be nearly horizontal with the body in the erect posture, the forearm is rotated away from the body of the patient and is used as a lever to roll the humerus, and thus carry its artic- ular surface upward. It is common at this moment for the reduction to take place. But this is not the only method by manipulation. An entire sweep of the arm, carrying it upward and outward around toward the place of beginning, will frequently disentangle the head of the bone, so that the muscles can carry it into its place with the characteristic snap. Notwithstanding all these devices, we still fail, in some cases, in effecting reduction, and from causes not easy to understand. In many of them where luxation has recurred frequently it will be found that the method which succeeds at one time will fail at an- other. It is, therefore, impossible to lay down an abso- lute rule of procedure. It very frequently happens that the unaided power of the surgeon fails entirely, and we are under the necessity of increasing it. In order to ob- tain this, pulleys, or the twisted rope, or the employment of many persons for the purposes of traction, will effect the object. It is wiser to apply the clove hitch above the elbow, rather than at the wrist. Doing this, we not only relieve the biceps, but we can employ the forearm as a lever to make rotary motion, in order to dislodge the head from the border of the capsule. And indeed this motion assists it in its movement over the edge of the glenoid fossa. I need not repeat here the special precau- tions to be observed in employing the power of pulleys. The great difficulty is in the proper adjustment of the coun- ter-extending band. It is easy to apply this around the thorax, below the axilla, but this does not fix the scapula. Sir Astley Cooper recommended a strong piece of cloth, somewhat like canvas, with a button-hole made just large enough to take in the arm, the two ends of which are carried upon each side of the body and attached to a fixed point. By these means he hoped to obtain a re- straint upon the scapula by catching the end of the acromion; but the method is inefficacious for this pur- pose, the edge of the button-hole slipping pretty readily away when the arm is brought up at right angles with the body. Another mode is to place in the axilla a ball, so contrived that a counter-extending band can be applied to the extremities of a bar running through it. This band will make its counter-extension in a direction parallel with the axis of the body. The traction is then made directly downward, as by the method in which the heel is placed in the axilla. The ball.is firmly fastened to the cross-bar, and is known as Skey's method. Dr. Heine, of Heidelberg, reports a case of subclavian luxation of the humerus of seven weeks' standing. Exten- sion and other means of reduction had failed. He grasped the arm with his right hand, and the forearm with the left; placing the forearm at right angles with the arm, he carried the humerus directly upward to a vertical posi- tion, forcing the elbow backward so that the humerus would make an obtuse angle with the back, thus using it as a lever with the scapula as a fulcrum. The arm was then circumducted from behind forward, and it was finally depressed and rotated inward, whereupon the head of the humerus slipped audibly into the articular cavity. Dr. Garms reduces the bone by laying the patient on his Fig. 838.-Sub-glenoid Dislocation, traced from photograph two years after injury. face, and making extension backward and downward, while an assistant draws firmly a bandage which has been looped around the upper part, in a direction upward and outward, the surgeon in the meantime placing his heel in the axilla. This differs from the usual method in one respect: the traction is made in a backward instead of a forward direction. Another procedure is brought forward by M. H. Salmon. This procedure is one that is to be executed with great gen- tleness and slowness, and consists in gradually raising the arm from the side to a right angle, gently rubbing the muscles of the shoulder, and arresting the movement when the slightest pain is complained of. If sufficient time is employed this method may be pushed to the point of bringing the arm into a directly upward position. When the limb is in this position the surgeon grasps the end of the scapula with his two hands over the shoulder, and with both thumbs gently pushes the head of the bone into the glenoid cavity, aided by gentle traction on the part of the assistant. Old Luxations.-In the attempt at the reduction of old luxations, so called, where adhesions have become perfected, it becomes necessary to supplement mere trac- tion by the rotation of the humerus by the forearm held 493 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. at right angles, for the purpose of breaking them up pre- liminary to the traction. The term " old and recent lux- ations," as has been stated above, does not indicate any exact period of time which separates them, but we intend to apply the term " old" to those cases in which the exu- dates have become thoroughly organized. As time goes on, the muscular tissue atrophies and takes on a rigid character, apparently in order that it may serve as a sort of ligament. But besides the difficulties arising from these changes, we find the bands of newly-formed tissue extend- ing from the bone to the fierves and blood-vessels. It can be readily understood that such conditions are not easily overcome, and that when these adhesions are very firm, a series of dangers will appear which are not present im- mediately after the accident. Inasmuch as these changes are gradual and progressive, a time will arrive wrhen re- duction will be impossible. But these adhesions are necessarily different in different persons, and it is im- possible to establish a diagnosis, either of their position or their amount. It is, therefore, the custom of surgeons to set a period beyond which it is wise not to attempt reduc- tion of an old luxation of the shoulder. The large ex- perience of Sir Astley Cooper induced him to lay down three months as the limit of time beyond which we should not attempt the restoration of a dislocated shoulder. This is the result of a vast experience on the part of this great surgeon. No further experience of modern times has materially altered this conclusion. A great many cases have been reported in which reduction has been effected after four, six, and eight months, and even a year and more ; but they are exceptions to a rule, and rare ones. The dangers that surround these attempts at reduction, after the period mentioned, are great and numerous. The record of deaths from this cause, even when the oper- ations were performed by the most distinguished sur- geons, is so large as to render the observance of this rule one of propriety. The writer has succeeded in effecting a reduction after the lapse of ninety-one days, but in two attempts, at the end of four months, he fractured the hu- merus each time. The most prominent danger in these cases has been shown to be rupture of the axillary artery; but we have also had rupture of the axillary veins and nerves. That the arteries should be more easy to give way than the other tissues can be readily comprehended when we reflect upon their elastic and fragile character. Even if we should be fortunate enough to ligate them successfully after a rupture, wre are confronted with the great danger of secondary haemorrhage. Ligature of the subclavian has been more successful after such ruptures, but this is so formidable a surgical procedure that no sur- geon would willingly run the risk of being obliged to resort to it. Moreover, in addition to the difficulties al- ready enumerated, we may have an obliteration of the ar- ticulating surface. The connective tissue and the capsule, infiltrated with the inflammatory exudates, often coat over and fill up the glenoid cavity. This condition, also, is one of great irregularity and uncertainty as regards the time of its completion, and even of its occurrence. Hence, we find irreducibility from this cause in some cases before the three months have expired, and in others we find a capacity for reduction at the remote periods already indicated. On one occasion, the writer having failed at four months, thought best to incur the danger of suppuration and anchylosis rather than leave the joint unreduced. For this purpose he made a dissection by splitting the deltoid and exposing the glenoid fossa, which he found so occupied as even then to foil his at- tempt at reduction. This is recommended as the proper practice, although there are a large number of cases re- ported of success after a long period-many months, or even a year-has elapsed. Tenotomy is not easy of appli- cation, in consequence of the nerves and blood-vessels in- volved. Sub-coracoid Dislocation.-It sometimes happens that the head of the bone does not become fixed under the border of the glenoid fossa, but is carried forward and a little upward, under the coracoid process. The diagnosis is to be made by observing the position of the head of the humerus. The elbow is carried a little backward, the lengthening of the arm is less, but in every other respect the symptoms are precisely the same as when the head is caught against the scapula, below the glenoid fossa. There is little to be added to what has already been stated, with reference either to the pathology, the etiology, or the treatment. It is believed that at the moment of "receiving the injury the arm is held backward, which givesit, when dislocated, a tendency to move forward. There is also, probably, a little more laceration of the capsule. Subclavicular Dislocation.-This dislocation, de- scribed as the forward one under the clavicle, is a rare one. The diagnosis as regards its special position is to be made out by finding the head of the humerus un- der the clavicle, which will be observed, even in a fleshy person, when the humerus is rotated. In these cases the elbow is carried still further back than in the two conditions already enumerated, and the lengthening of the arm does not exist; but in all other respects, especially as regards the fixity and the flattening of the shoulder, the conditions are the same ; the treat- ment is precisely the same, excepAas regards one point: we make the traction a little baclmard. Subspinous Dislocation.-This condition is recog- nized by finding the head upon the back of the scapula, below its spinous process, and hence the name sub-spinous, a synonym of the more common one of dislocation on the dorsum scapulae. The presence of so large an object can- not fail to be detected, and hence the diagnosis is not difficult. Besides, we have the elbow carried forward in- stead of backward, and when the arm hangs by the side, the palm is turned more outward than normal. These dislocations are very rare. Treatment. -The treatment of this luxation is similar to that to which we resort in the reduction of a dislocation into the axilla, modified by carrying the traction a little forward instead of directly outward from the body, except in the process of manipulation. When we resort to this procedure, the arm should be carried out fully at right angles from the side of the body, when, by means of the forearm at right angles to the arm, rotation is made outward. Dislocation of the Shoulder Accompan- ied with Fracture.- When the latter compli- cation exists, which is not very often, it almost uniformly interferes with the reduction of the dislocation. The break usually occurs at the surgical neck, and when this happens, the diagnosis can ordinarily be made out without much difficulty. The coarse crepitus of a fracture can seldom be mistaken, in experienced hands, for the modified form incident to true luxation. A firm pressure in the axilla will usually ena- ble us to reach the neck of the humerus, and then, upon rotation of the arm, we shall be able to distinguish a fract- ure at the surgical neck. If, however, the fracture is at the anatomical neck, it is almost impossible to make the diagnosis certain. The return of the head, in these cases, lengthening of the arm is less, but in every other respect the symptoms are precisely the same as when the head is caught against the scapula, below the glenoid fossa. There is little to be added to what has already been stated, with reference either to the pathology, the etiology, or the treatment. It is believed that at the moment of "receiving the injury the arm is held backward, which givesit, when dislocated, a tendency to move forward. There is also, probably, a little more laceration of the capsule. Subclavicular Dislocation.-This dislocation, de- scribed as the forward one under the clavicle, is a rare one. The diagnosis as regards its special position is to be made out by finding the head of the humerus un- der the clavicle, which will be observed, even in a fleshy person, when the humerus is rotated. In these cases the elbow is carried still further back than in the two conditions already enumerated, and the lengthening of the arm does not exist; but in all other respects, especially as regards the fixity and the flattening of the shoulder, the conditions are the same ; the treat- ment is precisely the same, excepAas regards one point: we make the traction a little baclmard. Subspinous Dislocation.-This condition is recog- nized by finding the head upon the back of the scapula, below its spinous process, and hence the name sub-spinous, a synonym of the more common one of dislocation on the dorsum scapulae. The presence of so large an object can- not fail to be detected, and hence the diagnosis is not difficult. Besides, we have the elbow carried forward in- stead of backward, and when the arm hangs by the side, the palm is turned more outward than normal. These dislocations are very rare. Treatment. -The treatment of this luxation is similar to that to which we resort in the reduction of a dislocation into the axilla, modified by carrying the traction a little forward instead of directly outward from the body, except in the process of manipulation. When we resort to this procedure, the arm should be carried out fully at right angles from the side of the body, when, by means of the forearm at right angles to the arm, rotation is made outward. Dislocation of the Shoulder Accompan- ied with Fracture.- When the latter compli- cation exists, which is not very often, it almost uniformly interferes with the reduction of the dislocation. The break usually occurs at the surgical neck, and when this happens, the diagnosis can ordinarily be made out without much difficulty. The coarse crepitus of a fracture can seldom be mistaken, in experienced hands, for the modified form incident to true luxation. A firm pressure in the axilla will usually ena- ble us to reach the neck of the humerus, and then, upon rotation of the arm, we shall be able to distinguish a fract- ure at the surgical neck. If, however, the fracture is at the anatomical neck, it is almost impossible to make the diagnosis certain. The return of the head, in these cases, Fig. 839.-Sub-clavicular Dislocation. Fig. 840.-Sub spinous Dislocation. 494 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. retention. After these experiments the limb, restored to its proper place, was held thereby the bandage described, under the head of the treatment for luxation of the clav- icle, under the name of the figure-of-eight from the elbow. By carrying the arm backward the head of the bone was naturally thrust forward, and this proved to be a perfect means of retention. Dislocation upward is a form that is not recognized as "regular." That it is possible there can be no doubt. The experiments detailed above show the possibility, and whatever can happen will sometimes do so. The marvel- lous protection of the joint in this direction, however, renders it almost impossible. W e know so little about it that no experience is of avail in the man- agement of such a luxation. But neither the diag- nosis nor the treat- ment would be likely to be diffi- cult. Dislocation o f the tendon of the biceps from the bicipital groove al- lows the head of the humerus to pass up higher than normal, and would present the appearance of luxation upward, but only in a slight degree. Symptoms.-Raising the arm is painful at the point of luxation, and by voluntary effort cannot be done. This, with the upward prominence of the head of the humerus, reveals the diagnosis. Treatment.-Flex the forearm, raise the arm from the side, and manipulate the tendons. Compound Luxation.-The treatment of these can hardly be a subject of much doubt. A suppurating joint is likely to recover, but it must be by permanent anchy- losis. The limb is exceedingly useful in this condition, in consequence of the mobility of the scapula, but the vast superiority of a " flail ''-joint at this articulation should not leave the surgeon in doubt of the propriety of resection. The danger of the operation is not greater, perhaps not so great, as that of suppuration of the joint. Luxation of the Elbow-joint.-This rather com- plicated joint is liable to luxations of a very considerable variety. But the most common one is that in which both the radius and the ulna are carried directly backward. The coronoid process of the ulna is lodged in the fossa for the reception of the olecranon, while the radius lies alongside of its fellow, retained in its normal relation by the annular ligament, but with its head resting upon the posterior surface of the humerus, near the edge of the fossa. The end of the humerus comes forward and rests upon the anterior surfaces of the two bones that enter into the formation of the forearm, thus making a very dis* tinct ball at the bend of the elbow, susceptible of being demonstrated even in a fleshy arm. The brachialis anticus becomes stretched over the head of the humerus, as around a pulley. The biceps lies in front, as a rule, though it has been known to have slipped behind the hu- merus. Symptoms.-The length of the wfliole arm is dimin- ished, and the forearm presents an angle of about one hundred and thirty degrees with the arm. It is also usually described as lying supine, but my own observa- tion concurs with that of Professor Hamilton, that pro- nation is the condition most constant; and I have seen a case in which a straight splint had been applied to the arm and forearm, so as to make the extension complete, which resulted in rendering the pronation extreme, and accompanied with a false anchylosis which prevented su- pination, even of the most moderate kind. The most into the glenoid cavity, is one of great difficulty. The usual custom has been to allow the parts to remain in situ, keeping the arm still, and waiting for union to take place between the broken bones, and then, at the end of four or five weeks, to attempt reduction. This also usu- ally fails, though it sometimes succeeds. If the efforts at reduction require much force, refracture of the bone is apt to result. A few cases are reported in which manipu- lations made directly upon the head, in the axilla, have resulted in its return to the glenoid cavity. In most cases, however, the bone remains unreduced. Where great suf- ering and inconvenience ensue, the head of the bone may be removed by dissection, and this with great benefit. But the following plan reported by Mr. Haines Walton has been known to succeed. The patient, aged forty-eight years, was seen ten weeks after the accident. For fear of reproducing fracture the following plan was adopted: ' ' The whole of the limb was most carefully padded from under the head of the humerus. A splint a yard in length was applied along the inner side of the limb, and another of the same di- mension along the outer side, the two being thoroughly fastened together by straps. A broad strap was then placed across the shoulder before and behind, and fas- tened in a line with the body, in order to restrain the scapula and the clavicle. A second and narrow strap was passed under the arm, so as to rest on the head of the humerus, to be acted upon by pulleys to draw up- ward and outward. The splints were used as a lever to ■carry the bone into the required position. Thus, no pulling was made on the bone, so that the fracture re- mained undisturbed, nor was there any lateral pressure on it, as the lever acted above it. After three quarters of an hour, unexpectedly, with a distinct noise, the reduction of the dislocation was effected." Recurring Luxation.-Luxations of the humerus are very apt to recur more readily than those of any other of the large joints. The absence of the cup upon the glen- oid surface readily accounts for this, especially as we are liable to have the capsule torn from the edge of the glenoid fossa. Even if the luxation does not immediately recur, it may happen within a few days as the result of some sudden contraction of the large muscles which draw the bone inward and downward. It is, therefore, espe- cially necessary to observe the rule of quiet, which is al- most the sole treatment necessary after reduction of luxa- tions, in order to allow the capsule and ligaments to become repaired at their torn surfaces, in as nearly a normal condition as can be gained. In order "to guard against recurrence of the dislocation it is wise to pad the axilla well, and then bind the arm to the side. These precautions should never be omitted, although they are not imperative. They need not be extended, ordinarily, beyond a period of ten days, when passive motion should be resorted to, to guard against the dangers of anchylosis. True anchylosis seldom occurs under these circumstances, unless there be suppuration ; but false anchylosis, of a very serious and protracted nature, will often occur when these precautions are not taken. In the after-treatment of sub-spinous luxation we cannot rely upon the pad in the axilla, with the humerus against the side and the forearm against the chest. The recumbent position favors the re- curring luxation in this sub-spinous form. The writer has recently restored a luxation of this kind after it had remained unreduced for a month. It had been in the hands of a very competent young surgeon, who had un- doubtedly replaced it and then secured it after the plan described for luxations of the shoulder in general. After the luxation had been reduced by the method of manipula- tion described above, the humerus was carried against the side, and the forearm brought across the abdomen, in order to retain the parts in situ; but the moment the forearm was brought down against the surface of the body, the luxation recurred. The reduction and the re- dislocation were several times executed on the spot, in order to obtain a clear understanding of the case ; and in this way the conviction was reached that, after the dis- location had been restored by the surgeon in the first place, it was reluxated by the very plan he adopted for its Fig. 841.-Luxation of the Biceps Tendon. 495 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. prominent symptom, however, of this luxation, is the projection of the olecranon backward when the forearm makes with the arm the angle above indicated. This symptom is presented in almost if not quite the same degree in the epiphyseal fracture at the lower end of the humerus, and one has need to exercise a good deal of care with reference to the diagnosis, when the patient is in the age before the ossification of the epiphysis takes place. When the condyles can be defined, the diagnosis may be rendered reasonably sure by measuring the dis- tances between them and the end of the olecranon behind, and between them and the styloid process of the ulna in front. Nevertheless, reputable surgeonshave often over- looked the nature of the injury. Causes.-These are usually falls upon the hand, with the forearm a little flexed ; but a twisting motion, as when the forearm is caught in machinery, is a frequent cause. Diagnosis.-The injuries with which this luxation is apt to be confounded maybe merely bruises or sprains of the joint, or what is more likely, fractures. The distinc- tion between the luxation and sprain is not very difficult to make out, if we insist upon carrying the joint through its normal motions. Rotation, supination, and prona- tion can be easily effected, even during luxation, but the forearm cannot be carried up beyond a right angle. On the other hand, a sprain will readily allow this to be done, although it may be accompanied with some suffer- ing. In fractures we are liable to error for various rea- sons. If the humerus becomes split the coronoid process can pass directly backward, and thus simulate a luxation, without that rupture of the capsule which is its charac- teristic. We will also find the symptoms very similar to those of luxation where there is a transverse fracture very low down. These cases, how- ever, are not ordinarily very puzzling, for the easy reduction of the defor- mity, accompanied with the marked crepitus of fracture, in the adult, usu- ally relieves all doubts with reference to the diagnosis. But the most obscure complication occurs from the separa- tion of the epiphysis, which has al- ready been alluded to. The line which divides this from the diaphysis runs so closely parallel to the joint, that when a separation takes place through this line, the symptoms, in all respects, as far as position is concerned, are those of true luxation of both bones back- ward. Moreover, the absence of harsh crepitus in all epiphyseal fractures still further complicates the diagnosis, and I am quite sure that mistakes of diag- nosis in these cases are constantly made. The parts are brought into their proper position with ease, but if they are not properly retained the deformity soon re- curs. It has been the experience of the writer to be called upon to rectify errors of this kind on five different occa- sions, after a lapse of time sufficiently great for union to have taken place with the bones in wTrong position. Per- haps these errors are often made and never discovered if the proper position after reduction of a true luxation be maintained during the period of a fortnight ; for this will not only restore, but retain, the fractured surfaces in their proper relation perhaps sufficiently long to prevent them from being disturbed, except by some excessive use. Treatment.-The restoration of this luxation is one, ordinarily, easy to perform, if the attempt is made shortly after the injury has been received. Simple traction upon the forearm is usually competent to draw the surfaces to- gether. The method laid down by Sir Astley Cooper, of placing the knee of the surgeon against the front of the humerus of the patient, and making traction from the forearm while it is at right angles with the arm, gener- ally succeeds. However, this facility of reducing the dis- location is not always experienced, for restoration is some- times not only difficult, but even impossible, from the first moment. The ease with which a displacement may be overcome diminishes very rapidly as time goes on. At the end of four weeks it is usually very difficult to re- duce a dislocation, and at the end of eight wreeks almost impossible. The writer has succeeded in two cases at seven weeks, but not until after very strenuous efforts, which will be presently described. Having failed by the two plans above mentioned, we should have recourse to more power. This can be applied by the use of a band put upon the forearm above the wrist for the purpose of extension, while another one is car- ried around the humerus, just above the elbow, for the purpose of counter-extension. This makes the rectangu- lar traction the one most convenient of application. More- over, we relax the muscle that is subjected to the most severe tension, namely, the brachialis anticus. It is true, we place the powerful triceps upon the stretch, and this, too, at a time when it has had its leverage increased. Nevertheless, the tension of the triceps is not excessive, though it seems to exert the chief force that stands in the way of a successful reduction. It unfortunately happens that, in placing the arm in this position, we have the coronoid process acting as a hook over the end of the humerus. The obstruction afforded by the triceps is shown by the fact that if we persist in carry- ing the forearm upward, it is liable to fracture the ole- cranon, and even the shafts of the radius or the ulna. If we fail in the reduction, success can sometimes be at- tained by subcutaneous division of the triceps. There is, however, another method, entirely different from the one above described, which has been brought forward by Dr. Waterman, of New England, and which reverses the lines of traction. It consists in drawing the forearm directly backward, instead of forward, carrying it farther back than can be done in the normal arm. The surgeon, grasping the humerus with one hand, and the forearm with the other, places his knee directly against the end of the olecranon ; then, drawing the forearm backward be- yond the straight line, the pressure drives the extremity down into the fossa for the olecranon, while by the same motion the coronoid process is lifted out of it and carried beyond the end of the humerus ; still holding with one hand upon the humerus, and firmly pressing the knee against the olecranon, he transfers the forearm to an as sistant, who suddenly flexes it. The restoration is imme- diately recognized by the ability to carry the forearm up to an acute angle with the humerus, and to place the hand on the neck while the body is erect. I have alluded above to the restoration of two cases, each of seven weeks' standing. I had exhausted upon them, by the aid of pulleys, all the power that I thought prudent to em- ploy ; my efforts being continued through a period of an hour and a half. By this process I have no doubt that the adhesions were thoroughly disrupted, but still the joint was not replaced. In both cases, after the failure by this plan, the clove hitch and counter-extending bands were thrown aside, and Waterman's method was success- fully applied. A considerable stiffness followed the res- toration, as the result of inflammatory process, but after some months the use of the arm was quite good, if not perfect. After-treatment.-When reduction has been effected, the forearm should be placed at right angles to the arm, and kept in this position for a period of ten days or a fort- night, when passive motion should be employed, and moderate use can be allowed. To attain this end, the writer has never thought it necessary to use anything more firm than a sling ; but in an unruly person, or a careless child, a rectangular splint would be safer. Long continuance, however, of the use of a splint might pro- duce a condition of false anchylosis. Recurring Luxation.-The literature with reference to recurring luxation of the elbow-joint is extremely meagre. This, perhaps, arises from the fact that the rule of placing the forearm at right angles to the arm, after reduction of the luxation, has been very generally fol- lowed. But this has not always been done, and it some- times happens that, in consequence of other injuries, the patient is under the necessity of taking the recumbent Fig. 842.-Dislocation of Radius Backward. 496 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. posture. The surgeon is then tempted to place the arm upon a pillow by the side of the patient, especially if there be much swelling. The forces that control the posi- tion of the forearm will naturally, through the action of the triceps, carry the forearm down so that it will occupy a semi-flexed position at about an angle of one hundred and thirty-five degrees. The writer is firmly convinced that, without any fracture of the coronoid process, a reluxation will often readily occur under such circumstances. The laceration of ligaments, which takes place in a complete luxation of this joint, will be sufficient to allow the coronoid process to drop down far enough to allow it to pass over the trochlea. This has occurred in the practice of a friend of the writer ; the patient having occupied a lounge during the night after the reduction of the luxa- tion, and having allowed the arm to rest upon a pillow in a chair by his side. The surgeon, upon making his morn- ing visit, ascertained that the luxation had recurred. It was replaced and retained in the rectangular position by a splint. No further displacement was experienced. The writer is also firmly convinced that this occurred in an- other case, in which, unfortunately, it was not recognized until too late, and which became the cause of protracted litigation. On one occasion, after reducing a luxation of this kind, and carrying the forearm up to an acute angle, so as to bring the point of the middle-finger to the shoulder of the affected side, the writer moved it down to an angle of one hundred and thirty-five degrees. Then, while he was holding the arm with the forearm slightly supinated, it became luxated as soon as it was allowed to fall beyond this point. He will also say that on another occasion this experiment failed. Dislocation of Both Bones Backward and Out- ward.-This luxation, fortunately very rare, differs from the one just described, though it may easily be confounded with it. The diagnosis between the two is largely to be made out by studying the outlines of the olecranon upon the side of the elbow; it must be confessed, however, that the relations very closely approximate those which exist in the luxation before described. The forearm is pronated, and the motions of supination are very much interfered with. The reduction is to be made in precisely the same way as in the other cases. The experiments upon the cadaver, which are here de- tailed, illustrate the positions which are taken by the bones when a dislocation recurs. The importance of the sub- ject is our justification for inserting the account of them in this place. Experiment 1. The muscles from the arm and fore- arm were entirely removed, and the ligaments left in place. The humerus being firmly held by staples to a strong block of wood, a lever was applied to the hand so as to bring pressure to bear in the line of the radius and ulna, with these bones forming an angle of one hundred and thirty-five degrees with the humerus. The lever was a strong bar of iron, four feet long, while the distance be- tween the attachment of the bone and the fulcrum was six inches. The pressure was maintained very nearly at this angle, though the swing of the lever altered it a little, and the flexion was slightly increased as the pressure was in- creased. Notwithstanding the use of this great power, the whole strength of a powerful young man being applied, the joint remained in its position until the head of the radius began to crumble, when a slight side movement caused the anterior ligament to suddenly yield, and both bones were carried backward. The attachment of the an- terior ligament gave way at its insertion in the coronoid process. A small scale of bone followed the capsule, but the point -of the coronoid process, or, as I may say, the process proper, was not carried away, although a line of fracture was to be observed running horizontally through the cartilage, but not displacing or running through the coronoid process. It will be remembered that the liga- ment is inserted below the tip of the coronoid process. In this case the radius seemed to leave its proper place first. Experiment 2. The opposite arm of the same subject was denuded of its muscles, and the humerus secured in the same position, with a similar arrangement of the lever and hand. The same force was applied, and when a slight leaning toward the ulnar side was made, the ulna left its place first; at the same time the anterior ligament suddenly gave way, carrying a scale of bone below the point of the coronoid process, and the dislocation was com- plete. In this case there was no fracture of the coronoid process at all; it remained entire. Neither1 the lateral ligaments nor the posterior portions of the capsules were injured. In both of these cases, when the radius and ulna, which of course represent the forearm, were carried down to the angle of one hundred and thirty-five degrees, it was found that the articulating surfaces would drop away from each other ; but when the forearm was carried up to the right angle, the joint was obviously held in its place by the tension of the lateral ligaments and the pos- terior capsule. It furnished, indeed, an excellent demonstration of the fa- cility with which a luxation may re- cur when the arm is placed at this angle upon the pillow, and also of the complete assurance that we may have of its remaining in its place when kept at the right angle. Experiment 3. The elbow was de- nuded of the integuments to a distance of three inches above and below, for the purpose of keeping the tissues under observation during the progress of the experiment. The arm was held upon the table, the elbow being carried just over its edge. The forearm was now used as a lever, and the force was applied so as to put a strain upon the joint in a direct line backward. As in the other experiments, it was found that the an- terior ligament yielded so as to allow the forearm to be carried backward ; and also, as in the other experiments already detailed, a scale of bone was carried away with the ligament, but the tip of the coronoid process remained uninjured. Dislocations of Both Bones of the Forearm at the Elbow Inward.-As modifications of dislocations of both bones backward, we find them occupying positions both on the inner and on the outer side of that which has been de- scribed above as direct. These, although classified by writers on surgery as being regular, are really not carried to certain exact points which define accurately their position. Some are barely moved from the direct line backward, while others are carried well over on the condyles. Fortu- nately these luxations toward the in- ner and the outer sides of both bones are rare. They are apt to be produced by a powerful lateral force. The symptoms of these displacements are to be determined by careful measure- ment of the salient points about the elbow. The symptoms have conditions similar to those of dislocation of both bones directly backward. When disloca- tion occurs outward there is flexion of the forearm accompanied with extreme pro- nation. When dislocation occurs inward the sigmoid cavity of the ulna becomes fittefl to the condyle, and consequently the ole- cranon does not project as much backward (although it is salient) as in the direct dis- location. The position of the forearm is, however, semi- flexed, and occupies the position between pronation and supination, as is found in the direct dislocation backward. Treatment.-Of this, as well as of the after-treatment, nothing need be added to what has been said above with reference to the treatment of dislocation of both bones di- rectly backward. Fig. 843.-Dislocation of both Radius and Ulna outward. Fig. 844.-Disloca- tion, both Radius and Ulna inward. 497 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations of the Head of the Radius Fok- Ward.-Of these very few cases have been reported, al- though a few have always fallen under the observation of surgeons in large practice. Causes.-A direct blow upon the side of the elbow is probably the chief one, but powerful wrenches, with ex- treme pronation of the forearm, will some- times produce them. The anatomical con- ditions are found to be a movement of the head of the radius forward upon the hu- merus, and generally a little outward. The anterior and external lateral liga- ments are usually torn, but the annular sometimes remains entire and sometimes is ruptured. Symptoms.-Even in a fleshy arm the head of the radius can usually be defined by rotating the forearm. The forearm is pronated moderately, but the most marked symptom consists in the fact, that the fore- arm cannot be flexed upon the arm beyond the right angle in consequence of the abutting of the head of the radius against the anterior sur- face of the humerus. Extreme extension is also painful. Treatment.-The reduction of this luxation is extremely difficult; indeed, such slight success has followed the ef- forts to effect a reduction that it is not easy to prescribe any formula for the purpose. It has been the usual cus- tom to employ extension of the fore- arm with counter-extension ; the arm and forearm not being placed at right angles with each other, but the fore- arm being carried downward in a line with the arm while the surgeon presses the head of the radius into its place. Dislocation of the Head of the Radius Backward.-Cases of this variety are still more rare than those of dislocation forward. They are caused, also, by direct blows impinged upon the front and upper part of the radius, as well as by wrenching and twisting motions. The diagnosis can easily be made by discovering the head of the radius lying behind the outer condyles. While the forearm may still be rotated, supination is im- possible, and much motion in any direction is difficult. Treatment.-The cases are too rare to justify me in stating from experience any form of treatment that has been successfully followed. The usual recommendation is to extend the forearm from the wrist while in a state of supination. Dislocation of the Ulna Back- ward.-Dislocation of the ulna back- ward has been reported as occurring a few times. It can be recognized by the projection of the olecranon, and by the absence of the head of the radius upon the posterior part of the humerus. The treatment already detailed as proper for the relief of dislocation of both bones backward is to be applied in these cases. Dislocation of Both Radius and Ulna Forward.-Remarkable as it may seem, instances are known of the ligaments having been so rup- tured as to allow the olecranon to be carried forward and lodged against the end of the humerus. Such cases are said to have occurred as the result of a blow impinged upon the olecranon in a direct line with the axis of the ulna. The treatment is by a little, extension and pressure upon the anterior surface of the forearm at its upper extremity. A case of dislocation of the ulna forward, at the elbow, without fracture of the olecranon process, which was examined after amputation by Mr. Cauton, of Dublin, explains the nature of this kind of injury. A man, forty years of age, driving a light cart, was thrown out, the right hand being extended to prevent an injury to his head. The weight of his body caused a sudden and forcible flexion of the elbow, and at the same time the forearm became twisted in under the chest. The injury resulting in a slough, amputation was made. The dis- section showed the ulna to have been dislocated forward in such a manner that the upper surface had come to lie in front of the capitellum humeri, and had thus assumed the position naturally occupied by the head of the radius during flexion of the forearm. The radius was supinated and maintained in situ, as regards the ulna, by the coron- ary and interosseous ligaments, which remained intact. Of the anterior ligament the only part at all remaining perfect was a shreddy portion about the centre ; all the rest of it had been torn through. The posterior and both lateral ligaments w'ere completely divided ; the coronary and oblique ligaments were uninjured. The triceps ex- tensor was detached from all its points of insertion. The supinator radii longus was not interfered with at its origin, but the two radial extensors of the carpus beneath it were torn away from the surfaces whence they spring. All the muscles which arise from the external condyle, with the exception of the supinator radii brevis and anconeus were detached from this process. The only muscle that was torn through at its origin was the flexor carpi ulnaris ; the olecranon and ulnar portions of it, however, continued intact. No injury whatever had happened to the prona- tors and flexors. The biceps and brachialis anticus were put greatly on the stretch. No large blood-vessel was in- jured, though the infiltration of blood was great. The ulnar nerve was torn across where it passes behind the inner condyle. The sheath of the median was distended, and its substance permeated with blood. The other nerves were uninjured. Besides all these varieties we may have luxations of the radius forward and of the ulna backward, and exactly the opposite ; there may also be luxation of the ulna inward, and of the radius outward, and the opposite, but these are so rare and ill-defined that they may be classed as irregular and receive no special notice. Compound Luxation of the Elbow.-There can be no question of the propriety of resection of the joint in all these cases. Amputation is not called for, and resec- tion of this joint produces such an admirable substitute for the natural joint, that it is much to be preferred to anchylosis. Dislocation of the Wrist.-This is, perhaps, rarer than any other luxation in the human body. For a long time it was thought to -be common, but the observa- tions of modern surgeons have entirely overturned this opinion. Yet the appearance assumed by a fracture of the lower end of the radius still convinces the inexperienced that a luxation of the wrist has taken place. Fractures of the lower end of the radius, that occur within an inch, one- half inch, or even less, of the carpal articulation, and that have been produced by a fall upon the hand, will force the wrist and hand backward, and the line is so close to the joint as to produce a displacement which has been very naturally mistaken for a luxation of the carpus itself. Although surgeons of the largest experience con- stantly proclaim that during a long life they have never seen a dislocation of the carpus, still a sufficient num- ber of cases have been reported to show that it does oc- cur ; and, moreover, what is possible will occasionally happen. Compound luxations of the wrist are more often seen than simple ones, which may be said to reverse all experience in luxations elsewhere. This may be ac- counted for by the fact that the hand is exposed to violent injuries from machinery and other causes of a violent nature. When a simple luxation does occur, the dis- placement is greater and more abrupt than in the fracture of the radius, and the diagnosis can readily be made out between the two conditions by careful observation of the styloid process of the radius. It is obvious that in luxa- Fig. 845.-Disloca- tion of the Head of the Radius for- ward. Fig. 846.-Dislocation of the Ulna backward without the Radius. Fig. 847.-Dislocation of both bones backward. 498 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. tion of the wrist backward, the carpal bones will be be- hind the end of the radius, the styloid process being well forward. But in the case of Colles' fracture the process of the radius will be elevated. The causes of luxation backward have been supposed to be similar to those of fracture by a fall on the palm of the hand. But a single case, reported by Dr. Hamilton, would seem to show that the opposite force was the cause. This case is an exceed- ingly interesting one: A gentleman, seventy-five years of age, is reported as receiving a fall while his hand was closed, grasping his satchel, which caused the force to be impinged upon the back of the hand. Dr. Hamilton first regarded it as a fracture, but changed his mind upon closer examination, the palmar surface of the wrist presenting an abrupt rising near the radio-carpal articula- tion, the summit of which was on the same plane and oontinuous with the bones of the forearm. A correspond- ing elevation existed upon the dorsal surface, terminating in the carpal bones and the hand. The hand was slightly turned backward, but the fingers were moderately flexed upon the palm. The projections upon the palmar and dorsal surfaces were more abrupt than in a fracture. By observing the styloid apophyses in their relation to the palmar and dorsal eminences, it was easy to see that these latter corresponded to the line of the articulation. The reduction was secured by extension, the bones suddenly resuming their places with the soundsand sensations pro- duced when a joint is returned to its proper position. Sixteen months afterward the arm was found perfect in all respects. It is found, in these luxations, that the capsule is torn upon the posterior sur- face, and the lateral ligaments are also ruptured. Dislocation of the Car- pus Forward.-Of this very little is known. A case, of which the accompanying cut is a representation, is taken from a report by Erichsen. It is ob- vious that this injury could hardly be mistaken for any other. No case, proved by dis- section, has thus far, to my knowledge, been brought for- ward. The case of a boy, thirteen years of age, has been reported by Mr. Haydon, of London, and quoted by differ- ent writers, but there may be a question of the correctness of the observation ; for at this age an epiphyseal fracture, which is far more likely to occur, might easily be mistaken for it, and, if restored to its po- sition, it would have the perfection of replacement which would be expected in the reduction of a true luxation. Dislocation of the Lower End of the Ulna Back- ward.-This luxation is rare, but has been known to occur as the result of the forcible use of the muscles, and from dragging at the hands of children. It consists in a rupture of the triangular fi bro-cartilage and the internal lateral ligament. A direct blow may also produce the result. The extremity of the ulna is easily perceived to be movable, so that the diagnosis is not difficult. There is difficulty in pronation and supination, the parts being in the most comfortable position when they are midway between the two extremes. The reduction is accomplished by manipulation, pressing the end of the bone into its place while extension and counter-extension are employed. Dislocation of the Lower End of the Ulna For- ward.-This is still more rare than that backward, and occurs as the result of violent muscular exertion, and also of direct force upon the posterior surface of the ulna. The end of the bone is to be felt upon the anterior surface of the forearm near the wrist, while in a state of extreme supination. The reduction is effected by forcible exten- sion, while the surgeon presses the head back into its place. In the dislocations, both backward and forward, that have just been detailed, while luxation may not recur even when no dressings are applied, it is far safer to keep the parts still, by the aid of a splint, for the period of a fortnight. But while luxations of the lower end of the ulna are ex- ceedingly rare when uncomplicated with any other in- Sof the forearm or wrist-joint, the dislocation of the of the ulna forward is, in my judgment, the most com- mon of all luxations, these occurring in connection with fractures of the radius at its lower extremity. I know that this opinion is not one accepted by the profession at large, but my own convictions are so strong that I un- hesitatingly assert that more than one- half, probably two-thirds, of all the cases of fracture of the radius within an inch of the wrist-joint are accom- panied with luxation of the ulna for- ward, and for the reason that the broken bone which is articulated with the hand is carried backward, taking the hand with it. The exact charac- ter of the luxation, or, if I may use the phrase, its extent, will depend upon the amount of force that has produced the fracture antecedent to the luxation. Of course, this vio- lence is always an irregular quantity. The fall comes upon the palm of the hand, and the radius, which sustains the full force of the strain, gives way at a point near the wrist. The line of fracture is usually an oblique one, starting from a point on the anterior aspect of the radius, near the articulation, and running backward and up- ward, making the posterior surface of the lower frag- ment longer than the anterior. It is seldom more than an inch from the joint, and rarely even so far removed as this. But the line of fracture is very variable in charac- ter, being sometimes simple and nearly transverse, but often comminuted to the last degree. The luxation of the ulna exists in more than half of the cases. I now feel quite sure, though I cannot demonstrate it by dissection, that a proper observation of the relation of the head of the ulna to the carpus will enable one to arrive at a just conclusion in regard to its luxation or non-luxation. The force of the fall may be just balanced by the strength of the radius, but in the nature of such accidents this would not often be the case. In most of them there 'would be some force still to be borne. Upon what struct- ures does this fall ? The radius instantly, on fracture, ceases to afford resistance, the hand is carried still further back, and then comes the strain on the attachments at the end of the ulna. It will be remembered that the ulna does not articulate with the wrist, but there is a distinct synovial cavity between its head and a strong membrane called the triangular fibro-cartilage. The membrane takes its origin from the rim and side of the radius, and, cover- ing the head of the ulna, is inserted into the pit at the root of the styloid process. The rupture takes place at the weakest point, which is its point of inser- tion in this pit at the root of the styloid process. But this is not the only resistance. The styloid process is held to the carpus by the internal lateral ligament, which takes a very firm hold upon the end and radial surface of the sty- loid. This also gives way, and usu- ally does so in a peculiar manner, viz., by pulling off the surface of the bone, ■which proves to be weaker than the ligament. Thus the re- maining styloid is often brought to an edge like a gouge-chisel, and is shortened about one-half. When these resisting forces are disposed of, the end of the ulna, now laid bare, is pressed against the posterior annular ligament, and is apt Fig. 849.- 1, Styloid Process, shortened by fracture: 2, tags of triangular flbro-carti- lage at the root of the styloid ; 3, smooth ar- ticulating surface at the end of the ulna. Fig. 850.-1, End of Ulna, sawed surface; 2, crust of eburnated bone. Fig. 848. Fig. 851.-1, Styloid Pro- cess, short and smooth, rounded by time ; 2, tags of membrane attached to and obliterating articular surface ; 3, crust of ebur- nated bone. 499 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to become engaged upon it either by a fold, or, what is more likely, by splitting its fibres and hooking upon it. If very great violence has been used in the production of these lesions, the head of the ulna will be driven forward through the annular ligament and skin, thus producing a compound luxation. These compound luxations have been noted at times, but have been considered irregular ; they are, of course, the results of severe forces. Figs. 850 and 851 represent different views of the ex- cised end of the ulna of a man, who, sixteen years previ- ously had dislocated his wrist. This specimen of an old luxation will be seen to pre- sent a very extraordinary appearance. The shaft of the ulna is apparently normal, but the side and part of the end are in as hard and polished a condition as if this part of the bone were made of ivory. The extremity of the ulna exhibits, instead of a smooth articulating surface, a rough one, made up of ruptured tags of cicatricial tissue. There can be but one inference from this case. We have, by the complete disappearance of the articulating surface, unmistakable proof of antecedent luxation. The eburnation also shows the effect of long friction upon the side of the head of the ulna, the result of the severe and protracted labor of a farmer's life. Below is another case, with description of the autopsy. Morris Huntington, aged fifty-six, a painter, fell from the roof of a three-story house, through a tree, to the side- walk. He was at once taken to the City Hospital, but only lived a few hours. A fracture of the wrist was ob- served, but he was so nearly moribund that it was not in- terfered with. I was invited, by the kindness of the staff, to make the autopsy. This was done by simply removing the skin from the posterior surface and sides of the wrist, thus exposing at once the annular ligament. The end of the chisel- shaped fragment of the styloid process protrud- ed through a rent in the ligament. This condi- tion of the parts was verified by Drs. Whit- beck, Montgomery, Lit- tle, Langworthy, Ely, Mallory, and others. The next move in the dissection was the removal of the skin on the anterior aspect of the arm, and the division of the muscles and tendons down to the bones. These were then lifted up just far enough to expose to view the end of the ulna. The triangular fibre-cartilage was found to be torn out at the pit of the styloid process, and the internal lateral ligament torn off with the end of the styloid, as in the other cases. This case would probably have been compound, but for the relief obtained by a fracture of the ulna, three inches above the joint. A belief in the existence of a luxation of this kind was entertained by Sir Astley Cooper, but it is obvious that he regarded the occurrence of the accident as not nearly as frequent as has been expressed above. The descrip- tion of the luxation, however, has never been made be- fore, so far as the writer knows. The limits of this paper will not permit me to bring forward any further evidence of the correctness of the views expressed, and it must be admitted that the diag- nosis cannot be made with the same degree of precision as in many other luxations in consequence of the presence of the fracture of the radius. I find, in what I deem to be cases of luxation, a mobility of the end of the ulna which is incompatible with the in- tegrity of the ligamentous apparatus. As regards the form of the wrist, every observer has recognized a differ- e n c e in different cases. Some are curved backward- the genuine silver- fork shape ; others have the hand car- ried more laterally. My convictions are, that those that present the wrist well curved back are more apt to be those of luxation of the ulna, with fract- ure ; but the lateral bend implies generally shortening of the radi- us from fracture, with- out luxation of the ulna. When fracture of the end of the styloid process occurs, it is, in the opinion of the writ- er, the evidence of luxation, it being in reality a rupture of the ligament, which tears off the portion of bone to which it is attached instead of parting in its own sub- stance. Professor Stokes, of Dublin, reports thirty-two cases of the fracture known as Colles', preserved in the College Museum, in which sixteen were accompanied with fracture of the styloid process of the ulna. Treatment.-Much force is often necessary to restore the luxation, which may usually be effected by seizing the hand of the patient with one hand and his forearm with the other, while the ul- na is pressed up into its place by drawing it against the sur- geon's knee. The af- ter-treatment must be carefully carried out, for otherwise luxation is likely to recur immediately in cases of oblique or comminuted fracture of the radius, apparently in consequence of the traction of the muscles of the arm. When the dislocation is reduced, the fracture will also be brought into place. The thumb of the surgeon should be firmly pressed under the ulna, while the fingers of the same hand hold down the wrist, and these forces must not be withdrawn for an instant until suitable dressings have been applied. These should be very simple. First, a simple roller, from half to three-fourths of an inch in diameter and two inches long, is to be carefully placed under the ulna, abutting against the pisiform bone and slowly displacing the thumb. Then a strip of ad- hesive plaster of the same width is drawn, with as much force as it will bear, around the wrist, and pinned fast, in order to prevent reluxation. The band of plastered cloth is carefully adjusted, so that the distal edge is brought around on a line with the end of the radius. It is mani- fest that this bandage will grasp the broken fragment, and hold it to the end of the ulna. The rule, of first ap- plying a loose dressing, is distinctly violated for a pur- pose. I repeat that I draw the band as firmly as I can, often breaking the plaster cloth. The dressing is entirely as in many other luxations in consequence of the presence of the fracture of the radius. I find, in what I deem to be cases of luxation, a mobility of the end of the ulna which is incompatible with the in- tegrity of the ligamentous apparatus. As regards the form of the wrist, every observer has recognized a differ- e n c e in different cases. Some are curved backward- the genuine silver- fork shape ; others have the hand car- ried more laterally. My convictions are, that those that present the wrist well curved back are more apt to be those of luxation of the ulna, with fract- ure ; but the lateral bend implies generally shortening of the radi- us from fracture, with- out luxation of the ulna. When fracture of the end of the styloid process occurs, it is, in the opinion of the writ- er, the evidence of luxation, it being in reality a rupture of the ligament, which tears off the portion of bone to which it is attached instead of parting in its own sub- stance. Professor Stokes, of Dublin, reports thirty-two cases of the fracture known as Colles', preserved in the College Museum, in which sixteen were accompanied with fracture of the styloid process of the ulna. Treatment.-Much force is often necessary to restore the luxation, which may usually be effected by seizing the hand of the patient with one hand and his forearm with the other, while the ul- na is pressed up into its place by drawing it against the sur- geon's knee. The af- ter-treatment must be carefully carried out, for otherwise luxation is likely to recur immediately in cases of oblique or comminuted fracture of the radius, apparently in consequence of the traction of the muscles of the arm. When the dislocation is reduced, the fracture will also be brought into place. The thumb of the surgeon should be firmly pressed under the ulna, while the fingers of the same hand hold down the wrist, and these forces must not be withdrawn for an instant until suitable dressings have been applied. These should be very simple. First, a simple roller, from half to three-fourths of an inch in diameter and two inches long, is to be carefully placed under the ulna, abutting against the pisiform bone and slowly displacing the thumb. Then a strip of ad- hesive plaster of the same width is drawn, with as much force as it will bear, around the wrist, and pinned fast, in order to prevent reluxation. The band of plastered cloth is carefully adjusted, so that the distal edge is brought around on a line with the end of the radius. It is mani- fest that this bandage will grasp the broken fragment, and hold it to the end of the ulna. The rule, of first ap- plying a loose dressing, is distinctly violated for a pur- pose. I repeat that I draw the band as firmly as I can, often breaking the plaster cloth. The dressing is entirely Fig. 853.-Anterior Aspect of Wrist. 1, Tag of the triangular flbro-cartilage, un- usually long ; 2, articulating surface of the head of the ulna; H, base of hand. Fig. 854.-Cylindrical Compress, two inches long and half an inch thick. Fig. 852.-Posterior Aspect of Wrist. 1, Wrist-joint; 2, comminuted fragments of the end of the radius; 3, shaft of the radius; 4, styloid process of ulna, pricking through the annular ligament; H, base of hand. Fig. 855.-Compress, with Ad- hesive Strap applied. 500 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. completed by the use of a sling which must not be more than three inches wide. This must be placed over the roller, and is made of this width to cause the whole bear- ing to come on the roller, which is both compress and splint. The hand is brought down and allowed to hang naturally. Thus its weight and that of the forearm are used to press the ulna up- ward into its proper place. If all this is success- fully accomplished, the broken fragments of the radius will easily remain in place. The full length of the arm is maintained if the ulna does not fall down, and the tendons that run over the back of the wrist are so closely parallel as to make the best possible splint. I do not commit so gross a violation of the pri- mary rule in dressing fractures, as to retain the bandage indefi- nitely in its tight con- dition ; but, after six hours, I cut it by thrusting one blade of a pair of scis- sors under it on the back of the wrist,, dividing it com- pletely. The few hours of such retention seem to be sufficient. The simplicity of the appliance has startled some who have attempted its use. But I have found that any additions that I have made have detracted from its value. There is a strong disposition on the part of the pa- tient to lift up the hand with the sound one. With unintelligent patients this is often troublesome, and a splint of iron, thin, such as hoop-iron, bent so as to come over the back of the wrist and hand, and bound upon the forearm but not upon the hand, will guard against this error. I am careful not to bind the hand to it, for I de- sire the constant action of gravity. The position can be maintained even in the recumbent posture. The slight motion in the joint which will necessarily be produced by allowing it to hang freely, prevents the stiffness that is so often a very serious inconvenience after the treatment of this fracture. Compound Luxations of the Wrist.-These are ac- companied by violent and extensive suppuration of the articulations of the bones of the carpus, many of which are likely to necrose. It is obviously better to remove the scaphoid, and semi- lunar, and perhaps the cuneiform bones, than to allow them to remain and by their presence increase the tension and accompanying pain. There is some prospect of a little motion if the space is wide enough to allow the for- mation of considerable cicatricial tissue. Dislocations of the Carpal Bones.-Little is to be said with reference to these luxations. The bones are so different from the long ones, and are held together by such firm ligamentous apparatus, that luxation and fract- ure are both of rare occurrence ; a force impinged upon any one of them is apt, through the ligamentous appa- ratus, to be distributed through them all. Indeed, it is often found, when fracture occurs, that one portion remains in place, attached to its ligaments, while the other be- comes dislocated. The diagnosis is not difficult, in con- sequence of the marked deformity and the superficial position of the bone. The enlargements which take place upon the tendons, and which are known as ganglia, are constantly misinterpreted by the uninformed for luxa- tions, but a surgeon of any experience can hardly commit such an error of diagnosis. Causes.-No known special direction of force will ac- count for these luxations, except that of a direct blow inflicted with an object of small surface. Treatment.-The bones, if restored at all, must be moulded into place by the pressure of the thumbs upon them, aided by extension of the fingers by an assistant, the surgeon employing the fingers of his two hands in grasping the sides of the wrist so as to produce in the wrist a motion which may alternately open and close the cavity from which the dislocated bone has emerged; constant pressure, as said above, being maintained with the thumbs. A compress and bandage will easily retain the dislocated part in its place. Dislocations of the Metacarpal Bones ; Thumb. -This bone may be dislocated either backward or for- ward, and indeed, it has been carried both inWard and outward. The diagnosis is not difficult, for the parts are so superficial that a comparison can be easily made. When dislocated backward, the direction of the metacar- pal bone is forward to the palm of the hand. The trape- zium can be felt and is unusually prominent. Causes.-The causes are falls on the back of the thumb, forcing it into extreme flexion, so as to wrench it out of its articulating surface. A direct blow would, of course, produce the same result. Treatment.-The reduction can be produced by exten- sion, and a slight rocking motion accompanied with press- ure on the metacarpal bone. But the formation of the joint is not conducive to the retention of the bone after reduction, and a splint should be applied and maintained for a period of a fortnight. For this purpose a plaster- of-Paris or starch bandage, or a gutta-percha splint, should have the preference. Besides the complete luxations of this character, we have those which are incomplete, but which should be treated in the same manner, in order to get a close union of the torn ligaments. Dislocation of the same Bone Forward.-This is recognized by a protuberance upon the palm of the hand, while the thumb is bent backward. This is extremely rare, having been very seldom seen. The treatment is again by extension and manipulation, while the after- treatment is the same as in the luxation backward. No special mention of the lateral dislocation is neces- sary. Dislocation of the Metacarpal Bones of the Fingers from the Carpus.-These are exceedingly rare, and seem to be produced by violent blows impinged directly upon the special bones. They can be carried either backward or forward, and the superficial position of the bones renders the diagnosis very easy. The end of the bone can be easily defined, and it resembles no other injury. Treatment.-The reduction is to be effected in the man- ner just described for replacing displaced bones of the carpus. Dislocation of the Phalanges : Thumb.-Dislocation of first phalanx of the thumb may be either backward or Fig. 856.-Dressing Complete, with Sling three inches wide. forward. When carried forward it is by a violent direct blow, which has been impinged on the back of the pha- lanx. The diagnosis is simple, for the proximate end of the phalanx projects forward and the metacarpal bone backward. Treatment.-This is effected, in the few cases that have been reported, with ease, by means of extension. When restored, the tendency to recurring luxation is not very great. When the phalanx is thrown backward, it is re- cognized by its projection behind the head of the meta- carpal bone, which results in a moderate flexion of the thumb. The causes of this luxation are usually falls upon the palmar surface of the thumb. The constant expos- Fig. 857.-Dislocation of Phalanx of the Thumb Backward. 501 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ure of the thumb in this position will undoubtedly ex- plain the greater frequency of this luxation when com- pared with that of the one forward. There are, in my opinion, two different conditions of the joint in this lux- ation, a circumstance which will account for the great difficulty, and even impossibility, of reducing it in some cases, while but little difficulty is met with in others. The phalanx can be forced backward and the cap- sule ruptured, with the head of the bone pass- ing through it, and yet both the tendons of the flexor longus and brevis may lie in front of the head of the metacarpal bone. The insertion of the flexor brevis is down close to the proximal extremity of the phalanx, and, in- deed, becomes incorporated with the capsule for a short distance, and reinforces it. In making experiments upon the cadaver, when the bone is carried backward slowly, by means of a powerful lever, it is found that the capsule will be ruptured just sufficiently to allow the exit of the head of the metacarpal bone. Indeed, it is one of the luxations in which the rupture which takes place in the capsule presents the characters of a button-hole, which slips back of the head with the closest possible fit; and in manipulating the phalanx upon the cadaver, where we are dealing with no force except that of the capsule itself, the end of the phalanx passes over into its place with some little difficulty, incidental to the closeness of the relation of the aperture to the head of the metacarpal bone. The correctness of this position is readily established by making a cut upon the edge of the capsule less than one-eighth of an inch in width. The phalanx can then be moved backward and forward with the greatest facility. An- other condit ion which has been alluded to as incidental to this luxa- tion is one in which a greater violence has carried the head of the metacarpal bone farther forward. When this takes place, the bone parts the tissues, ruptur- ing a portion of the external branch of the flexor brevis, sliding the tendon of the long flexor toward the ulnar side of the thumb, and thus presenting its surface directly under the fascia and integuments. Perhaps the diagnosis of these two conditions cannot always be established, but the sensation upon palpation is not at all the same in both. The metacarpal bone can be felt and more accurately de- fined than when it is covered by the flexor muscles and tendons, and seems to have a sort of freedom of move- ment under the skin much more marked than in the other condition. Treatment.-It has always been found that the reduc- tion of this luxation is apt to present more difficulties than that of any other phalanx. It is my firm conviction that the cases which are difficult of reduction (some of which, indeed, cannot be reduced by extension or manipulation) are those of the second variety, in which the flexor ten- dons and muscles have been displaced. The disturbed re- lation and rupture of the flexor brevis muscle has been long since observed by surgeons. If the tendons or mus- cular fibres are not broken or displaced, except as they may be bent forward over the head of the metacarpal bone, it is easy to understand that their integrity and posi- tion may assist the process of reduction. This is to be undertaken by two methods : one by extension, and the other by special manipulation. When undertaken by extension, it is to be executed by attaching the clove hitch (a cord or a very narrow band) to the phalanx. The pressure of this cord will be sufficiently great to crush the arteries and veins, if it is powerful and long continued, unless the integuments are protected by an abundant thick- ness of bandage, or, what is better, by means of a flexible piece of leather or buckskin. The counter-extending band should be broad and full, and must be placed in the com- missure between the forefinger and thumb. Everything being now arranged, traction may be made in a direct line, in order that the phalanx shall move toward the ar- ticulating surface of the metacarpal bone. A force that can be tolerated if the tendons of the flexor muscles are in their places ■will usually be sufficient to dilate the button- hole, if necessary, enough to reduce the luxation. There is another method, which was proposed by Dr. Crosby, and which changes the whole method of reduction. The surgeon, placing the thumb of one hand directly against the end of the phalanx, on the posterior surface of the metacarpal bone, presses it firmly forward ; then, seizing the end of the thumb with his other hand, he uses the phalanx as a lever, pressing it backward until the articu- lating surface may lie flat upon the posterior one of the metacarpal bone. By this process it will be observed that the tendons of both the flexor brevis and flexor longus are rendered tense, thus pressing firmly against the dislo- cated surface of the metacarpal bone, and assisting in drawing it back, while the thumb of the surgeon is urging the end of the phalanx forward. If the thumb be carried backward a little beyond a right angle with the meta- carpal bone, the end of the phalanx becomes lifted up from a depression upon its posterior surface. I have a firm conviction that nearly every case of this form of luxation will be restored by this manipulation. But in the other, already described, with displaced tendons, both methods will be very likely to fail. The tendon of the flexor brevis is here carried along the side, and behind the projecting head of the metacarpal bone, instead of lying upon its front, and there it is apt to remain as an additional restraint, even when the patient is under the full influence of ether. If, now, extension is made, the tendon of the flexor brevis is rendered tense, and draws the capsule downward upon the posterior surface of the metacarpal bone, which is a movement precisely the reverse of that which it exerts when lying anterior to the articulating surface in the manner already described. Thus it has been found that no amount of tension that the thumb can tolerate will cause a reduction of the luxation. The method of manipulation is not any more fortunate, for, if we undertake to bend the thumb backward sufficiently far to lift the anterior border of the articulating surface: of the phalanx up from contact with the posterior sur- face of the metacarpal bone, so as to open the capsule, it will be found that we have increased its constriction upon the lateral portion of the head of the metacarpal bone by tension of the flexor brevis, and, in addition to these diffi- culties, the tense tendon of this muscle is caught behind the head of the bone. I seriously question whether any obstacle is presented by the tendon of the long flexor. Still, it will have no effect in assisting the reduction. The treatment that has been described, after moderate and reasonable attempts have been made at reduction, may now be abandoned. It should not be continued with a belief in its success; but operative procedure must be undertaken as preliminary to its further use. This pro- cedure has usually been undertaken by surgeons in a blind and indefinite way. By some the operation is made for the purpose of dividing the lateral ligaments ; by others, division of the tendon of the long flexor has been relied upon ; and by others, still, that of the short flexor. In the judgment of the writer this last method is the proper one, and the division should be made so that the tenotome will reach with its point the edge of the articulation of the phalanx, so as to cut the border of the torn capsule as well as the tendon of the muscle. An extraordinary experience in a single case, confirmed by his experiments upon the cadaver, has led the writer to these conclusions. The patient, a young man, dis- located his thumb backward by a fall upon its palmar surface. He was absent from home, and the attempt was made at reduction by extension by some very competent surgeons, who carried this to an extreme degree ; but the Fig. 858.-Dislocation of Phalanx, without Rupture of the Flexor Brevis. Fig. 859.-Dislocation of Phalanx, with Rupt- ure of Muscle; head of metacarpal bone covered only by skin. 502 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. attempt having failed, the young man returned to his home the next day, where he came under the care of two other surgeons, who repeated the attempts at reduction in the same manner, with a similar result. Upon the following day he visited the writer, who found, upon examination, that the head of the metacarpal bone was very distinctly defined as lying directly under the skin. It clearly be- longed to the class of luxations in which the muscles are penetrated and displaced. Strenuous efforts by the ma- nipulation of carrying the thumb backward utterly failed. A subcutaneous cut was then made upon the side, to divide the tendon of the flexor brevis ; but, as was after- ward learned, it was insufficiently made. At this point it was advised that the joint be deliberately opened wide, and the tissues divided, so as to bring the bones into their position and obtain recovery by anchylosis, which would almost necessarily result from a suppurating joint. This was thought to be preferable to an abandonment of the case. A horizontal cut was now made directly in front, and down upon the head of the metacarpal bone, thus freely opening the joint. The tendon of the long flexor was divided, then the elevator which we employ for rais- ing portions of the skull was carried over the top of the metacarpal bone, and under the end of the phalanx, so as to exert a great force by this powerful lever, believing that nothing in the ligamentous or tendonous apparatus could resist this power. But, to the surprise of all, the bone could not be brought into place, although strained up to within a space of more than one-eighth of an inch be- tween the two surfaces. But now the tendon of the flexor brevis was cut directly across, the knife being carried down to the edge of the phalanx. At once all difficulty was re- moved, and with the fingers of the surgeon alone the parts were brought into apposition with the utmost ease. Dislocations of the Phalanges of the Finger.-These may occur backward or forward. When they occur forward, simple extension is the proper method of restoration. But when they occur backward, which is by far the more common of the two, we find the method of manipulation proposed by Dr. Crosby remarkably successful, though we may also use the method of extension. If both fail, resort may be had to subcutaneous incision of the liga- ment and capsule. Compound Luxation of the Joints of the Hand. -With the exception of what has been said of the wrist, it is not wise to resect the metacarpal joints, or those of the phalanges. The ' ' flail-joint " does not make a useful one in the fingers. Anchylosis is to be preferred. Moreover, it is in these small joints that the attempts at converting the com- pound into simple luxations are most successful. The pha- langes should be replaced, and then dressed in the semi- flexed position, and not straight, as is usually practised. The former position takes off the strain incident to the ex- tension of the flexor tendons, which the latter insures. The best splint is a slip of tin, which, w'hile it can be perfectly moulded, has strength enough to retain the parts in a perfectly quiet condition. The bandaging should also be neat, different from that proper for a limb. Strips of adhesive plaster, cut very narrow (less than one-fourth of an inch), should be wrapped around the finger, beginning at the end and continued up above the injured articula- tion. These should be drawn very tight. Close apposi- tion of the torn surfaces is necessary to promote union by adhesion. At the end of six hours the blade of a pair of scissors should be carried under the plaster, which should be cut entirely through. The swelling will cause the plaster to slide, but it will hold all that is necessary-. Dislocations of the Thigh. Dislocations of the Head of the Thigh-bone.-These luxations occur only as the re- sult of great violence, or of the action of the powerful muscles that control the movements of the femur. This force is sometimes sufficient of itself to displace the head from the acetabulum, notwithstanding its great depth, but there can be no question that luxations of this joint are almost uniformly due to the combined influence of a blow and of muscular action. There are but four different positions which the head of the bone may assume that are of sufficiently frequent occurrence to be called regu- lar. There are, however, numerous other varieties of dislocation which have been determined by autopsies, the description of which will be given below. These four have, from time immemorial, been spoken of as luxations upon the dorsum ilii, into the ischiatic notch, into the thyroid foramen, and upon the pubis. The head of the bone is not found in identically the same location in all of the cases arranged under each of these several varieties, but its position is so nearly the same in each form that the descriptions given are sufficiently accurate to estab- lish a proper diagnosis, and to serve as the foundation for a proper method of treatment. In establishing the diag- nosis it has been urged by some surgeons that we should ascertain, as far as possible, the exact position of the limb at the time of luxation, and they assert that this kind of information is of still more importance with reference to the proper method of restoration, insisting that the limb should be placed in the position it was at the time of exit in order to obtain the better chance for its restoration. Of all this, however, serious doubts may be entertained, notwithstanding the well-known rule of surgery and med- icine, that no well-established fact can be considered un- important. This is insisted upon by its advocates, largely on the ground that the head of the bone will pass out of the capsule at the point upon which direct pressure was made. The correctness of this position may be doubted, on the ground that the capsule will often yield at its weakest point, which may not be in the direct line of pressure upon it at the time of the accident. Dislocations upon the Dorsum Ilii.-These luxations are more frequent than those that occur in this joint in all other directions added together. This can be readily believed when we recollect the great power of the muscles that sur- round the femur, and whose action would tend to draw the bone upward as soon as its head was freed from the socket. The symptoms are wyell marked. The limb is shortened from one to two inches, and even more. This shortening is less marked immediately after the luxation than after the lapse of a few' hours. The laceration of the capsule is also different in degree, and is an element in the production of this symptom. When the patient stands erect the appearance is very characteristic. The knee is turned toward the opposite thigh, and the toe comes upon the instep of the opposite foot. The femur is slightly flexed, and even when the patient takes the recumbent position it cannot be completely extended, so as to enable one to make a satisfactory comparison by measurement with the opposite limb. The limb is firmly fixed, and is capable of but little motion. The trochanter approximates the ante- rior superior spinous process. There is no other luxation that can be easily confounded with it except that in the ischiatic notch. Fractures of the neck of the thigh-bone will occasionally, but very rarely, assume the position already indicated, but the differential diagnosis will be spoken of below. The position of the trochanter is also to be noted, for although the head of the bone is carried back, the trochanter is turned forward, an important fact in diagnosticating between this luxation and that into the ischiatic notch. Reduction of this form of dislocation is to be effected by one of two methods : either by powerful traction made in a direct line from the displaced head of the femur to the acetabulum, or by the method of manipulation. Ex- tension was the favorite method of Sir Astley Cooper, and of all surgeons, even back to the time of Hippocrates, who employed his celebrated scamnum for this purpose. Cooper relied upon pulleys in order to obtain the requisite amount of power, placing the counter-extending band in the perineum. The other method is termed that by manipulation; one in which there is little or no force employed, but in which the limb is made to assume in succession a variety of positions, in order to relax the muscles and remove the strain from the capsular liga- ment, and especially from its powerful re-enforcement, the ligament of Bertin. The fact that the bone, when in certain positions, will be restored without violence has been known since the days of Hippocrates. Surgeons, after making violent efforts by means of traction, and failing, have discovered that the bone would sometimes slip into its place in consequence of certain positions 503 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. which it would take ; or, as may be said, it was reduced by accident. Some have gone farther, and planned cer- tain movements to imitate this accidental position. Now, when we compare the testimony of these various writers, we discover that the positions which are adopted in the method of manipulation were those that accident pro- duced. Dr. Nathan Smith's description of the method of manipulation is too meagre to serve as a guide to the plan of operation ; and Dr. Reid's directions are not en- tirely complete, and, indeed, are somewhat incorrect, and his explanation of the causes which prevented reduction of the luxation have, by common consent, been proved to be errors. Nevertheless, it is to Dr. Reid that the profession is indebted for the revival and practical appli- cation of this invaluable method, which has become the property of the whole world, and which, in the hands of most surgeons, has replaced the methods by extension. Some variation in minute details has taken place, reflect- ing the experience of various surgeons, but the move- ments are essentially the same, and were all, with one ex- ception, accurately described by Dr. Reid. This method consists in placing the patient upon his back, and re- straining the pelvis by a band carried across it and firmly secured. Then seizing the leg, the operator flexes it upon the thigh, and flexes the thigh upon the pelvis, carrying it up to a position a little beyond a right angle to the body, causing the knee to overhang the umbilicus. In executing this motion the thigh will be swung around across the opposite one, and pretty well adducted. But, by the time it reaches the position before named, it moves slightly outward. Thus far it describes the segment of a circle. The abduction now begins, and is to be continued by swinging the knee outward. The thigh is also to be car- ried downward, and at the same time rotated outward. If during the time of extension of the thigh the head of the bone slips into its place, as it often does shortly after it has descended beyond the right angle with the line of the body, the leg ordinarily becomes extended by automatic action of the muscles, and the heel drops down upon the surface of the bed, occupying its proper place beside its fellow. Thus, it will be seen that the thigh makes one continuous sweep, almost in a circle, returning nearly to the place of beginning. It unfortunately happened that, during the early practice of this method, throughout the region in the neighborhood of Dr. Reid's residence the surgeons executed it precisely as he had done, and thereby com- mitted one grave error. When the flexion was complete and the abduction begun, Dr. Reid was in the habit of pressing upon the knee, one hand being placed over its top, while the other grasped the leg near the ankle. At this point of time, as abduction was progressing, he bore down on the top of the knee, thus making a pressure downward ; and when the thigh had been brought down to an angle of about one hundred and thirty-five degrees with the horizontal posture, its head would suddenly slip backward with a grating thud, passing into the ischiatic notch. Inasmuch as the toes were now carried forward, and the limb was almost as long as the other, the momen- tary impression was given that the head of the bone had passed into the acetabulum. This happened with Dr. Reid's third case, and there were four other cases in the hands of neighboring surgeons in which this accident oc- curred, in but one of which the limb was eventually re- placed by the process of extension. Dr. Reid, however, learned what is now universally understood to be correct, that when adduction and flexion are completed the thigh is to be lifted upward, so as to draw the head toward the acetabulum. In addition to the general plan, it is proper, when the abduction is to begin, that rotation of the thigh outward is to be made, so that the heel will be carried across the opposite limb. Dr. Reid also committed the error of regarding the muscles as the cause of the diffi- culty in restoring the head of the bone. By these mo- tions he proposed, first, to relax the hamstrings by the flexion of the leg; next the adductors, by carrying the thigh across the opposite one as it went upward. He also thought to relax the psoas and iliacus by flexing the thigh. He entertained also the erroneous idea that the muscles were rigid, and incapable of extension beyond their normal length. The movements in the process of manipulation, which have just been described, should be supplemented by lifting the thigh upward after the com- pletion of flexion, and during the period of abduction and rotation outward. Perhaps the attempt will fail. In one case of forty-two days' standing, in the hands of the writer, the movements were executed three times, when the head slipped into its place with a snap. But if it fails, it may be from the fact that the rupture in the capsule barely allows the caput femoris to emerge, and the edges of the rent are caught at the border of the head. It is now incumbent on the surgeon to enlarge the open- ing. This can be done by forcible abduction. The powerful lever furnished by the thigh itself is sufficient to accomplish this. But a too sudden and violent effort may cause a fracture of the neck-a circumstance very likely to occur where the luxation is ancient or the sub- ject in the epiphyseal age. The whole effort at reduc- tion by manipulation should be quiet, gentle, slow. It is probable that violent and sudden movements defeat the object by holding the head entangled by the tense liga- ment. The writer had the very remarkable experience of success in a few moments by performing the operation in the gentle manner urged, accompanied with a slight rocking motion, where a complete failure had occurred, on the two antecedent days, at the hands of four compe- tent physicians who had, as they believed, practised the movements precisely as the writer himself had executed them, with the exception that theirs were performed with constant effort. The operation was overdone. If, how- ever, the surgeon fails to reduce the dislocation by this method, extension can be resorted to, and should be per- severed in to the tolerance of the vital powers before the patient is abandoned to his permanent disability. It is, however, to be recollected that, even if the reduction is not effected, the limb is very useful. The process by extension, by drawing the two surfaces that are separated in a direct line to- ward each other, would seem to be the Fig. 860.-Extension. Sir Astley Cooper's Method. natural one. The plan of Cooper has been alluded to, but may properly receive more minute explanation. The pa- tient occupies the recumbent posture, and has a band fas- tened to the thigh just above the knee by the methods described in the introductory part of the article. A counter-extending band (a cravatted sheet is, perhaps, the most convenient and useful) is passed between the limbs close to the dislocated member, and secured to some fixed point on a line with the body. The leg can be flexed on tlie thigh by bringing the patient to the edge of the table and turning him a little toward the unaffected side. Extension is best made by pulleys or twisted rope, but the strength of several men can be employed when these aids cannot be easily obtained. The extension by human ef- fort is, however, unsteady, and apt, unless great caution is used, to be too violent. It should not be made with- out a resort to some means of passive retention for a while during the pauses of increasing traction. This can be done by wrapping the rope or band around some fixed object. The extension should be slow and gradual, mak- ing distinct pauses to allow the stretch or tear to go on. It is a good custom to pause for a minute, and then add a little more power. This extension can be aided by using the leg as a lever to rotate the limb backward and for- ward. Whatever obstruction may arise from the locking of the head on the dorsum will thus be relieved, and this procedure facilitates the additional rupture of the liga- ment that may be necessary. 504 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. It was thought that one of the great difficulties in the reduction by this method arose from the tension of the adductor muscles of the thigh holding the head down firmly upon the posterior surface of the dorsum, as it at- tempted to rise over the edge of the acetabulum. Ac- cordingly, the instruction has been given to draw the thigh during extension across the lower third of the oppo- site thigh, in order to relax the adductors, as well as to exert the traction in a direct line toward the acetabulum. The practical surgeon, however, finds this to be very difficult, and the more violent the extension the more liable is the thigh to be brought out in a straight line with the body. But if we are obliged to resort to extension, the better plan is to make traction with the thigh at right angles with the body, or, in other words, in the same position as that in which we have the limb when we commence abduction by the process of manipulation and draw upward. The appa- ratus for traction is the same, and can be fastened to a joist or to a derrick, while the pelvis is held to the floor by a band fastened to staples (see Fig. 861). Dislocations of the thigh, as has been said above, are far more rare than fract- ures. They are also more common during the early period of adult life, al- though it is rare to find them in the very young. Mr. Stanley, however, reports a case of luxation on the dorsum in a child of eighteen months, which was reduced shortly after the accident - time not stated exactly. It was reduced by drawing it downward and ab- ducting it, the bone slipping into its place with a marked thud. A case is also reported by Mr. Kirby of a child three years of age, who fell from a jaunting-car, receiving a blow upon the external condyle of the left femur. Upon examination the leg was found shortened two and a half inches; the knee was brought forward and adducted, and the toes were much inverted. There was little or no pain. Moderate exten- sion with the hand restored the head of the bone instantly with a sudden snap. No deformity of the limb remained, and restoration was perfect. The following table, copied from Hamilton, presents the differential signs between fractures of the neck of the femur and dislocations upon the dorsum ilii. toes are directed forward, in a nearly normal position. This is obviously due to the shape of the ilium, which is curved at this point so as to allow the head of the femur to stand in a direction similar to that which it has when in its normal position. The trochanter does not lie so flat as it does in dorsal luxation, and is further removed from the anterior superior spinous process than its fellow, and is also carried a full inch nearer to the median line of the sacrum. Professor Bigelow, in his admirable treatise upon Luxa- tions of the Hip, insists that the term, luxation into the ischiatic notch, is a misnomer, and that these symptoms are due to the fact that the head of the bone is caught under the tendon of the obturator. However, the shape of the ilium, and the fact that the head of the bone is car- ried further back than when it is thrown upon the dor- sum, largely determines the special character of the symptoms. It is hardly credible that the limb should be so nearly in the normal direction, if it was not received in the de- pression that simulates the acetabulum. The symptoms are similar to those of dislocation on the dorsum, but still somewhat different. The knee is brought forward, but not inclined to the opposite limb. When the patient can bring down the limb on the couch nearly straight, as he sometimes can, the shortening is not more than a half- inch to one inch. If the patient is fleshy the deformity is somewhat masked, and a question of the existence of fracture may be raised. Of course, the limb is fixed. The figure here given is traced from a photograph of a Fig. 86f.-Bigelow's Method. Fig. 862.-Luxation in Ischiatic Notch. (From a photograph.) Dislocations upon Dorsum Ilii. 1. Very rare in advanced life. 2. Never caused by a fall upon the trochanter major. 3. Absence of crepitus. 4. I'reternatural immobility. 5. Limb always shortened. 6. Limb almost always rotated in- ward. adducted and flexed. Fractures of the Neck of the Femur. 1. Very frequent in advanced life. 2. Often caused by a fall upon the trochanter major. 3. Crepitus. 4. Limb can be moved freely, ex- cept when the motion causes pain. 5. Limb not always shortened. 6. Limb never in this position ; al- most always slightly rotated out- ward, and generally lying paral- lel with the other limb. man (W. C.) forty years of age, who received, when stooping over with the body nearly at right angles to the lower limbs, a very severe blow posteriorly on the pelvis by the fall of a heavy piece of timber. An injury of the hip was obvious. The position of the toes, directly for- ward, is well shown in the illustration. But when the patient was sitting (which was the easiest posture he could assume) the toes of the injured limb were thrown outward, and presented a most natural appearance. But Fig. 863, traced from another photograph taken while the patient lay upon the table, admirably illustrates the value of Dr. Buchan nan's method of diagnosis. The dif- ference in length of the two thighs was an inch and a half. Dr. Andrew Buchannan proposes, as an aid to the diag- nosis of these dislocations, to institute a comparison of the limbs, " not while resting in the same plane with the body, but when bent to a right angle with the abdomen. The reason of this must be sufficiently apparent from a Luxation of the Head of the Femur into the Ischiatic Notch.-This position of the head is characterized by Pro- fessor Bigelow as dorsal under the tendon. Although this is really upon the posterior surface of the ilium, the position is different from that upon the dorsum, and the symptoms are much modified. The limb is not much shortened, there being ordinarily a difference of not more than half an inch in the length of the two limbs. The 505 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. consideration of the anatomy of the joint and the nature of the injury. The head of the femur being thrown backward, and very slightly upward, it is clear that so long as the limbs remain in the plane of the body there can be very little difference in their relative lengths, since that difference is only measured by the extent of the dis- placement upward ; but if the limbs be slowly bent toward the abdomen, the difference in their lengths must become greater and greater until it attains a maximum when the limbs are at right angles with the body, the luxated limb being then shortened by the whole extent of the displace- ment backward. Dr. Buchannan was able to apply this in the case of a child only three years of age, who had been hurt six days before by a fall. It was difficult from appearances to make a diagnosis when the patient was erect. There was a great deal of mobility, which seemed inconsistent with the theory of a dislocation. The thigh could be bent toward the abdomen with great facility, and without producing much pain. Adduction and rota- tion were more painful. All uncertainty was at once re- moved, however, when the patient was placed upon her back upon a table, and both thighs bent to a right angle with the trunk. The shortening was very remarkable, and appeared to be even an inch. The reduction of the described as proper for reduction of luxation on the dor- sum. But it is even more necessary in these cases to draw the limb upward than it is in dorsal dislocations. If, however, we resort to the use of pulleys, it will be found that the amount of force necessary to reduce this luxation is far greater than that which is found sufficient in Fig. 864.-Normal Position, Showing Obturator Tendon. the case of dorsal displacements. Professor Bigelow offers an explanation of this difficulty by stating his belief that the head of the femur becomes hooked over the unyielding tendon of the obturator. This is very likely to be the case. Experience has shown that there is great difficulty in re- ducing the luxation by Cooper's extension method. It may be added that he advises that traction should be made Fig. 863.-Drawn from a Photograph ; the same case as that shown in Fig. 862. femur with an audible snap, and the recovery and per- fect use of the limb, confirmed the diagnosis. Dr. Dawson has made the same observation as Dr. Buchannan. Dr. Squires' points out the fact that the head of the bone can be detected, in cases of long stand- ing, by the finger passed into the rectum or • vagina, and Dr. Dawson has made the same observation in the recent cases. In addition to the symptoms indicated by the drawings, the writer will add another which, so far as his reading goes, has not been observed by others, although it is a symptom of a very obvious character. By placing the patient with his abdomen on a table and the lower limbs on the floor, the latter are brought to a rectangular posi- tion in relation to the body. Although the nates do not allow of a minute examination of the trochanters, they are, nevertheless, sufficiently distinct to establish the fact that the process on the side of the dislocation is nearer the median line by an inch and a half than is the one on the uninjured side. The symptom is so palpable that it can scarcely be overlooked, and can be confounded with no symptom of any other injury or disease. The reduction of the luxation in the case pictured above was easily effected by manipulation, in the hands of the writer, four days after the injury. Whatever relation the head of the bone may have to the obturator tendon, the reduction by this method is as easy as when the head is on the dor- sum. The handling of the limb is the same as has been across the upper third of the opposite thigh. But this is practically almost impossible. It is one of those directions given upon theory. The writer, many years since, made the attempt at reduction after Cooper's method at four dif* Fig. 865.-Luxation Behind the Tendon. 506 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. ferent times, and succeeded only once. It is needless to say that he will never attempt it again, but will exert traction upon the thigh while placed at a right angle with the body, if manipulation should prove unsuccessful. Dislocations of the head of the femur upon the dorsum ilii, below the tendon, is undoubtedly a form of dorsal luxation, but we cannot confound this condition, with its exaggerated inversion, with the symptoms mentioned by Sir Astley Cooper, which are so admirably shown in the illustration taken from a photo- graph. The diffi- culty in reducing this form of lux- ation is well il- lustrated by the drawings from Bigelow, showing the relations of the head of the femur in its normal posi- tion and when dis- located. That the tendon of the obturator would hook upon the neck of the femur when drawn upon, is admirably illustrated by the Figs. 864 and 865. Dislocation of the Head of the Bone on the Pubes.-This luxation is accompanied by symptoms of a very marked character. The limb is shortened from one-half to one inch ; the toes are everted, and the joint is nearly immovable. Thus far the symptoms have a close re- semblance to fractures of the neck of the thigh bone. The mobility, to be sure, is less than in fractures, but in these the difficulty of obtaining motion, on account of the contraction of the muscles which the patient produces in order to protect himself from anything which may cause pain, is a source of delusion against which we must guard. The symptom, however, which is pathognomonic, is the presence of the head of the bone upon the pubes, where its rounded form can be distinguished by palpation. The writer has seen but two cases of this luxation ; one in a patient seventy-two years of age, and the other in one sixteen years of age. The dislocation in the first case was successfully reduced, and recovery was perfect; but in the second pa- tient, who was seen three weeks after the accident, the luxation was never reduced, the neck of the bone having been broken in the attempt to effect reduction. The shortening of the limb is not great, being usually from one-half to one inch, and but seldom more. The position of the limb in its rela- tion to the axis of the body is vari- able. Sometimes it is nearly parallel with the opposite limb, at other times, some- what flexed and abducted. This is clearly due to a vari- ation of position upon the pubis. The symptoms mentioned, with marked fixation of the limb, will scarcely allow an error of diagnosis. The reduction may be attained both by extension and by manipulation. If extension is employed, we may apply the apparatus as already described, but should make the traction a little backward. The writer succeeded by this method in reducing the dislocation in the case of an old man of seventy-two years of age, with the employment of less force than he had ever usedin any other form of lux- ation. Nevertheless, the method by extension has been often followed by bad results and failure. Manipulation has succeeded, and, oddly enough, by movements diametrically opposite to each other. The method that has been successfully em- ployed, and which would seem to be the most natural one, is to reverse the movement of the thigh as compared with that employed in the re- duction of the dislo- cation on the dorsum ilii. The process begins by flex- ion of the leg on the thigh, followedbyab- duction with flexion of the thigh upon the body, then by a sweep which carries the knee across the opposite limb downward, and finally, by rotation inward, unaccom- panied by upward traction. This movement would carry the head downward, with the ilio-femoral ligament suspending the neck. But reduc- tion has also been accomplished by quite a different plan. Dr. Hamilton quotes Dr. Fountain thus: "The patient (an adult male) was laid on the floor and placed completely under the influence of chloroform. The dis- located limb was then seized by the foot and knee and rotated outward, the leg flexed and carried over the op- posite knee and thigh, the heel kept well up and the knee pressed down. This motion was continued by carrying the luxated thigh over the sound one as high as the upper part of the middle third, the foot being kept firmly ele- vated. Then the limb was carried directly upward by elevating the knee, while the foot was held firm and Fig. 868.-Anterior Oblique Dis- location. (Bigelow.) Fig. 866.-Dislocation on the Pubis. (Bigelow.) steady, at the same time making gentle oscillations by.the knee, when the head of the bone suddenly dropped into- its socket. The time occupied was not more than thirty seconds, and the force employed was very slight." The anterior oblique dislocation of Bigelow (see Figs. 868 and 869) is clearly a modification of those that have been described with the head looking forward, the ex- treme adduction being obviously due to the integrity of the ligament. A more extensive rupture would allow the limb to drop in a line with the body. Dislocation of the Head of the Bone into the Thyroid For- amen.-This is one that produces the appearance of an elongation of the limb by two or three inches, but this Fig. 869.-Anterior Oblique Dislocation. (Bigelow.) Fig. 867.-Dislocation on the Pubis. (Bigelow.) 507 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. when the muscles will draw it into place, with the usual sound. But the method by manipulation has been ap- plied with as much success, and more convenience. The leg, flexed upon the thigh, is used as a handle or lever, for purposes of rotation, which may be made in either an inward or an outward direction. When one fails the other may be tried, for we cannot be sure of the exact point of the capsule through which the head of the bone has emerged. As a rule, however, the rotation inward may be considered as the most likely to secure the reduc- tion. The rationale of this movement is to be found in the fact that rotation, while it disengages the head from its point of fixation, causes it to be lifted up by the twist which shortens the ilio-femoral ligament. There are modifications of this luxation in which the head of the bone rests to the inner or outer side of its usual point of lodgement over the foramen, but they are "irregular," and the consideration of them would transcend the pur- poses of this paper. A single case may, however, be quoted for illustration. It is reported by Dr. E. W. Hodder, surgeon to the Toronto Hospital. A muscular man, aged twenty-two years, wTas crushed by a mass of earth. " On examination it was found that the head of the femur had been thrown downward and inward, com- pletely under the arch of the pubis, the neck of the bone resting on the ramus, immediately below the origin of the gracilis muscle, and either be- tween or through the origins of the adductors. When supported in the upright position, the thigh formed very nearly a right angle with the trunk, the knee being as high as the head of the bone ; the leg was at right angles with the thigh, and the knee was rotated very far outward. The toes turned slightly outward and pointed downward." Another irregular form of luxation is styled by Professor Bigelow the everted dorsal. The head of the bone is turned forward, but is entirely upon the dorsum. The symptoms are similar to those of luxation upon the pubes. The toes are turned out- ward even more than in this regular luxation, and the limb is more shortened, the difference in the length of the two limbs being about two in- ches. It is obvious that the head of the bone may be lodged at any point of the surface from near the pubes to the dorsum. Sometimes it is im- mediately above the inferior spinous process, at other times completely on the dorsum, with the head of the femur looking forward. The posi- tion of the globular head will show the exact nature of the dislocation. The writer has seen two cases of the everted-dorsal form of luxation. They were both produced in protracted and unsuccessful attempts at reduction of luxation on the dorsum by man- ipulation. In the first one (a laboring man), the head was finally thrown into the ischiatic notch and left there. The second one came under observation tw'o years after the attempts at reduction of a luxation on the dorsum by manipulation had failed. Unfortunately, the bone was left in the condition of eversion, as was shown at the autopsy. After-Treatment.-The treatment, after the reduction of these luxations, should be carried out by placing the pa- tient in the recumbent posture, bandaging the two limbs together, and maintaining them in this position for about a week. Notwithstanding the great depth of the cup of the acetabulum, a relaxation of the ligamentous apparatus of the joint will occur, unless we keep the'joint at rest dur- ing the time that is necessary to complete repair. The writer has known of three cases in which this relaxation lengthening, while it is so characteristic as to be a path- ognomonic sign, is more apparent than real, the pelvis being tilted downward on the affected side. The real lengthening is not more than an inch, frequently much less. The trochanter is not so salient as in the normal condition, the head of the femur being carried toward the me- dian line of the body, and so deeply buried as not to be recognized by palpation on the exter- nal surface, but it can be perceived by a rectal or vaginal examination. The fixation of the head of the bone is also very marked, for, in addition to the tension of the large muscles, especial- ly the psoas magnusand iliacus internus, the ligament of Bertin is put severely upon the stretch, and, perhaps, more or less torn. In addition to the symptoms enumerated we find the toes point- ing downward and the foot everted. Treatment.-The re- duction of this luxa- tion, even in former times, was not attempt- ed by any direct exten- sion downward, but the body and limb were so fixed that the latter could be used as a lever, with a fulcrum placed upon the side of its superior extremity, close to the peri- neum. This fulcrum might be made with a band passed around the limb, and held outward at right angles, or some fixed object, such as a post, which should, of course, be well padded, might serve the purpose. These fixtures Tig. 870.-Dislocation into the Thyroid Foramen. (Bigelow.) Fig. 872.-Luxation Re- duced. (From photo- graph; case of Parker.) Fig. 871.-Dislocation into Thyroid Foramen. (Bigelow.) being properly applied, the limb is to be seized at the nnkle and drawn across the opposite thigh, and a little backward. The powerful lever furnished by the limb is usually found sufficient to press the head of the bone outward, 508 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. occurred, and in which recurring luxation could be pro- duced spontaneously. The relation of one of these cases will suffice. John B. Parker, private, com- pany H, 148th New York Volun- teers, while on the march from Bermuda Hundred to Drury's Bluff, May 13, 1864, was skir- mishing up a hill, and sprang hack suddenly to avoid the gun of a comrade in advance. His left foot became entangled, and the movement caused a disloca- tion of the hip. He felt the in- jury, supposed that the bone was out of joint, and some comrades by pulling upon the limb effect- ed a reduction. He immediately resumed his skirmishing, and marched seven miles from 10 a.m. till 6 p.m. He lay down at night, and went on duty the next day, sharp-shooting, crawl- ing all day. He continued this kind of duty five days, and re- turned to camp, when he was immediately put on entrench- ments, and worked two days and nights. Afterward he went on picket duty, and entered the hospital May 28th. At present he can luxate the hip-joint at any time, and does it by pressing the foot on the floor to fix it firmly, contracting the adductors, and throwing out the pelvis. The head suddenly leaves the acetabulum and goes on to the dorsum ilii. But recurrence may take place at once without the pe- culiar causes that mark Parker's case, as is shown in the case below. Dr. J. Gibbon, of Swansea, reports a case of a man sixty years of age who had a dislocation of the right shoulder and of the left hip-joint. Within a week after the reduction the left leg gradually shortened, the foot turned inward, and the head of the femur was found to be quite out of the acetabulum. With considerable difficulty it was again reduced by extension. Dislocation occurred again at the end of a fortnight. It being sur- mised that the acetabulum was broken, the limb was held down to its place for four weeks by being fastened to the bedstead. At the end of this time it was released and remained in posi- tion. Pathological Conditions.-Un- til within the last thirty years the surgical world was almost absolutely governed in its opin- ions, with reference to the causes of obstruction to the return of the head of the femur to the ace- tabulum, by the teachings of Sir Astley Cooper. He in his turn had followed the practice and adopted the theories which had undoubtedly prevailed since the time of Hippocrates. Never- theless, observations were not wanting of accidental restoration of the luxations which seemed to controvert the established opinions on this subject. But no one before the time alluded to seems to have grasped the ideas of the present day. The change of opinion with refer- ence to the pathological facts and the proper inferences to be drawn from them which has improved our practical methods in such a remarkable manner is entirely due to the labors of American surgeons, notwithstanding the facts above stated, that the restoration of the luxation had been long ago attained by Columbut and others by a method of manipulation. That Dr. Nathan Smith was the earliest teacher of the practice of manipulation in this country, is probably true, but he seems to have had but little experience in the matter, and no changed views of the pathological conditions interfering with the reduction of the luxation. As above stated, it is to Dr. W. W. Reid that the credit is due of reviving and placing the method of manipulation upon a firm footing by a very clear statement of most of the conditions essential to suc- cess. But he still groped in the dark, as regards the true cause of the positions assumed by the limb when luxated, and was bound to Cooper's opinions with refer- ence to the part that the muscles play in producing these novel positions. Immediately after Dr. Reid's startling announcement of a new and very easy method of reducing a luxation, which had always been one of the most formidable undertakings of mechanical surgery, various observers directed their attention to the subject, and very soon the same view of the causes that interfere with the reduction of the luxation became apparent. Few instances are more striking than the one under consideration, of the necessity of observation and the danger of acting upon mere inference. The first case upon which Dr. Reid had a full opportunity for the practice of his plan was furnished by the writer of this article. This was that of a laboring man who had a dislocation upon the dorsum. He had previously employed the method upon a woman in a profound state of intoxication. But the diagnosis in this case was unsatisfactory. The method was so bril- liant, that the writer was led, a short time afterward, to make a study of the action of the capsule of the hip- joint by denuding the bone of everything but this, and then producing a luxation by making a button-hole in it large enough for the emergence of the head of the femur. This he at once exhibited to the class before which he was lecturing. Two years later, Professor Gunn made the same observation from an entirely independent study, and arrived at the same conclusion. A little later still, Professor Bigelow, without any knowledge of these pre- vious investigations, arrived at the same result. To the labors of Professors Gunn and Bigelow the profession are indebted for a most luminous and exhaustive study of the whole subject. The writings of the latter gentleman are the more elaborate, and leave little to be said. It is not surprising that there should be such unanimity among observers as to the cause of the positions of the various luxations. Every one who should undertake the study by the plans above stated could come to but one conclu- sion, and that is that the ligamentous apparatus, and not the muscles, govern the positions of the bone. Professor Bigelow regards the ilio-f emoral ligament, or ligament of Bertin, or, as he chooses to name it from its shape, the Y-ligament, as the sole cause of the special restraints in the four regular luxations, and as more or less modifying those that are not classed under these heads. That his views upon this point are, at all events, essentially true, can hardly be doubted, for the fibres of this ligament are very much stronger than those of the capsule proper. But the writer can scarcely admit that the remaining fibres of the capsule are entirely unimportant as agents of restraint when reduction is attempted. The ilio-femoral ligament is described as arising from the anterior inferior spinous process, and spreading out to be inserted into the anterior inter-trochanteric line. The strong bands arising from the single origin at the spinous process diverge to the ex- tremities of this line, giving great firmness to the hold of the femur to its socket. Besides the two ligaments de- scribed, there is the ligamentum teres, which is inserted into the bottom of the acetabulum, and also into the head of the femur. Luxation on the Dorsum llii.-The symptoms have al- Fig. 873.-Femur Luxated on the Dorsum. (From photo- graph ; case of Parker.) Fig. 874.-Back View of Same. (From photograph; case of Parker.) 509 Dislocation*). Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ready been described. The knee is turned inward and the limb shortened. The shortening is obviously due to the action of the muscles, but when this shortening takes place the ligament is drawn upon, and inasmuch as the head is held by it, this round extremity cannot stand upon the convex dorsum, but must lie flat. This throws the trochanter forward, the neck lying against the dorsum. This is the position assumed with or without the presence of muscles. As said above, the natural method of reduc- ing a luxation is to draw the separated bones toward each other. This is the plan by extension, drawing the thigh downward and across the lower third of the opposite thigh. But when the head comes to the edge of the ace- tabulum, it is obvious that the ligament, with the thigh in the position of extension, must be rendered more tense than normal by the difference of the depth of the socket. Although the capsule is already torn, it must often under- go a much more extensive rupture before the reduction can be effected by this plan. By the method of ma- nipulation the non-elastic ligamentous apparatus is at once relaxed by bringing the line of its insertion toward the acetabulum. It may be added that the ligamentum teres is usually torn in complete dislocations. Neverthe- less, it has been shown by post-mortem examination that the head of the femur can be on the dorsum with this untorn ; but such a condition must be one of unusual relaxation of this ligament. The doctrine that the capsule is torn in the direction of pressure cannot be sustained by the facts. The records of autopsies are very few, and most of these are collected from times dating back prior their pelvic attachments, and were lying loosely on the neck of the femur. The quadratus femoris was unin- jured. The capsule of the joint had given way pos- teriorly, but in front and above it was perfect. The ligamentuni teres had some fibres ruptured, but still with- stood all attempts to tear it across. The ilio-femoral and pubio-femoral bands were also uninjured, notwithstand- ing that the acetabulum had separated into its three component parts, the fracture also traversing the ilio- pectineal eminence. The lowermost fibres of the obliquus externus, and some fibres of the sartorius, psoas magnus, and iliacus internus muscles were also ruptured. Case 2. The patient was admitted to the hospital suffer- ing from dislocation of the right femur upon the dorsum of the ilium, and from other injuries, of which he died. The posterior fibres of the gluteus minimus were torn across, and the cellular tissue beneath the muscle was filled with blood. The quadratus femoris muscle was torn in two, and the uppermost fibres of the adductor magnus, and some fibres of the gemelli and obturator muscles, were lacerated. The capsule was perfect in front and above, but torn at the most posterior part. The ligamentuni teres had been ruptured close to its femoral attachment. Case 3. Reported by Dr. Janies Scott. On dissecting down to the hip-joint, an extensive extravasation of blood presented itself in the cellular substance, covering the trochanter major, and also the fascia lata of the thigh, ex- tending several inches above and below the trochanter. The gluteus magnus being raised from its origin, a con- siderable extravasation was found in the loose cellular tissue under the gluteus medius. A cavity capable of containing a pullet's egg was also brought into view. This cavity was situated exactly w'here the great ischiatic nerve passes under the pyriform muscle. It contained fluid blood. Its boundaries were the pyriformis above, the sciatic nerve in front (supposing the body to be up- right), the trochanter major and insertion of the gluteus medius to the outer side and posteriorly, the gluteus max- imus posteriorly. Here the displaced head of the femur had been lodged. The fleshy portion of the gemelli and quadratus muscles was found torn across. The pyri- formis and obturator were perfect. The extravasated blood followed the course of the sciatic nerve deep into the thigh. There w'as also extravasation between the gluteus medius and minimus muscles. The internal and upper part of the capsular ligament was ruptured ; the external portion remained unbroken. On turning the head of the bone out of its socket, the ligamentum teres was found to have been torn from its insertion into the dimple of the head of the thigh bone. The brim of the acetabulum at its upper margin was fract- ured to the extent of about an inch. The fractured portion lay loose and nearly unconnected. A fracture traversed the acetabulum in the direction of the junction of the ilium and ischium. In confirmation of the opinion that the capsule rupt- ures at the weakest place first, and also of the facility of dislocation from the twisting motion, the following ex- periments are quoted: Experiment 1. The two larger glutei muscles were re- moved, while the minimus, the rotator, the obturator, the pyriformis, and the gemelli were allowed to remain. The limb was extremely adducted, being carried across the opposite thigh above its middle ; a powerful lever was affixed to the knee, while a strong rope, carried around the pelvis and beneath the perineum, was attached to it about six inches from its end, in order to furnish the proper fulcrum for the application of the necessary force. But, although the full strength of two active young men was applied to the long arm of the lever, luxation could not be induced. Experiment 2. The lever was now thrown aside, and the limb being seized by one hand upon the thigh, and the other upon the ankle, the thigh was abducted, while the leg was partially flexed and used as a lever to rotate the thigh outward. The hands of the surgeon were quite sufficient to cause a rupture of the capsule, beginning at its inferior border and running upward from the acetab- ulum toward its internal portion. By this motion the Fig. 875.-The Position (according to Bigelow) of the Ligament in Lux- ation on the Dorsum. to the period at which the change of opinion occurred with reference to the cause of the special position of the head of the femur. We, therefore, find that greater stress is laid upon the condition of the muscles, which are shown to be pretty extensively torn. Reports of three autopsies are here inserted. They are all of luxation on the dorsum. In two of them, reported by Mr. Jere- miah McCarthy, the capsule was ruptured posteriorly, and in one the internal and not the external portion. Another case is reported by Mr. Henry Morris, in which a rupture similar to the one last quoted was made. Case 1. Man, admitted with severe injuries ; in a dy- ing condition. No attempt at reduction. The head of the bone was found on the dorsum. The deeper fibres of the gluteus maximus were found extensively lacerated, while the head of the femur was lying with the lowest fibres of the gluteus minimus interposed between it and the acetabulum. The posterior fibres of the gluteus me- dius were also torn. The pyriformis, obturator internus, and gemelli muscles had been completely torn away from 510 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. the end of which time it was found that the left lower ex- tremity was inverted, and the patient could not move it. But at length the pain subsided, and as he improved it became evident that his hip-joint was dislocated. The limb becoming anchylosed, it was operated upon by cut- ting off the bone so as to obtain a false joint. The man lived to the age of fifty-seven. The autopsy revealed the fact of a partial dislocation upward and backward, strong, bony anchylosis, one-half or more of the acetabulum re- maining as a free and open cavity, while the upper part had been absorbed by the steady pressure of the head of the femur. Luxation is sometimes accompanied with fracture of the thigh, and, unfortunately, when it occurs, it is usually at the neck. Such cases are almost necessarily irremedi- able, but the excellent results in the following case, re- ported by Dr. Tunnecliff, demonstrate the success of care- ful and gentle manipulation. This should be tried at once, although we can do little else than flex the thigh and draw it upward. A young farmer, Edward Humes, thirty years of age, while employed in felling trees was crushed by one as he was standing on the ice. The pressure forced him to the earth, driving his feet through the ice, and as he fell the right trochanter struck with great force on the solid ice. Dislocation of the right femur into the ischiatic notch, with fracture, was diagnosticated. The exact point of the fracture could not be determined. The limb was shortened an inch and a half, the right knee was turned inward, and the right foot was inverted. Rotation, adduc- tion, and even extension could be readily made without causing much pain. Crepitus was distinctly felt during these movements in certain portions of the limb. The fracture was treated in the first place by a splint, the part being kept quiet, and this was maintained for a month. The method by manipulation was then slowly and gently carried out while the surgeon made pressure with his hands upon the head of the femur and the great tro- chanter. These manipulations failed the first time, but when they were renewed with a little more force, the head of the bone returned to its socket with an audible snap. But upon examination it was learned that at the very last moment the bone had been re-fractured, and prolonged treatment for this condition had to be carried out. The complication, it would seem, could be easily explained from the circumstances of the case. The crushing force caused a dislocation of the bone, and the subsequent blow of the trochanter on the ice fractured it, as a secondary accident. Old Luxations of the Femur.-These are difficult of reduction, but do not present the dangers to which those of the humerus into the axilla are liable. Sir Astley Cooper's experience caused him to limit his efforts to cases which had not gone beyond the period of two months. But the method of manipulation will probably change this rule. As time goes on, the adhesions grow firmer, and the bone-tissue weaker. The leverage ob- tained by the use of the thigh will be quite as likely to fracture the bone as to rupture the new tissue. Never- theless, after breaking up the adhesions, traction at right angles with the body should be employed as the means most likely to succeed. It cannot be said that we have thus far developed any definite operation of subcu- taneous surgery to assist the reduction of these ancient luxations. Cooper quotes a case in which restoration of a luxation on the dorsum occurred from a fall at the end of five years, and similar cases have been reported by others. But such cases prove only the possibilities of reduction, and throw no light on any method. There are numerous reports of the reduction of old luxations, and reasonable efforts should be made, with no reference to Cooper's rule. I merely quote one case, which shows how easily the luxation can sometimes be reduced. The following case of reduction of a dislocation of the femur on the dorsum, eight months after luxation, is re- ported by H. F. Gisborn. William W , aged forty- five, under the influence of chloroform, had his thigh freely bent and rotated to detach the connections. Grad ual extension with pulleys was then made, and in about head of the bone was thrown upon the pubis, and, as it was well carried up, the rent was extended toward the posterior border until the ilio-femoral ligament was the only portion that remained uninjured. Experiment 3. No interference with the integrity of the tissues, not even the removal of the integument was made. The limb was forcibly adducted, while rotation of the knee inward was made. By this process the head of the bone was forced from the acetabulum, having ruptured the capsule at its inferior border. After this procedure it was found, on dissection, that the head of the bone had been carried upon the dorsum. It might also be observed that the pyriformis, quadra- tus femoris, and gemelli muscles were ruptured. Spontaneous Dislocation of the Femur.-This occurs as the result of muscular action, entirely unaccompanied by external violence. The change of the form of the acetab- ulum by disease, such as cancer, would allow the head of the bone to be readily drawn upon the dorsum by the tonic power of the muscles. But the most common cause is inflammation, which softens the tissues, while it in- creases the reflex activity of the muscles through the pain incident to such conditions. The cartilage, the capsule, and the ligamentum teres, all become softened and lose their capacity of resistance. When the ligamentum teres becomes softened it is capable of being extended, and luxation may take place without its rupture, a circum- stance that never can occur from traumatic cause, while the ligament is in a normal condition. The distended capsule allows the freer motion of the head of the femur, and the violent and persistent action of the muscles may produce luxation. The writer has seen one case of this kind, in a young woman twenty-two years of age. In this case the inflammation had resulted in a denudation of the head of the bone of its cartilage, a rupture of the ligamentum teres, and a displacement of the head of the bone upon the dorsum, so as to produce a shorten- ing of the limb to the extent of two inches. The pain during a period of two months had been what might be called frightful, and was caused by the violent spas- modic contraction of the muscles due to reflex action. The condition of the tissues was revealed by an operation for the resection of the head of the bone. It might be mentioned in this connection that the case illustrates the point already stated, that the position of the thigh in luxa- tion upon the dorsum is due, not to the action of muscles, but to the power of the capsule and the ligament of Ber- tin. These having been softened, and their integrity im- paired, the thigh was found presenting almost its normal direction, with the toes forward instead of inward, and the limb not especially adducted. The symptoms of luxa- tion upon the dorsum, with the single exception of short- ening, were entirely absent. This case, however, does not present the usual charac- teristics of a spontaneous luxation. There are many cases in which the action of the muscles is not spasmodic, but continuous, and the steady pressure of the head of the bone upon the upper and outer portion of the acetabu- lum produces an absorption of its border, and a dilata- tion of the capsule, which thus does not retain the head of the bone in its socket. Dr. White reports the case of a lady, aged twenty-eight, who, without having received any injury, became bed- ridden about two years before, with much pain in the right hip and leg. The thigh was flexed upon the pelvis, and she suffered from spasmodic action of the muscles. The writer saw this patient, and confirmed Dr. White's diagnosis. The limb was shortened two and a half inches, the toes were turned toward the opposite instep, and all the signs of luxation were present. No attempt was made at reduction, but the patient was encouraged to use the limb, first beginning with crutches, and afterward walking upon it as a person lame with a dislocation does. Dr. Charles Homans relates a case of John S , a house-servant, in perfect health, who was called on to shovel a large quantity of snow, and the next day was at- tacked with intense pains in the pelvis and loins, for which he was treated, but without relief. This almost insupportable pain continued for two or three months, at 511 Dislocations. Dislocations. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bone away from its entangling border, when the muscles will swing it into place. This is not always true, it some- times being necessary to flex the leg in a very marked degree, and then to suddenly extend it, in order to effect its restoration. In all luxations more or less quiet after reduction is neces- sary, but when the knee-joint is the one involved, extraordinary care is necessary. The limb should be placed, slightly flexed, in a splint, one of the best forms of which is a double in- clined plane. This slight flexion will usually place the torn edges of the ligaments in close relation to each other, and this is the more necessary since a normal length of the crucial ligaments is essential to the perfect form of the limb and performance of the joint functions. The retention upon the splint, however, must not be too long continued. Passive motion, after the expiration of a week, should be employed daily, but very gently at first, and at the end of a month the patient may be allowed the use of the limb. The writer has notes of one case of incomplete dislocation of the end of the femur into the ham. The crucial ligaments seemed to be ruptured, from the facility with which motion could be procured. The reduction was sim- ple. A little extension and pushing of the bones into place were all that was necessary. There was, however, rather a protracted recovery in conse- quence of the inflammation of the joint. Mr. Rose reports a case of posterior dislocation of the tibia in a woman, who fell a few feet from a ladder upon the knee. The head of the tibia was thrown behind the condyles of the femur into the ham, with the patella thrown to the outer side of the exter- nal condyle of the femur. The leg was in extension. It was reduced " without difficulty to the normal con- dition, by applying one hand to the patella, the other to the back part of the upper portion of the tibia, and simultaneously pulling and pushing those bones into their natural positions. " Recovery was rapid. The following is a report of some experiments in producing dislocations of the knee artificially. Experiment 1. The muscles and skin having been removed, leaving only the ligaments, the femur was held firmly in the frame in a lateral position, and upon its external sur- face, and the leg was used as a lever, so as to carry the lower seg- ment of the limb outward. The internal lateral ligament was the first to yield, but it was found that the crucial ligaments must also be torn before a lateral dislocation could be produced. A strong ten- dency to an oblique position was found to be produced when the bone was carried far enough to transfer the internal articular sur- face of the tibia to the external con- dyle of the femur. This seemed to be due to the action of the ex- ternal lateral ligament. Experiment 2. The parts being denuded as before, and the femur held firmly, the leg was fifteen minutes it was restored to the socket with an au- dible snap. Dr. Bessy reports a case of luxation of nine months' standing, in a boy aged twelve years. Extension was tried for a considerable time, and then abandoned. Ma- nipulation was now practised, and succeeded upon the third trial. The patient was kept quiet for a period of three weeks, and then allowed to move on crutches, and finally recovered. Of compound luxations nothing need be said. They are too uncommon for us to draw any inference from ex- perience. When they occur, there is almost inevitably such severe injuries of other kinds that the results are usually fatal. However, there can be no doubt of the propriety of resection of the head, if anything is to be done. The inflammation could be no greater, and the swelling would increase the danger of septicaemia, while the limb would be less useful if life were preserved. Congenital Luxations.-These have been alluded to un- der the general head, and nothing is to be added ; but, as stated, cases of this kind have been more frequently met with at the hip-joint than in any other location. (See also under the heading Hip, Congenital Dislocations of.) One case will be quoted. Josephine G , aged eleven, the subject of a double congenital dislocation of the hip, was under the care of M. Breschet, and died of phthisis pulmonalis. At the autopsy the heads of the thigh bones were found in the external iliac fossae, covered over by the gluteus maxi- mus muscle, and between the gluteus medius and mini- mus, lying close to the lateral edges of the sacrum. Not the least depression was found on either side. The ten- dons of the pyriformis, gemelli, and obturator internus passed from below upward around the head of the femur, before they reached their insertions. The tendons also of the psoas and iliacus muscles were directed from within outward, and from below upward, so as to arrive at their point of insertion in the lesser trochanter. The head of the femur was scarcely deformed. It was, however, some- what flatter than natural on the surface lying in contact with the ilium. The cotyloid cavity was narrow and somewhat shallow. The ligamentum teres was wide like a ribbon. A large quantity of synovia was found within the capsular ligament. The cotyloid cavity was, as usual, surrounded by the cotyloid ligament. Diarthrodial car- tilage lined the cavity, and the usual vascular synovial glands were found between the bifurcations of the round ligament. If the thigh remains unreduced, the limb is still very useful, for one can walk with any one of the four regular luxations. There is a great difference in them, however, as regards the utility of the limb. The dislocation into the ischiatic notch, as shown by the figure above, results far more usefully than any other of the luxations. In the everted dorsal variety, which was described above, the extreme evertion of the toes and shortening of two inches renders the limb absolutely useless. A resection of the femur below the trochanter was made in the case referred to, and the bone turned around a quarter of a circle, to bring the toes forward. This was success- fully performed, and resulted in a great benefit in walk- ing, which was impossible before. Dislocations of the Knee.-These may occur in one of four different directions: forward, backward, inward, or outward. On account of the large size and superficial location of this joint, luxations are seldom complete with- out being at the same time compound. When they are lateral the condyle of the femur, which fits into the de- pression on the articular surface of the tibia on one side, is transferred to the depression that corresponds with its fellow, either on the inner or the outer side, and the other condyle overhangs the extremity of the tibia. When the displacement is either forward or backward, it may be complete, but is not always so. Little need be said of the diagnosis, for the parts are so superficial that these rela- tions that have been described can hardly fail to be re- cognized. Treatment.-The reduction of any of these luxations is usually easy, simple extension being enough to lift the Fig. 876.-Dislocation of Knee Outward. Fig. 877.-Dislocation of Knee Inward. Twisted. Fig. 878.-Dislocation of Knee Forward. 512 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dislocations. grasped at the ankle, so as not to be used as a lever in either direction. By means of a lever a powerful force was now applied at the upper part of leg, a few inches below the knee, so as to make pressure in a lateral direc- tion. The internal lateral ligament was again the first to give way ; then the anterior crucial ligament. At this point a strong tendency to eversion of the leg was mani- fested, and the articular surfaces acquired a transposition which, though not complete, was very nearly so, without a rupture of the posterior crucial ligament or the external lateral ligament. In order to produce a complete transposi- tion with the toes forward, it was necessary to rupture both cru- cial ligaments. Experiment 3. The integu- ments being removed from the knee, the thigh was placed upon the table upon its ante- rior surface. The leg being seized near the ankle, was used as a lever bearing downward, while the knee overhung the edge of the table. The crucial ligaments gave way, but not without drawing out a thick piece of cancellated bone from the head of the tibia. As the force was continued the condyles of the femur passed backward, rupturing the capsule as they slipped over the edge of the tibia. The lateral ligaments remained uninjured. Compound dislocation of the knee will usually be ac- companied with very alarming symptoms. The great surface will hardly escape suppuration under any man- agement. Anchylosis is evidently the best result to be hoped for. Amputation is usually clearly indicated, for the injuries that complicate compound luxations of the knee are apt to be great. If, however, an attempt is made to save the limb by bringing the surfaces of the wound together, and suppuration occurs, the writer re- commends the transfixion of the joint with a drainage- tube through which warm water (105° F.) can be passed frequently, as often at least as every hour. The knee should be enveloped in cotton, which should be sur- rounded with rubber or oiled silk. This should be kept constantly at the temperature above named by warm water. The fatal tendency of such injuries has often led to indiscriminate amputation. If the subject is young and of good habit, and living in the country, the expecta- tion of saving the limb is good. In young and healthy subjects resection of the knee should be preferred to am- putation. Dislocation of the Patella.-This is not very common. When it occurs the limb is slightly flexed, and motion of the knee produces a good deal of pain. The surface of the joint becomes flattened, and the out- line of the head of the femur can be readily distinguished, while the patella is sufficiently large to form a tumor easily recognized, whether upon the inner or the outer side, for dislocations may occur in either of these two di- rections. The displacement is usually the result of the combined action of a blow and muscular tension. Thus, when the patella is forced out mechanically upon the edge of one of the condyles of the femur, the quadriceps mus- cle becomes sufficiently tense, with the leg partially flexed, to draw it away from its normal position. But a blow alone, while the muscles are relaxed, may produce the result, and muscular action also, during the act of walking, will sometimes be a sufficient cause. The writer has known of one case in an adolescent in which the dis- placement was so produced. After this had once hap- pened, recurrence was easy, and it required a good deal of care in walking to prevent it, for the slightest twist sidewise placed the patient in danger. But as time went on, perhaps the more marked development of the lines of the bone aided in breaking up the habit. Treatment.-In order to effect reduction of the luxa- tion, the thigh should be flexed upon the body, and the leg upon the thigh, as a preliminary movement. The patella then being pushed well up upon the knee, and held flnnly by the hand of an assistant, the leg is to be suddenly extended. By this movement it is expected that the quadriceps muscle will draw the bone into place with a sudden sharp snap. The after-treatment should be continued for a period of a fortnight, by bandaging the knee carefully and forbidding its use, so as to allow as complete a restoration of the ruptured parts as possi- ble, for recurrence of the luxation is common. Dislocations Upward.-These are spoken of as luxa- tions, but improperly. The patella is merely a sesamoid bone, and when the ligamentum patellae is ruptured the bone passes upward from the contraction of the quadriceps muscle. ■ The treatment is the same as that for fracture of the patella, the bone being brought down and retained during a period of five or six weeks, by the methods em- ployed in case of fracture. Dislocations of the Upper End of the Fibula.- These very rare dislocations may occur either forward or backward, and, as the head of the bone is superficial, the diagnosis can be readily made by inspection. When dislocated anteriorly, the head of the bone seems to lie near the ligamentum patellae. When the external ham- string tendon is carried forward, the reduction is to be effected by first making extreme flexion and then push- ing the bone into its place. The principal factor in the causation of this form of dislocation is traumatism, al- though it may be produced by muscular action alone. When backward dislocation occurs, reduction is to be made very much in the same way, namely, by manipula- tion, the head of the bone being pressed forward into its normal place. It has not always been found necessary to resort to any restraint, but it is obviously more safe to have the parts held in their place until the ruptured liga- ments can unite. Dislocations of the Lower End of the Fibula.- These dislocations are still more rare than are those of the upper extremity of the bone. The broad, strong end of the bone, held in its place by very firm ligamentous at- tachments, will almost always yield above the articulation by a fracture rather than give way at the articulation it- self. Still, a violent direct blow falling exactly upon the edge of this articulation has been known to separate the two bones composing it. Restoration must first be ef- fected by manipulation, and then a retentive apparatus is to be applied. Dislocations of the Astragalus.-This bone may be dislocated in almost any direction ; either forward or back- ward, inward or outward, the two former being the positions most usually found. These two luxations are sometimes partial. As the bone has a peculiar shape, it is susceptible of being twisted in various directions by a sort of pivotal motion. But the only forms of disloca- tion that are sufficiently common to be considered as de- serving the term " regular" are those in which the bone is carried backward or forward. The symptoms consist in the production of a prominence of the bone, easily recognized from the circumstance that it is located so superficially. A complete luxation of the bone will produce such an extreme tension of the skin that it is apt to cause its rupture. There is a slight shortening of the leg, in con- sequence of the approximation of the calcaneum to the tibia. The foot is also apt to be a little twisted. When the bone comes forward, which is the more common con- dition, it is usually at the same time carried slightly out- ward. The foot, in consequence of this, becomes ad- ducted. But the astragalus may also, though very rarely, be carried directly forward, and even inward. When it is carried backward, we may find it directly back of where it belongs; but it is more apt to be twisted a little, inward or outward, in consequence of the presence of the tendo Achillis. The diagnosis of complete luxation is easy. The writer has known of two cases in which fracture occurred, the bone being broken nearly through the centre, with a complete dislocation of Fig. 879. - Disloca- tion of the Knee Backward. 513 Dislocations. Dissection. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. one fragment backward along-side of the tendo Achillis, while the other portion remained in situ. In addi- tion to these forms we have, as above stated, luxations that are partial, but accompanied with great fixation of the bones in their new relations. The question of treat- ment must depend largely upon the degree of dislocation, whether complete or partial. The writer has succeeded in one instance in returning to its proper place an astrag- alus which seemed to be removed about one-half its length forward from its normal position. The reduction was successfully accomplished, but only after great efforts, by extension, with motion of the foot backward and for- ward. In this case necrosis did not follow. When, however, the luxation is complete, the vessels are so badly ruptured that resection of the bone should be un- dertaken at once. It has often been believed that res- toration of this bone was successfully made when it was completely luxated, but it is doubtful whether the great tension which exists, even in partial luxations, was not misinterpreted. It is scarcely necessary to say that the after-treatment should be carried out in the same manner as in luxation of the ankle-joint. Dislocations of the Ankle-joint.-These may oc- cur in either of four different directions : inward, out- ward, forward, or backward, and it is seldom that they occur without the complication of fracture of the lower end of the fibula or the tibia, or, indeed, of both bones. Dislocation of the End of the Tibia Inward.-Writers use different terms in describing this luxation. When the tibia is carried inward and foot outward, the con- dition is usually spoken of as dislocation of the ankle outward. In these cases the fibula is usually fractured two or three inches above the ankle, and the internal malleolus is ordinarily broken off. That this should happen to the fibula can be easily understood, when we measure the distance that it projects upon the side of the astragalus. As the foot is carried outward, it is hardly possible for it to be completely dislocated without pro- ducing this fracture, yet this does occasionally happen. The lateral ligament in this case may be torn off from the bone and thus allow the astragalus to pass outward. The internal lateral ligament is also generally strong enough to pull off the end of the tibia, this fracture oc- curring as the direct effect of the pulling force, and not resulting from a blow or any muscular action. Symptoms.-The foot is greatly abducted, its sole being raised at the outer surface, while the end of the tibia projects under the skin on the inner side, rendering it very tense. Indeed, a compound luxation is more com- mon at this joint, in relation to the whole number of luxations, than at any other in the body. Such extreme displacement is accompanied with a great deal of pain. In this form of luxation the astragalus is forced com- pletely outward, so as to produce a separation of the ar- ticulating surfaces, but inexperienced persons may con- found this condition with the sliding of the surfaces upon each other where there is a simple fracture of the fibula, a condition which produces a marked deformity. But, under these circumstances, the bone slides back into its place almost with a touch, there being no fixation ; this is due to the fact that the side of the astragalus is not caught against the outer side of the tibia or fibula, and fixed there. Treatment.-When this luxation occurs the reduction is not always easy, but, nevertheless, it cannot be considered as one of those that often offer any serious difficulty. The traction should be made directly downward, in a line with the leg, by which the muscles whose contrac- tion causes the edges to be caught against each other may be extended sufficiently to disentangle them; when this is done the bones will immediately resume their normal re- lations. If much difficulty occurs, assistance may be de- rived from a rocking motion. If this method should fail the pulleys may be employed, with a hitch around the heel and instep, and the counter-extending band from the ham, with the leg at right angles to the thigh, in or- der to relax the gastrocnemius muscle. The after-treatment requires a little more care than in the case of similar injuries to most of the joints of the body. The dependent position is very likely to develop the bad consequences of a sprain, and therefore special precautions should be taken to secure an elevation of the limb during the time required for the repair of the liga- ments. The period of time required for the treatment of fractures, when they occur in connection with these luxations, will compel the rest which is necessary for ligamentous repair. It is also a wise precaution never to allow the ankle to be used for some weeks after this re- pair without the support of an elastic bandage. Dislocation of the Lower End of the Tibia Outward.- This is, of course, the same as a dislocation of the foot inward. In this case we have the symptoms very marked, and the reverse of those which have just been described. The fibula is usually fractured two or three inches above the joint, but the internal malleolus is not so apt to be broken off as in the dislocation above described. The re- duction is to be effected by extension in the same manner as when dislocation in the opposite direction exists. Nothing need be added with reference to the after-treat- ment. Dislocation of the Lower End of the Tibia Forward.- This form of luxation is an exceedingly rare one, and the different cases often vary much in degree. The tibia is sometimes carried forward a short distance only, but it may, however, be carried so far that, instead of resting partially upon the astragalus, it may leave it entirely and stand upon the instep. As in. the lateral luxations, the fibula is apt to give way above the ankle, and the dis- placement is sometimes complicated with a fracture of the end of the tibia. The deformity is striking : the heel projects, the lower extremity of the tibia overhangs the instep, and the motion of the ankle is lost. The reduc- tion is effected by flexing the leg upon the thigh, then drawing upon the foot in the line of the tibia. Dislocation of the Lower End of the Tibia Backward.- In these cases the heel seems to have disappeared, inas- much as it comes in a line with the tibia. The foot is ap- parently elongated. Such a deformity must necessarily occur with the end of the tibia carried back of the astrag- alus. The leg is shortened, but in order to recognize the fact we must measure from the sole of the foot. The re- duction is to be effected by extension, precisely as in other luxations of the ankle. The following case of dislocation of the foot forward was reported by Dr. Demarquay: The tibia touched the tendo Achillis; the malleoli were displaced backward, while the astragalus made a projection in front. The foot also was rotated so that the sole looked inward. The external border rested on the bed, the inner edge di- rected upward. It was reduced by bending the foot on the leg, but the manipulation had to be resorted to several times before reduction was effected. Compound Dislocations of the Ankle.-The attempt to save the foot in these cases has too often been condemned as a matter too dangerous to be left to the operations of nature. It is far more inexcusable to perform amputa- tion on these cases than on the compound luxations of the knee. Nevertheless, this has been usually the advice of teachers of surgery. The statistics of hospitals cannot govern the usage of private practice in this matter. The best results are obtained by Cooper's plan of re- secting the end of the tibia and fibula. The best result the writer has ever known was in the practice of a friend who found, as is usually the case, that both malleoli were fractured, and the ends held to the foot by the ligaments. The saw was carried directly across the end of the fibula and tibia above the point of fracture. The two malleoli were allowed to remain. Union of these to their respective bones took place, and an excellent " flail " joint was made which possessed quite a free motion. I doubt if, under the circumstances, and I repeat that they are the common ones, any better method can be devised. Cooper removed the malleoli. The writer has, on two occasions, removed the astragalus in this luxation, and thereby procured a flexible joint. It is not wise to produce anchylosis by reducing the luxation. The parts fit so neatly that the swelling creates great pain, and the pus is apt to "pocket " so as to increase the danger ; and moreover, the limb is 514 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dislocations. Dissection. not as useful as one that has been shortened a little. If anchylosis is to be the result, the limb should be short- ened an inch. If of the full length, when the movement on the foot is forward the patient must rise. If the limb is shorter he does this with more ease. Nevertheless, the chances of converting a compound into a simple luxa- tion are greater than in the knee, and the attempt, if it fails, is not likely to be so disastrous. One case, reported by Dr. R. W. Gibbs, of successful closure under very unpromising conditions will be quoted, but it will be seen that the subject is young. The patient was a negro, twenty years of age. The sole of the foot was said to have been turned outward and upward, the whole lower end of the tibia protrud- ing. When seen by Dr. Gibbs, about half an hour after the accident, the foot was in its normal position, but the internal malleolus and an inch and a half of the tibia were exposed. The inferior lip of the wound, which consisted of nothing but skin and cellular tissue, was firmly caught inside of the joint between the astragalus and malleolus. This had occurred during a spontaneous reduction, in raising or removing the patient for a short distance, and caused the wound to gape widely, the supe- rior lip extending from about the middle of the limb an- teriorly, nearly back to the tendo Achillis. The internal lateral ligament was completely severed. Two or three pieces of loose articular cartilage were removed and the parts were restored. The fibula was found fractured about two and a half inches above its inferior extremity. About half a pint of blood was lost. A thick compress, wrung from cold water, was placed under and above the malleolus, to prevent any further amount of blood from escaping or entering the joint. The wound was then neatly closed by three points of interrupted suture. The wound was dressed mostly with wet compresses of cold water, and the patient made a successful recovery with- out anchylosis. The experiments here described illustrate what we see w often in practice, viz., the separation of bones by the greater strength of the ligaments. Two powerful limbs which had been just amputated through the thigh were the subjects of these experiments. The skin was removed in order that the sequence of events in the production of luxations might be observed. A rope was carried around the foot, while the leg was firmly attached to the table. The foot was allowed to overhang its edge. Great force was brought to bear by means of a lever so as to twist the foot laterally. In attempting to carry the foot out- warciwith the leg lying upon its external border, the first tiling observed to yield was the internal malleolus, the bone being literally pulled off in consequence of the superior strength of the internal lateral ligament. The tendon of the tibialis anticus was also pulled from its at- tachment to the foot, drawing out a scale of bone instead of being itself ruptured. But although the foot was twisted well upc^i itself, so as to lie horizontally, the fibula did not give way. In the second experiment the limb was held upon the table lying upon its internal border, the same attach- ment was made around the foot so as to twist it sidewise upon itself by means of a lever. The external lateral ligament was detached from the end of the external mal- leolus, carrying with it spiculae of bone. No other in- jury was inflicted upon the internal malleolus, and no fracture of the fibula was produced. Dislocations of the Metatarsal Bones.-Disloca- tions of the individual bones have been known to occur backward or forward. They may be caused by falls upon the feet, but more often are the result of some crushing force or entanglement in machinery. There has also been a few rare instances of dislocation of all the bones in mass, produced by a weight falling across the foot. The reduction of these luxations is often very difficult, and even impossible. When a single bone is displaced backward, reduction may be attempted by extension of the toe that corresponds with it. The thumbs of the surgeon must be pressed firmly upon the bone from above, while he moves the sides of the foot backward and forward with 41 rocking motion, so as to cause the spaces to gape open, in the hope that the bone may be thus forced back into its proper place. If the dislocation is toward the sole of the foot, the same plan should be adopted, except, of course, that pressure is to be exerted in the opposite direction. Dislocations of the phalanges of the toes require no special consideration. They must be treated in the same manner as those of the fingers. Luxations of the tarsal bones are fortunately rare. The displacements of the cuboid and cuneiform bones are obvious, and they must be restored in the same manner as their analogues in the carpus, by pressure and a rock- ing motion, to cause a gaping of the parts. Addendum.-Subluxation of the Radius Forward.-While this ar- ticle is being put in type, it occurs to the author that he has made no men- tion of a form of displacement of the superior end of the radius, the exact pathology of which is a matter of dispute; for autopsies have not revealed its true nature. It exists, so far as is known, only in young children, and is caused by lifting them by the forearm or hand. Of course the tendency is to draw the radius away from the humerus. The symptoms are peculiar in the fact that the complaint, with reference to pain, is not at the elbow, so much as at the shoulder and wrist. The little one holds the arm in a semiflexed position (with the wrist dropped and pronated), resembling that observed in paralysis from lead. To one who has not seen a case of the kind the diagnosis is misleading, on ac- count of the reference of the pain to a point remote from that of the real injury. These cases are usually reduced easily by flexing and supinating the forearm. They require no after-treatment. E. M. Moore. DISSECTION AND POST-MORTEM WOUNDS are lesions of the integument produced usually by instru- ments, sharp pieces of wood, spiculae of bone, etc., dur- ing the anatomical and pathological examination of the human cadaver. Included in this class, moreover, are already existing, and previously clean, wounds which have become inoculated with the products of putrefaction of animal tissues. Clinically they derive their significance, not from the extent of the injury, which is usually trifling, but from the fact that they are, from the beginning, in- fected, or surgically poisoned wounds. The nature of the virus thus introduced into the system has not as yet been fully determined. We know, however, that con- trary to previously accepted views, we do not have to deal with a single specific poison. The characteristic symptoms and appearances observed in post-mortem and dissection wounds depend on inoculation with micro- organisms. Clinically we meet with a considerable va- riety of these lesions, and corresponding to this observed fact, no single specific group of bacteria can be regarded as the cause of all. In the majority of cases an inocula- tion occurs simply with the products of putrefaction as found in ordinary decomposing animal tissues. The re- sulting wound runs the usual course of a small but pro- nouncedly septic lesion. Here we are undoubtedly jus- tified in regarding as the excitants of inflammation the Bacillus saprogenes. No. 1 and No. 2, of Rosenbach (" Mikro-organismen bei den Wund- Infections-Krank- lieiten des Menschen," p. 70). In other cases, however, the nature of the product inoculated has evidently been influenced by the disease which caused the death of the anatomical or pathological subject. Thus inoculations received during the examination of pyaemic and septi- caemic bodies run a course widely different from that of wounds obtained in cases where the body is that of a healthy subject, and the cause of death some sudden ac- cident. Hence the clinical picture presented by post-mortem and dissection wounds varies within a very considerable range, and a number of well-defined varieties claim our consideration. 1. In a certain number of cases we meet with a small primary lesion, and a minute amount of the noxious matter originally introduced into the system through this channel, while symptoms of a general constitutional infection are of the severest and most threatening type. Here, evidently, a rapid increase in the amount of the poi- son-a rapid multiplication of the particular micro-or- ganism-takes place in the body of the patient. We see the clinical picture of putrid infection, and at times that of putrid intoxication, which can be produced experi- mentally in animals by the injection of putrescent ma- terial (Virchow'ss Archie, Bd. 100, lift. 3, p. 377). 515 Dissection. Dissection. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The constitutional symptoms are very marked and severe. A few hours after receipt of the injury the pa- tient becomes restless and anxious, and suffers from in- creasing debility, possibly accompanied by tremors and cold sweats. The pulse is weak and rapid, respirations rapid and shallow. There are nausea and vomiting, and at times diarrhoea or involuntary faecal evacuations. The urine may be suppressed, or diminished in amount, and frequently contains albumen. Periods of delirium are followed by increased debility and depression, gradually merging into coma. Death occurs in from twenty-four to forty-eight hours, with high temperature, which may continue to rise after death. In a small number of cases the temperature falls prior to dissolution, the patient dying in a condition of profound collapse. The local lesion, as stated, is very trifling. At the time of death a small vesicle, or an incipient lymphangitis, may alone indicate the point of infection. 2. Besides these very exceptional cases, there is a second class in which the symptoms are acute and threat- ening, and the course severe. Here also the local lesion is originally trifling in extent, but it soon assumes a threat- ening appearance, and this change is ushered in by more or less severe constitutional disturbances. A rapidly increasing swelling and oedema of the cellular and connective tissues proceeds from the point of intro- duction of the virus, accompanied by intense burning and aching pain. Suppuration and gangrene of the tis- sues involved follow in quick succession, probably as a direct consequence of the severe infection, for the ex- treme rapidity with which these conditions are developed indicates that they do not result merely from an acute inflammation. The subsequent course of the affection varies somewhat. (a) In certain cases the process remains a local one, and terminates in the death and separation of the tissues involved. (b) In others the process is progressive. An extensive lymphangitis, accompanied by lymphadenitis, makes its appearance, or the nearest lymphatic glands may exhibit a severe inflammation without a preceding lymphangitis. Cellulitis and' suppuration of the synovial sheaths of the tendons is added, and all these local inflammations are accompanied by constitutional symptoms of the severest type - rigors, an active febrile movement, rapid and feeble heart action, nausea, vomiting, general malaise, and debility. Post-mortem wounds obtained in making autopsies on the bodies of septicaemic and pyaemic patients are es- pecially prone to run this course. Indeed, pyaemia and septicaemia are thus directly inoculated, as a second gen- eration of the micro-organisms, and run their course with great rapidity and malignity. The patient dies of acute pyaemia, with all the symptoms well marked, and metas- tatic abscesses and infarctions in all the organs. Occasionally a more chronic form of pyaemia, or a chronic septicaemia, results from these inoculations, ter- minating fatally after several weeks or months. 3. A local manifestation of the cadaveric infection has received the name of Erysipeloid (Erysipelas Chronicum). It occurs in other persons besides anatomists, whose oc- cupation brings them in contact with decomposing ani- mal bodies, e.g., butchers, tanners, cooks, etc. A small abrasion or puncture of the integument affords entrance to the virus, and the resulting inflammation is indicated by a dark red or violet area, with sharply de- fined margin. This margin presents the same appear- ances, and progresses in exactly the same manner, as that of ordinary erysipelas. The portions of integument in- volved remain so for a longer or shorter period, becoming indurated and discolored. There is also some pruritus, and a slight degree of burning pain. Gradually these symptoms subside in the parts first involved, while the margin progresses, always retaining its sharply defined erysipelatous appearance. In this manner the process ex- tends from the terminal phalanx of a finger as far as the line of the metacarpo-phalyngeal articulation. It may stop here, or invade the dorsum of the hand, and involve it as far as the wrist-joint, or it may pass to an adjoining finger, or finally, travel back along the finger originally involved, as far as its extremity. This " wandering " may be repeated a number of times, thus prolonging the course of the affection and extending its duration to sev- eral weeks. At the same time there is a complete absence of all constitutional disturbances. Occasionally, when the process began on the dorsal surface of the hand proper, it may extend upward into the forearm, producing marked swelling, the formation of blebs, and other local symp- toms of a threatening appearance. But no fever or other general symptoms develop, and the affection of the integ- ument terminates with desquamation in from eight to fourteen days. The hands, as already indicated, are the chief seats of this peculiar inflammation. Very rarely is it observed in other parts of the body. Bosenbach records a case in which it appeared on the face. The same observer has succeeded in demonstrating the microbe which is the cause of the affection, a small irregularly shaped coccus. 4. Finally, a peculiar circumscribed hyperplasia of the- papillary structures of the skin is observed, chiefly on the dorsal surface of the hands and fingers of persons who are in the habit of handling dead and decomposing bodies. The Germans have given the name of " cadaver tubercle" (" Leichen tuberkel") to this affection. These so-called "tubercles" form hard, rounded elevations, iso- lated, or arranged in groups, which gradually extend and become confluent if the exciting cause continues to act, until finally large nodular masses are developed, which bleed freely on the slightest provocation. As a rule, they remain mere local manifestations of the irritation pro- duced by contact with the decomposing animal matter. Quite exceptionally they become the seat of an acute in flammatory process, which gives rise to constitutional symptoms. Recently Karg (Centralblatt fur Chirurgie, 1885, No. 32, p. 565) reported a case of this affection in which the- tumor, which was of considerable size, broke down and formed a suppurating cavity, lined with large fungous granulations. The lymphatic glands of the upper ex- tremity were enlarged and indurated. The tumor was removed, and microscopical examination revealed the presence of the bacillus tuberculosis (Koch), and gelatine cultures that of staphylococcus pyogenes albus (Rosen- bach). The case is still under observation for the pur- pose of determining if a constitutional tubercular in- fection has occurred. In connection with this case, Riehl, of Vienna, has published very recently an inter- esting communication (Centralblatt fur Chirurgie, 1885, No. 36, p. 631). He examined two small "cadaver tubercles/' which appeared on the hand in consequence- of an inoculation received while performing the autopsy on the body of a phthisical patient. He found the- histological picture of tuberculosis, giant-cell tubercle, and detected the bacillus tuberculosis in the granulation tissue. He inclines to the belief that the affection is a true tubercular process of a local character. It must be- stated, however, that ordinarily, in the majority of cases, the characteristic features of a tubercular neoplasm are not observed. The process remains local, and the pecu- liar new-growths frequently disappear spontaneously when the occupation which constituted the etiological factor is abandoned. In other cases, which prove more obstinate, the application of fuming nitric acid, repeated perhaps several times, suffices for their speedy removal. As regards the treatment of the other forms of infec- tion which we have considered, very little remains to be said. Prophylaxis is, of course, the important point. Autopsies and dissections should only be performed with perfectly sound hands. If lesions of the integument exist they should be protected by rubber gloves, or the application of flexible collodion. In winter, fissures of the skin, i.e., " chapping " of the hands, must be guarded against by inunctions with vaseline or lard, to which a small quantity of oil of bergamot has been added. If inoculation has taken place, immediate suction ap- plied to the wound affords the best chance of escape. Very thorough irrigation, and the application of a few drops of glacial acetic acid, or deliquesced carbolic acid, may also be employed. 516 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dissection. Dissection. If several days have elapsed since the inoculation, the wound is to be enlarged, irrigated with a solution of •corrosive sublimate, 1 to 1,000, and dressed with subli- mated gauze, 1 to 200, moistened with the same solution of 1 to 1,000. Small local inflammations, furuncles, etc., should be in- cised and treated in the same way, or cauterized with fuming nitric acid. Cases in which general constitutional infection has occurred require energetic treatment, but the results in the severe forms are, of course, not satisfactory. If an abscess has formed at the point of inoculation, the same must be opened freely and treated antiseptically. Stim- ulants are indicated, and the constitutional symptoms must be met in the usual manner as they arise. The " cadaver tubercle " may be treated in the manner above indicated, or extirpation may be performed in view of the possible tubercular nature of the neoplasm. The erysipeloid affection will disappear spontaneously, but the cure may be hastened by the application of moist bichloride gauze dressings. George 8. Huntington. of the King's Bench decided, however, that the act was a criminal one, saying that it was " highly indecent and contra bonos mores, at the bare idea alone of which nature revolted." The punishment inflicted, however, was a fine of only five marks, as the judges thought that Lynn might have committed the wrong in ignorance. A num- ber of cases have since occurred, which have been pun- ished more severely ; and quite recently (Queen vs. Price, 1884) Justice Stephen said : " The law to be collected from these authorities seems to me to be this : The prac- tice of anatomy is lawful, though it may involve an un- usual means of disposing of dead bodies, and though it certainly shocks the feelings of many persons; but to open a grave and disinter a dead body without authority is a misdemeanor, even if it is done for a laudable pur- pose. " In this country the earliest act on the subject was passed in New York in 1789. By it the removal of dead bodies for purposes of dissection was forbidden, but the courts were allowed, in passing sentence of death upon criminals, to award the bodies to the surgeons. A more compre- hensive law was passed in 1854, and it has been amended by enactments passed in 1879, 1881, and 1883. The law, as it now stands, is clear, distinct, and satis- factory in its workings. It is, as follows: " It shall be lawful for the governor, keepers, wardens, managers, and persons having lawful control and management of all public hospitals, prisons, almshouses, asylums, morgues, and other public receptacles for deceased persons, to de- liver, under the conditions hereinafter mentioned, and in proportion to the number of matriculated students, the bodies of deceased persons therein, to the professors and trustees in all the medical colleges of the State authorized by law to confer the degree of doctor of medicine. And it shall be lawful for the said professors and teachers to receive such bodies and use them for the purposes of medical study. Medical colleges which desire to avail themselves of the provisions of this act shall notify said gov- ernors, keepers, wardens, and managers of public hospi- tals, penitentiaries, almshouses, asylums, morgues, and other public receptacles for the bodies of deceased persons in the counties where the colleges are situated, and in counties adjacent thereto, of such desire, and it shall be obligatory upon said governors, keepers, wardens, and managers to notify the proper officer of said medical col- leges whenever there are dead bodies in their possession that come under the provision of this act, and to deliver said bodies to said colleges on their application. Pro- vided, however, that such remains shall not have been desired for interment by any relative or friend of such deceased person within forty-eight hours after death; provided also, that the remains of no persons who may be known to have relatives or friends shall be so delivered or received without the assent of such relatives or friends ; and provided that the remains of no person detained for debt, or as a witness, or on suspicion of crimp, or of any traveller, or of any person who shall have expressed a de- sire in his or her last illness that his or her body be in- terred, shall be delivered or received as aforesaid, but shall be buried in the usual manner ; and provided also, that in case the remains of any person so delivered or re- ceived shall be subsequently claimed by any relative or friend, they shall be given up to said relative or friend for interment, and it shall be the duty of said professors and teachers to dispose of said remains in accordance with the instructions of the Board of Health in said localities where such medical colleges are situated, after the remains have served the purpose of study aforesaid. And for any neglect or violation of the provisions of this act, the party so neglecting shall forfeit and pay a penalty of not less than twenty-five nor more than fifty dollars, to be sued for and recovered by the health officer of said cities and places for the benefit of their department." Similar laws have been passed in some of the States, and twenty-four have declared dissection to be legal, and have indicated the source of supply, which generally is the gallows. The following is the list of States : Ala- bama, Arkansas, California, Colorado, Connecticut, Georgia, Illinois, Indiana, Iowa, Kansas, Maine, Massa- DISSECTION, THE LAWS OF. The legislation on the subject of dissection has been mainly enacted during the present century, there having been prior to that time a strong popular prejudice against permitting any vio- lence to the dead, even in aid of medical science. This prejudice has not entirely disappeared even yet, but it does not now avail to prevent the legal exercise of the practice. In England the first permission was granted by Henry VIII., in 1540, but this favor does not seem to have been granted with any enlightened idea of its ad- vantages to physicians and surgeons. It appears rather to have been granted for the purpose of adding another horror to the death of malefactors. The statute then en- acted allowed the masters of the mystery of barbers and surgeons of London to take annually four persons, put to death for felony, for anatomies, and to make incision of the same dead bodies, or otherwise to order the same after their dissections at their pleasure, for their further insight and better knowledge, instruction, learning, and experience in the science or faculty of surgery. Queen Elizabeth, in 1565, allowed the College of Physicians a similar privilege, directing that they should observe all decent respect for human flesh. In 1752 George II. permitted the bodies of all murderers executed in London and Westminster to be delivered to the surgeons for anatomical purposes. These statutes were far from furnishing an adequate supply of bodies for anatomical ■examination, and numerous attempts were made by grave- robbers to meet the wants of medical students. This evil became so great that in 1832 the Anatomy Act was passed, and it is in pursuance of its provisions that the medical profession of Great Britain now secure material for dis- section. The preamble of the statute recites the insuffi- cient supply of bodies for anatomical examination, and its principal section is as follows : ''It shall be lawful for any executor or other party having lawful possession of the body of any deceased person, and not being an under taker or other party intrusted with the body for the pur- pose only of interment, to permit the body of such de- ceased person to undergo anatomical examination, unless to the knowledge of such executor or other party such person shall have expressed his desire, either in writing at any time during his life, or verbally in the presence of two or more witnesses during the illness whereof he died, that his body after death might not undergo such exami- nation ; or unless the surviving husband, or wife, or any known relative of the deceased person shall require the body to be interred without such examination." Justice Stephen says that the result of this statute is, " that the bodies of persons dying in public institutions, whose relations are unknown, are so dissected." It was an offence at common law to disinter a body, and in 1788 a man named Lynn was indicted for opening a grave and removing a body for dissection. The case was a novel one, and the jurisdiction of the criminal court was denied on the ground that the offence was cognizable only in the ecclesiastical courts. The judges 517 Dissection. Dita. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. found in the mucous lining of the ducts and gall-bladder, due to disease caused by the worms, or to calcification. The disease has been proved to exist in but few cases in the human being, but unless the number of parasites present is considerable, the symptoms may not be prominent, and the dis- ease may escape notice. From being- found in the gall-ducts, it was thought the animal might feed on bile, but its food is the blood-corpuscles and mu- cus. This induces the chlorosis which is one of the chief symptoms. To prevent the disease in sheep, keep them on high ground, feed on dry food, give plenty of salt. The flesh of animals dying of rot is not absolutely unfit for food, but it is watery and poor eating. 2. Distoma lanceolatum, or lancet- shaped fluke, is reported as having- occurred a few times in the human subject; it is a small, flat worm, eight to ten millimetres long and half as broad ; broader posteriorly near the termination of ovaries. The skin is smooth, and it has no booklets. The oral sucker is very near the end ; the testes are globular, one in front of the other in the median line ; the; uterine canal is long and in convolu- tions, reaching nearly to the posterior- end of the body. The changes in the larvae and the intermediary host are not at present known. 3. Distoma crassum, or large human fluke, has a thick, flat body, four to six centimetres long and one and a half to two centime- tres broad ; suckers close together and near the end ; the alimentary canal, dividing into two, passes to the poste- rior third of the body ; just behind this bifurcation, and before the ventral suck- er, is the regenerative opening, according to Kiichenmeister (just be- hind, according to Cob- bold) ; the body is point- ed anteriorly, rounded behind. The testes form round prominences be- low the ventral sucker in the median line; long folds anteriorly are probably uterine, while laterally are two large vitelline glands. The most noted cases of the occurrence of this para- site in man were in a missionary and his wife, from China; the other cases quoted by Kiichen- meister were also from China. Diagnosis i n such cases would prob- ably be accidental ; it would be confirmed by finding the eggs in the fseces. The presence of this parasite induces no special symptoms. Cob- bold thought milk diet was the best treatment. 4. Distoma sinense (D. spathulatum, Chinese fluke), has a small, flat body, conical in front, oval be- hind, fifteen to eighteen millimetres long (-^ to inch), with smooth skin ; oral sucker terminal. This worm also occurs in China, and a diagnosis of its presence can chusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, Ohio, Pennsylvania, Tennessee, Vermont, and Wisconsin. A large number of States (twenty-nine) have, by law, forbidden the removal of bodies interred in the usual way for purposes of dissection. These States are: Ala- bama, Arkansas, California, Connecticut, Georgia, Illi- nois, Indiana, Iowa, Kansas, Kentucky, Maine, Massa- chusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Virginia, West Virginia, and Wisconsin. A large number of the States have made no provision for anatomical study, except as is furnished by the bodies of condemned criminals, and it is to be hoped that legisla- tion similar to that passed in New York will soon be gener- ally adopted. Henry A. Riley. DISTOMA, commonly called fluke-worm or fluke, be- longs to the trematode worms. They derive their name from having two suckers on their ventral surface for im- bibition and adhesion; gen- erally the male and female organs of reproduction occur in the same individual. There are several subdivisions. 1. Distoma hepaticum, Fas- ciola hepatica, or liver-fluke, has been found in almost all ruminating animals, in whom, when present exten- sively, it produces the dis- eases termed rot, coathe, iles, bone, pourriture, Egelseuche, etc. This prevails especially at certain seasons and in cer- tain places where the land is low and moist. Free eggs escaping from animals af- fected, cling to herbage, or enter small snails (Linnaeus truncatulus ?) and are thus transferred to other animals. This may occur from July to September; then, after an incubating period of one to three months, they develop and induce a series of symp- toms. After expulsion with the faeces, the eggs continue to develop into a ciliated em- bryo which can swim in water; after a few days the cilia fall off, leaving the embryo as a creeping larva; this, entering an intermediary bearer, becomes a sac or sporocyst (redia); then an active migrating larva (cer- carius); then becomes encysted (pupa), and in this shape, with food or drink, enters the body of some ruminant and grows to be a sexually mature fluke. This is a flat worm, two to three and a half centimetres long, shaped somewhat like a pumpkin seed, with two suckers near the anterior extremity of the ventral surface, below which are the reproductive orifices ; it is covered with ring-like spiny scales. The development of the larva? is favored by warm, moist weather ; salt seems to disagree with them ; they are often numerous in fresh-water mollusks, such as snails, etc. Immense numbers of sheep die from the " rot; " when affected with this disease pressure on the loins causes the animal to wince, and the sensation given to the hand is peculiar ; after a time the spines of the vertebrae pro- ject and the belly sags; the eyes become watery, the conjunctiva oedematous, the wool brittle, and it is easily plucked. On examination after death flukes are found in the biliary passages, sometimes as many as a thousand being present; the bile is full of the eggs, which may also be found in the intestines. Hard spots are sometimes Fig. 881.-Distoma Lanceolatum. Mag- nified. Showing di- gestive and repro- ductive organs. (After Blanchard.) Fig. 880.-Fasciola Hepatica. (En- larged ; after Blanchard.) Fig. 882. - Distoma Crassum. a, Oral sucker ; 6, intestine ; c. caecum ; d. re- productive papilla ; e, uterine rosette ; /, one of its folds ; A, a hernial protru sion ; i, upper testis ; J, streaks of es- caped seminal fluid ; A. lower testis ; I, ventral suckers. Magnified. (Cobbold.> 518 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dissection. Dita. only be made by finding its eggs. The development has not been observed. 5. Distoma conjunctum much resembles the above, but is smaller ; McConnell describes it as be- ing the same, but Kiichenmeister and Cobbold give it as distinct. It is eight millimetres long by two and a half milli- metres broad ; first found in an American fox, but also found in a patient at Cal- cutta Hospital. 6. Distoma heterophyes is very minute, being little .more than a millimetre in length (I line), discovered by Bilharz, of Cairo, in the intestines of a boy. It is called small Egyptian fluke. Cobbold describes it as having " an oblong, pyri- form outline, attenuated in front, and obtusely rounded behind ; " especially characterized by having a circular disk around the reproductive orifices, whose margin supports seventy fish-basket-like ribs. Distoma oculi humani, D. ophthalmo- bium. Four specimens were found in the eye of a dead baby, but were probably unripe specimens of one of the above helminths. Amphistoma ho- minis, according to Kiichenmeister, has been found twice in patients who have died of cholera in India ; they cling in hun- dreds to the large intestine, especial- ly the caecum; they resemble tadpoles; they subsist on blood from the in- testinal walls; they are five to eight millimetres long, and half as broad ; they have a sucker at the tail end. The symptoms induced by them would be irritation of the mucous membrane, more particularly of that lining the caecum, causing dysenteric symptoms ; and eggs would be discoverable in the stools, possibly also some of the worms or their remains. Per- haps, from difference in loca- tion, treatment might be more successful here than in other cases of these worms, as large injections of vermicide de- coctions might be brought to bear on them. Kiichenmeister describes as doubtful trematodes Tetras- toma renale (which Cobbold says has been found in the urine), Ilexathyridium vena- rum, and H pinguicula. The specimensdescribed probably belonged under some other head. D. haematobium, or Bilhar- zia haematobia, is a trematode worm having male and fe- male organs of reproduction on distinct animals. The male is cylindrical, twelve to fourteen millimetres long, the female filiform, sixteen to nineteen millimetres long ; in both, the oral and ventral suckers are near together in front ; the reproductive ori- fices are just below the ventral sucker. The body of the male contains a gynaecophoric canal below the ven- tral sucker, in which the female is lodged during copula- tion. The eggs are oval, .09 millimetre or less in di- ameter ; they do not hatch out in the urine, but do so in a few minutes if placed in fresh water, or if the urine be freely diluted with water ; they then become swimming animalcules or ciliated embryos. If decomposing matter be added to the solution containing the embryos they die. Passing the urine into fresh water insures speedy hatch- ing. The host in which these embryos develop is un- known. In human beings the Bilharzia is found in the vessels of the liver, mesentery, bladder, etc. In Egypt, Cape of Good Hope, and elsewhere, it often causes disease, with symptoms of haematuria, diarrhoea, chlorosis, and pros- tration ; the seat of the disease is the blood, which is the habitat of Bilharzia, which enters the body with drinking- water. Distoma Ringeri. Patrick Manson, in his book on " Fi- laria Sanguinis Hominis," speaks of endemic haemopty- sis in parts of China (Formosa and elsewhere) and in Japan. In the sputa of such cases eggs were found which, by cultivating in water for six or eight weeks, were developed into ciliated embryos. These he supposes may be taken up by some fresh-water fish or mollusk as their host, or they may enter the human stomach with drinking-water and then develop. In one case, which died of aortic aneurism, the parent worm (containing ova) was found on a cut surface of the lung (by Dr. Ringer); so it is not known if its location is in the bron- chi or in the pulmonary artery ; the difference in location would affect the treatment; if in the bronchi inhalations might benefit. The ova are probably laid in or under the bronchial mucous membrane ; being expectorated they often reach the water and there develop as above sug- gested. This is still another reason for boiling water be- fore using. Charles E. Ilackley. Fig. 8S3.-Distoma S i n e n s e. En- larged. a, Oral sucker ; b, oeso- phageal bulb; c, intestine ; c', its c te c a 1 end ; d, ventral sucker; e, genital pore uterine folds; g, ovary; A, vitella- rium;i, vitelligene duct ; k, upper seminal reservoir; I, testes; m, lower seminal pouch ; o, vas de- ferens ; p, pulsa- tile vesicle; p', water vessel. (From Cobbold, after McConnell.) DITA (Codex Med.). A name given to the bark of Alstonia scholaris R. Brown {Echites scholaris Linn.); Order, Apocynacea. A large, handsome Indian and Poly- nesian tree, with whorled leaves, and long hanging pods. Its wood is fine-grained and useful. Its bark has been a valued remedy in the East for years, but although oc- casionally referred to by travellers during the past century or more, it scarcely found its way to this country until about a dozen years ago, when it was proposed as a gen- eral substitute for quinine. It consists of irregular pieces of a rather coarse, spongy bark, up to a centimetre or more thick (J to i inch), and from five to twenty in length, with a rough and uneven dark gray or brownish, often spotted, external surface, and a buff, striated in- ternal one. The fracture is short and cellular ; the broken surface light-yellowish brown. Taste, decidedly bitter ; odor, none. Composition.-Jobst and Hesse, some years ago, se- parated half a dozen or more constituents from this bark, among which were three alkaloids, ditamine, echitamine, and echitenine-all amorphous, of which the second has a paralyzing power comparable to curare. Harnack, some time later, succeeded in isolating a crystalline base, which, he claims, is the only one in the bark, and which he named ditaine. It appears to correspond with the echi- tamine of Hesse. The commercial " ditain" is a yellow, amorphous substance, considered to be an impure ditaine of Harnack. Action and Use.-The alkaloids of dita are not used ; the bark and Galenical preparations from it were offered with considerable enthusiasm, at one time, as substitutes for quinine, both as an antiperiodic and tonic ; as the for- mer they have completely failed ; as a tonic, the bark has probably some value, but not enough to recommend it over the common bitters now in use. Dose said to be from four to sixteen grams, in infusion (Rice). Allied Plants.-The genus Alstonia contains thirty species of fine tropical trees, mostly Asiatic. A. constricta, "yellow parillin," an Australian species with opposite Fig. 884.-Distoma Hete- rophyes. Enlarged. Showing large ventral sucker, uterus, and testes. (Cobbold.) Fig. 885.-Distoma Hsematobium. The lower end of the female is withdrawn from the gynsecoph- oric canal of the male. (From Cobbold, after Kuchenmeister.) 519 Dita. Diuretics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. leaves, has also lately furnished a medicinal bark. Like the other, it is a thick, corky bark with rough brown ex- ternal surface ; the color of the internal surface is, how- ever, more yellow, and its fracture more fibrous. Taste, exceedingly bitter. It contains, according to Hesse, Al- stonine, porphyrine, and alstonidine, all amorphous sub- stances, making fluorescent solutions. This bark is also proposed as tonic and antiperiodic. Allied Drugs.-Bitters in general. See Gentian, etc. W. P. Bolles. normal state of the organism the general blood-pressure is such as to supply the kidneys with an abundance of blood, so that they can rapidly remove from it the urinable sub- stances it may contain. Some of the ordinary changes in the quantity of urine are attributable to variations of the general blood-pressure. Thus when the surface of the body becomes cold the vessels of the skin contract, and the general blood-pressure slightly increases ; the urine then becomes more abundant, less dense, and light-colored. On the contrary, when the surface of the body is exposed to a very warm atmosphere, the superficial vessels dilate, and the blood-pressure falls somewhat ; as a consequence the urine becomes scanty, dense, and high-colored. But the quantity of water flowing from the glomeruli depends also upon the concentration of the renal blood. When the renal blood contains a minimum of water, the glomerular epithelium can remove or secrete but little, and the urine becomes dense, scanty, and high-colored. On the contrary, when the renal blood contains a maxi- mum of water, the renal epithelium removes the surplus rapidly, and the urine becomes copious and light-colored. This is well illustrated in health by the variations in the quantity of urine resulting from the amount of fluid in- gested. Soon after imbibing large draughts of water, a copious flow of light-colored urine takes place. By most writers, the abundant secretion of urine after the ingestion of large quantities of liquids, is attributed to an increase of the general arterial blood-pressure, and is supposed to take place in consequence of augmentation of the volume of the blood. But the experiments of Heidenhain,3 Cohnheim,4 and others have established the fact that a mere augmentation of the volume of the blood does not elevate the general blood-pressure. As, there- fore, the ingestion of liquids produces no alteration of the pressure and velocity of the blood-flow in the renal ves- sels through the general circulation, it is evident that the presence of large quantities of water in the blood of the glomeruli excites the glomerular epithelium to aug- mented aotivity. The indirect diuretics have been defined as medicines which increase diuresis by augmenting the general arte- rial blood-pressure. This results from their action on the heart, wdiose energy becomes increased. They do not, it is now held by most authorities, exert any direct action on the kidneys, since they are incapable of augmenting the flow of urine when they fail to increase the force of the heart's action. In the normal state of the organism, they do not markedly augment the quantity of urine, evidently because the blood-pressure is generally at its maximum height. But when the blood-pressure is ab- normally low from inefficient heart action, and the secre- tion of urine has abated in consequence of scanty supply of arterial blood, they display great power over the secre- tion of urine, often in a short time producing a copious flow. The quantity of the solids of the urine depends upon the activity of the epithelial cells of the uriniferous tu- bules. All authors accord to these cells an active secre- tory function. They take from the blood in the capil- laries surrounding the tubules the urea, uric acid, kreatinin, and other products of metabolism, and prob- ably foreign substances such as medicines and poisons, and discharge them into the channels of the tubules. The activity of the epithelium depends upon the quan- tity of such urinable substances contained in the renal blood, increasing when they are abundant, and diminish- ing when they are scanty. It depends also upon the ve- locity of the blood-current, since with an accelerated flow a larger quantity of urinable substances is brought into relation with them in a given time. When the blood flowing into the kidneys contains a large amount of such substances and a minimum of water, the urine becomes dense, scanty, and high-colored. On the contrary, when the renal blood contains only a minimum of them and a maximum of water, the urine becomes pale, less dense, and very copious. It is evident, therefore, that the de- gree of activity of the two secreting structures of the kidney is dependent primarily on the quality of the renal blood. DIURETICS are medicines which increase the secre- tion of urine. They are divided into two classes, direct and indirect. To the first class belong all medicines which produce an increase of diuresis by influencing the kidneys di- rectly ; to the second, those which accomplish this by augmenting the general blood-pressure. In order to have a clear conception of the practical bearing of this division, it is necessary to understand the conditions which modify the urinary secretion in health and disease. The activity of the kidneys, in their healthy state, de- pends upon the quantity of blood flowing through the renal vessels, and the amount of urinable substances (that is, substances which are eliminated by the kidneys, such as water, inorganic salts, urea, uric acid, etc.) which it contains. As both the quantity and quality of the renal blood undergo marked changes, the urine secreted at different times by healthy persons presents striking variations in amount, color, and density. These varia- tions are readily accounted for by the well-established fact that the principal constituents of the urine, the water and the solids, are secreted in different parts of the kid- neys, the Malpighian bodies, and the uriniferous tubules. These two parts are not always equally active, and hence the normal variations in the composition and quantity of the urine. The quantity of the water of the urine depends chiefly on the activity of the Malpighian bodies or glomeruli. They separate from the renal blood its surplus of water and those salts which it normally holds in solution, such as chloride of sodium, etc. From the glomeruli the water passes into the lumen of the uriniferous tubules, where it serves as a solvent or vehicle for any substance which may have been secreted by the epithelial cells of the tubules. The quantity of water yielded by the glomeruli is regu- lated, according to Ludwig,1 by the pressure of the blood in the capillaries of the glomeruli, but according to Hei- denhain,2 by the velocity of the blood-current. Ludwig holds that the passage of water through the walls of the capillaries, and the simple layer of epithelial cells cover- ing the tuft of capillaries, is merely a mechanical filtration. Accordingly, the greater the pressure in the capillaries, the more abundant the water which filters through them, and the more the pressure in the glomeruli exceeds the pressure in the tubules, the more rapid and extensive the process of filtration. Heidenhain, on the contrary, maintains that it is the velocity of the blood-current which deter- mines the quantity of water flowing from the glomeruli. The more rapid the blood-current in the glomerular capil- laries, the more copious the flow of water. When the blood-current is very rapid, a larger quantity of water is brought into relation with the epithelial cells of the glo- meruli in a given time, and hence their activity becomes augmented. Thus Heidenhain regards the removal of w'ater from the blood of the glomerular capillaries to be a process of active secretion by the epithelial cells of the glomeruli. Normally, blood-pressure and rapidity of blood-flow in the Malpighian bodies are simultaneously increased or diminished, but in some pathological states the pressure may be augmented while the flow is retarded. As the quantity of water flowing from the glomeruli depends upon the abundance of blood in their capillaries, it is evident that the quantity of urine secreted must be controlled by the general arterial blood-pressure. When the blood-pressure is high, the urinary secretion is abundant; when it is low, the secretion is scanty. lu the 520 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dita. Diuretics. The kidneys, like all other organs, in a measure regu- late their own blood-flow. When they are active, they contain an abundance of blood ; when inactive, they are comparatively bloodless. When, for instance, the activ- ity of the epithelium becomes excited by the presence of urinable substances, there quickly takes 'place a more abundant flow of blood to the kidneys, or rather to the secreting apparatus, in consequence of dilatation of the renal arterioles. This statement does not rest merely on general principles. Heidenhain (op. cit., p. 339) found in experiments that a very dilute solution of nitrate of sodium, or urea, injected into the blood, greatly increased the flow of urine, when it had abated in consequence of low blood-pressure. No change of the blood-pressure re- sulted from the injections, and hence the augmented flow of urine could not be attributed to rise of the general ar- terial pressure. That it was solely due to an increase of the local pressure in the vessels of the kidneys, and aug- mented velocity of the blood-current, is evident from the experiments of Cohnheim and Roy.5 These investiga- tors found that small quantities of a very dilute solution of urea, or chloride of sodium, injected into the circula- tion, which in no wise influenced the general blood-press- ure, soon caused a very decided increase of the bulk of the kidney. This shows that the amount of blood flow- ing through the kidneys-that is, the degree of dilatation of the renal arterioles-depends upon the quantity of urin- able substances in the renal blood and the activity of the renal epithelium. Augmented activity of the epithelium is hence always attended by an active physiological hyper- aemia. From this it follows that all medicines which increase the flow of urine by a direct action on the kidneys cause more or less active hyperaemia. Some of the direct diuretics, if given in large doses, diminish the quantity of urine and render it bloody and albuminous, which shows that they may so greatly irritate the secreting epi- thelium and the walls of the capillaries as to produce in- flammation, and thus retard and even completely arrest the blood-flow of many parts of the kidney. Direct Diuretics.-Some of the direct diureties pro- duce a change in the chemical reaction of the urine, rend- ering it less acid or even alkaline. They are called saline diuretics. Numerous diuretics, when administered in ■excessive doses, diminish the quantity of urine, and cause other symptoms characteristic of irritation or inflamma- tion of the kidneys. Hence they are distinguished as irritant or stimulant diuretics. Some of the members of this group arrest diseases of the genito-urinary mucous membrane caused by micro-organisms. They accomplish this, at least in part, by acting destructively upon the micro-organisms, and may therefore be styled antiseptic •diuretics. Saline Diuretics.-To this group belong many of the salts of potassium, sodium, lithium, calcium, and mag- nesium. The salts of potassium cause a more decided increase of the urinary secretion than the other salts, and hence are always preferred when an increase of the quantity of urine is indicated. Of the salts of potassium the acetate, citrate, and bitar- trate seem to possess equal diuretic power. This is readily explained by the fact that in the organism they are all converted into the carbonate, and as such are eliminated by the kidneys. Doubtless, in being eliminated they excite the renal epithelium to increased activity, in consequence of which an active hyperaemia results, and hence an augmented flow of watery urine. That the increase of diuresis is not due to an augmentation of the general blood-pressure is proved by the fact that injections of dilute solutions of chloride of sodium into the veins are rapidly followed by an increase of the bulk of the kidneys and a free flow of urine, although the general blood-pressure is not altered. The urea of the urine becomes increased by the action of some of the saline diuretics. Formerly it was held that all of them have this effect. But in careful obser- vations, Mayer6 found that carbonate of sodium markedly increased both the water and urea of the urine, while acetate of sodium increased only the water and dimin- ished the urea. It is evident, therefore, that the increased diuresis fs not dependent on an augmented quantity of urea in the renal blood. After large doses of carbonate, citrate, acetate, and bitartrate of potassium, the urine becomes alkaline. The bicarbonate of potassium was found by Ralfe1, when ad- ministered before meals, to increase the acidity of the urine, but, given after meals, to diminish it. The action of salines is held by many physicians to be due in part to changes of the general circulation, and, in febrile diseases, to lowering of temperature. If they are capable, as claimed by some recent writers, of produc- ing antipyretic effects, their diuretic action in fevers may partly result indirectly. For it has been found ex- perimentally by Mendelson8 that in fevers the kidneys become diminished in bulk, in all probability in conse- quence of the action of the hot blood on the vasomotor centres. Husemann9 recommends nitrate of potassium, even in small doses, in inflammatory diseases, on the ground that it lowers the febrile temperature and im- proves the general condition of the patient. Indications for the use of saline diuretics.-The saline diuretics are employed to meet two indications : first, to remove morbid accumulations of serum; secondly, to neutralize an excess of acid in the urine. Excessive accumulations of serum occur in a variety of pathological states, diseases of the heart, liver, kidneys, and as a consequence of inflammations. When the mor- bid condition giving rise to the dropsy is amenable to treatment, the diuretic action of the salines is often fol- lowed by rapid absorption of the effused liquid. This is especially the case when an abundant effusion occurs in consequence of inflammation of serous membranes, as in pleuritis, pericarditis, peritonitis, etc. After the symp- toms of active imflammation have subsided, the use of salines is generally followed by rapid absorption. Their utility is less evident in dropsies dependent upon organic diseases of the heart, lungs, liver, and kidneys ; but when associated with other therapeutic means indi- cated by the pathological condition giving rise to the dropsy, they often greatly hasten absorption. Thus, in cardiac dropsy the chief indication is an increase of the arterial blood-pressure. This the saline diuretics cannot accomplish. But when they are combined with the in- direct diuretics which augment the force of the heart's action, they promote the diuretic action of the latter and thus accelerate absorption. In renal dropsy saline diuretics may be useful or harm- ful, according to the condition of the kidneys. In the dropsy attending acute nephritis, they will do harm as long as the inflammation is the cause of the diminished secretion of urine. The kidneys, when inflamed, like all other organs, require rest. The administration of salines may not only cause injury to the kidneys directly by augmenting the quantity of blood in them, but may hasten the appearance of uraemic symptoms. When, however, the inflammation has subsided, and the free flow of urine is prevented by the presence of tube-casts and masses of blood in the uriniferous tubules, they may become useful by hastening the removal of these impedi- ments. In the dropsy of chronic renal disease the saline diu- retics rarely possess much utility. But in some cases their administration is followed by increased diuresis. This is observed especially when the dropsy results from failure of the compensatory action of the heart. Com- bined with digitalis, or other medicines which augment the force of the heart's action, they often cause a copious flow of urine. So, too, in the hydraemic dropsy following exposure to cold, or disorder of digestion, the saline di- uretics, associated with such remedies as the special pathological condition indicates, are often followed by efficient action of the kidneys. In any case of chronic renal dropsy the use of saline diuretics, if they do not produce an increase of diuresis, should not be long continued; for if the kidneys have become so severely damaged that they cannot remove the surplus of water from the renal blood, they will also be unable to eliminate these medicines. Their persistent 521 Diuretics. Diuretics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. employment will, therefore, soon be productive of serious disorder, especially feebleness of the heart's action and symptoms of uraemia. For the purpose of increasing diuresis, the acetate, citrate, bitartrate, and nitrate of potassium are given in doses of ten to thirty grains every two or three hours. The acetate and citrate may be administered in several tablespoonfuls of water, to which may be added a small amount of orange or lemon syrup. The nitrate, if given in large doses, should be administered in more water, say a wineglassful, lest it act injuriously on the gastric mucous membrane. On account of its slight solubility the bitartrate also requires a large amount of water. To meet the second indication for the use of saline diuretics, namely, to neutralize excessive acidity of the urine, and thus to prevent the irritation resulting from excess of uric acid and its deposition in the urinary pas- sages, the salts of potassium are generally preferred, especially the acetate and citrate. This preference de- pends upon the fact that the urate of potassium formed under these circumstances is a very soluble salt. Should it, however, be necessary to employ remedies for a long time, and evidences of gastric disorder become manifest, the salts of sodium would be more eligible, as they are better borne by the stomach. The acetate and citrate of potassium may be given to adults in doses of a drachm twice daily, at bedtime and early in the morning, in a tumbler of water. Recently the salts of lithium, especially the carbonate and citrate, have been much used to prevent deposits of uric acid and urates in the urine, and have proved very effectual. Experimentally it has been found that these salts are more powerful solvents of uric acid than the salts of potassium and sodium. They seem also to dis- solve, to some extent, the deposits of urate of sodium occurring in gouty subjects. The carbonate of lithium is given in doses of three to ten grains, in a tumbler of water, several times daily. It may be ordered as follows: B- Lithii carbonatis, 9ij. ; sacchari albi, 9iv. M. Div. in partes aequales viij. Sig.: One powder three times a day. Stimulant, or Irritant Diuretics.-This group includes all direct diuretics which increase the urinary secretion when used in moderate doses, but diminish it and pro- duce various symptoms of severe irritation or inflamma- tion of the kidneys when given in excessive quantities. They differ greatly from one another in the degree in which they manifest these properties, in some the diu- retic, in others the irritant property, preponderating. Only the former are useful in cases requiring an increase of diuresis. The most frequently employed are juniper, scoparius, and resin of copaiba. Juniperus.-Besides a volatile oil, juniper berries con- tain a notable quantity of alkaline salts. Their diuretic action is usually attributed solely to the volatile oil, but the fact long observed that the infusion is more efficient than a corresponding quantity of the oil, shows that the salts exert a decided effect. Juniper is frequently used as a diuretic in the forms of dropsy due to heart-disease, affections of the lungs inter- fering with the circulation, and contracted kidneys. Without other remedies acting directly on the heart, so as to increase the arterial blood-pressure, it is not very effective. Hence it is generally combined with digitalis, squill, and sweet spirit of nitre, as in the following well- known formula: B. 01. juniperi, 3 ss. ; spiritus aetheris nitrosi, tincturae digitalis, aa 3 iij. M. Sig.: From twenty to thirty drops every three hours. In very large quantities juniper, especially its volatile oil, may excite much irritation of the kidneys, and cause the urine to become bloody, albuminous, and very scanty. Hence it is contra-indicated in all cases of dropsy in which the kidneys are inflamed. It is, however, sometimes em- ployed in the dropsy following scarlatina, but only in the form of infusion, with saline diuretics. It should never be employed until other methods of treatment have re- lieved the kidneys. The following formula has been much used to hasten the absorption of inflammatory effusions : B • Infusi juniperi (ex. | ss.), 3 vj.; potassii acetatis, 3 iij.; syrupi scillae, 3 ss. M. Sig.: One tablespoonful every two hours. Scoparius.-This medicine is highly esteemed as an active diuretic by English physicians. Stille lu holds that no diuretic is^ entitled to more credit than broom for re- moving dropsical effusions. Administered in ordinary doses, it decidedly increases the urinary secretion, and sometimes also the action of the bowels. Excessive doses may cause vomiting, purging, and irritation of the urinary organs. Scoparius contains two proximate principles, scoparin, a neutral substance, and sparteine, a volatile liquid alka- loid, besides a notable quantity of potassium salts. Its. diuretic power is partly attributable to the salts, but chiefly to scoparin, which was found by Stenhouse to produce very great increase of the urinary secretion in doses of three to seven grains. According to Frou- miiller11 it acts when applied hypodermatically in doses, of half a grain, and in normal as well as abnormal states, of the organism. The alkaloid sparteine acts strongly on the nervous, system. According to the experiments of Fick15 on ani- mals, it produces staggering gait, enormous increase of the- pulse and breathing, followed by great dyspnoea and slow heart action, and finally convulsions with dilatation of the pupils. It probably also possesses diuretic properties, as Froumiiller found an increase of the urine in some pa- tients after administering from thirty to seventy-two drops of an alcoholic solution containing one part in forty. Scoparius is usually employed in the form of a decoc- tion containing one part in twenty. Of this the dose for an adult is about two ounces, at intervals of three to six hours, It may be employed in any form of dropsy, if the- kidneys are healthy. Pulmonary congestion and inflam- mation are said to contra-indicate its use. Frequently the- decoction of scoparius is combined with other diuretics, as in the following formula : 5 • Potassii acetatis, 3 ij.; syrupi scillae, § ss. ; decocti scoparii (Br. Ph.) ad 3 vj. M. Sig.: One tablespoonful every two hours. Resina Copaiba.-In some forms of dropsy, especially in ascites, the resin of copaiba has been found to be a. very active diuretic. In 1872 Wilks13 called attention to this property of the resin. He had succeeded with it in numerous cases of dropsy, but particularly in ascites, after other remedies had failed. It acted less certainly in cardiac dropsy, but sometimes produced decided diuresis when other remedies had been powerless. Brudi14 and others have also reported decided success in ascites, and in a few cases of cardiac dropsy. Frederick Taylor,15 who used the resin in more than sixty cases of different forms of dropsy, fully confirms these observations. The dose of the resin varies from five to twenty grains, which may be given three or four times daily. In exces- sive doses it may produce great irritation of the stomach, intestines, and kidneys. The urine of patients taking the resin may throw down a precipitate, on the addition of nitric acid, which may be mistaken for albumen. It may be readily distinguished from the latter by its disappear- ance on the addition of alcohol. Wilks gave fifteen or twenty grains of the resin in mucilage and flavored water three or four times a day. Brudi used the following formula : B • Resinae copaibae, 9iv. ; alcoholis, 3 ij. ; chloroformi, gtt. xx. ; mucil. acaciae, 3 ss. ; aq. destillatae, 3 vss. M. Sig.: One table- spoonful three times a day. The following medicines stimulate the kidneys, but their diuretic action is not very decided, and hence they are not often employed in cases requiring an increase of the urinary secretion. They also exert a decided influ- ence on the mucous membrane of the urinary passages, especially noticeable when a catarrhal state is present, as in pyelitis, cystitis, and urethritis: chimaphila, buchu, uva ursi, pareira, petroselinum, taraxacum, erigeron canadense, carota, armoracia, and cantharis. Antiseptic Diuretics.-To this group belong medi- cines which arrest morbid processes of the urinary pass- ages produced by micro-organisms. They are supposed to act destructively on the disease-germs, although their cur- ative power is also due, at least in part, to a peculiar in- 522 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diuretics. Diuretics. passages. Binz 21 maintains that the resinous acid exist- ing in the cubeb, or formed in the organism by oxidation of the oil, in flowing for several days over the affected •mucous membrane, lowers the vitality of the gonococci in the same manner as injections of bichloride of mer- cury and other substances. The dose of cubeb varies from ten grains to one drachm. The oleoresin is administered in doses of ten to thirty drops, usually in gelatine capsules, or in emulsion. Oleum Santali.-According to numerous observers the oil of yellow sandal-wood possesses properties analogous to those of copaiba. In doses of ten to thirty drops it imparts a peculiar odor to the urine and rapidly modifies the symptoms of catarrhal inflammation of the genito- urinary mucous membrane. According to Keyes,22 it is less effective in true gonorrhoea than in ordinary ureth- ritis, though sometimes it rapidly diminishes the discharge and scalding. In excessive doses it is productive of severe irritation of the kidneys, marked by intense pain over the regions in which these organs are located. The dose of sandal-wood oil is from ten to twenty drops. It is usually administered in gelatine capsules, each containing ten drops, or in emulsion. Indirect Diuretics.-To this group of diuretics be- long all medicines which modify the heart's action so as to increase the general arterial blood-pressure. As the urine secreted during their action is copious and watery, they are often called hydragogue diuretics. Digitalis.-In healthy persons digitalis exerts no obvi- ous effect on the quantity of urine secreted, unless it be taken in excessive doses, or be too long continued, when the quantity becomes lessened. In cardiac dropsy it usu- ally produces its action upon the kidneys as soon as the heart's action becomes slower and stronger, and the gen- eral blood-pressure is increased. When the cardiac fail- ure is so profound that digitalis cannot invigorate the ventricular contractions, it completely fails as a diuretic. Digitalis is indicated as a diuretic in cardiac dropsy ; that is, whenever an abnormal accumulation of serum in the areolar tissue, or in a serous cavity, is the result of inefficient heart action, and hence of general venous con- gestion. Hence it is applicable in the forms of dropsy due to valvular disease, degeneration of the hypertrophied heart, fatty heart, and dilatation of the right ventricle in consequence of chronic bronchitis and emphysema, or other pulmonary diseases. Digitalis is alwsiys contra-indicated when the pulse is strong and hard. In all cases it must be very cautiously given, as after some days, without having produced any obvious effects, it may suddenly act with unexpected severity. The cause of this cumulative action is not known. Schmiedeberg23 supposed it to be due to slow absorption and apparently slow elimination of its active principles. Of the elimination of its active principles, however, nothing is known, as they cannot be detected in the excretions. Van der Heide,24 who has recently in- vestigated the cumulative action of digitalin on animals, holds that the active principles of digitalis form chemical compounds with the constituents of the organs upon which they act, and that these compounds are slowly formed and very gradually disintegrated. He advises that digitalis be given in small doses, at long intervals, and that extreme caution be exercised in its use, if no dis- tinct change of the heart's action is induced in a few days, as then the continued administration may cause very threatening symptoms, and even death. As a rule, its use should be interrupted as soon as the pulse has be- come slower and diuresis increased. The following symptoms are regarded as cumulative effects, and their occurrence requires immediate discontinuance of the medicine : Decided slowness and irregularity of the pulse, nausea and vomiting, severe headache, dimness of sight, giddiness, sleeplessness, and delirium. The initial dose of digitalis is one or two grains three times daily. If it be necessary to repeat the dose every two or three hours, the patient should be visited twice daily. Scilla.-Squill is a diuretic of very decided power, often in a few days greatly increasing the quantity of urine, when before it was very scanty. It is not, however, equally fluence on the blood-vessels of the affected mucous mem- brane. Hence they are often used in catarrhal diseases of the urinary passages of doubtful or unknown etiology. Oleum Terebinthince.-In small doses, ten to twenty drops, at intervals of three or four hours, oil of turpentine slightly increases the urinary secretion and imparts to it an odor of violets. Large doses, from half a drachm to two drachms, repeated several times, soon cause marked irritation of the kidneys, manifested by diminished secre: tion of urine, which may be bloody and albuminous, and by frequent micturition. * Since oil of turpentine is incapable of causing decided diuresis, it is never employed in dropsy. But in catar- rhal affections of the genito-urinary tract it is in frequent use, as it usually soon diminishes the amount of mucus and pus in the urine. Thus, in cystitis Edlefsen 16 found that it ameliorated the dysuria, restored the acid reaction of the urine, and arrested the purulent discharge, in doses of ten drops given five times daily. Rossbach 11 investigated the action of oil of turpentine on the mucous membrane of the trachea. Air, passed through the oil so as to become saturated with it, forcibly projected against the mucous membrane, arrested the secretion of mucus. A watery solution containing one or two per cent., dropped upon the tracheal mucous mem- brane, caused an increase of secretion,' but greatly di- minished the supply of blood. It is held that a similar action on the blood-vessels takes place in catarrhal affec- tions of the urinary passages, in consequence of which the morbid action ceases. Oil of turpentine acts destructively on low organisms. This property is still further increased by the free oxygen which the oil usually contains (Binz *•). Hence it is very probable that the effects of the oil in putrid processes of the respiratory and urinary mucous membranes is chiefly due to its destructive action on the low organisms always present under such circumstances. Oil of turpentine is administered in gelatine capsules, or in emulsion with gum arabic, oil of almond, or yolk of egg. Olei terebinthinae, olei amygd. expres., aa 3 j.- ij.; mucil. acacise, syrupi, aa § ss.; aq. destill., | iij. M. Sig. : One tablespoonful three times a day. Copaiba.-In small doses, ten to twenty drops, this oleoresin usually somewhat increases the quantity of urine, and imparts to the urine a darker color and a peculiar odor. It also renders the urine aseptic, so that it resists putrefaction for a long time. Large doses, one or two drachms, are apt to cause irri- tation of the kidneys, marked by diminished secretion, frequent micturition, and even haematuria. Often, how- ever, such doses are well borne. Copaiba is doubtless able to produce very decided diuresis, and it was quite frequently employed in dropsies before it was known that the diuretic power is chiefly attributable to its resinous constituent. The oleoresin is often decidedly useful in catarrhal af- fections of the genito-urinary mucous membrane, especi- ally in those of specific origin. In cases of cystitis with alkaline urine, copaiba often rapidly restores the normal acid reaction. Edlefsen,19 and numerous other observers, have reported speedy amelioration of all the symptoms of cystitis. Binz20 holds that the constituents of copaiba, or the products resulting from their oxidation in the or- ganism, passing into the urine, paralyze the cells about to escape from the vessels, prevent alkaline fermentation, and weaken the energy of infectious bodies. The utility of copaiba in gonorrhoea is doubtless chiefly due to its antiseptic action. Copaiba is given in doses of ten drops to one drachm. Rarely are doses exceeding half a drachm required. It is administered in gelatine capsules, or in emulsion with gum arabic and sugar. Cubeba.-In moderate doses cubeb increases somewhat the urinary secretion. In excessive doses it may dimin- ish the urine and render it bloody. Some individuals are very sensitive to its action and may suffer from irritation of the kidneys after several drachms of the powdered drug. Cubeb is frequently employed in gonorrhoea and other catarrhal diseases of the mucous membrane of the urinary 523 Diuretics. Dosage, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. active in all forms of dropsy, manifesting little influence when the effusions are due to organic alterations of the kidneys or liver, or to inflammations of serousmembranes. Formerly it was held that squill acts directly on the secreting structures of the kidneys, since excessive doses were sometimes followed by strangury and bloody urine. But the experiments of Husemann 25 on animals, in which toxic doses produced no marked changes of the kidneys, show that squill exerts a very slight, if any, direct influ- ence. On the contrary, the recent investigations of Drouot,26 Jarmersted,21 and Husemann and Konig28 ren- der it certain that its diuretic action takes place in con- sequence of a modification of the heart's action. In its action upon the heart it closely resembles digitalis, influ- encing it, however, more rapidly and less durably. The slowing and strengthening of the pulse, which, in man, in- dicate an increase of the blood-pressure, usually continue only a few hours after ordinary doses. The indications for the use of squill as a diuretic are the same as for digitalis. It is, perhaps, less efficient in cardiac dropsy than the latter remedy, but is often com- bined with it, as the combination acts more rapidly and effectually than either medicine alone. Squill is often administered in the dropsy occurring in anaemic and cachectic patients, generally together with iron and quinine. The dose of squill is from one to three grains, admin- istered from three to six times a day. In excessive doses it rapidly disorders the stomach, but never produces cumulative effects ; hence it may be continued for a long time in moderate doses without risk. Squill is generally supposed to be contra-indicated in acute nephritis, and all forms of Bright's disease. There is, however, no evidence that it causes decided irritation of the kidneys. Caffeina.-This alkaloid acts as a decided diuretic in some forms of dropsy, especially those resulting from cardiac disease. For some years it has been freely em- ployed by French and German physicians in cardiac dropsy, when digitalis had failed. It has been strongly recommended by Gubler, Dujardin-Beaumetz, Riegel, and Binz. According to these observers it regulates the heart's action, slows the pulse, and augments the arterial blood-pressure. It produces these effects more rapidly than digitalis, has no cumulative action, and is usually well borne. Often it succeeds after digitalis has been used in vain. Caffeine is indicated in cardiac and hydraemic dropsy, especially when the heart is fatty. The citrate or hydrobromate may be given in doses of two grains every three hours, or from fifteen to twenty grains, in divided portions, in twenty-four hours. The follow ing formulae are recommended by Riegel: R. Caf- feinae citratis, gr. iv.; sodii salicylatis, gr. iijss.; aquae, § j. M. For one dose, internally. R. Caffeinae citratis, f;r. xx.; sodii salicylatis, gr. xvijss.; aquae, 3 j. M. Dose, rom one to six minims, subcutaneously. Adonis vernalis.-This plant, long used in Russia as a popular remedy for dropsy, was recommended by Bub- noff29 in 1879, and again in 1882, as a succedaneum of digitalis. He carefully investigated its action and uses, and found it to produce the following effects in cardiac disease with dropsy: the heart's impulse became decid- edly stronger; its dimensions were markedly lessened ; the heart-sounds and murmurs, especially the praesys- tolic and systolic murmur of aortic stenosis, became better defined ; the rhythm wras rendered more regular and mostly slower; and the pulse was correspondingly in- fluenced, becoming slower, stronger, and fuller. The flow of urine was decidedly increased, sometimes, in the course of twTenty-four hours, from ten to eighty or one hun- dred ounces. Its diuretic action was equally marked when cardiac failure occurred in chronic kidney disease, but only w hen the dropsy resulted from the weak heart action. Nothnagel30 tried adonis in cardiac dropsy, and gen- erally found it to increase the general blood-pressure and the flow of urine, sometimes acting after digitalis had failed. More frequently the reverse was the case, adonis failing and digitalis succeeding. The action of adonis on the heart is due to a glucoside, adonidin, isolated by Cervello31 in 1882. Adonis has no cumulative action, but it often causes nausea, vomiting, and diarrhoea. Bubnotf usually gave an infusion containing from one to two drachms of adonis in six ounces, in doses of a tablespoonful every two hours. Convallaria majalis.-This drug contains a glucoside, convallamarin, which was found by Marine32 to act on the heart like digitalin. Both convallaria and its active principle have been tried in cardiac dropsy, with varying results. Thus Leubuscher,33 who administered as much as one gramme of the active principle in twenty-four hours, in no instance observed an increased flow of urine, a fall of the oedema, or a rise of the blood-pressure. Hil- ler also reported unfavorably. Maragliano,34 on the con- trary, found convallaria and its active principle useful in mitral disease with cardiac failure, the heart's action be- coming stronger and more regular, and the urine in- creased. It had no cumulative effect. Frederick Roberts35 also succeeded with convallaria. In a case of mitral ob- struction the heart's action became more regular and ef- ficient, the thrill and murmur more evident, the quantity of urine progressively increased, and the dropsy disap- peared. But in some other cases its action was less satis- factory. Falkenheim36 tried convallaria in eight cases of heart-disease, and found it to exert a decided control over the heart's action and diuresis, but it seemed less certain than digitalis. He gave a tablespoonful of an infusion of the strength of one part of the flowers in twenty parts of water every two hours. Roberts used a liquid extract in doses of ten minims every four hours. Apocynum cannabinum.-It has long been known that this medicine produces infrequency of the pulse and, in some forms of dropsy, copious diuresis. From its botan- ical relations Husemann31 supposed that it contains an active principle affecting the heart in the same manner as digitalin. Schmiedeberg38 has since isolated two active principles, apocynin and apocynein, which resemble digi- talin in properties. It seems very probable, therefore, that apocynum in- creases diuresis by acting upon the heart, and that it is specially adapted to dropsy resulting from inefficient car- diac action. Usually it is administered in the form of an infusion made with a drachm of the bark of the root in eight ounces of water, of which the dose is a tablespoonful at intervals of four to six hours. Excessive doses cause nausea, vomiting, and purging. Samuel Nickles. 1 Ludwig: Lehrbuch der Physiol., 1856, Bd. 2, p. 274. 2 Heidenhain : Hermann's Handbuchd. Physiol., Bd. 5, Abth. 1, p. 318. 3 Heidenhain : Ibidem, p. 334. 4 Cohnheim : Vorlesungen uber Allg. Pathol., 1882, Bd. 1, p. 400. 6 Cohnheim and Roy: Ibidem, Bd. 2, p. 358. 6 Mayer, J.: Binz' Vorlesung. uber Pharm., 1885, p. 469. 7 Ralfe : London Lancet, New York reprint, February, 1879, p. 88. 8 Mendelson : Amer. Journ. of the Med. Sciences, October, 1883, p. 380. 9 Husemann : Handb. d. gesammt. Arzneimittell., 1883, p. 883. 10 Stille: Nation. Disp., 1884. p. 1358. 11 Froumuller : Husemann's Pflanzenstoffe, 1884, p. 1027. 12 Fick, J.: Arch. f. exp. Path. u. Pharm., Bd. 1, p. 397. 13 Wilks : London Lancet, March 22, 1872, p. 410. 14 Brudi: Deutsch Arch. f. kl. Med., Bd. 19, p. 498. 16 Taylor, Fr.: Nat. Disp., 1884, p. 506. 16 Edlefsen : Deutsch. Arch. f. kl. Med., Bd. 19, p. 82. 17 Rossbach : Festschrift d. Facultat zu Wurzburg, 1882, p. 42. 18 Binz : Vorlesungen liber Pharm., 1885, p. 413. 19 Edlefsen: Deutsch. Arch. f. kl. Med., Bd. 19, p. 87. 20 Binz : Vorlesung u. Pharm., 1885, p. 437. 21 Binz: Ibidem, p. 435. 22 Keyes: Venereal Diseases, 1880, p. 262. 23 Schmiedeberg : Arch. f. exp. Path. u. Pharm., Bd. 15, p. 185. 24 Van der Heide: Ibidem, Bd. 19, p. 149. 25 Husemann : Arch. f. exp. Path. u. Pharm., Bd. 5, p. 255. 26 Drouot: Amer. Journ. Med. Sciences. July, 1879, p. 243. 27 Jarmersted : Arch. f. exp. Path. u. Pharm., Bd. 11, p. 22. 28 Konig and Husemann : Arch. f. exp. Path. u. Pharm., Bd. 5, p. 253. 29 Bubnoffi : Deutsch. Arch. f. kl. Med., Bd. 33, p. 285. 30 Nothnagel: Nothnagel and Rossbach's Arzneimittellehre, 1884, p. 816. 31 Cervello : Arch. f. exp. Path. u. Pharm.. Bd. 5. p. 245. 32 Marmo : Husemann's Pflanzenstoffe, 1882, p. 402. 33 Leubuscher : The Year-Book of Treatment for 1884, p. 5. 34 Maragliano : Ibidem. 35 Roberts : Ibidem, p. 6. 36 Falkenheim: Arch. f. kl. Med., Bd. 36, p. 84. 37 Husemann : Arch. f. exp. Path. u. Pharm., Bd. 5, p. 245. 3b Schmiedeberg : Ibidem, Bd. 16. p. 161. References. 524 Reference Handbook of THE Medical Sciences. PLATE 8. CORNUS FLORIDA. H. BENCKf., LITH. N. Y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Diuretics. Dosage. DOCK, YELLOW (Rumex, U. S. Ph. ; Patience [I?a- cine de], Codex Med.). The roots of several European species of Rumex (order, Polygonacece), which have be- come naturalized in this country as persistent weeds, con- tribute to the "Yellow Dock" of the Pharmacopoeia. They are all bitter perennial herbs, with long spindle- shaped or fleshy, simple or slightly branched yellowish tap- roots, and coarse leaves and stems ; the flowers are rather thick and strongly veined, and have wavy or crimped borders; the stems are simple or but little branched, leafy, and terminate in long, often lax and wandlike racemes or panicles. Flowers small, perfect, trimerous. R. crispus Linn, is smooth, with narrowly lanceolate, very much crimped leaves. R. obtusifolius Linn, is coarser, with broader, blunter, and partially downy ones, and those of R. sanguineus Linn, are usually bloody- veined ; and there are others. Dock is an old European medicine which has become pretty much obsolete in respectable practice. The roots, which should Ije collected either in spring or autumn, and if large, spliror sliced to facilitate drying, are " From eight to twelve inches (20 to 30 centimetres) long, about half an inch (12 millimetres) thick, somewhat fusiform, fleshy, nearly simple, annulate above, deeply wrinkled below ; externally rusty-brown, internally whitish, with fine, straight) interrupted, reddish, medullary rays, and a rather thick bark ; fracture short; odor slight, pecu- liar ; taste bitter and astringent." Composition.-This has some resemblance to that of inferior Rhubarb, especially the European, excepting that in Dock the astringency is predominant, while in Rhubarb the cathartic elements are so. Ghrysophomic acid and tannin are the most important constituents ; oxalate of lime, starch, gum, resin, etc., are also noted. Action and Use.-Dock is slightly astringent, with a suppressed laxative element, and possibly tonic. It has been used in chronic skin troubles, scurvy, etc., but its principal employment is in the concoction of domestic and proprietary " Spring Bitters" and " Blood Purifiers." A Fluid Extract is officinal (Extractum Rumicis Flu- idum, U. S. Ph.). Dose, 4 c.c. (- 3 j.). Allied Plants, etc.-See Rhubarb. IF. P. Bolles. bitter tonic ; as such, however, it is good and useful. It was one of the drugs proposed as a substitute for cin- chona in the treatment of intermittents, and, like them all, has been completely set aside by the general use of quinine. A Fluid Extract is prepared {Fxtractum Gomus Fluidum, U. S. Ph.), of which the tonic dose is about two cubic centimetres ( 3 ss.). Allied Plants.-There are about twenty-five species in this genus, having, in general, the same qualities. G. sericea L'Herit, and C. circinata L'Herit, were formerly both officinal; cornin has been found in the former. The order contains no other important medicinal plants. Allied Drugs.-Willow, Magnolia, etc. ; for pure bitters, see Gentian. W. P. Bolles. DOSAGE. Under this title will be discussed the prin- ciples that determine standard dosage, and the circum- stances that necessitate modifications of such dosage. 1. Standard Dosage.-The word dose, in connection with the matter of the administration of medicines, is used in two distinct senses, which must be carefully dis- criminated, as follows : In one sense the dose of a medi- cine may be taken to mean the quantity necessary to produce a certain therapeutic effect for the time being, and in another acceptation the same word signifies the quantity to be administered in a single portion. Very frequently the two doses, in these two senses, are identi- cal-the quantity necessary for an effect being given all at once-but very often again they are not. Thus twenty grains of quinine-a dose of that medicine for an anti- pyretic effect-may be administered in four individual doses of five grains each, taken at short intervals. Dose, in the sense of quantity necessary for a given effect, is, of course, determined by trial. In stating doses, in this sense, regard must be had to whether the effect aimed at be a passing one only or a continuous one. In the former case the dose can be categorically stated, as, for instance, that the purgative dose of castor-oil is a tablespoonful; but in the instance of a continuous effect such categorical statement is impossible, since dose now refers to the quantity necessary to be present in the blood at any single moment. Dose, in such cases, must be stated in terms of the amount required to be given within a certain period for the maintenance of the necessary im- pregnation of the system. In such statement the period most convenient, and therefore most commonly used, is the term of twenty-four hours. So, for instance, we say that the dose of a bromide as a single sleeping-draught is simply so much, but we state the dose of the same medi- cine for the controlling of epilepsy at so much a day, since now a certain grade of bromism must be main- tained unremittingly for months or even years. Standard dosage can never be set at a precise figure ; in the first place, because therapeutic achievements do not permit of precise mensuration, and, secondly, because the factors that determine degree of medicinal effect are many and impossible of exact estimate. All posological tables must therefore be taken to exhibit only averages. Individual medicines may have more than one standard dosage if they subserve different purposes attained by dif ferent dosage. Thus quinine has one dose as a simple bitter stomachic, but another and quite different one as an antipyretic. Dose, in the sense of amount to be administered in one portion, is, of course, primarily based on dose in the fore- going sense, but is also affected by other considerations. In cases where a transient- effect only is wanted, the rule is to give the whole dose at once, unless there be positive dis- advantage in so doing; and that practically means unless the whole dose, swallowed in single portion, be likely to disorder the stomach. In such case the charge is given, as the phrase is, in divided doses; that is, in moieties ad- ministered in even succession at intervals long enough to save the stomach, but short enough to secure the practical presence of the whole charge in the blood at once. In cases where the medicinal impression is to be con- tinuous, the daily allowance is to be given in such division of dosage as will best harmonize the conflicting considera- tions of maintenance of equability of impression on the DOGWOOD, FLOWERING (Cornus, U. S. Ph.). In previous editions of the Pharmacopoeia several species of Cornus were admitted ; now, however, the name is re- stricted to the bark of Cornus florida Linn., order, Corna- cece, the Flowering Dogwood, or Shad-Blow, as it is called in some parts of the country. The Cornels are shrubs or small trees, with generally opposite, simple leaves, and minute tetramerous, perfect flowers, in close glomerules, or in flatfish cymes. C. florida is a small tree, from twelve to thirty feet high, with slender, spread- ing branches, hard wood, ovate-pointed leaves, and very showy flower-clusters. These are each supported by four large, broadly obovate and notched, cream-colored, peta- loid bracts, which make the whole look like an enormous whitish flower (see accompanying plate); the real flowers, however, are minute, greenish-yellow, and closely aggre- gated. Fruit clustered, small, scarlet, two-seeded berries. It is common in the middle and southern portion of the United States, rarer and smaller in northern New England. When thrifty it is very showy in blossom, and pretty also when the fruit is ripe. Dogwood Bark consists of the liber deprived of the corky portion ; it is in irregular flattish pieces, or in quills from two to four millimetres thick (| inch), and of varying length. The surfaces are smooth, pale reddish or reddish-brown, the fracture short and brittle, the text- ure hard. Taste, bitter and astringent; odor, none. Dogwood is exclusively an American remedy. Composition.-A bitter, crystalline, neutral substance, cornin, first described by Geiger, and afterward by Frey. It is in white, silky, very bitter crystals, soluble in alco- hol and water. Tannic acid, sugar, fatty oil, and resin are among the other constituents. The cornin and the tannin are its active principles. Action and Use.-There is no reason to suppose that this medicine is anything more than a slightly astringent, 525 Dosage, Driburg. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. one hand, and avoidance of undue disturbance of the pa- tient on the other. For the one consideration calls for administration by frequent small moieties, and the other for the minimum of frequency. Practically, the rule is to administer in as few doses as will suffice for equability and for non-derangement of the stomach or other avenue of introduction, and, if the frequency so determined be still so great as to unduly disturb (a serious consideration in very ill subjects), to reduce further, even at the sacri- fice of perfect equability. The amount of each dose will of course be determined by the frequency. In following out this rule, the first thing to find with a given medi- cine is that minimum of frequency of giving which will attain a practical equability of effect. This minimum will differ enormously with different drugs-a fact often not properly recognized-being determined by the rela- tion between rate of absorption and of elimination, which varies greatly among medicines. In a general way, com- pounds of the heavy metals are slow of elimination, whence follows the fact that a mercurial impression is practically equable with a renewal of doses, by the mouth, of no greater frequency than thrice daily, or, by inunc- tion or fumigation, once daily even ; and, similarly, that tonic doses of iron hardly require more frequent giving than three times a day. Salts of the alkalies of high diffu- sion power, however, are much more rapidly eliminated ; so that to maintain an equable effect with them the daily allowance in continuous medication should be broken up into at least four charges, and a distribution into six, even, may in many cases be distinctly advantageous. The alka- line iodides and bromides are prominent examples of this class of medicines, and the best therapeutic effects of these salts are often missed through the error of giving at too long intervals. Diffusible alcohols and ethers require an even greater frequency of administration, if the effect is to be maintained with any approach to equability, and the same is true also of many neurotic alkaloids. A prominent example in point among alkaloids is aconite, which, given for the purpose of reducing heart-action, should be administered at least hourly, the amount given on each occasion, of course, bearing proper relation to the frequency. The second consideration, in practical application of the rule laid down, is to so grade the frequency that each individual dose may be of such size as, locally, not to de- range the stomach, and, constitutionally, not to produce an initial over-great effect. Here again the importance of the consideration is often overlooked by prescribers, and a patient is unnecessarily sickened, or his functions un- duly perturbed, by large infrequent dosage, when pre- cisely the same therapeutic effect from the medicine could have been gotten without distress or without derangement by the same dosage broken up into more frequent, and hence smaller, individual charges. From the foregoing presentment there appears, then, distinct advantage, in the case of the majority of medi- cines when given for the purpose of maintaining a con- tinuous impression, of administering the daily quantum by the method of little and often, as opposed to that of much and seldom, and the only consideration calling for a halt in carrying the method to its extremes is that of the disturbance of the patient entailed by frequent ad- ministration. This disturbance is most serious in the extreme condition of slight indispositions on the one hand, and desperate illness on the other ; in the former case the patient, not too sick to attend to his ordinary avocations, being intolerably annoyed by an over-frequent dosing, and in the latter instance the subject, ill nearly unto death, and needing the most careful nursing of fast- ebbing vitality, being likely to have his life literally worried out of him by incessant wakings and liftings to swallow medicine. An important factor affecting standard dosage-whether dose for a transient or continuous effect-is bulk of sub- ject, since obviously, for constitutional effect of constant degree, the amount of drug must be proportioned to the amount of blood in which the drug is to be dissolved. Cognizance of this factor is most important in pre- scribing for children. To meet the case of the necessary scaling of doses to fit the varying bulks of this class of patients, several formulae have been devised, of which the two in commonest use-Young's and Cowling's-work by the age of the subject, on the presumption-true enough for the purpose in hand-that children of a given age are of a given bulk. Young's rule is that, taking the adult dose at unity, the fraction thereof proper for a child of given age is expressed by the formula - age six, for instance, the fraction is ~A = i, i.e., O 6 4- 12 ' a child six years old should be given one-third of the dose proper for an adult. Cowling's formula is, under . age at next birthday . . the same premises, - * At age six, by this formula, the proper fraction of the adult dose is, then, A = a little less than In general, with the younger ages Cowling's formula yields a slightly smaller dosage than Young's. A formula much less used, because of its in- convenience, is Clarke's, wherein actual weight, instead of age, determines the dose. In this formula, standard dose being unity, the dose for a subject of given weight is ex- pressed by a fraction of which the numerator is the num- ber corresponding to the weight in avoirdupois pounds, and the denominator is the arbitrary number 150, corre- sponding to the pound weight of the average human adult. 2. Circumstances Necessitating Modification of Standard Dosage.-These circumstances, which are many and potent, are as follows: Age, apart from the consideration of bulk of subject, calls, in the case of many medicines, for special adjustment of dose. In general, children are more susceptible to drug-influence than adults, and, in striking particular, this fact obtains in the instance of opium. In general, further, both ex- tremes of age bear actively perturbing medication badly. Sex is another element to be considered in adjusting dosage, women, bulk for bulk, being generally more sus- ceptible to medicines than men, and particularly so as re- gards neurotic drugs. Climate must also be regarded, with especial reference to the facts that in warm weather the digestive system is unduly sensitive, and that depress- ing measures are disproportionately enfeebling to vitality. Custom may powerfully affect dosage, sometimes en- hancing, but more commonly lessening, normal effects. This lessening is markedly seen in the case of the strictly neurotic effects of so-called neurotic drugs, such as opium or alcohol, although with this same class of drugs-a fact often overlooked-the effects other than immediate nerve- function disturbance may be wholly uninfluenced, or even enhanced in intensity, by habit. Thus is presented, for instance, the curious anomaly that the habitual toper, while with increasing potations he gets no more drunk, in the common sense of the word, yet does get progres- sively more and more catarrhal as to his stomach and bowels, more cirrhotic as to his liver, more apoplectic as to his brain, and more debased as to memory, manners, and morals, with every drop added to his daily allow- ance of liquor. Idiosyncrasy is another important factor in dosage, working now to increase, and now to lessen, the standard ; and, lastly, physiological status must be re- garded, since, in practice, morbid conditions may pro- foundly modify normal susceptibility to medicinal in- fluences. A notable instance of this circumstance is again in the case of neurotic drugs, which, in conditions of great devitalization, require vastly larger doses than normal to produce normal grades of effect. Thus a sub- ject at death's door from a sudden voluminous loss of blood may swallow doses of opium or of brandy that would be actually fatal in health, with no other effect than to have the faltering heart and flickering nerve- functioning sustained until natural recuperation begins. In actual prescribing, therefore, particularly of neurotic drugs, while the standard dosage of the posological tables is of course the basis, yet the wise physician regards this merely, so to speak, as a function of the status of his patient, such dosage to be boldly and intelligently in- creased or diminished according to the effects produced or producible. 526 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dosage. Driburg. From all the foregoing two corollaries appear, of obvious practical importance-the one, that dosage can- not for a given drug be set at one categorical figure ; and the other, that, even with given conditions, dosage can never be estimated with any approach to precision. Edward Curtis. The symptoms induced by Dracunculus are called dra- contiasis; they do not usually appear till the worm has attained some size, unless it is located in the eye, nose, tongue, or other especially sensitive part. The local symptoms depend on the locality ; an abscess forms, and the pain which it causes is usually out of proportion to the apparent swelling. When the abscess opens, and the head of the worm is seen, gentle traction may be made on it, and as the an- terior part of the worm is drawn out, it may be wound around some soft substance and fastened to the body by adhesive plaster; this may be repeated several times daily; it may be from three to ten days before the whole worm will be extracted. Should the worm break during this operation, severe inflammation may result; this is, perhaps, due to the escape of the embryos into surround- ing tissues. That severe inflammation is not a constant consequence of this rupture was shown in the only case of this kind that the writer has seen. It was in the per- son of a man who said he had served in the English army in India. Prophylaxis against this, as against so many parasites, would be by filtering drinking-water and by ob- serving great cleanliness of utensils ; but even this does not seem to be wholly effective. Charles E. Hackley. DRACUNCULUS MEDINENSIS, Filaria medinensis, Medina worm, or Guinea worm, as it is variously called, is one of the Nematodes found only in hot countries, or in persons who have been there. This parasite is supposed by many helminthologists to be the "fiery serpent" which attacked the children of Israel in the Red Sea region. Speaking of the same region, Plutarch is quoted as saying: "Little snakes, which came out upon them, gnawed away their legs and arms, and when touched retracted, coiled themselves up in the muscles, and gave rise to the most insupportable pains." The male dracunculus is unknown, but is probably very small. The female is only known as found in the human body, where it attains a length of 60 to 80 ctm. ; it is shaped like a catgut, with a thickness of 0.5 to 1.7 mm. ; the head is flatly convex, mouth central, sur- rounded by four equidistant papillae ; the cylindrical body is transversely striated, tail pointed, skin yellowish- white. The mode of reproduction is vi- viparous, and the young are supposed to escape by rupture of the mother's body and uterus, as there is no vagina and no anus in the adult female ; though there is an anus in the smaller females. (In some similar worms (Ichthyonema) the male has a couple of firm spiculae, and it is supposed that he enters these into the body of the female, and thus introduces the spermatic fluid ; her inside being all uterus.) This makes it resemble a prog- lottid of the Cestodes, while the differ- ence in sexual organs distinguishes it somewhat from Filaria, which it other- wise closely resembles. It was long supposed that the young obtained entrance to the human body through the skin, by the patient's ex- posing his hands or feet in the water. But Fedschenko, whose investigations were made at Leuckart's suggestion, and are fully described in- the latter's book on Human Parasites, has shown that, after leaving the human host, the em- bryos enter certain Crustaceans, where in twelve hours they change their skin and begin to grow, and in the course of five weeks attain a length of 1 mm. They pass with drinking-water, etc., to the stomach of their future host. It is supposed they may here mature and copulate, and the females pass to their location under the skin and develop farther for twelve to fifteen months, while the males die and pass away with the faeces. But this parasite may be an example of parthenogenesis, a number of successive generations coming without further impregnations. A complete discussion of this question, as well as of the anatomy, etc., of Dracunculus medinensis maybe found in Leuckart's " Menschlichen Parasiten," vol. ii. When the worm is broken or slit open, a creamy sub- stance escapes; this consists chiefly of filamentary em- bryos. They have not been free in the abdomen ; but the uterus is so enlarged that its walls are closely applied to the abdominal walls, and the two are ruptured together. Leuckart estimates the embryos in a single worm at eight or ten millions. In India most cases are seen from March to June. And the period of incubation, from the time the embryo enters the stomach till the worm is developed, is supposed to be from nine to eleven months, which would make the period of infection correspond with the end of the previous rainy season. DRAGON'S BLOOD {Sang dragon, Codex Med.). A deep-red resin which exudes spontaneously from the ripe fruits of Calamus Draco Willd, order, Palmce, one of the Rattan Palms of Borneo, Java, and other Polynesian islands. It is collected by shaking the ripe fruits in a basket, sifting out the resin and, by means of warmth, moulding it into little balls, or more usually into slender sticks, twenty or thirty centimetres long and about as thick as the finger. These are wrapped in pieces of palm- leaf and tied. Inferior qualities are made by boiling out the resin from the fruits, and hardening it in masses. Dragon's Blood is in mass a brown-black, brittle resin, of no odor, and of a sweetish, afterward slightly acrid taste. It breaks with a reddish fracture, and is translu- cent in thin layers. It is entirely soluble in alcohol, chloroform, carbon disulphide, etc., with the exception of from ten per cent, upward of vegetable tissue and other impurities. It softens and becomes sticky by the warmth of the hand, and at a higher temperature is partly decomposed, liberating among other things benzoic acid. It is extensively used in coloring wood-stains, var- nishes, etc., but has no peculiar medical properties. Its only use in pharmacy is as a harmless coloring matter for tooth-powders, ointments, and similar pharmaceutical mixtures. Allied Plants.-Other species of Calamus {C. rotang, etc. Linn.), and some other genera in the order, are pro- vided with a red juice, but their products do not often reach here. For the order, see Areca Nuts. Allied Drugs.-Kino, Shellac, the Balsams, etc. Several other varieties of Dragon's Blood are or have been articles of commerce. IK P. Bolles. Fig.8S6.-Outline of Female Dracuncu- lus Medinensis, re- duced. (From Cob- bold.) DRENNON SPRINGS. Location, about ten miles north from New Castle, Henry County, Ky. Analysis.-A qualitative analysis shows this to be a mild sulphur water. Therapeutic Properties.-Thirty years ago this was a very fashionable resort for residents of the South- west, the waters being esteemed for their mild aperient, diuretic, and diaphoretic effects. Unfortunately the cholera appeared during a very prosperous season, and soon afterward the buildings were burned. George B. Fowler. DRIBURG is a small place in Westphalia, Prussia, lying in a pleasant valley at an elevation of about six hundred feet above the sea. There are numerous medicinal springs in the place, the waters of some of which are taken internally, while others are employed only in baths. Mud, douche, vapor, and gas baths are also given. The composition of the Trinkquelle, one of the most impor- 527 Driburg. Drinks. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tant of the springs, is as follows, according to an analysis of Witting. Each litre contains : minish or abolish those reflex activities of the great nervous centres upon which the uniform and symmetrical innervation of the most important organs of the body de- pends ; or, finally, which chemically or otherwise hinder or pervert the absorption and assimilation of nutrient and reparative material, or in any other way upset the usual and natural sequence of activities by which the organic integrity of the body is preserved and processes of growth and repair are carried on. With the disarrangement of any of these important factors of health, are generally, if not always, associated a train of secondary and depend- ent conditions, such as fever, delirium, rigors, spasm, vomiting, anuria, etc., which may still further embarrass the system in the effort which is constantly going on toward recovery from disease, or restoration from injury. Under these circumstances, the nourishment of the wasting structures and the reproduction of exhausted tissue-elements necessary for the maintenance of the nor- mal condition of the system, is attended with serious and sometimes insurmountable obstacles. The vigor of the body therefore depends upon two factors : first, a proper nutritive supply, and second, the capacity of the body to use this supply of nutritive material for the needs of the various organs and structures. The materials which are capable of thus supplying the wants of the system compose the great class of substances which we call/ood. Foods differ from medicines, in that these latter do not often of themselves directly minister to the organic requirements of the body. Medicines are usually employed to produce certain definite energetic effects of temporary duration, and frequently of purely local character. The selection of the proper articles of food for the sick becomes therefore a matter of the gravest importance. The choice of the materials by which the body may be most easily and perfectly nourished is of vastly greater moment for the well-being of the patient than the most careful medication could possibly be. It is to be feared that often too little attention is directed to the diet of the sick-room, the choice and preparation of which is fre- quently confided to the skill of persons who may be quite ignorant of delicate cooking, and totally irresponsible. As the digestive and assimilative functions are often materially impaired during sickness, so the food for the sick should be most carefully selected, in order to present the nourishing material in the least objectionable form, and most convenient bulk ; and as all foods must neces- sarily be reduced to a liquid form before absorption can take place from the alimentary canal, it follows that a more or less fluid condition is the essential requisite for the easy and most effective alimentation of the sick. The diet of the sick is therefore practically a liquid diet, and the subject of drinks for the sick properly in- cludes the discussion of the entire diet of the sick-room, and conversely by "drinks" for the sick-room is gen- erally meant the preparation of some form of liquid food. The easy and painless administration of liquid nourish- ment to a helpless person in a horizontal position is an art which is most frequently noticeable from its absence. Probably the majority of attendants on the sick are not qualified for that occupation, which really requires a special adaptation, and intelligent training. When feed- ing a person in a reclining posture, if a spoon is used it should be one possessing a deep bowl, and fairly steep edges. The spoon should be only about two-thirds or three- fourths filled with the liquid, and should be touched to the edge of the bowl or other vessel containing the sub- stance to be administered, in order to remove the drop ■which would otherwise cling to the bottom of the spoon, and most probably soil the patient's clothing. The edge of the spoon should then be gently carried to the patient's mouth, and allowed to rest lightly upon the body of the lower lip; upon elevating the handle of the spoon, the contents will flow over the body of the lip and into the mouth, in the same manner as in the natural act of drinking, and will avoid much of the discomfort attend- ing the effort to assume an inclined or a vertical posture, as would be necessary in order to drink from the edge of a cup or other vessel. Grammes. Calcium sulphate 1.2044 Sodium sulphate 0.8072 Magnesium sulphate 0.8463 Calcium carbonate 0.8463 Magnesium carbonate 0.0651 Ferrous carbonate 0.1106 Sodium chloride 0.1953 Magnesium chloride 0.0651 Calcium chloride trace Potassium chloride trace Phosphates, silica, and bituminous matters trace Total solids 4.1403 Carbonic acid gas is present in large quantity, and the waters of the springs are in an almost constant state of ebullition from its disengagement. Driburg is frequented during the season, from the middle of June to the mid- dle of September, by sufferers from anaemia, chlorosis, disorders of the female sexual apparatus, rheumatism, neuralgia, and joints crippled by traumatism, but in which there is also a rheumatic taint. T. L. S. DRINKS FOR THE SICK. The nourishment of the human body while in a state of health and in the exercise of its normal activities, is accomplished by means of a complexity of processes, which requires the organic in- tegrity and normal functional activity of a multitude of important organs and parts. These varied processes are distributed in location and specific character, and extend the entire length of the ali- mentary canal. They include numerous large visceral or- gans, generally of glandular character, which furnish fluids gifted with the power of modifying the processes or re- sults of action of other neighboring or remote organs or parts. The phenomena of alimentation really commence with the preparation of the food, in the way of cooking, or otherwise modifying its quality, as a means either of rendering it more acceptable to the taste, or being more easily utilized by the organs of digestion and absorption, for the purposes of nutrition and repair of the body. The alimentation of the body in abnormal conditions, from disease or injury, is a process presenting many and varying differences from the ordinary course of nutrition in a state of health. When all the organs of the system are in uniform and reciprocatory activity, and mutually react in relation to each other and to the entire economy, as the composite expression of a functional response to the natural demands of the healthy organism, the waste of tissues and the consumption of parts or elements is quietly and insensibly restored, by the processes of absorp- tion from the blood-vessels and other nutrient channels, of materials suitable for supplying the losses of the sys- tem, by which its original integrity is again established and its former healthy condition entirely restored. Any disturbance ot the normal relations of the individ- ual members of the body to each other, or of a group of visceral or other associated organs to the system at large, at once destroys the equilibrium of the natural processes of the body-, and induces new and strange conditions, at- tended with the development of different physical and physiological relations which we are accustomed to group under the generic term " disease." Disease may therefore be of grave or trifling impor- tance, accordingly as the interference with the ordinary and natural actions of the body be of such a character, or located in such a part, as to cause serious and continued deviation from the usual and unimpeded course of phe- nomena in organs vital to health; or as it may be con- fined to tissues of either lower structural value, or of mechanical or sensory function. Among the graver lesions may be mentioned those con- ditions by which the vigor of the circulatory apparatus is impaired, or any disturbance of the process of respira- tion and oxygenation is produced, or which involve the destruction of portions of the pulmonary parenchyma, or which induce changes in the chemical constitution of the physiological excretions, or occasion an interruption in the transmitting power of nerves, or mechanically di- 528 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dribu rg. Drinks. The use of vessels provided with a hollow nozzle or spout is not to be commended, on account of the facility with which the interior of the tube or nozzle becomes contaminated, and the danger attending their use in this condition. Frequently much comfort is afforded by the use of a tube made from glass piping, bent at an angle of about 75°, one end of which is placed in the cup or other vessel containing the liquid, while the other is held between the lips of the patient. The benefit derived from these tubes is from the fact that the patient is not obliged to change the position of the body in using them, and the sensations are almost exactly those of natural drinking. The glass tube being quite transparent, at once betrays any soiling of its canal; and may be purified by boiling water or by being passed through the flame of a spirit lamp. The cost of glass tubing is so trifling, and the skill required to prepare a suitable tube for drinking is so little, that this simple apparatus is to be recommended for use in the sick-room rather than anything possessing opaque or invisible parts in which impurities may accu- mulate and be retained. The tube should be slightly en- larged at the end designed for the patient's lips, in order to be more easily grasped and retained between the lips. The administration of fluids to a person in a state of partial or complete unconsciousness from shock, or loss of blood, or while under the influence of an anaesthetic, or after the ingestion of a narcotic poison, is often an im- mediate necessity. There is grave danger that fluids in- troduced into the mouth may be inspired with the air in breathing, and thus cause immediate symptoms of suf- focation, or awaken some acute traumatic condition in the air-passages or in the pulmonary parenchyma. These serious risks are best avoided by employing the following measures: The patient should be placed in a horizontal position and the clothing well loosened about the throat and chest. The mouth should if possible be freed from saliva, and the base of the tongue made to ad- vance from the posterior pharyngeal wall by placing the lingers behind the angle of the lower jaw on either side and gently lifting it forward. When this is accom- plished, a small quantity, never more than half a tea- spoonful, of tepid water should be allowed to flow back- ward upon the tongue from a spoon. If the reflex irritability of the pharyngeal and laryngeal mucous membrane is not entirely suspended, the presence of even this small amount of water -will induce an attempt at swallowing, or at least a closure of the glottis to prevent its entrance into the trachea. If this attempt is success- ful, and the patient swallows the fluid, it is safe to give small amounts of other bland nourishing or medicinal substances in the same manner. If, however, there should be no reflex excitability in the pharynx or larynx, no further attempt should be ventured at the administra- tion of liquids by the mouth until the powers of the system are somewhat restored, when a small quantity of water may again be placed upon the tongue and allowed to flow backward to the throat as before. This minute amount of water is fully sufficient to excite reflex action and provoke attempts at swallowing, whenever this is possible, and it also possesses the additional advantage, that if no attempt at swallowing should follow its admin- istration, the presence of this small amount of tepid water in the air-passages is productive of no serious con- sequences. This procedure may be continuously re- peated at intervals of ten or fifteen minutes until the function of deglutition is restored, or the attempt is aban- doned as hopeless. In delirium tremens, mania, dementia, as well as in some rare forms of hysteria, it may be necessary to ad- minister liquid nourishment to the patient contrary to his will, or at least without his co-operation. This may be accomplished in several ways ; the easiest and simplest of which is probably to introduce the liquid into the cavity of the mouth at the angle of the lip, between the cheek and the molar teeth, whence it will flow into the posterior part of the mouth and thence into the pharynx. The cheek should be separated from the jaws and held by the finger inserted into the angle of the lip. Into the space between the lip and the teeth the fluid may be in- troduced by means of a large spoon. In cases in which it is impossible to nourish the patient by these gentle means, it was formerly the universal custom to make use of the stomach-tube, which is essentially a large and long catheter, which, being passed down the oesopha- gus and into the stomach, allowed the liquid food to be introduced through it directly into that viscus. This pro- cedure is not now, however, so generally employed, hav- ing been superseded by the nasal catheter, a flexible tube, which is passed through the nostril into the pharynx, where it is deflected downward, and at once glides easily and surely into the oesophagus. Through this tube the patient may be fed even more easily than when the stom- ach-tube is used, and the passage of the instrument is far less painful and less dangerous. Extended experience has seemed to recommend this method of nourishing an incapable or refractory subject above any other procedure at present in use, and it certainly seems free from the lia- bility of injury to the patient which attends most of the other methods of feeding where the employment of force is necessary. This seems the appropriate place to allude to the prac- tice, recently advocated by eminent practitioners, of wash- ing out the cavity of the stomach in cases of serious func- tional disturbance of that viscus, as well as in some forms of organic disease. The end to be attained is the intro- duction of a considerable quantity of warm, or even quite hot, water, usually rendered alkaline by the addi- tion of bicarbonate of soda, and its immediate evacuation by means of a flexible tube passed through the entire length of the oesophagus and into the cavity of the stom- ach. The operation is free from pain if carefully per- formed, and is not accompanied with the probability of injury to the stomach. A tube of sufficient length should be employed, so that about two feet of tube may protrude from the mouth when the instrument is in position. Be- fore being introduced, the tube should be carefully cleansed by repeated washings, followed by immersion of the entire tube.in a solution of permanganate of potas- sium, of carbolic acid, of mercuric chloride, or some other efficient disinfectant. The entire tube should be then submerged in warm water, or in the solution which is to be introduced into the stomach. When the interior of the tube is filled with the liquid so as to displace all contained air, a pinch-cock is to be applied to the distal end so as to completely close its lumen. Then, upon introducing the tube into the stomach, with the ex- ternal end still beneath the surface of the liquid to be used as a washing agent, upon elevating the vessel con- taining the liquid and removing the pinch-cock, the fluid will flow gently and continuously through the tube into the stomach. When a sufficient quantity has en- tered the stomach the pinch-cock should be again ap- plied to the tube so as to obliterate its calibre, and the end of the tube be depressed so as to be lower than the level of the body of the patient. Upon again removing the pinch-cock the contents of the stomach will be quickly and completely discharged, so far as the size of the tube will allow. In this manner the stomach may be alternately filled with fluid and emptied as long as may be desirable, not only without disturbing the po- sition of the patient, but without pain or discomfort. This procedure is especially to be recommended in cases of narcotic and other poisoning, in which a rapid and com- plete evacuation of the contents of the stomach is impera- tively demanded, and in which the organ may not respond to the ordinary methods of treatment, either from some local action of the harmful substance, or from depression of the general system. As a safe and efficacious means of immediately discharging the stomach contents, this mode of treatment seems to deserve a wider recognition and more general employment than has thus far been the case. By this method, also, any proper and desired amount of liquid food may be passed into the stomach, when for any cause the ingestion of fluids in other ways is impossible, or the refractory disposition of the patient interferes with his bodily nutrition. 529 Drinks, Drinks, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Drinks for the sick may be divided into five general groups, according to the character of the substance em- ployed, or the effect which it is desirable to produce, viz. : 1, diluents ; 2, restoratives ; 3, nutritives ; 4, medicants ; 5, miscellaneous. 1. Diluents.-The first and primary object to be at- tained by the ingestion of liquids is the maintenance or restoration of the normal proportion of fluid in the tis- sues, by which the natural consistency of the various structures of the animal body is preserved, and the con- stant loss of liquids through the various channels of ex- cretion, and by means of the respiratory membranes and insensible transpiration is replaced. The supply of the necessary amount of fluid to the system for these pur- poses is of even greater importance to the animal econ- omy than the ingestion of food, and animals have been known to exist for a considerably longer time when granted a necessary amount of fluid, without food, than when am- ple food has been provided without the addition of liquids. The first object, therefore, of any drink is to satisfy the constantly recurring demand of the system for fluid, as expressed by the sensation of thirst. The composition of the fluid elements of the body, other than the blood, is to a very large proportion water, and naturally this substance alone is the most appropriate material for the diluent purposes of the animal economy. No other fluid, nor any compound, can compare with pure water for the simple objects of drink, and this must form the basis of any and all forms of simply diluent drinks. This, and this only, can satisfy the physiological require- ments of the animal system. Other substances may be combined, mingled with water, in the form of drink, for the purposes of modifying, or in some way changing to a certain degree its action, either upon the entire economy or upon the alimentary organs with which it first comes in contact. Thus a variety of mucilaginous substances may be added to water, in order to produce a soothing or emol- lient effect upon the mucous membrane of the stomach, and we have the various forms of demulcent drinks, which form a large and useful group of fluid substances. The mucilaginous substances ordinarily added to water for demulcent purposes are of bland and unirritating quality, and render the drinks less liable to produce sensations of discomfort and distress. The mucilaginous substances are generally excreted unchanged by the kidneys, and here again exert a soothing effect by rendering the urine less irritating to the sensitive mucous membranes of the renal passages. Thus a double object is attained in the employment of demulcent fluids as drink, in the benefit derived from the bland nature of such fluids upon their ingestion into the stomach, as well as their effect upon the mucous membranes of the excretory channels. The substances which may be employed for this pur- pose embrace decoctions of flaxseed, Irish moss, arrow- root, gum arabic, and cotton-seed, with barley-water, toast- water, crust coffee, and the more simple forms of gruel, etc. Those substances should all be quite dilute, those made from flaxseed, gum arabic, the gruels, etc., should be boiled, in order to liberate the oily and gelatinous qualities which belong to them, and all should be care- fully strained before being brought to the sick-room. These liquids possess but feeble nutritive power, but are bland and unirritating, and often serve to allay the dis- tress arising from inflammatory or other painful condi- tions of the alimentary mucous membranes. To this list may be added the alkaline waters, the administration of dilute lime-water, or weak solutions of bicarbonate of soda, which are often grateful to the stomach on account of their antacid properties, and are particularly applicable to many chronic disorders of the alimentary system. The alkaline quality of the fluid taken as drink is often pre- served in the fluid excretions of the body, and thus may exercise a second remedial effect. 2. Restoratives.-The second group comprises those substances which possess the power of temporarily in- creasing the vigor of the system by means of direct stimulation. These substances are not foods, they pos- sess little or no nutritive value in themselves, but are often excellent adjuvants to the real nutrient supply, on account of the momentary increase of vigor which they awaken in the system, thus enabling the body to derive an increased amount of benefit from the foods which are mingled with, or soon follow the restorative ; and con- sequently this class of substances ministers indirectly to the better nutrition of the entire system, and is an im- portant addition to the dietary of the sick-room. This group of liquids comprises the various wines, both sweet and dry, champagne, the spirituous liquors and cordials, milk-punch, eggnog, grape juice, cider, porter, beer, etc. ; further, coffee, tea, wine whey, wine jellies, the dilute mineral acids, lemonade, tamarind-water, soda- water, seltzer-water, etc. These substances should not be employed alone : that is, they should be considered simply as useful adjuvants to articles of real nutrition, which should always accom- pany, or at least immediately follow, them into the stomach. The wines and other direct stimulants should be taken in dilute form, so as to be readily absorbed with- out unduly irritating the gastric mucous membrane. The other articles, as tea, coffee, etc., are usually taken warm, and thus by their elevated temperature arouse the stomach to increased activity. It should never be forgotten that a stimulant is unable to supply any real addition to the powers of the system, but simply excites the existing functions to a temporary increase in activity, which is followed by a reaction in which the vital depression is proportionately more marked than was the antecedent exhilaration. Therefore, if a stimulant be administered alone, its presence in the body is a positive disadvantage to the system, but by judiciously combining a stimulant with some nutrient material, the temporary elevation of functional power is made the means for the more satis- factory administration of the nourishment, and the actual vigor of the body may thereby be sensibly increased. This class of substances should therefore be employed only at such times and under such conditions as render it desirable to excite an increased functional activity in the entire organism, or in its parts. The proper occasions for their administration would therefore be either at, or im- mediately before, the times of taking food, during periods of great temporary depression of the vital powers, in sud- den collapse, during shock from loss of blood or other cause, in sudden exhaustion, syncope, and similar con- ditions. 3. Nutritives.-This class embraces the entire list of liquid substances which are adapted to the requirements of the sick-room, and which can be properly classed as foods. Chief among these is milk, which forms the only proper and entire nutritious supply of the body during the earlier periods of growth, and is the most perfect form of human alimentation. This substance alone contains within it- self all the elements required for the complete develop- ment of the various tissues and organs of the animal sys- tem. It is, therefore, entitled to be ranked as the most important constituent of any form of drink for the sick. It is of bland and unirritating character, is, when fresh, of a pleasant taste and agreeable odor, and is usually well borne, even in cases in which but little can be taken by the stomach. It may be administered in its fresh state, or, as the Germans express it, "raw," or it may be gently warmed, or finally it may be heated to the boiling point, by which the coagulable parts are separated, and it ac- quires a more pronounced taste. This process also di- minishes the tendency to looseness of the bowels, which milk occasions in some persons. Of all articles of food- supply, none are probably more easily digested and as- similated than good milk. The human organism, in all stages of existence and under all usual conditions, can be sufficiently and completely nourished upon milk as a food. Its use in disease, therefore, supplies a complete and sufficient nutrition for all the structures of the sys- tem, and there need be no fear of inanition while milk is the chief article of diet. It may be combined with many substances, which thus become supplementary to it. The various amylaceous foods, in the form of gruels, make excellent adjuvants to milk. The addition of a stimulant may frequently be of service, not only in the temporary increase of the patient's vigor, but also in the better nu- 530 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Drink*. Drinks. trition derived from the milk itself. The milk may be artificially digested by means of the various ferments prepared from the alimentary glands of the pig, calf, etc. Thus, by means of the peptone products we may com- pletely digest all the albuminoids in milk before it is taken into the stomach of the patient, in this way remov- ing the necessity for gastric digestion. This is a most desirable end to be attained, in the nourishment of patients suffering from any organic disease which prevents or perverts the physiological activity of the stomach. By the combination with the pancreatic fluid, which may be obtained by extraction from the pancreas of pigs, the fatty matters of milk are transformed into an emul- sion, in which form they are immediately absorbable by the lacteals, thus materially assisting intestinal digestion. We are in this way enabled to adapt a diet of milk to the special and particular requirements of the individual pa- tient in a manner and to a degree which it is impossible fully to do with the other articles of liquid diet; and in this respect, as well as in its character as a nutriment, milk is far to be preferred as a drink for the sick. In any case in which it may be desirable to administer milk, the condition of the patient should be the criterion of the form and amount to be employed. Under ordinary cir- cumstances the digestion of milk is completed in a com- paratively short period, and therefore it may be given at more frequent intervals than most articles of food. In -conditions of great debility, of irritable stomach, of or- ganic disease of that organ, of intestinal catarrh, etc., milk may be given in the amount of twenty-five cubic centimetres every hour. When any gastric difficulty exists, the addition of one-fourth part of lime-water to the milk does much to prevent disturbance of the stom- ach, the milk passing quickly and easily through this vis- cus into the duodenum, where its digestion by the intes- tinal fluids at once commences. A small amount of the bicarbonate of soda exercises a similar effect, the milk passing through the stomach in an alkaline condition and entering the intestine soon after being swallowed, and without acid coagulation of the casein from the gastric fluid. As the functions of the alimentary canal become restored, a larger quantity of milk may be taken, and the intervals may be gradually prolonged. Eggs, bread, po- tato, and other amylaceous substances may be cautiously added, and beef-tea, broth, etc., may be substituted for the milk at regular intervals. At length the ordinary diet may be resumed, by gradually adding solid food and slowly diminishing the milk. A very bland and nourishing drink is prepared by the addition of an acid wine, such as sherry, to milk, by which the casein of the milk is at once coagulated and may be removed by straining. As the casein is often a .source of distress in conditions of debility of the stomach, the abstraction of this constituent of the milk is favorable to the more easy and perfect digestion of the remaining components. The fluid which is obtained by the action of an acid upon the casein, or by the admixture of ren- net-the gastric principle obtained from the stomach of the calf-is a cloudy limpid fluid of a faintly milky taste, and when wine is the agent employed, of a flavor partak- ing of that of the wine. The alcohol contained in the wine is also retained by the liquid, and this forms the wine whey of the sick-room. It is a very appetizing fluid, and is both mildly stimulant and nutritious. Its use may prepare the way for pure milk, or some of its prep- arations, where this could not be borne at first. Another most excellent form of milk, in case of great prostration of the entire system or excessive debility of the digestive powers, is found in Koumiss. This is a somewhat thick liquid, which is formed by the alcoholic fermentation of milk from the addition of yeast and the cautious regula- tion of the temperature. Koumiss has a fragrant odor, a taste reminding one of fresh, sweet buttermilk, a spar- kling quality due to the contained carbonic acid, and a rich food-capacity, as it contains all the original compo- nents of the milk except the sugar, the decomposition of which has caused the chemical changes accompanying the formation of koumiss. To most invalids this is a most agreeable and refreshing drink. It should be drawn from the bottles in which it is made by a tap, and is best drunk through a glass tube, as the froth will other- wise soil the lips and face. To many persons the curd forming from the early spontaneous coagulation of milk is an acceptable form for the ingestion of milk. In some countries, particularly Germany, the writer has seen milk in this form exten- sively employed as an article of diet. It is palatable, contains all the components of milk, and has attained the first condition which occurs in stomach digestion, viz., an acid reaction and consequent coagulation of the con- tained casein. The cream may be removed by skimming if desired, but should preferably be stirred into the milk. Beef-tea.-After milk, the most nourishing form of liquid food is doubtless beef-tea, or a similar drink made from mutton, chicken, or some other albuminoid sub- stance. No form of drink made from any kind of meat is a perfect food, but all require the addition of other sub- stances if the integrity of the animal tissues is to be pre- served unimpaired. Beef-tea is, or should be, a dark, or amber-brown liquid, of an agreeable flavor partaking of the taste of the meat from which it is made, and should contain all the soluble elements of the animal tissues in a free and uncoagulated condition. It should be prepared by digesting the meat, cut into small fragments, in a closed glass vessel at a low temperature by means of a water-bath. The temperature should never be allowed to go above 160° F., or 72° C., in order that the contained albuminoid substances may not be solidified. After a period of two to four hours the soluble parts of the meat will have been extracted, and the resulting fluid should be strained, and any free fat should be removed by skimming. Salt and pepper may be added to suit the taste, and the resulting liquid, if taken in sufficient dilution and as warm as can be com- fortably borne, is usually a grateful and refreshing drink. It presents the easily assimilable properties of animal muscular tissue in that form in which they may be most readily absorbed. Beef-tea should be prepared by adding sufficient water to the meat to amply cover it, and allow a quantity of supernatant liquid equal in bulk to that of the meat. The vessel should be closely stopped to prevent loss by evaporation, and after digesting for two to four hours it is ready for use. A very nutritious drink is prepared by the addition of twenty drops of hydrochloric acid and two grammes of pepsine (crystals) to the water, when, upon exposure to the same temperature, almost the whole of the muscular tissue will be dissolved by the action of the pepsine, and the resulting fluid will resemble the products of natural gastric digestion. A very excellent addition to any meat tea is the extract of malt, which not only adds to the flavor of the liquid nourishment, but greatly increases its nutritious value. In amount it may be considered that from one-tenth to one-fifth the volume of the liquid may represent a very desirable proportion. Another valuable drink is found in weak beef-tea, taken quite hot, into which a fresh egg has just been broken. In fact, the German "Bouillon mit Ei" is nothing else than such a combination, and all continental travellers know how invigorating a drink this mixture forms. It is also usually very well borne, even by those in -whom gastric disease may be present. The various jellies made from fruits are generally acceptable to the stomach of the invalid. They are prepared either by concentrating the juice of the fruits after the addition of sugar, or may be made by adding the fruit juices to a hot solution of common gelatine, when it solidifies into a jelly on cooling. Beef-tea and other nourishing liquids may be gelatinized in the same way, and thus be easily preserved for use ; when, the jelly being added to a proper quantity of warm or hot water, solution occurs almost instantly with the production of a palatable and strengthening drink. To either the fruit or the beef-tea jellies a small amount of wine may be added, with the result that the drink becomes slightly stimulant as well as nutrient. Gruels.-Gruel is a drink prepared by boiling the va- rious cereal starches in a large proportion of water, by 531 Drinks. Dropsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. riably do harm ; taken in combination with, or followed immediately by, articles of nutritive value, they aid the debilitated system to obtain an increased degree of strength from the food taken. The principal restoratives are those containing alcohol, and these only will be considered. Foremost among these in immediate and active stimulating properties is to be placed champagne, which is to most persons a pleasant and refreshing beverage, as well as an active invigorating agent. The alcoholic content of champagne is not neces- sarily high, seldom being above ten to twelve per cent., but champagne also contains a considerable amount of unfermented sugar, and is highly charged with carbonic acid gas, giving it a sparkling quality which is most grateful to many sick persons. Champagne may be taken in the amount of a wineglassful before, during, or im- mediately after taking food, and often aids the processes of stomach digestion, from its diffusible character, and its easy absorption as a mild alcoholic agent. The lighter wines, as sherry, port, hock, and claret, may be used for a similar purpose, and may be taken pure, or diluted with water to suit the taste. Of these, claret is an acid wine, port is a sweet wine, and hock and sherry are usually "dry wines," that is, contain little or no sugar. The various " cordials " and " liqueurs " are usually very high in percentage of alcohol, and quite sweet, and contain also a large degree of rich flavor from various ethers and essential oils which enter into their composition. They serve generally as relishes, and should be taken only in small amount, say a small wineglass, lest their exceeding richness produce nausea. Among these may be mentioned the Benedictine, Maraschino, Cura^oa, and other choice cordials of this character. The stronger spirituous liquors, rum, brandy, whiskey, etc., are all used as stimulants or restoratives in the treat- ment of disease. They contain a very large percentage of alcohol, forty-five to fifty-six per cent., and should never be employed except in a diluted form. As pure stimu- lants they are often given with water, or with milk, and immediately exercise upon the system their restorative powers. They are "dry" in quality and can be borne by very sensitive persons if sufficiently dilute, and slowly given. An agreeable flavor is imparted to whiskey by the addition to its watery solution of a small amount of lemon or of ginger. The disagreeable taste of rum is pleasantly obviated by mingling with hot water, sugar, and milk, and adding a small quantity of nutmeg. Brandy is rendered palatable by sugar dissolved in a suitable amount of water. The stronger alcoholic liquids should be diluted to at least three times their volume with water or milk. They should not be taken suffi- ciently strong to irritate the mucous membrane of the stomach, or to impede gastric digestion, which these sub- stances will do when taken in too concentrated form. The therapeutic dose of either of the stronger alcoholic liquors for its restorative effect, as a drink for the sick, should be from five to thirty cubic centimetres, diluted sb as to make from twenty to one hundred cubic centimetres. If taken warm or hot, its restorative action is increased in intensity and accelerated in time. 5. Miscellaneous Drinks.-Under this head are com- prised a large number of fluids which do not belong to either of the classes above enumerated. Such are the various " teas," such as flaxseed, ginger, and the various herbs employed for this purpose. To this class also be- long lemonade, the aerated spring and mineral waters, domestic and manufactured herb beer, and many other in- nocent drinks of agreeable taste and refreshing character. Their chief office is to produce a comforting effect by moistening the mucous membranes of the mouth and throat; to which several add the grateful sense of cool- ing produced by the presence of citric or other acid in the liquid. They possess little or no food value, are not generally stimulating, but effect a temporary soothing result from their contact with the mucous membranes. They should be taken in small amounts, as they easily produce a feeling of fulness and of pressure in the stom- ach, and are frequently a cause of nausea. Such bland drinks as toast-water, barley-water, crust-coffee, chocolate. which a homogeneous, thin, smooth, semi-gelatinous mass is obtained, which may be diluted to a proper consistency by the addition of milk or water. The substance from which the gruel is to be made, be it corn-meal, flour, bar- ley-meal, oat-meal, or whatever may be chosen, is first thoroughly moistened with cool water so that every part is wet. This mash is slowly stirred into the necessary quantity of boiling water, and the boiling should be prolonged for half an hour in order to thoroughly soften and cook the particles of flour or meal from which the gruel is made. This, when cooled, may be flavored by the addition of a small amount of salt, and is rendered more palatable to some persons by adding some fruit syrup. Gruel is much improved as a nutritive agent by incorporating with it, when cool, about one-fifth its own volume of extract of malt, a substance which possesses considerable value as a partially digested nutriment, and is easily absorbed in the form of soluble grape-sugar. It should also contain a considerable amount of diastase, that digestive ferment which changes soluble starches into grape-sugar. The action of diastase upon the starchy matters of the gruel aids materially in their easy assimilation by the system, and thus contributes directly to the well-being of the patient. Gruel is in no sense a perfect nutriment, and its use as a continuous and sole article of liquid food would be followed by faulty nutri- tion of some parts of the economy. It is necessary to supplement its defects by albuminoid and fatty articles of extra diet. Another palatable and useful drink may be prepared by scraping very lean beef with a knife or other appro- priate instrument, thus obtaining the meat in fine shreds and particles. The mass of finely divided beef-fibre may then be suspended in water or milk, and after macerating for a short time may be drunk, and will be easily di- gested by the stomach of most persons. A similar drink may be prepared by bruising oysters or crabs in a mortar and submitting the mass to pressure in a cloth, when much of the flesh will come through the meshes of the strainer and may be mingled with water or milk and taken as a drink. The addition of a small amount of pep- sine would doubtless be of advantage. These substances may also be incorporated with gela- tine and thus given the form of a soft solid, and may be taken with some piquant sauce as a relish. When these forms of liquid nourishment are chosen, care should be taken that sufficient time be allowed for complete stom- ach digestion and the passage of the nutriment into the bowel before more is given. 4. Restoratives.-This class of drinks includes the various groups of alcoholic and other stimulants-cordials, liquors, wines, beer, porter, ale, etc. These substances con- tain little or no true nutritive value, but are useful in excit- ing the system to unusual activity for a limited period, during which time the powers of the system may be called upon to perform an unwonted amount of labor. The momentary, or at least temporary, exaltation produced by stimulants is followed by a corresponding depression of the powers of the body, so that the final result of stimu- lation is to leave the system in a worse condition than ex- isted when the stimulant was given. In this way the use, or more properly the abuse, of stimulants is productive of incalculable harm. Their dangerous qualities are ten- fold augmented by the fact that in most persons their employment is productive of an irresistible craving for the injurious substance, and thus their evil action upon the economy is perpetuated. The judicious and prudent use of stimulants may be followed by very great benefit in many cases. Their em- ployment alone must, however, never be advised. They should be followed at once by the administration of some substance of real nutritive value, or they may be taken in combination with some form of nourishment. When administered in this way the temporary invigoration of the system is employed in an increased effort of digestion and assimilation, and the augmented strength of the body may be the means of a real elevation of its vital condition. This is the real, and we may say the only, indication for the employment of stimulants. Taken alone, they inva- 532 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Drinks. Dropsy. bread-and-butter broth, etc., belong to this category, and are especially mentioned from the fact that they are often palatable when most other drinks are refused, on account of the faint aromatic quality which they possess, as well ns possibly a very small degree of nutritive value. The ■employment of one of these substances may be followed by an inclination on the part of the patient for some other form of drink which may contain true nutritive qualities, and thus by small advances the debilitated system may gradually be restored to its normal condition. Albert N. Blodgett. sage of blood through the heart, especially tricuspid in- sufficiency. Renal dropsy and uraemic dropsy are sy- nonymous terms, uraemia being constantly related to disease of the kidneys. A confusing variety of defi- nitions are given to the terms anasarca and oedema. In this article both terms are limited to transudations into the connective tissue. When the effusion is into the sub- cutaneous connective tissue, and involves it extensively, it is called anasarca : when limited in extent, or con- fined to the connective tissue of individual organs, it is called oedema. Ascites is dropsy of the peritoneal sac ; hydrocephalus, of the ventricles of the brain and the arachnoid cavity ; hydrothorax, of the pleural sac ; hy- dropericardium, of the pericardial cavity. Composition of the Fluid.-The blood is the source of this, as of all other fluids found in the cavities and tis- sues of the body. Certain of them, like the saliva, the bile, and the pancreatic juice, are the product of special glandular elaboration. These have each a specific work to do in the vital economy of the body, and are called se- cretions. Others, like the urine, convey excrementitious substances out of the body, and are called excretions. In the inflammatory process certain elements of the blood, more or less changed, escape through the involved vessel- walls into tissues or cavities, where they undergo further metamorphosis, either destructive or constructive. These are called inflammatory exudates. In dropsy the fluid which normally escapes from the blood-vessels into the lymph-spaces, and becomes the lymph, accumulates by reason either of excessive transudation or diminished ab- sorption. It becomes more or less modified by the physiological activities of the tissues ; if long retained in the tissues a sort of macerative process occurs, and ele- ments of destructive tissue-metamorphosis are added; and it is not unlikely that certain chemical changes take place in it, such as the conversion of the sero-albumen into a peptone resembling that produced in digestion (Rind- fieisch). It is always thin and watery, and usually color- less, or of a pale yellowish hue. Rarely it is opalescent, and tinged with the coloring matter of the blood or bile. Its specific gravity ranges from 1.008 to 1.014. Its re- action is generally alkaline. Its proportion of water varies from ninety-two to ninety-five per cent., and may even reach ninety-nine. The albumen is in less proportion than in the blood, but is said to increase with the age of the transudate. There is usually no fibrine, but fibrino- gen is commonly present. The saline constituents of the blood are found in varying proportions. It may contain a few red and white corpuscles, cholesterine, biliary acids, mucin, the various pigments, and, in cases of renal dropsy, urea. Pathology.-In dropsy the normal adjustment be- tween transudation and absorption is disturbed. The whole connective tissue is a network of lymph channels ; its interstices are connected directly or indirectly with the lymphatic capillaries and larger vessels; the serous membranes are parts of the lymphatic system, great membranous expansions of it, and their cavities lymph- sacs, which play an important part both in the elabo- ration and absorption of the lymph. The lymphatic system is the connective-tissue circulatory system, and the same forces which move on the circulation of the blood are concerned in maintaining the flow of the lymph. In health there is a large transudation of blood- serum, more or less modified, through the thin-walled capillaries, and, in less degree, through the walls of the small veins into the lymph-spaces. The larger part of this, after undergoing various changes, is at last returned to the blood-current through the lymph-ducts ; part of it, first elaborated in the specific cells of various glands, ap- pears upon free surfaces in the form of secretions ; part of it enters again into the inside of the vessels by endos- mosis, when the chemical condition of the fluids inside and outside of the vessel-walls is favorable to that pro- cess, or, possibly, sometimes by force of external press- ure, the pressure from without being greater than that within the vessels. Let either transudation be increased, or absorption hindered, and dropsical accumulation oc- curs. DROPSY (WpoiL from vSwp, water, and appearance). Syn. : Lat., Hydrops; Fr., Hydropisie; Ger., Wasser- sucht. Definition.-Dropsy is the accumulation of a fluid, transuded from the blood-vessels, in the interstices of the connective tissue, or serous cavities of the body, or in both at the same time. It is obvious that dropsy, as thus defined, is not prop- erly a disease per se, but rather a symptom or indication of some pre-existing morbid condition. It is, however, so marked a phenomenon, is found under so many diverse conditions, and presents so many important varieties, that it seems fairly entitled to separate consideration and de- scription. The term dropsy, especially as related to se- rous cavities, is differently limited by different authors. By some it is made to include inflammatory exudations and effusions, which are spoken of as active or inflamma- tory dropsies, as distinguished from passive or mechanical ■dropsies. Tuberculous meningitis, with free effusion, is called acute hydrocephalus, and subacute pleuritis, with abundant serous outpouring, is termed acute hydrothorax. It is better to make the sharp modern distinction between inflammatory exudation and dropsical transudation. The inflammatory exudate is rich in albumen and fibrine, contains numerous leucocytes, and, as a rule, but few red corpuscles ; while the dropsical effusion, or transudate, has a small percentage of albumen, little or no fibrine, but few leucocytes, and sometimes few, sometimes many, red globules. But it must not be forgotten that atony of vessel-walls, resulting from inflammation, may lead to subsequent transudation, e.g., oedema of lung following pneumonia ; nor that the inflammatory stasis in the centre of an inflammatory area may induce enough capil- lary and venous distention outside of that area to cause oedema of the adjacent tissues. Cystic disease of the ovaries is sometimes spoken of as ovarian dropsy, and dis- tention of the gall-bladder, from obstruction of its duct, as dropsy of the gall-bladder. The term spurious dropsy is sometimes applied to such cases. Varieties.-It is customary and convenient to divide dropsies at the outset, into two classes : first, those due to some morbid change affecting the general circulation, or the composition of the blood, and so favoring transudation alike into the connective tissue and the serous cavities ; and, second, those in which the cause is of local operation, and only induces dropsy of limited extent. Thus we have -I. General dropsies : 1, cardiac; 2, renal, or uraemic ; 3, anaemic. II. Local dropsies, such as, 1, ascites ; 2, hydrocephalus ; 3, hydrothorax ; 4, hydropericardium ; 5, cedema. The term general dropsy is commonly applied to cases in which, with extensive involvement of the connective tissue there is also effusion into one or more of the serous cavities, with tendency to progressive invasion of them all. In cardiac dropsy accumulation usually appears first in the most dependent parts, the feet, ankles, etc., where intra-vascular pressure is greatest and absorption least. Exceptions to this rule, however, occur, which may be perhaps accounted for by supposing an unequal distribution of vaso-motor influence. In renal dropsy it usually appears first about the eyelids, or other parts dis- tinguished by looseness of tissue. It is said that dropsy of the external genitals, often so extensive in uraemic dropsy, is not at all, or but lightly, developed in pure cardiac dropsy. In pure anaemic dropsy the amount of liquid transuded is usually quite limited. Cardiac dropsy is that resulting from some obstruction to the free pas- 533 Dropsy. Dropsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The following pathological conditions are generally recognized, viz. : 1. Obstruction to the flow of blood from the veins and capillaries. 2. Increased permeability of the vessel-walls. 3. Morbid states of the blood : (a) anaemic (hydraemic); (b) uraemic. 4. Feeble cardiac impulsion. 5. Lymphatic obstruction. It is essential to the normal circulation that there should be free channels for the blood to flow through, that the vessel-walls should be possessed of a certain power of retention, that the blood itself should be of a given composition and quality, and that the cardiac im- pulsion should be of sufficient force. Failure in either of these particulars favors the occurrence of abnormal, excessive transudation. In the advanced stages of gen- eral dropsy several or all of these conditions are found to coexist. Obstruction of a single vein would tend to produce local dropsy just in inverse proportion to the facility of establishing a collateral circulation. Obstruc- tion of the thoracic duct alone would not act as a very efficient cause of general dropsy. Some noticeable ac- cumulation of fluid in the abdominal and thoracic cav- ities might occur. But when the obstruction depends, as it generally does, upon excessive distention of the sub- clavian veins, from tricuspid blood reflux, it may act as a decided co-operative cause of general dropsy. Obstruc- tion of single lymphatic ducts by external pressure may lead to some accumulation in the related lymph spaces. Causes.-In general, anything capable of producing either of the pathological conditions above mentioned may act as a cause of dropsy. These causes may be divided into four classes, viz.: 1. Obstructive conditions of the heart, lungs, or blood- vessels. 2. Certain affections of the kidneys, characterized by the waste of albumen, and accumulation of urea in the blood. 3. Insufficient food, unsanitary conditions, loss of blood, chronic discharges, certain other diseases, and everything capable of making poor and watery blood, or atony of the vessel-walls or cardiac muscle. 4. All causes of obstruction of the thoracic duct, or its branches. Cardiac obstructions play a very important part in the production of general dropsy. Distention of the veins and capillaries of the systemic circulation is the essen- tial resulting condition, and tricuspid insufficiency is quite constantly the final heart lesion, from which this disten- tion immediately results. The tricuspid lesion is, however, very rarely primary. It is usually secondary upon dis- ease of the left side of the heart, or upon primary ob- struction of the lung capillaries. If the primary heart lesion be mitral, dilatation of the left auricle, distention of the pulmonary veins and capillaries, dilatation of the right ventricle, and tricuspid insufficiency are likely to follow in the order named. If the primary lesion be aortic, we have the same results at two steps further of remove; thus, dilatation of the left ventricle, insuffi- ciency of the mitral valve, and then the train of lesions just mentioned as following upon mitral disease. When the primary obstruction is in the pulmonary capillaries from asthma, emphysema, or other chronic disease of the lungs, distention of the pulmonary artery, dilatation of the right ventricle, and insufficiency of the tricuspid valve naturally follow. Morbid conditions of the blood, as a cause of dropsy, are chiefly seen in two classes of cases, viz., the hydrae- mic and the uraemic. In normal blood the red globules average about thirty-six per cent, of its volume, no other solid matter being seen in fresh blood under the micro- scope, with the exception of a rare occasional white cor- puscle. In pernicious anaemia the number of red glob- ules is sometimes reduced from the normal average of five millions per cubic millimetre even to half a mill- ion. Dr. Wm. Osler has counted the number as low as this in two cases. It is easy to conceive how blood thinned to this degree, especially when associated with the tissue atony which usually attends it, may constitute a cause of dropsy. In uraemic dropsy the blood, besides being poor in red corpuscles, contains an accumulation of urea. This substance, " the ultimate product of albumi- noid substances in the organism prepared for excretion," failing of elimination by the kidneys in certain forms, of renal trouble, now grouped under the name of Bright's disease, accumulates in the blood, and, besides other toxic influences exerted upon the blood and tissues, im- pairs the vitality of the vessel-walls, and renders them abnormally permeable. Our third class of causes includes all those numerous de- bilitating agents and influences which either make poor and watery blood, or impair the vitality of the vessel-walls, and so favor the escape through them of their liquid con- tents, or weaken the muscular power of the heart. It is not probable that diminution of the muscular impulsive power of the heart alone, without either venous obstruc- tion or increased permeability of vessel-walls, would act as an efficient cause of dropsy. But a slight obstruction, which might be compensated for by an increased vigor of impulsion, might, when associated with enfeeblement of impulse, induce transudation. A feeble circulation would favor transudation through morbidly permeable walls. Local dropsies are produced by the same obstructive,, debilitating, and toxic agencies which produce general dropsy, acting upon single or separate parts Of the body, and especially by obstruction of large veins. Ascites is caused by obstruction of the portal vein, leading to disten- tion of its branches and radicles, and especially by cir- rhosis of the liver. Hydrocephalus is usually due to pressure upon the venae Galeni and straight sinus. Hy- drothorax is most often part of a general dropsy, but is sometimes a result of mitral obstruction and consequent distention of the pulmonary capillaries; sometimes it is caused by intra-thoracic pressure upon the pulmonary veins. Hydropericardium, when independent of diffused dropsy, results either from local stasis in the veins and lymphatics of the heart and pericardium, or from ob- struction of the circulation in the same vessels by outside pressure from disease of adjacent organs or parts. (Edema of the thigh and leg often results from thrombosis of the femoral and tibial veins ; sometimes from compression of the veins by tumors. (Edema of the leg in the later stages of phthisis, and the more extensive swelling of the limb in the so-called "milk-leg," are common examples of this. (Edema may occur from obstruction of the main vein of any part, and also, in less degree, from pressure upon a large lymphatic duct. In the former case the fluid accumulation would result from excessive transudation, and in the latter largely or wholly from failure of absorption. (Edema may also occur as a sequel of an inflammation which has left the vessel-walls of a part in a state of impaired vitality, e.g., oedema of lung following pneumonia. Occurring in paralyzed limbs it probably -mainly results from want of the normal influ- ence of the vaso-motor nerve-filaments. Course and Terminations.-In Cardiac dropsy the accumulating fluid, usually appearing first in the feet and ankles, gradually invades the subcutaneous connec- tive tissue from below upward, and may progressively involve the serous sacs, peritoneal, pleural, pericardial, and arachnoid, though, from some modification of vaso- motor influence, or other incidental peculiarity, either cavity may become involved before the others. The amount of the effusion and consequent distention is some- times enormous, and the mechanical pressure of it inter- feres greatly with the functional activity of organs. There is venous engorgement of both pulmonary and systemic circulations, with capillary distentions and hy- postatic oedemas. Dyspnoea, orthopnoea, haemorrhage, palpitation, fluttering and irregularity of heart-action, dyspepsia, jaundice and swelling of liver, headache, wandering, stupor, and cyanosis are common symptoms of the advancing disease. The urine at last is often found to contain more or less of albumen, renal epithelia, and sometimes a few casts of the uriniferous tubules. The renal trouble in this form of dropsy is secondary in de- velopment, and apparently dependent upon a passive hyper- aemia of the kidneys, resulting from the cardiac obstruction. 534 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dropsy. Dropsy. Renal dropsy presents the same fluid accumulations, and the same effects of pressure that are found in cardiac dropsy. There are the same disturbances of the circula- tion, the same engorgements and oedemas of the different organs and tissues, and the same functional derangements growing out of them. The dropsy usually shows itself first in the loose connective tissue about the eyelids, and becomes progressively general. The external genital or- gans are more constantly and extensively involved in renal than in cardiac dropsy. The urine contains albu- men and casts of the renal tubules in the several varie- ties-hyaline, granular, corpuscular, and epithelial. Loose epithelia and red and white corpuscles are also found. There is great variation in the amount and proportion of these elements, and some of them are occasionally found in the state of fatty degeneration. But renal dropsy is also specially marked by the oc- currence of uraemic symptoms, such as headache, ver- tigo, dimness of vision, ringing in the ears, twitchings, delirium, stupor, paroxysms of dyspnoea, convulsions, and coma. The uraemic symptoms sometimes precede any considerable effusion, and convulsions and coma may abruptly supervene with quickly fatal issue. There is greater tendency to irritations of the skin and mucous membranes than in cardiac dropsy, perhaps due to the elimination through them of altered urea. An ammoni- acal odor is often noticed in the breath and perspiration. Diarrhoea and vomitings occur. The tissues seem to suf- fer from a blended macerative and toxic process. Ery- sipelas and various skin eruptions may appear, and occa- sionally gangrenous points are developed. In chronic uraemic dropsies secondary cardiac lesions are very commonly found at last. Not only are the capillaries of the kidneys the seat of an obliterating endarteritis, but, as pointed out by Johnson and others, the small systemic arteries show a thickening of walls with narrowing of calibre which induces marked ten- sion of the larger arteries. The left ventricle of the heart becomes hypertrophied, and other cardiac lesions may become progressively induced. Dr. Bristowe holds that the transudation, in this form of dropsy, is from the small arteries rather than from the capillaries and veins, there being no obstruction to the return of their blood to the heart. Their walls, while abnormally thickened, may at the same time be possessed of an increased per- meability and allow of profuse transudation, as do the thickened walls of the Malpighian vessels of the kidneys in amyloid disease of those organs. The organic affections of heart and kidneys, which un- derlie the two most important forms of general dropsy, ad- vance with considerable variety of course to a fatal issue. They are described in their appropriate sections. Fully de- veloped dropsy is one of their advanced symptoms, and largely contributes to determine and hasten the fatal issue. Purely anaemic dropsies, those existing without asso- ciation of structural disease of organs, may be com- pletely recovered from as the full proportion of normal red corpuscles becomes restored. Dropsy from lymphatic obstruction probably never occurs alone to any percepti- ble degree, except in cases of pressure upon the thoracic duct, preventing its free discharge into the blood. It may co-operate to an important extent when tricuspid re- flux has induced obstructive distention of the superior vena cava and subclavian veins, and impeded the dis- charge of the duct. Slight transudation of lymph may occur from obstruction of lymphatic glands or ducts. Ascites is constantly a symptom of cirrhosis of the liver, or some other affection which obstructs the portal circu- lation, and so leads to transudation into the peritoneal sac. Its course must be studied in connection with such affections under the head of Diseases of the Liver. Hy- drocephalus, hydrothorax, and hydropericardium are elsewhere separately described in this work, and so do not require further notice in this connection. Diagnosis.-The presence of the accumulated fluid in the lymph spaces and sacs constitutes at once the fact and the proof of existence of dropsy. In dropsy of the sub- cutaneous connective tissue, besides the distention, we have a very characteristic sign called pitting. When the finger-tip is pressed firmly into the skin an indentation, or pit, is formed, which remains for a little time after the removal of the finger, being only slowly and gradually obliterated. This is a pathognomonic sign of oedema. In dropsy of the serous cavities we find distention of the sacs, displacement of adjacent organs and parts, and other effects of pressure, and, when the sac is only par- tially filled, constant gravitation of the fluid to the most dependent parts, as the position of the patient is changed. In ascites, especially, a sense of fluctuation may be ob- tained on palpation and gentle tapping with the finger- ends. This sign, when present, is very characteristic. In general dropsy the question of variety at once arises. Is it cardiac, renal, or anaemic ? Cardiac dropsy, as a rule, first appears in the feet and ankles, and gradually invades the subcutaneous connective tissue and the serous cavities, with some regularity, from below upward. When it occurs in young persons there is generally a history of an- tecedent articular rheumatism, and in all cases evidence of some organic lesion of the heart is present. In renal dropsy the early appearance in the urine of albumen and casts of the uriniferous tubules constitutes distinctive evidence. Sometimes one or both may be absent from single speci- mens of urine, and in doubtful cases repeated examina- tions must be made, through a series of weeks, before a positive conclusion is reached. In renal dropsy, too, the fluid usually appears first about the eyelids, and the ex- ternal genitals are earlier and more extensively involved. Uraemic symptoms arc present and prominent. They often appear very early in the history of the case. Urae- mic coma, or convulsions, may even be the first symp- tom to draw attention to the true nature of the disease. In advanced stages of general dropsy, cardiac and renal lesions are often found coexisting, and the question arises which are primary and which secondary ? It cannot al- ways be answered with certainty. In the case of a man, aged sixty, who recently died at the Maine General Hospital, with general dropsy, presenting in his last days erysipelas of the face and gangrene of one eyelid, there was a loud and constant mitral regurgitant murmur, and plain signs of hypertrophy of the left ventricle were present; the urine was highly albuminous, and contained casts in large numbers ; the scrotum and penis were con- siderably involved ; he was stupid and dull when ad- mitted, and, being a stranger, no satisfactory history could be obtained. The autopsy showed a degenerated mitral valve, with resultant opening large enough to ad- mit readily the finger-end, and both kidneys presented cortical degeneration and cysts. In this case the ques- tion of priority of lesions was not certainly determined, even after the autopsy. In most instances the history of the case, and the greater prominence, either of the renal or the cardiac symptoms, lead to a pretty clear conclusion. In anaemic or hydrsemic dropsy we find a history of pre-existing anaemia, absence of proof either of cardiac or renal disease, limitation of the effusion to the subcutane- ous connective tissue, only a small amount of fluid, and that usually limited to the regions of the face and ankles, often appearing mainly, or entirely, about the feet in the evening, and about the face in the morning. In ascites the effusion is nearly always limited to the peritoneal cavity until the pressure of the accumulated fluid upon the large abdominal veins becomes sufficient to induce oedema of the lower extremities. An excep- tional case might possibly arise in which a morbid growth developed in that region might at the same time obstruct both the portal vein and the inferior cava, and so induce simultaneously ascites and dropsy of the lower parts of the body. Dropsy above the level of the diaphragm is never a direct result of ascites. Prognosis.-Dropsy being always a symptom, never a disease per se, the prognosis must be mainly based upon the nature and extent of the underlying affection. It may be said, in general, that uraemic and cardiac drop- sies, as a rule, advance with varying phases of ameliora- tion and aggravation of symptoms to a fatal issue. Ex- tensive dropsical accumulation is a bad prognostic sign in the course of chronic cardiac and renal diseases. It shows that the conservative powers of the system are 535 XSUhXjt REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. giving way, and usually indicates that the end is ap- proaching. In acute dropsies, such as follow scarlet fever, and accompany pregnancy, the prognosis is much more favorable, the recoveries probably much outnum- bering the deaths. In purely anaemic dropsy the progno- sis is favorable. That in the several forms of local dropsy must be left for discussion under other headings, with- out further consideration here. Treatment.-It will be convenient to consider the treatment in connection with three indications, viz., the removal of the accumulated fluid, the treatment of the un- derlying affections, of which the dropsy is but a symptom, and the general care of the patient. 1. The removal of the accumulated fluid. There are two ways in which the fluid can be removed, by absorp- tion and by surgical procedures. Absorption is promoted by the use of the three great classes of evacuant remedies, diuretics, diaphoretics, and hydragogue cathartics. As a rule, it is well to use the different classes of evacuants one after another by turns, so as to utilize all the elimi- nating powers of the system, and at the same time to distribute the extra work. But observation must de- termine which remedies are most effective, and which are best borne in each particular case, and choice must be made accordingly. In many cases of dropsy the kidneys are more or less disabled from the outset, and so diuretics are of but little use. Of the diuretics infusion of digita- lis, in combination with iodide of potassium, is probably the most effective. Cream of tartar, scoparius, and pip- sissema are much used, and copaiba is sometimes quite useful, especially in the treatment of ascites. Of the hydragogues, elaterium and its alkaloid elaterine stand decidedly at the head of the list. Elaterium is often given in pill, gr. i to gr. E combined with calomel, squill, and belladonna, in which combination it is often very effective. It is not, however, uniform in strength, and the white elaterine is probably more reliable given in the average dose of one-twentieth of a grain. It may be given every day, or every other day, for a week or two at a time. It may be repeated every hour or two till it operates. Large quantities of water may be worked off by the bowels, and absorption be correspondingly pro- moted. In case of exhaustion from profuse operations a little alcohol may be given in any convenient form. Diaphoretics have a special adaptation to unemic dropsy. Jaborandi and its alkaloid pilocarpine stand at the head of this group. They may be used daily for a succession of weeks, if needed. The nitrate of pilocarpine may be given hypodermatically in dose of gr. | to gr. i, the pa- tient being in bed between blankets. A very profuse and general sweating is usually the prompt result, with free elimination of urea. Various simple surgical procedures are made use of for the removal of dropsical accumulations. They are used a little more freely in cardiac than in uraemic dropsies, because of the greater liability in the latter to the super- vention of erysipelas. In extensive anasarca acupuncture of the feet and legs is often made, and large quantities of the fluid are slowly drained off. It is also made to the external genital organs, when they are badly swollen. Common round needles are preferred to the triangular- pointed ones for this use. The small trocars, with ca- nulae, having long drainage tubes attached, invented by Dr. Southey, are convenient and effective. Incisions half an inch long, near the inner ankle, are often used. Tapping is rarely used, except for the abdomen in ascites. Aspiration is preferable for the other serous sacs, when their distention is so great as to demand surgical relief. 2. Treatment of the underlying affections, of which the dropsy is but a symptom. For the treatment of under- lying cardiac lesions reference must be made to the sec- tion of diseases of the heart. Unhappily they are not often susceptible of cure, and the treatment looks only to temporary relief. A few words may be allowed here. Digitalis, alcohol, and strychnine are the three most valu- able drugs for stimulating, sustaining, and regulating heart action. According to Dr. Brunton, digitalis has a threefold action in cardiac dropsy, strengthening the heart, inducing contraction of the arterioles, and stim- ulating the kidneys to increased action. In all cases of cardiac dropsy the heart should be saved, so far as pos- sible, from all strain, physical or emotional. Quiet and repose of mind and body are especially desirable. For the treatment of renal diseases underlying dropsy, reference must also be made to the appropriate section of diseases of the kidneys. It is the treatment of Bright's disease in its several forms. In pure anaemic dropsy the essential treatment consists in the administration of iron, with ap- propriate dietetic and hygienic adjustments. Whenever local dropsy is the result of compression of a large vein or lymphatic trunk by a tumor, surgical relief should be given if possible. 3. General care of the patient. In general dropsy de- bility is a constant element, and tissue-nutrition greatly suffers. Hence it is of prime importance that the pa- tient should have the benefit of the best diet he is able to digest, and of the most favorable sanitary surroundings. Warm clothing to protect the surface from chilling and an equable climate are desirable. Tonics, especially iron, are usually indicated. In renal dropsy, particularly, chilling of the surface is dangerous, from its liability to induce hyperaemia of the kidneys. The skin should be kept warm and dry ; undue pressure at any one point should be avoided; gentle rubbing of a swollen limb from below upward may be practised, and the position of the limb should not be such that it would not be un- favorably affected by gravitation of the fluid. Sometimes the uniform support of a well-applied, soft, flannel band- age is both comfortable and useful. Great attention should be given to the palliation of suffering, and in- dividual indications for relief should be promptly met. Morphine by hypodermic injection, chloral in safe doses, and the bromides may be cautiously and judiciously used with great advantage. Israel T. Dana. DRYDEN SPRINGS. Location and Post-office, Dryden, Tompkins County, N. Y. Access.-South from Auburn on the New York Cen- tral & Hudson River Railroad, or north from Oswego on the Erie and Delaware, Lackawanna & Western Railroad, via Southern Central Railroad to Dryden. Analysis.-None, but the water is said to contain a large quantity of sulphate of magnesia. Other springs in the neighborhood are chalybeate. The waters are cold, 50° F. Dryden is situated about tw'elve miles east of Ithaca, at the foot of Cayuga Lake. The climate is cool in sum- mer. Accommodations are furnished by the Dryden Springs Hotel. G. B. F. DUERKHEIM is a town of some 6,000 inhabitants, situ- ated in a valley in Bavaria, at an elevation of about three hundred and fifty feet above the level of the sea. The climate is mild and pleasant. There are seven medicinal springs at Durkheim, the three most important of which are the Bleichbrunnen, Fitzschenbrunnen, and Virgilius- brunnen. The following is the analysis of the Bleich- and Virgiliusbrunnen, as made by Herberger. Each litre contains: Virgilius- Bleich- bmnnen. brunnen. Grammes. Grammes. Sodium chloride 10.27571) 12.850 Calcium chloride . 1.7!)!)!)!) 1.580 Magnesium chloride . 0.49242 0.190 Potassium chloride . 0.08833 0.048 Aluminium chloride . 0.00505 Lithium and ammonium chloride.... trace trace Sodium bromide 0.02513 0.013 Sodium iodide . 0.00250 0.001 Calcium bicarbonate 0.24118 0.232 Magnesium bicarbonate . 0.00077 Ferrous bicarbonate . 0.00122 6.612 Manganese bicarbonate . 0.00053 Barytnm and strontium bicarbonate . trace Calcium sulphate . 0.02193 6.025 Sodium phosphate 0.00083 Aluminium phosphate ... . 0.00026 Silica . 0.01055 6.005 Aluminium . 0.00010 Organic matters, etc . 0.00040 Total solids 12.96689 14.956 The gases are nitrogen, oxygen, and carbonic acid. 536 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Juodeno-Chile^ The composition of the Fitzschenbrunnen is very ■similar to that of the Bleichbrunnen, except that there is only about one-half of the quantity of sodium chloride in the former. The waters are employed in baths (douche, vapor, and water) and are taken internally either pure or mixed with milk. The Bleich- and Fitzschenbrunnen are the springs most employed for internal use. They are purgative and diuretic in large doses, but when taken in small quanti- ties are constipating, and are thus useful in chronic diarrhoea. The waters are given in the treatment of en- larged glans, ophthalmia, and other forms of scrofulous disease, of certain dermatoses, of constipation with hy- pochondriasis, of diseases of the female sexual organs, and of chronic joint inflammation. Besides their therapeutic uses, the waters of Durkheim are a source of revenue to the inhabitants in the salt which is obtained from them. The town is also frequented during the season by in- valids coming to try the grape-cure, for which it is cele- brated. T. L. S. Whether the bile be regarded as a secretion or an ex- cretion, it combines with the alimentary materials and so modifies the ingesta as to fit the mass as it descends for imparting nourishment to the body. The biliary fluid, combined with the pancreatic juice in the duodenum, so modifies the effect of gastric action upon the diversified ingredients that constitute the chyme as to fit it for re- storing the waste and decomposition of materials in the body, and the superfluous bile excites intestinal action so as to promote fecal evacuations. An interruption of the normal supply of bile may re- sult from a deficient secretion, or from arrest of the dis- charge in any part of its course from the liver to the alimentary canal. It may occur even in the small tubes which convey the bile from the various glandular rami- fications in the secretory organ to the hepatic ducts.1 The proper secretory function of the liver becomes in- terrupted in the course of chronic obstruction to the dis- charge of the bile by a sort of reactionary influence, which arrests to a greater or less extent the" production of this fluid. It is observed, under such circumstances, that no fresh supply of bile is mixed with the long-stand- ing accumulation of bilious matter in the gall-bladder, and, though the cystic duct may be patulous, the obstruc- tion of the common duct prevents any outlet, so that there is a complete stagnation of the contents. There is-event- ually a suspension of action in the hepatic organism, and a torpor of its delicate mechanism, causing it to remain a quiet looker-on at the troubles which ensue to other parts. " When occlusion2 is once effected, the gradual changes in the liver lead to slow decline of the nutrition; the bile- elements circulating in the blood poison it, and set up al- terations in the structure of the kidneys; and ultimately, the brain becoming effected, the end is reached by con- vulsions and coma. Although permanent occlusion, if unrelieved, terminates in death, a small proportion of cases get well, either in consequence of giving way of the obstructing cause or from the opening of a new route to the intestine." " As the eliminating action of the liver and the part played by the bile in the intestinal digestion are necessary to life, it follows that the complete cessation of these functions must lead to death." The inflammatory action which is sometimes set up in the cavity of the gall-bladder seems to point to relief in the direction of the duodenum, and an autopsic observation of the ulceration of the contents of the gall-bladder into this canal first directed my attention to the practicability of effecting a direct communication between these two organs. This result is well shown in Fig. 887, from Jean<?on. A very instructive report to the New York Surgical Soci- ety, at its meeting of April 28, 1885, by George A. Peters, M.D., gives the de- tails of an autopsy made by Dr. Frank Ferguson, which illus- trates strikingly this ulcerative tendency from occlusion of the gall-bladder, and the accompanying adhe- sions surrounding the perforation of the duodenum; and from it the following ex- tract is taken: " An inch below the pylorus there are two openings in the wall of the duodenum, separated by a thin band of mucous membrane, and each opening admits a probe one- fourth of an inch in diameter. The probe readily passes through these openings into the gall-bladder, as there is firm union between it and the first portion of the duode- num ; thence through the sinus above mentioned into the DUODENO-CHOLECYSTOSTOMY. This term is em- ployed to distinguish an operation for uniting the gall- bladder and duodenum with an opening between them. This mode of effecting a passage of the bile is proposed in cases of impermeability of the common bile-duct, while the cystic duct is permeable, or may be rendered so by surgical means. In the event of a remediable obstruction of the cystic duct, with accumulations within the sac of inspissated bile, of mucus, of sero-purulent fluid, or of gall-stones, the evacuation of its contents externally is requisite prior to connecting the gall-bladder and duodenum. If there should exist such degeneration of the tissues as may lead to disorganization of the gall-bladder, extir- pation is preferable to any undertaking for preserving its •outlet, either by an external opening or by a communica- tion with the duodenum. The prime consideration in determining upon chole- cystotomy, cholecystectomy, or duodeno-cholecystos- tomy, is the comparative integrity of the structures in- volved in disease from biliary obstruction. All the ten- dencies to ulcerative connection between the adjacent tissues, which are noted as resulting from inflammatory action, call for an early resort to operative procedures for maintaining some outlet for the bile. If the conditions warrant a conclusion that the normal communication be- tween the gall-bladder and the alimentary canal can be re- stored, cholecystotomy would be justifiable. But in case •of permanent obstruction of the common bile-duct, the operation suggested by me for effecting a communication between the gall-bladder and the duodenal canal, by means of a loop which shall attach their walls together and cut an opening between them, is the most feasible proceed- ing. If there is satisfactory evidence of such agglutina- tion of the walls of the common duct as to render this canal incapable of conveying the bile into the alimentary tube, we may undertake to substitute an abnormal for the normal route of the bile from the gall-bladder into the duodenum by direct cysto-duodenal communication. It will be seen that it is not a circuitous route from the liver into the alimentary canal, as a large portion of the bile flows ordinarily into the gall-bladder, and by this new channel of communication it will pass directly into the duodenum for admixture with the chyme. The phy- siological status of bile in the animal economy has not been fully ascertained by the various experiments on inferior animals and the occasional opportunities afforded in acci- dental or intentional fistulous outlets of this secretion in the human subject; but the knowledge obtained by ob- servation in regard to the properties of the bile in pro- moting the nutrition of the organism, and in stimulating the peristaltic movement of the intestines, goes to corrob- orate the results of clinical experience as to its salutary effect. Any material diminution of the quantity, or any considerable change in the quality, of the bile from the normal standard of its supply by the liver tends to pro- duce derangement in the assimilative process, and to im- pair the alimentation of the entire organization. Fig. 887.-Copy of Plate from Jeanfon. A, A, section of duodenum ; B, B, com- mon bile-duct; C, hepatic duct; D, cys- tic duct; E, excised wall of gall-bladder; E, probe in ulcerated opening; G, two small gall-stones. 537 Duodeno* Cliolecystostomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cavity in the abdominal parietes of the right hypochon- drium ; thence through the incision previously alluded to. "The cystic duct is impervious. There are several small calculi in the hepatic duct, the orifice of which is normal in size. The gall-bladder contains nineteen cal- culi of various sizes, some of them as large as a walnut, and presenting several facets. There is a slight increase in the fibrous tissue of the liver. The biliary ducts are dilated moderately." Apart from a fluctuating tumor in the right iliac region, which Dr. Abbe incised, and from which he let out a con- siderable quantity of greenish-yellow pus, it will be ob- served that nature was providing an outlet from the gall-bladder into the duodenal canal. If this had been accomplished at an earlier period, the serious disorganiza- tion might have been obviated. An interesting report of a case of fatal obstruction of the ileo-csecal valve by a gall-stone, from Dr. Russell H. Johnson, of Philadelphia, appeared in The Medical News of June 27, 1885. The stone was an inch and three-quarters in length, and one inch or over in diameter, and was firmly wedged into and completely occluded the ileo-caecal valve ; it consisted of cholesterine, inorganic and coloring matters, the cho- lesterine vastly preponderating (some eighty per cent, of the whole), and was therefore a true gall-stone. The author states that " the facts of this case warrant the conclusion that the gall-stone under consideration es- caped from the gall-blader by means of a fistulous tract connecting it with the duodenum. There is nothing im- probable in this supposition. A large foreign body lying in the gall-bladder, and closely approximated to its walls, must in time cause inflammation, and finally ulceration, of its tissues. The local peritonitis accompanying these changes would by the exudation of lymph cause the ag- glutination and adhesion of the opposing surfaces of the gall-bladder and duodenum, and thus by one of the con- servative efforts of nature give the patient at least a chance for his life." " Such a local peritonitis may occur without giving rise to any well-defined symptom, as the history of this case and of others reported makes sufficiently obvious." " Autopsic examinations (especially those made by Murchison) have in many instances shown the presence of these fistulas, and lead us to infer that it is not a very unusual occurrence." The principles of surgical pathology involved in the statements here made are so exactly in accordance with the facts connected with the results of my experiments, without the preliminary history of lithsemia, that this case is presented in corroboration of my operation, de- duced from the observation of similar results in my autopsies on the human subject. It is evident that the slow progress of such cases at the outset, and the gradual concentration of these masses in the gall-bladder, favor the development of a subacute form of inflammation that prepares the tissues for the subsequent ulceration and suppuration processes which ensue. But in the event of the arrest of such develop- ments by an operative procedure that removes the cause of trouble and establishes an outlet for the bile into the duodenum, it is reasonable to infer that permanent relief will be secured. The terms used in describing these cases leave us in doubt as to the obstruction of the ductus communis choledochus ; and if it was not closed, a timely operation by the process of cholecystotomy or by that of cholecys- tectomy might have given relief, while in the event of its occlusion duodeno-cholecystostomy might have been re- sorted to with a good prospect of success, provided the cystic duct could have been opened previously. That the surgeon should hold a ready attitude in regard to these complications is apparent from my paper on " Obstruc- tion of the Gall-duct and its Bad Consequences, with Remedial Operation Suggested," in Gaillard's Journal for October, 1884 (see pages 372, 377, 378, 379, and 380.) Viewing cholecystotomy as an effort to establish a fistu- lous discharge externally, by which the bile shall be di- rected from its appropriate channel and thus be prevented from filling the role which normally pertains to it, it be- comes us to inquire whether there is any guarantee of final and complete recovery with the interruption of a supply of the biliary secretion to the alimentary canal, as occurs in the proposed diversion. In alluding to the results of various cases, it is stated in my article above mentioned, that we may take them as a corroboration of the fact that suppuration within the gall-bladder from the presence of gall-stones, or without them, is not incompatible with the preservation of an out- let by the gall-duct. It is not improbable that though a stoppage of the gall-duct may occur temporarily from in- flammation of its walls, there may not be adhesion, and with the subsidence of the swelling and turgescence of the tissues by the evacuation of the contents of the sac, the tract of the canal may be restored. That gall-stones form in the gall-bladder, with an open duct for the partial outlet of bile, does not prove that any considerable collec- tion of fluid would remain while there existed an opening for it to flow out by the duct. It will be seen that this matter should be understood in its bearings on the con- templated operation for relieving the sac by an external fistulous opening. The entrance of the bile into the upper division of the intestinal canal being essential to health, if not to life, is there any assurance, when the bile-duct becomes obliter- ated, that an artificial communication by catheterization or by puncture can be effected to convey the contents of the gall-bladder into the alimentary canal ? This is a requisite for the favorable issue of any opera- tion looking to an outward discharge of the contents of the sac in dropsy of the gall-bladder, and unless this point can be resolved satisfactorily, surgeons will be under the dire necessity of abandoning the subjects of occlusion of the bile-duct to their sad fate, rather than become the ac- tive instruments of precipitating such a calamity. It is proper under some circumstances to evacuate the distended gall-bladder externally, with a view to establish- ing subsequently a free communication between it and the intestinal canal, which is requisite for a successful result of the operation. The practice of introducing an exploring trocar or needle, with a view to the detection of gall-stones, with- out making a cutaneous incision, has been attended with such serious consequences that, notwithstanding Harley's recommendation of this process, it will be more honored in the breach than in the observance. In like manner the use of a trocar and cannula for drainage of the fluid con- tents of the gall-bladder through the parietes of the ab- domen has its inconveniences, and is liable to conse- quences similar to those which followed tapping the dis- tended ovary in advance of the operation of ovariotomy, and which have led to its abandonment by gynecolo- gists. Preliminary explorations by puncturing through the skin are therefore very rarely justifiable in those cases. When the diagnosis of distention of the gall- bladder can be made out, as most frequently it can, upon a thorough manual examination connected with the his- tory of biliary retention, it is preferable that an abdom- inal incision be resorted to as a preliminary step to com- pleting the operation, and whatever exploration by instru- ments or by manipulation that may be requisite can then be executed satisfactorily. After an opening has been made into the peritoneal cavity, at a convenient distance below the costal arch, to the right of the median line, a digital and ocular examina- tion should enable the operator to determine as to the pro- priety of incising the sac. A thorough and painstaking exploration with the fingers along the line of the different ducts may be relied upon for the discovery of gall-stones contained in them, and after aspirating the gall-bladder so as to get rid of its fluid contents, manipulations exter- nally may detect the presence of concretions within its cavity, if of considerable dimensions. If there is con- clusive evidence of either gall-stones in the ducts or of concretions in the sac, an incision will be warranted, with a view to facilitate their removal, and the reader is referred to the article on Cholecystotomy for the details of this proceeding. 538 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Duodeno- Cholecystostomyv If the cystic duct is found permeable, or can be freed from obstructions by an operative procedure, and the common duct is open or can be made permeable by opera- tion so that a communication with the duodenum by the natural channel may be established, there would be no indication for the establishment of an artificial communi- cation between the gall-bladder and the alimentary canal. Should there exist a channel for the free outlet of the bile from the liver, however small it may be, there is en- couragement to expect complete relief by dilatation of the cystic duct and the common duct with a flexible sound so as to restore the normal relation of the parts. Should it be found practicable only to open the tract of the cystic duct, while the common duct remains impermeable, then our recourse for restoring the bile to the alimentary canal consists in effecting a direct cholecysto-duodenal outlet by the remedial operation suggested in my paper above referred to. This proceeding is simplified by the dilated condition of the wall of the gall-bladder, which lies in close proximity to the duodenum, so that a needle armed with a ligature will readily unite them. While steps have been taken for the removal of ob- structions from the bile-ducts, and an external fistulous opening for the discharge of bile has been provided as a means of temporary relief to the patient, no measure apart from that of Von Winiwarter has been adopted thus far with a view to convey the bile from the gall- bladder into the alimentary canal. It must be understood by all who are aware of the ne- cessity of biliary matter for the proper execution of chymefaction and chylifaction in the upper part of the in- testinal tube, that a permanent obliteration of the com- munication of the gall-bladder with the duodenum is in- compatible with health, if not inconsistent with the continuance of life. The prime consideration for the pathologist is whether any considerable collection of bile ever occurs in the gall-bladder without occlusion of the common duct, and the question of paramount importance for the surgeon is the practicability of restoring the flow of bile into the duodenum by the natural channel, or into the adjacent portion of the intestinal canal by an artificial communication between them. It should be noted that a cholecysto-duodenal opening may meet all the requirements in cases of impermeability on the part of the common bile-duct while the cystic duct is patulous, and this fact seems to have been overlooked by some surgeons who have not given due consideration to the details of my proposition. It is evident that there has been a total misconception in supposing that this process is suggested as a substitute for other modes of proceeding in occlusion of the cystic duct, when really it is not applicable to cases of this nat- ure, but is claimed to afford relief in closure of the common duct, for which the other procedures are not available as radical operations. There certainly is a fundamental difference in our views as to the ultimate destination of the bile in the physical organization, as some claim that it can be dispensed with in the animal economy, while I hold that it is a requisite for completing the normal digestion and assimilation. Some propose to cast it aside as useless, through an ex- ternal cutaneous opening, while I undertake to utilize it by an artificial communication with the alimentary canal. In other operations the abnormal surroundings of the gall- bladder have been continued, but this remedial measure restores the biliary function to its proper field of activity. My conviction in regard to occlusion from impaction of gall-stones in the duct, or from agglutination of the sides of the canal without complete obliteration of the passages, is that operative measures are likely to afford relief by removing the obstruction to the outlet of the bile. I am likewise impressed with the prospect of se- curing a salutary result when the ductus communis cho- ledochus is permanently occluded, and the bile enters the gall-bladder by the cystic duct, and accumulates in the sac, by an operation such as has been described and de- monstrated, in passing a ligature through the walls of the sac and duodenum. But if the case has run on until there is no more bile furnished by the liver, and only degenerated fluids are found in the sac, it seems to me that the occasion does not offer any encouragement for cholecystectomy as has been undertaken, nor for cholecystotomy with a view to the establishment of a fistulous discharge externally. We should see to it, then, that no case under our care be al- lowed to reach this hopeless condition ; we should rather seek to avoid by timely operation the development of such results from obstruction of the gall-duct, and a favorable termination may be anticipated by dilatation of the cystic duct, and by establishing an outlet into the duodenum. The practical discernment of Harley3 led him to the conclusion that "the triumph of operative surgery would be to establish an artificial fistula between the gall-blad- der and the duodenum. For then not alone would the pent-up bile be removed, but the disturbances arising from the non-admittance of bile into the intestines likewise be at the same time overcome. I am not quite sure if, in these days of antiseptic surgery, the operation is not practi- cable ; for I can see no reason why the adjacent surfaces of the gall-bladder and duodenum should not be eroded by potassa fusa and speedily stitched together." The principle of cholecysto-duodenal communication seems to have been grasped in this suggestion for creating a fistulous opening ; but the process of accomplishing it presents objectionable features, which do not hold against my plan of uniting the two walls by a loop of suture which shall induce an amount of adhesive inflammation sufficient for the union of their outer surfaces, with a certainty of cutting through the adjoining tissues and ef- fecting a passage from the gall-bladder into the duodenum for the bile. It may be practicable, however, to effect this communication in some form which shall recom- mend itself to the profession more than either of these processes; and the desirableness of such a result being established, it only rests with the surgeon to discover the most practicable means of accomplishing the end in view without risk to life. The cases which led me to the conclusion that an open- ing directly from the gall-bladder into the duodenum was the proper remedy for obstruction of the gall-duct, were reported subsequently to the publication of Harley's book, and therefore he is justly entitled to priority in suggesting it to the medical profession. But his work had not been seen, nor was I aware of his views, when my paper appeared in the October number of Gaillard's Journal for 1884 ; and, moreover, by consulting that ar- ticle it will be noted at the top of page 366, that in a case treated by me in 1879, " the autopsy revealed ulcerations connecting the gall-bladder with that part of the intestine adjacent to the duodenum." On page 368, near the bot- tom, it will be seen that I diagnosticated in another case that " the channel by which the inspissated bile found its way from its receptacle into the intestinal canal could not have been by any dilatation of the natural outlet, but must have been the result of ulceration, which caused a communication of the gall-bladder with the upper part of the small intestine, adjacent doubtless to the duodenum." And in my cases reported at the close of 1880, and early in 1881, at the foot of page 370 and top of page 371, it is stated that "with the continued gastric and intestinal trouble, associated with more or less tenderness over the epigas- trium, along with nervous excitability and acceleration of the pulse, dating from the period of the attack of he- patic colic, it is perhaps a legitimate inference that the structural changes initiated then had progressed with ul- ceration in such form as to account for the whole train of disorders. The rest and quiet of a sea voyage, it being known that the patient did not suffer from sea-sickness, was advised by me as most conducive to a subsidence of any inflammatory process which had existed, and the result has confirmed my anticipations. If the jaundice had been present at the outset, and given way shortly after the re- turn of the bilious matter to the evacuations, it might be supposed that there was an error in diagnosticating obstruction of the gall-duct with abnormal cysto-intestinal communication." These notes of cases, considered as the basis of the measure of relief by an opening directly from the gall- 539 Duodeno- Cholecystostomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bladder into the duodenum, must be taken in connection with my statement upon page 362, near the top, in the same paper, as follows : " When the obstruction has gone to the point of agglutination by the effusion of coagula- ble lymph, it will be found impracticable to combat the adhesive inflammation of the tissues, and the canal re- mains impermeable. When the ordinary channel be- comes thus closed, it may occur that an artificial opening will be effected by an ulcerative process between the gall- bladder and the duodenum, or the adjacent portion of the small intestine, thus remedying the difficulty tempo- rarily, if not permanently. An outlet is afforded in this way to the biliary concretions or collections of fluid bile, and even sero-purulent discharges have taken place through such an ulcerated communication between these parts." With such impressions of the results of ulcerative pro- cesses in giving an outlet from the gall-bladder into the duodenum, my conviction became fixed, in the course of the year 1881, that surgical means should be adopted with a view to the same end, and my article, substantially as published, with the exception of the experiments on dogs, was sent on to Gaillard's Journal, with the injunction to incorporate reports of two autopsies of cases, involving the gall-bladder, that had been forwarded to Dr. J. Marion Sims. But on October 29, 1881, my communi- cation was acknowledged, with the statement that Dr. J. Marion Sims had returned to Europe, and that my note had been sent to Dr. Harry Sims, neither of whom ever sent the desired reports. Thus it occurred that the pub- lication of the article was deferred until I was enabled to add the matter from the middle of page 378 to the end of the paper, including the results of my experimental re- searches, made in 1884, as to the feasibility of effecting a fistulous connection between the gall-bladder and duo- denum. It is due to the history of this operation that these facts should be known, and especially in view of their relations to the measure suggested by Harley for attaining a similar result in a direct cholecysto-duodenal communication. All who have noted the report of Von Winiwarter's case, in which the gall-bladder was first united to the colon, and subsequently to the small intestine, must per- ceive that it is quite a different proceeding, with a widely dissimilar effect, from the operation suggested by Harley, or that adopted by me in re-establishing the flow of the bile into the duodenum. The proximity of the duo- denum to the under surface of the gall-bladder presents favorable conditions, when there is distention of the gall- bladder, with more or less thickening of its walls, in cases of obstruction of the common duct in the human subject. It is probable under such circumstances that there will be less liability to extension of inflammatory action than in the sensitive normal susceptibility of the tissues presented in the experiments upon dogs, and as a consequence less tendency to a fatal result. It is an interesting fact that in some conditions of traumatic origin secondary opera- tions are attended with less risk to life than those under- taken soon after the receipt of injury ; and we are led to infer that the reaction or tolerance of the organization in its abnormal state may be favorable to the result of surgical procedures in the human system after the dis- orders connected with biliary obstruction have diminished the tendency to active or acute inflammation in the or- ganism. A problem of serious import for the surgeon is, however, sometimes presented, as to the extent of im- pairment in the vital energies that is compatible with re- covery from an operation; and we must not delay sur- gical relief until the capacities of the physical constitution are exhausted. In the human subject there is certainly a diminished energy in the animal structure connected with the progressive obstruction of the common bile- duct, either from the presence of gall-stones or from ste- nosis by thickening of its walls; yet the tendency to destructive inflammation must be lessened by this ady- namic element, so as to impart a tolerance of surgical interference. If the relations of the parts after such direct communication is established be comprehended, it must be evident that no complications with the coils of the small intestines occur, as the somewhat distended sac lies naturally in contact with the outer and upper part of the duodenal canal, while the intestinal coils are located below and cannot become involved in the cysto-duodenal attachment. There are three features in this operative measure which are essential to a successful issue: the firm union of the ex- terior surfaces of the walls that are brought in contact; a free opening through both structures by which their cavi- ties are in communication ; the removal of the suture, after cutting its way, by a spontaneous passage into the intes- tinal canal. If either of these conditions should not be fulfilled after attaching the gall-bladder to the duodenum, the result cannot prove satisfactory. But so far as our experiments upon the dog are capable of illustrating what might be expected in the human being, we have every reason to expect a favorable result.* I may appropriately introduce at this point an abstract from the recent report of a case of cholecystotomy by W. W. Keen, M.D.,' ■which presents some interesting points bearing upon the relations of the duodenum to the gall-bladder. On October 10th, Dr. Keen operated on Albert Henry K , a German, aged forty-five years, with the usual antiseptic precautions. An incision three inches long was made, parallel with the margin of the ribs, commencing one and a half inch below the ensiform cartilage, and ex- tending over the prominence of the tumor, which proved to be an enlarged left lobe of the liver, and the gall-bladder could neither be seen nor felt. The incision was prolonged about two inches to the right, when the colon and omentum were exposed, and a hard mass could be obscurely felt, which was believed to be gall-stones. Another incision was made, beginning at the upper end of the first, and extending downward in the linea alba for three inches. Into a soft mass, supposed to be the gall-bladder, a small opening was made ; but it was soon evident that this was the duodenum, as the fin- ger detected the pylorus. On discovering this, the wound in the duodenum was closed with five interrupted and five carbolized silk Lembert sutures. The harder mass was now carefully lifted to a slight extent by the finger and thumb, and the wall and tissues in front of it cau- tiously incised for about three-fourths of an inch, and two stones, respectively three-fourths and one and one- fourth inch in size, were removed. The gall-bladder was as firmly contracted around them as a kid-glove clasps the finger, and contained absolutely no fluid. The open- ing of the cystic duct could be felt by the finger and was patulous. No other stones could be felt by the fin- ger. A probe, it was thought, could be passed from the cystic to the common duct. The wound in the gall-bladder was stitched with four interrupted and four Lembert's carbolized silk sutures. All haemorrhage had apparently ceased. The cavity was carefully cleansed, and the abdominal walls, including the peritoneum, -were sutured with wire, and the wound dressed with bichloride of mercury gauze. The patient died at eight o'clock next morning, and the post-mortem examination was made at 12 m. About six to eight ounces of blood were found in the belly, and as the greater part of it was behind the peritoneum and extended to and around the right kidney, it presumably came from vessels injured in the lifting of the mass in which the gall-stones were situated. No gall-bladder ex- isted in the proper site for it, but it was found lying transversely, in a shrunken condition, far posteriorly. The common and cystic ducts were patulous. The wounds in the gall-bladder and the duodenum were effectively closed by the sutures. The mucous mem- brane of the duodenum was deeply congested for a wide extent, and thought by Keen to be undoubtedly from in- flammation existing before the operation. The duct of the pancreas was found pervious. Dr. Keen, on review- ing the case, ' ' was inclined to believe that it would have been better to close up the abdominal wound, and trust to * The reader will see erroneous views of it corrected in the Medical and Surgical Reporter, September 12, 1885, under the heading of Duo- deno-cholecystostomy. 540 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dnodeno- Cholecystostoiny. the possibility of the stones ulcerating into the duodenum, to which, the gall-bladder was already closely malted." I have italicized the above passage as bearing directly upon the operation proposed in cases of obstruction of the common bile-duct; and the fact that the duodenum was mistaken for the gall-bladder, and actually incised for it, shows how closely they are related to each other in the human subject. It is very probable that the congestion in the duodenal mucous membrane resulted from the incision and stitch- ing of its walls, and thus throws some light upon the traumatic injury of these tissues in the operation of duodeno-choiecystostomy. In the Atlanta Medical and Surgical Journal for Sep- tember and October, 1884, I reported a series of experi- the sac, into the cystic duct, it took the course of the hepatic duct, and could not be made to descend into the common duct, probably owing to the angle at which they unite. And upon introducing the probe from the duo- denum into the common duct, it passed up into the hepa- tic duct, without finding an entrance into the opening of the cystic duct. There was evidently no obstruction to the passage of the bile in either duct, as, prior to incis- ing the gall-bladder, the duodenum was laid open oppo- site the outlet of the common duct, and pressure upon the sac caused the escape of bile at its orifice in the canal. It is, therefore, clear that the various ducts did not become Fig. 890.-Incision in Duodenal Wall. 8, Fistulous communication of cavities ; 9, entrance of common duct; 10, adhesion of surfaces form- ing septum; 11, pyloric curvature of duodenum. Fig. 888.-View of Relations in the Dog. 1, Duodenum with pylorie curve; 3. attachment by stitch to gall-bladder; 2, common, cystic, and hepatic ducts. The figure indicates the mode of uniting the walls by a single silk thread. involved in the inflammation propagated from the silk thread to the serous investments of the parts which were brought in contact. A very important feature in the history of this case is the absence of any undue inflam- matory action in the peritoneal cavity, notwithstanding the second laparotomy eight days after the first, when it might have been supposed that there existed a predisposi- tion to inflammation. Apart from the adhesion of the approximated walls of the sac and duodenum, with the attachment of the latter to the lower surface of the right lobe of the liver, and a slight adhesion of the stomach to the under surface of the left lobe of the liver, there re- mained no traces of peritonitis in the abdominal cavity. The contained viscera had not contracted any adhesions ments on dogs, intended to show the aim and end of this process for connecting the gall-bladder with the duode- num. As these have an important bearing on the pro- posed operation in the human being, I will refer to them briefly in this place. The first experiment, on August 20, 1884, consisted in opening the abdomen and passing a loop of silk through the approximated walls of the gall-bladder and duodenum, while the second laparotomy verified their union by adhesive inflammation ; and the third was done with a view to replace the loop if the hole had become closed, and also with the expectation of ligating the common duct so as to prevent the escape of the bile by the nat- ural channel, and thus force it to pass through the arti- ficial opening. But unfortunately the animal died from an overdose of the anfesthetic soon after the peritoneal cavity was en- tered, and the specimen shows the intimate union of the exterior sur- faces, forming a firm septum be- tween the gall-bladder and duode- num without any aperture re- maining in their walls. The action of the thread in cut- ting through and passing into the intestine, certainly made an open- ing that continued for a time, but not having ligated the common duct, this gave a free outlet to the bile, and hence the artificial communication between the sac and canal was ulti- mately obliterated. Upon passing a probe through an incision made in Fig. 891.-Union by Adhesive Inflammation. 12, 14, Duodenum and pyloric extremity: 16, 15, gallbladder and ducts; 13, agglutination of walls of gall-bladder and duodenum. to each other or to the parietes, and there was no attach- ment even with the line of suture through the extensive abdominal wound, that was closed by the hair-lip suture with the needles penetrating through the edges of the peritoneal lining and the skin. September 5th is the last date given in the published record, when it is stated that "the animal eats and moves about the room, leading to the inference that the result will be favorable." It was entirely restored within a month, and continued in a healthy condition until it succumbed from an imprudent administration of sulphuric ether on February 4, 1885, preparatory to a final exploration. Fig. 889.-Posterior View of Attachment. 4, Incised gall bladder; 7. curvature of duodenum ; 6, entrance of common duct; 5, arti- ficial opening through their walls. 541 Duodeno- Cliolecystostomy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. During the past three months I have performed a new series of experiments upon fifteen dogs. I have been placed under the disadvantage of dealing with tissues in their normal condition of susceptibility to traumatic lesions in all these experiments, and it is somewhat re- markable that some of the dogs should have exhibited such a degree of tolerance to the operative proceedings, involving the abdominal viscera, as are to be herein pre- sented. In repeating the measures already detailed of attaching the gall-bladder to the duodenum by a single stitch of doubled white silk thread, I resorted in some cases to ligation of the common duct on the same occa- sion (see illustration in Fig. 892), but death ensued early denum seems to have been shock, while two of the cases, in which a communication was effected by the punching operation, accompanied by ligation of the common bile- duct, died from a like cause, making five deaths within twenty-four hours after primary operations. The fatal result in all four of the cases that underwent ligation of the common duct, along with the attachment of the gall- bladder and duodenum, may be traced to the permeation of the bile through the natural connections with the liver into the parenchymatous structure of this organ ; and in one of these cases there was extravasation of the bile into the thoracic cavity. Death ensued finally, perhaps, in the case of a second laparotomy, and in the two cases of a third laparotomy, from the mistake in ligating the he- patic duct instead of the common duct, which caused the regurgitation of the bile into the corresponding lobe of the liver. In three remaining cases of this series of ex- periments the fatal result was due to peritonitis. The fatality attending the ligation of the common bile- duct before another outlet for the accumulation of bile Fig. 892.-Modification of Plate from Cloquet. The duodenum is drawn up with the liver. I, Knotted loop, attaching it to the gall- bladder ; J, the cystic duct; A' hepatic ducts; 27, ligation of common bile duct. Fig. 893.-Immediate Communication between the Duodenal and Cystic Cavities. 18, Temporary attachment of walls ; 17, circular excision from each by punch. in these subjects, with extravasation of bile into the he- patic tissue. In four cases of attachment by a single loop of silk passing through the walls of the gall-bladder and duo- denum, in which the common bile-duct was ligated with catgut, fatal results ensued, respectively, in the course of thirty-six, forty, and iifty-six hours, and in three and a half days. In five cases of simple connection by a stitch of silk thread, without ligation of the common duct, death occurred in eighteen, twenty, twenty-four, and forty-eight hours, and in twenty days, respectively. In one case of securing the gall-bladder and the duo- denum together, and perforating their walls with a shoe- maker's punch with suture of the margins, while the common duct was left open, death resulted in thirty-six hours. In two similar operations, with ligation of the common bile-duct, death resulted in twenty and twenty-two hours, respectively. In a second laparotomy, one month and three days after the primary operation of attaching the gall-bladder to the duodenum, for verifying their union and ligating the common duct, death took place within forty-eight hours. An animal that underwent a second laparotomy one month after the primary attachment of the gall-bladder and duodenum, was subjected to a third opening of the abdomen when another month had passed, in which the wall of the duodenum was incised and a puncture made into the gall-bladder through the septum, and died four days subsequently. In another dog, a second and third laparotomy were practised, with like intervals, and the animal died ten days afterward, having survived three months and five days from the first operation for attaching the gall-bladder and duodenum. The cause of death in three of the cases in which there was simple attachment of the gall-bladder to the duo- was effected, induced me to undertake three experiments for effecting an immediate communication between the gall-bladder and duodenum (see Fig. 893). The gall-bladder was secured temporarily in contact with the duodenum by a loop of silk thread passing through their walls, and the doubling of each was excised with a shoemaker's punch, thus leaving a round aper- ture whose margins were united in two cases with a con- tinuous catgut suture, and in one with interrupted suture of Snowden's iron-dyed silk (see Fig. 894). The common duct was not closed in one of these cases, yet the subject died in thirty-six hours, while in the other two this duct was ligated, and the animals succumbed in less than Fig. 894.-Result of Direct Opening in Walls. 19, Orifice with sutured margin ; 20, incision into duodenum. twenty-four hours. In each of these latter cases the autopsies revealed a yielding of the suture around the cir- cular opening, and consequent escape of bile into the peritoneal cavity, instead of passing directly from the gall-bladder into the duodenum : and it was inferred that the contractile tissue of the intestinal wall led to the closure of the orifice made by the punch, yet there was no agglutination or stoppage remaining after death. With proper precautions in removing a larger section 542 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Duodeno- Cliolecystostomy. from the duodenal wall, so as to make allowance for its contractility, and a secure union of its margin with that of the opening in the sac (see Fig. 895, showing this suture), this operation ought to succeed. Space is not allowed for minutiae here, but all the de- tails are given in my published record of these cases. from the action of the simple loop of silk thread passed through their walls more than three months previously, and there was a solid union around the aperture resulting from adhesive inflammation between their serous surfaces which had been brought in contact. It was ascertained by exploration that the ductus communis choledochus was pervious, and that in consequence of the occlusion of the hepatic duct leading from the right lobe of the liver, by the mistake in applying the ligature, there was partial disintegration of the parenchymatous structure of this part of the organ, which most probably led to the fatal result. It is evident that the preservation of this artificial com- munication between the gall-bladder and duodenum for three months, while the natural outlet was open, affords strong ground for belief in the maintenance of such an out- let for the bile, when there may be an obstruction of the common bile duct, as occurs in all cases requiring surgical interference in the human subject. The great increase of pressure from the accumulation of bile in the gall-bladder, when there is occlusion of the common duct, must assist materially in preserving the outlet for the bile into the duodenum. The inferences from these experiments are : 1. That shock overpowers the vital forces in operations requiring much violence to the gall-bladder and duo- denum, under their normal conditions of susceptibility to a traumatic impression. 2. The sudden interruption of the discharge of bile by the natural channel, when no artificial outlet exists, leads to the disintegration of the cysto-hepatic connection, and to disorganization of the parenchymatous structure of the liver, terminating speedily in the death of the subject. 3. A single loop of silk thread which attaches the walls of the gall-bladder and duodenum in close contact, se- cures their union by adhesive inflammation, and effects a fistulous communication through the septum thus formed, without leading to a fatal result. 4. The preservation of a fistulous opening for three months, in a case without any obstruction to the ordinary outlet of the bile, affords a reasonable presumption in favor of such communication being maintained perma- nently, with occlusion of the common bile duct, as found in all human beings requiring operative interference. 5. This operation for creating a cysto-duodenal com- munication is only indicated in cases of impermeability of the common bile duct, while the cystic duct is open or may be ffeed from obstruction. 6. An effort should first be made to overcome tempo- rary obstruction by catheterization of the ducts ; and the instructive case of Dr. C. T. Parkes assures us of the practicability of passing a sound from the gall-bladder through the cystic and common ducts into the duo- denum, so that dilatation of the gall duct may be at- tempted before proceeding to attach the gall-bladder to the duodenum. 7. In case of failure to open the natural outlet for the bile, an artificial communication may be made between the cavities of the gall-bladder and the duodenum, with agglutination of their walls, without material alteration in the subsequent condition of their tissues. No constric- tion of the canal or induration of its intimate structure has resulted in the animals which survived, and conse- quently it may be inferred that the normal calibre of the duodenum will be preserved after making this fistulous opening for the bile. 8. The walls of the gall-bladder under such conditions contract and partake of the nature of a conduit, so that the biliary secretion is urged forward and prevents the ingress of the alimentary mass from the duodenal canal. The constant flow of bile through the orifice must pre- serve it open, as in a cutaneous fistula, and maintain a per- manent communication between the gall-bladder and duodenum. James McF. Gaston. Fig. 895.-Exterior View of Operation by Punch 21, 22, Stitches in margin of aperture through walls of gall-bladder and duodenum; 23, ligation of common duct. A report of this second series of experiments for illus- trating the cholecysto-duodenal communication as an out- let for the bile in obstruction of the common duct, will be found in the Atlanta Medical and Surgical Journal for the months of September and November, 1885. Out of fifteen subjects only three dogs finally survived the primary operations ; yet it will be observed that the results of attachment of the gall-bladder to the duodenum, by a single loop of white silk thread, are their intimate and firm union by adhesive inflammation between their serous surfaces, and the formation of a fistulous opening through this septum, which affords a communication between their cavities. Thus the conditions are afforded for a free discharge of bile when the flow is impeded by the natural channel; and I sought by secondary operations on the survivors to test the practicability of turning the bile entirely into the artificial channel. The adhesions of the duodenum with the liver were such in each case as to obstruct the view of the ducts, and consequently the touch only could be depended upon for passing the ligature, so that failure resulted in my own undertakings, and in that of a col- league, to secure the common duct in all three of the ■cases in which the abdominal cavity was opened for this purpose. A second laparotomy proved fatal in one of these cases under my care within forty-eight hours, and death ensued in another case in my hands on the fourth day after a third laparotomy. Laparotomy was resorted to at the expiration of a month after the primary opera- tion for attaching the gall-bladder to the duodenum, made at my request, in one case, by my colleague, Dr. W. D. Bizzell. The firm union between the gall-bladder and duodenum around the point of suture was verified by him, and he entertained a strong impression that an opening existed for the flow of the bile through this septum, so that he attempted, but without effect, to ligate the common bile duct. The abdominal cavity of this animal was laid open for the third time, two months subsequently to the second operation, when it was corroborated by the examination of several medical men who were present, that there ex- isted a strong attachment of the walls of the gall-bladder and duodenum, and from the want of distention of the sac it was inferred that it was kept drained by an arti- ficial outlet into the duodenum. After tearing loose some of the adhesions of the liver with a view to expose the ducts, another attempt was made by Dr. Bizzell to ligate the common duct, but it was ascertained subse- quently that the catgut ligature was passed by mistake around one of the hepatic ducts. This dog died ten days after the third laparotomy, and the autopsy showed a free communication between the gall-bladder and duodenum 1 Lepg : On the Bile, Jaundice, and Bilious Diseases, p. 344. 2 Pepper's System of Medicine, vol. ii., p. 1092. ; Art. by Dr. Roberts Bartholow. 3 Diseases of the Liver, p. 700. 4 Maryland Medical Journal for November 21, 1885. A paper read before the Philadelphia Academy of Surgery, November 2, 1885. 543 Dynamometer. Dynamometer. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. DYNAMOMETER. The word dynamometer, derived from Suragn, force, strength, and /merpov, a measure, is used to denote an instrument for measuring strength or force. This may be either mechanical, muscular, or even physi- cal. As applied to medical science, however, dynamom- eters are used chiefly in two ways : (1) To determine and regulate the strength of forces applied to the human body; (2) to measure the amount of strength or force which can be exerted by the human body, or various portions thereof, under various conditions. More par- ticularly are these instruments used to determine the force of contraction of certain muscles, or groups of muscles, as the flexors of the fingers and thumb in meas- uring the force of the grasp of the hand, or of the muscles concerned in pushing or pulling in different ways. Less commonly they are susceptible of employment in de- termining resistances in which not only the muscles but the firmer and more solid parts of the organism are involved. The earliest direct attempt to estimate the human strength for scientific purposes seems to have been made by De La Hire, who in 1699 published his " Examen de la Force de 1'Homme," in the " Memoirs of the Academy of Sciences" at Paris. He determined the strength of men from their ability to lift weights and carry burdens, and compared it with that of horses. The first instrument, however, which was directly used for this purpose, and to which the name of dynamometer was given, was invented by an Englishman named Graham ; but it did not obtain notoriety until attention was drawn to it by Desaguliers, who in 1719 published his work on " Experimental Philosophy." The latter was a Frenchman by birth, but came early to England, and was made professor at the University of Oxford. He modified Graham's machine in various ways, and thus produced a machine of his own. His machine, or rather machines, because different ones were required to test different muscles, consisted practically of a large wooden frame and stout uprights to offer points of support or resistance, and handles at- tached to a crossbar which moved a steelyard. By hang- ing weights on the latter the force used could be directly determined. Desaguliers decided from his investigations that five Englishmen were equal in strength to a horse, but only seven Frenchmen or Dutch. These instruments were, however, too unwieldy and cumbersome to be used outside of the laboratory, and being also somewhat expensive fell rapidly into disuse and were forgotten. Meanwhile Leroy, like De La Hire, a member of the French Academy of Sciences, proposed an instrument which consisted simply of a metallic tube, within which was placed a spiral spring with an attached graduated rod terminating above in a globe. This was to be grasped by the hand, and the spring compressed from above, the amount of force exerted being marked on the rod. In 1807 Regnier first described his dynamometer. This consisted principally of an elliptic spring of metal, to which was attached a dial furnished with two rows of figures and with two hands, one for each row. The dial was so arranged that the hands were moved by any change in the form of the spring, and the force of either tension or pressure could be easily measured. The two rows of figures corresponded to the effects produced by action on the instrument according as the force was ap- plied in the direction of the long or in that of the short axis ; the upper row in myriagrammes corresponding to the former, the lower row in kilogrammes to the latter. This instrument was the first dynamometer of practical value, and most of those in present use are more or less varying modifications of the same type. As may easily be understood, it served not only to measure force as con- nected with the human frame, but also the strength of machines, and the forces exerted or applied by them. It was first employed in surgery by Sedillot about 1836. He used it to determine and regulate the amount of force exerted in reducing dislocations and in other surgical operations. For this purpose the instrument was attached to one of the cords which extended from the pulley to the limb of the patient, and the measure of the force exerted was read from the dial. Sedillot used the dynamometer of Regnier, but the needles worked in a somewhat differ- ent manner. Instead of serving to mark the result of forces according as they were applied in the direction of the long or of the short axis, in this instrument one of the needles simply marked the maximum variation, while the other was freely movable and corresponded in position with the amount of the traction at each given moment, thus enabling the operator to recognize varia- tions and to provide for continuous steady action. " He thus succeeded in producing continued extensions, that is to say, those maintained at the same strength and gradu- ally and regularly increased." None of the dynamometers thus far used appear, how- ever, to have been simple or readily capable of applica- tion to medical purposes. In 1859 Burq first published his description of a new pocket dynamometer, " formed of the metals most active in metallo-therapy." This was to serve, firstly, for the ready exploration of the strength of pressure and of traction in all the muscular systems of external life ; secondly, for the closely approximative de- termination of the forces which the surgeon may be called upon to use, as in the reduction of certain disloca- tions ; thirdly, for the more usual metallo-therapeutic investigations. Burq's dynamometer (see Fig. 896) consists simply of a small box or case of metal, rectangular and open in front. Fig. 896.-Burq's Dynamometer. Its upper and lower portions are, when it is not in use, maintained at a slight distance from the point of com- plete closure by a double spring of steel, which is so placed in the interior as to be always perfectly protected. This records accurately, on a dial placed in the centre of the case, the force of all efforts which may be made, di- rectly or indirectly, with the hands or the feet, to close the case. When it is desired to test the force of traction the hooks represented in the figure are inserted into open- ings made for them in the top and bottom of the case, and the traction is exerted by means of the handles which are attached to them below. Another important modification in the form of dyna- mometers, was that introduced by Duchenne, of Boulogne, and apparently first described in 1863. A little later he speaks of it thus : " I have had made a powerful dyna- mometer (measuring from one to one hundred kilo- grammes), and a sensitive dynamometer (measuring from one to eight kilogrammes). The powerful one serves to measure the force of the pressure of the closed hand, that of all movements of parts, and the amount of what I 544 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dynamometer. Dynamometer. have called nervous excitability (irritability nerveuse), or the degree of exhaustion of this excitability. Firstly, we measure the force of pressure of the closed hand by placing in the palm of the hand, between the thenar em- inence and the second phalanges of the flexed fingers, the handles of the dynamometer crossed. Secondly, it is de- signed to measure the force of the movements of parts. Then its handles should be uncrossed. For example, if we desire to measure the force of the movement of flex ion of the lower arm, we fasten something to the end of it (a handkerchief folded crossways or a strap), to which we can attach the handle of one of the branches ; then, while the subject holds the forearm powerfully flexed, the operator seizes the handle of the free branch, and pulls on it until the forearm begins to extend. The sen- sitive dynamometer, of a form analogous to the preceding, is designed to measure in grammes the force of partial movements in persons who suffer from paresis. Thirdly, the movable needles are designed to measure the force of the nervous excitability. The instrument (see Fig. 897) is composed of: 1, A near which the patient sits. He presses with his right hand on the short arm of the lever, while the physician places the weight so as to neutralize the pressure. The limit of the muscular power stands at that point at which the patient is no longer able to keep down the short arm of the lever. Among dynamometers for special purposes mention should be made of Mallez' vesical dynamometer, intended to measure the muscular force of the bladder. It is com- posed of the following parts : 1, A tube 0.04 mm. long, and 0.01 mm. in diameter ; 2, a little cap, which forms one of the extremities of the tube, extends into it, where it moves up and down with slight friction, and receives the shock of the column of liquid ; 3, the cap is sur- mounted by a rod, surrounded by a spiral spring of known resistance, and this rod extends a certain distance beyond the farther extremity of the tube ; 4, a pin placed on the rod at its exit from the tube is in contact with the shaft of a needle, and communicates to it the upward move- ments of the rod. The divisions of the dial over which the needle plays indicate the degrees of impulse, and the point of stoppage shows the measure of the greatest force developed. All the instruments hitherto described are more or less complicated or designed for special purposes, and they are not much used at the present time. On the other hand, their place is supplied by simpler and less costly instruments. Mathieu's dynamometer, which is now in general use, is a modification of Regnier's, in which the dial, instead of projecting beyond the spring, is placed between its branches, making the instrument smaller and easier to handle. As it is intended only for medical use, the spring need be only of a moderate resistance. The Fig, 898.-Dynamometer of Collin. dynamometer of Robert and Collin is practically the same as that of Mathieu (see Fig. 898). Dr. Graeme Hammond, objecting to the fact that the hand of the patient sometimes covers the dial-plate in Mathieu's instrument, so that the steadiness of the muscu- lar contractions cannot readily be perceived, has, in his form, placed the dial-plate at one extremity of the ellipse instead of on the side, as does Regnier. In his instrument the dial-plate has the double rows of figures, which should be used on all dynamometers, and the plate being larger and the hands longer than in the ordinary form, smaller degrees of pressure can be registered. Hamilton's dynamometer consists of a graduated glass tube which dips into a rubber bulb. This bulb is tilled with colored water, which rises in the tube when the bulb is compressed. Hamilton thinks that the rubber bulb is better adapted to receive pressure exerted by all the flexors of the hand than the spring dynamometer, which is only acted on by some of them. The uses of the dynamometer, from a medical point of view, have already been indicated. In disease it is used frequently to determine the amount of muscular force in muscles or series of muscles, either by comparison of those on the one side with the corresponding ones on the opposite side, or by comparison with the standard of health. It is of greatest value in cases of partial paralysis, where it is desirable to test more or less accurately the strength of special muscles. In this way it is used both as a means of diagnosis and of prognosis. In health, also, the dynamometer has been frequently used: (1) to determine the average power which the human body can Fig. 897.-Duchenne's Dynamometer. powerful spiral spring, which ends in two straight branches (0, 0) placed side by side and parallel-the spring is made tense by the separation of these branches ; 2, two handles (P, P), which are fixed at will either at the extremity of the branches or near their central point, and by means of which the branches can be separated ; 3, a plate (C), placed on the anterior face of the spring, and on which are engraved two rows of numbers (A, B), mark- ing in the first from one to one hundred kilogrammes, in the second from one to forty ; 4, a needle (D), which is set in movement by the separation of the branches, and marks the amount of force which causes this separation. Donhoff's myodynamometer was designed to "deter mine with mathematical exactness the degree of muscular power in disease." The instrument acts on the lever principle. A bar fifty-five inches long, with a notch five inches from one end, is so placed that the notch fits into the corner of a prism-shaped support on which the bar can be moved as a lever. The long arm of the lever con- tains fifty notches an inch apart, and oh any of these a ten-pound weight can be suspended. The beam itself can be held in equilibrium by a two-pound weight fas- tened to the end of the short arm. In order to use the instrument it should, if possible, be placed on a table 545 Dynamometer. Dysentery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. exert during a given time. Thus has been calculated the average amount of labor of various kinds which can be performed in a day. (2) As a method of selection for special duties. In regard to the muscular power of men as determined by the force of the hand-grasp, Rey gives the following table, which he obtained from the examination of sea- men in the French navy or applicants for the service. first to give an accurate description of its symptoms. He clearly differentiates it from diarrhoea, as the follow- ing extracts from his works will show : " But when, the body being heated, acrid matters are discharged, the in- testine is excoriated, ulcerated, and the stools are bloody; this is dysentery, a grave and dangerous disease. " ' * When there is dysentery, pain occupies the whole abdomen; bile, phlegm, and heated blood are discharged." From the time of Hippocrates to that of Celsus(25 b.c.-45 a.d.), the contention of schools and theorists did but little to advance medical knowledge, but the writings of the medical Cicero, as Celsus has been called, may be said to epitomize the learning and practice of his predecessors, and that the chief features of dysentery were then understood, this quotation from his works well illustrates: "The next disease of the intestines is usually called tormina; in the Greek language it is termed dysenteria. The intes tines are ulcerated internally ; grumous evacuations come from them; sometimes the excretions are mixed with fecal matter always liquid, at other times the discharges are slimy; sometimes particles like flesh pass with them ; there is a frequent desire of going to stool, with pain in the anus; with this pain a small portion is voided, and even by this the pain is augmented ; that is relieved after some time, and then there is a short repose. The sleep is interrupted, slight fever ensues, and in the progress of time that disease either destroys the patient, when it has become inveterate, and even although it may be termi- nated exerts a baleful influence for a long time. " Aretseus (50 a.d.) recognized, without doubt, by actual observa- tion, that the ulcer was the peculiar and dangerous lesion of the intestine in dysentery. Matters resembling flesh, he says, come away in the discharges which accompany ulceration of the lower bowel. The flesh-like masses are shreds of the lining membrane of the intestine ; healing takes place by granulation and cicatrization of the outer coat, which remains intact. That he also observed the lesions of typhoid fever, and appreciated their relation to continued and dangerous fever, is proved by the statement that, if the ulcers in the small intestine become exca- vated and phagedenic, acute fevers set in, which in some cases are latent and smoulder in the intestines; in other cases ardent fevers occur, accompanied by prostration of strength, thirst, anxiety, dry tongue, and small, feeble pulse. A century later Galen (164 a.d.) said that the physician of his time limited the term dysentery to cases of intes tinal ulceration. The shreds passed from the bowels are scrapings from the internal membranous surface of the intestine. " At first there is an excretion of very biting (i.e., corrosive) bile ; then shreds of the intestines follow, afterward a little blood is discharged along with the shreds, and now the affection is dysentery." Caelius Aurelianus (400 a.d.) called dysentery rheu- matism of the intestines, an error adopted by Stoll nearly four hundred years later. Alexander of Tralles (575 a.d.) distinguished dysentery, " in which various humors are discharged by stool, from the graver variety due to ulceration of the bowels, in which shreds of the intestine are mixed with the dis- charges." Other writers of antiquity, as Paulus JEgineta (660 a.d.), who made tenesmus and dysentery separate affections, Fernelius, and Fabricius Hildanus, gave more or less ac- curate definitions of the disease and of its characteristic phenomena. Fernelius drew attention to the difference in the discharges, which are found in the two varieties of dysentery, the catarrhal and the diphtheritic ; in the lat- ter form, he says, the ulcer penetrates and eats more deeply into the flesh, and the proper substance of the in- testine drops out putrid or corrupted. From this period until the revival of the study of human anatomy, in the early part of the fourteenth century, no opportunity was offered for adding any further knowl edge to the rich legacy of these ancient observers. In- deed, it was not until the year 1506 that the first records of post-mortem examinations of dysenteric subjects were published in the posthumous work of Antonio Benivieni. In the writings of Hallerius (1565), Schenckius (1584), Rev's Table. W 05 Number of sub- jects observed. 10 12 14 15 15 16 16 17 17 18 18 19 19 20 20 21 £ OOlCWOCTCWOCTOOTOCTOOT 20.00 15.00 21.50 27.50 22.00 32.00 37.75 30.92 35.82 34.72 38.94 38.80 40.00 40.61 40.14 40.70 Mean muscular power in kilo- grammes. Number of sub- jects observed. bbobwcCTOCTbcbtcorcCT 40.00 43.20 45.00 39.75 41 00 42.75 37.50 46.00 40 00 44.00 44.00 40.00 35.00 37.25 45.00 42.00 Mean muscular power in kilo- grammes. Mean between ages of 10 and 20 31.54 kilogr. " " " 15 and 20 35.75 " " " " 20 and 25 41.11 " " " " 20 and 30 41.25 " " " " 25 and 30 41.40 " Mathieu's dynamometer was used. The subject stand- ing firmly, seized the instrument in the palm of his hand, and was asked to exercise progressively the strongest pressure of which he was capable. Rey concludes that the mean muscular power of a man 19.5 years old, as measured in this way, equals 38.17 kilogr. Michea quotes Marechal to the effect that 28 kilogr. is the maximum ef- fort that a cannonier should use to execute a manoeuvre, and 21 kilogr. the mean. He states that in good health a man has a power of pressure equal to 50 kilogr., and a force of prehension equal to 132 kilogr. A woman has about two-thirds that of a man. The average daily work of men has been carefully de- termined in various ways. A table giving the results ob- tained may be found in the ninth edition of the " Encyclo- paedia Britannica," article " Mechanics." Bibliography. De la Hire: Examen de la Force de 1'Homme, Memoires de 1'Acad. des Sciences, 1699. Desaguliers: A Course of Experimental Philosophy, second edition, 1745. Regnier : These de Paris. 1807. Burq : Dynamometrie m6dicale, Union M6d., 1859, iii., 460. Duchenne : Bulletin de 1'Acad. de Medecine, 1863, xxviii., 919. Donhoff : Ein Muskelkraftinesser. Arch. d. Heilk., 1861, ii., 191. S6dillot: Trait6 de m6d. operatoirc, third edition, 1865. Mallez ; Dynamomdtre vesical. Bull, de 1'Acad. de Med., 1864, xxx., 124. Duchenne : De 1'electrisation localisee, 3d ed., 1870. Michea : Nouveau dictionnaire de med. et de chir. pratiques, xi., 702. Rey : Annales d'hygiene, 1874, xli., 86. Hamilton : Psychol, and Medico-Legal Journ.. N. Y., 1875, n. s. ii., 255. Hammond, G. M.: N. Y. Med. Journ., Jan. 17, 1885. William y. Bullard. DYSENTERY. Synonyms.-Auo-erTepia, tormina intes- tinorum, fluxus dysentericus, fluxus cruentus, fluxus torminosus, rheumatismus intestinorum cum ulceratione, difticultas intestinorum, rheuma ventris, febris dysenter- ica, colonitis, colonia, colo-typhus, flumen dysentericum, fluxus cruentus cum tenesmo, tormentum intestinorum, alvi fluxus torminosus, catarrhus intestinorum spasmod- icus ; bloody flux ; dysenteric, colite (Fr.); die Ruhr, die rothe Ruhr (Gr.); disenteria (Itai.) ; dysenteria (Sp.). History.-Dysentery was one of the best known of the diseases of the ancient world. It was noticed before the time of Hippocrates (430 B.c.), but this writer was the 546 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dynamointer. Dysentery. Sennertus (1626), Sydenham (1672), Bonetus (1679), and Morgagni (1762), there accumulated gradually a fund of pathological data which formed the basis for subsequent gains of positive value. Sennertus was well acquainted with the morbid anatomy, symptomatology, and treat- ment of the disease. He says, " Dysentery consists in fre- quent bloody dejections from the bowels, with pain in the abdomen and ulceration of the intestines ; or it is an ul- ceration of the intestines with frequent bloody and puru- lent dejections, with pain in the abdomen and griping, arising from an acrid matter, peculiarly adverse to the intestines and eroding them." He also observed and de- scribed the difference between the sporadic and epidemic forms, and gave the indications for healing the ulcerated surface, expelling from the bowels irritating substances, and checking profuse discharges. Following these came a host of writers, who added much to the clinical knowledge and therapeutics of dys- entery by a large experience in epidemics in Europe, India, and Africa, and in armies and fleets. Among those of whom special mention should be made are; Degner (1743), Pringle (1752), Vogel and Mayer (1765), Zimmermann (1765), Stoll (1780), Rollo (1786), Hunter (1796), Desgenettes (1802), Fournier and Viday (1814), O'Brien (1822), Annesley (1828), Cambay (1847), Catteloup (1851), Dutroulau (1861), Woodward (1879), and Fayrer (1881). When we come to later periods in the history of dysen- tery it is a matter of surprise to find that the ulceration in the intestine, which was considered so essential a feat- ure of the disease by ancient observers, should have been denied by those who in the frequent study of morbid tis- sues had every opportunity for arriving at the truth. Pringle, in his autopsies of soldiers who had died of dysentery in Holland in 1744, observed that the mucous membrane of the intestine was black and putrid, or thick- ened and ulcerated, especially in the lower part of the colon and rectum, and yet Pringle, later, in consonance with the opinions of Hewson and Hunter, doubted if the intestine was ulcerated. Fournier and Viday, Chomel, Andral, and others, denial that there was ever any ulcera- tion of the mucous membrane in acute dysentery. But Thomas, writing in 1833, of the epidemic at Tours said : " I recognized, after having made a considerable number of autopsies with the greatest care, that the ancients were right in their opinions and that the moderns are com- pletely in error. The mucous membrane is promptly in- vaded by ulcerations, so numerous, so well defined, and so constant, that I claim as an undoubted fact that the ulceration of the mucous membrane is as essential a feat- ure in dysentery as phlyctenulae in erysipelas, le bour- billon in a furuncle, or pus in an inflammation of the cellular tissue." Etiology.-There is the greatest contrariety of opin- ion in regard to the causes of dysentery, for, although every condition under which the disease appears has been closely studied, there is no one factor which is invariably present. It is necessary, therefore, to mention in detail all those conditions outside of and belonging to the in- dividual which precede or accompany the outbreak of dysentery, and which, with good reason, have been thought to take part in its causation. Geography.-Dysentery is ubiquitous, but it is most common, most intense, and fatal in the tropics. It prevails extensively on the southern coast-line of Asia, especially in India and in the Indian Archipelago, on the east and west coasts of Africa, in Guinea, in Senegambia, at the mouth of the Niger and on the adjacent islands, in Egypt and in Algeria. In the western hemisphere it is also a formidable dis- ease, appearing in the southern and southwestern parts of the United States, but having a graver character in Mexico, Central America, on the west coast of South America, and in the West India Islands. In all these localities it is endemic, and frequently destructively epidemic, increas- ing its ravages in its approach to the equator, diminishing in intensity in temperate regions, and becoming infre- quent above 48° north latitude. It is met with, however, in Greenland, Lapland, Kamtschatka, and Iceland, while epidemics have occurred at Esthonia, Dorpat, St. Peters- burg, Jaroslav, Novgorod, in the north of Russia, al- though less frequent in the Crimea and Southern Russia. It was epidemic in Norway from 1859 to 1862, and from 1853 to 1860 it produced about 2,500 deaths annually in Sweden. In 1857 there were 37,000 cases and 10^000 deaths in the same country. The statistics of the French army illustrate the dif- ferences in the rate of mortality in temperate and inter- tropical regions. In France the death-rate among the troops from dysentery is one-twentieth of the total mor- tality ; in Algeria it is one-fifth ; in Senegal one-third. In the English army at home the disease is rare, while in India and China more soldiers die from dysentery alone than from all other diseases to which they are liable in Europe. In Ceylon twenty-three die annually from dys- entery out of every thousand of effective force. In the United States army, in the Northern Depart- ment, three die from dysentery out of an effective of one thousand men; in the middle region the proportion is one death to every one thousand ; and in Florida, five deaths to one thousand. In regard to the distribution among the civil population, the more temperate and colder regions do not, however, seem to have a greater immunity than the southern and southwestern parts of the country. Sporadic dysentery prevails in all parts of the country and has proved most fatal in the New England States. In the Atlantic States the greatest mor- tality from dysentery in 1850 was in Connecticut and Massachusetts, in 1860 in Massachusetts and Virginia, in 1870 in Vermont and Massachusetts. In 1850 the deaths from dysentery in Ohio and Indiana exceeded by far those in the Gulf States. The history of epidemic dysentery shows a wider spread in the New England States, be- tween the years 1749 and 1798, than elsewhere, and since these years epidemics have not shown a preference for any one region. Topography and Conditions of the Soil.-Efforts have been made to associate dysentery with special topograph- ical or geological features, but no such association exists. Dysentery prevails in countries and in localities which differ widely in these respects. It is strange that epi- demics of dysentery have been more general and more fatal in the country than in the city. This was the case in the epidemic of 1774 in France, and in the epidemics in Germany between the years 1795 and 1829. When epi- demics prevailed in the country, the disease was often sporadic in the cities. When houses are built upon a low, damp soil, and when the soil in the immediate neighborhood of build- ings, as hospitals, barracks, or prisons, is saturated with moisture, a favorable condition exists for the propagation of dysentery. Emanations from a wet soil are probably prejudicial to health, and exert a depressing influence which is favor- able to the inroads of disease. Dr. Baly, in 1842, with a view of ascertaining the cause of frequent epidemics of dysentery in Millbank Penitentiary, visited many prisons, barracks, workhouses, and lunatic asylums in England. The bowel complaints, he found, bore a close relation- ship to the site of the institution. They were infrequent where the building was erected on an elevation, with a dry soil and a gravelly subsoil ; but very frequent if the situation was low, the soil wet from imperfect drainage, and the subsoil of peat. But dysentery does prevail in elevated and dry plateaus in India, Mexico, and Peru. Overcrowding and Imperfect Ventilation.-The over- crowding of human beings in badly ventilated buildings or ships is often followed by outbreaks of dysentery. It was not rare for a slave-ship, in making the transit from Africa to America, to lose three-fourths of her living cargo. In prisons, reformatories, etc., before attention was paid to such matters, epidemics of dysentery were frequent and destructive. This was due in part to the deterioration of health from imperfect ventilation, and in part to the accumulation and improper disposal of fecal matter. Season and Temperature. - In all climates dysentery is most prevalent in the hot season. In the United 547 Dysentery. Dysentery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. states August is the month of its greatest mortality, and in the summer and early autumn the largest number of cases occur. This is true of sporadic as well as of epi- demic dysentery. Hirsch has collated the histories of 546 epidemics, of which 404 were in the summer and autumn, 113 in the autumn and winter, 16 in the spring and summer, and 13 in the winter. The minimum mor- tality in this country is in January and February. Elevation of temperature conduces to the origin and spread of dysentery. Unusual heat preceded the epi- demic of 1813 in Holland, of 1834 to 1836 in France, Switzerland, Belgium, and Germany, of 1853 in Sweden, and of 1859 in France. That there is no necessary re- lationship between dysentery and extreme heat is shown by the rarity of the disease in the cities of the Atlantic sea-board in seasons of long-continued high temperature. Epidemics have appeared in cold weather in Russia, Sweden, and Canada. In Ireland an epidemic lasted from autumn until spring, and in 1732 there was an epi- demic in Siberia in January. Of 13,900 cases in Bengal there were 2,400 in the cool season, 4,000 during the warm and dry season, and 7,000 in the period of warmth and moisture. Atmospheric Moisture.-The saturation of the air with moisture is recognized as offering another favorable con- dition for the spread of dysentery. Heat and moisture combined enfeeble the individual, and favor putrefactive decomposition in animal and vegetable matters, and hence assist materially in the propagation of disease. Moisture alone is not an essential factor, however, as out of 119 epidemics, 62 were preceded by moist, and 57 by dry weather. When cold and atmospheric moisture are combined the effect upon the individual is the same, and dysentery may result. Thus, Pringle states that at the battle of Dettingen, the French army was exposed to an abundant rain, and the soldiers spent the night in their wet cloth- ing. A large number were attacked with dysentery, while a corps stationed at some distance, and not thus exposed, escaped illness. Vicissitudes of Temperature.-The season of dysentery is when cooler nights succeed hot days, and when sud- den changes of weather are apt to occur. In tropical coun- tries oscillations of temperature, after periods of pro- longed heat, often precede epidemics, and the same thing has been noted in temperate climates. A cold wind after hot weather has been followed by a local epidemic. In Trenton and Gibson Counties, Tenn., an epidemic ap- peared simultaneously in different places. The season was dry, and there was no animal or vegetable decompo- sition, but a high day temperature, with cool nights, and the exposure of a large number of persons from different localities at a country fair, were the causes to which the outbreak was attributed. The largest number of deaths oc- curred when the temperature oscillations were the greatest. Pruner in Egypt, Lame in Guiana, McMullin in the Bar- badoes, Ruthay in China, Lavacher among the negroes at Santa Lucia, have noted the appearance or aggravation of dysentery after sudden and marked temperature varia- tions. In armies on the battle-field or in exposed camps, dysentery follows unusually cold nights or sudden changes in temperature, the officers always suffering less, how- ever, as they are better clothed and better protected against such influences. Impure Water Supply.-From the earliest times bad drinking water has been believed to be a potent cause in originating dysentery. But no part of the study of the etiology of the disease gives a better idea of the contra- dictory nature of the evidence than that upon which a belief or disbelief in the evil influence of impure drinking water is based. Read in 1770 noted that, in an epidemic at Metz, a regiment occupying a certain caserne had ninety-one cases of dysentery, while other regiments suf- fered much less. The soldiers of this regiment used water contaminated by sewage from neighboring privies, and the closure of the infected wells was followed by a diminution in the number of cases. This is an early ob- servation which is the counterpart of an innumerable number of the same sort. Cases and epidemics have been traced to the use of water contaminated with sewage, with sewer-gas, animal excrement, and with matters from animal and vegetable decomposition. The cutting off of the supply from the contaminated source has frequently not prevented outbreaks of dysentery, nor stopped the spread of it. The use of rain-water in ships at infected foreign ports is not a preventive, nor do the Chinese es- cape who, according to Dudgeon, invariably use boiled water. In the Millbank penitentiary three hundred and fifty prisoners were given pure water from an artesian well, while seven hundred drank Thames water, but in- testinal diseases were as common in the one class as in the other. On the other hand, an epidemic of dysentery be- gan on the Pacific Mail steamer Alaska, and several of the crew were attacked eight or ten days after the tanks were filled at Hong Kong. The water in the tanks was found to be filled with bacteria and other septic organ- isms ; the crew was put on condensed waiter and the further spread of the disease stopped. There is some testimony which goes far to show that water obtained from the vicinity of cemeteries is not al- ways hurtful. J. F. A. Adams, in the " Sixth Annual Re- port of the Massachusetts State Board of Health," states that he failed to find a single example of disease due to water contamination in close proximity to burial grounds. Examination of the water from the wells in fifteen church- yards in Berlin showed a higher average purity than the water from the city wells. Such evidence is of negative value only, and is offset by direct proof of the effect of a known impure water supply. The constant prevalence of dysentery at Secunderabad, in India, was found to be due to the percolation of the water through a graveyard. In the Peninsular War the great loss by dysentery at Ciudad Rodrigo was, in part, attributed to the use of water pass- ing through a cemetery where twenty thousand bodies had been hastily interred. Davis mentions that at Tor- tola, in the West Indies, the inhabitants use rain-water only, and while they escape, the ship's crews are invariably attacked with dysentery. So well known is this that the residents, when invited to dinner on board a man-of-war, frequently carry their own supp^ of drinking water with them. Other observers mention facts which are in direct op- position to these. In 1848, two French ships-of-war, the Brandon and the Embuscade, visited St. Pierre. A vio- lent epidemic of dysentery attacked the crews, who used distilled water, or water brought from France. The merchant ships in port, which took no such precautions, escaped the disease. The workmen engaged in the Suez Canal had a greater immunity from dysentery after 1863, when the purer water of the Nile was obtained. Lalluyaux d'Ormay demon- strated at The-dau-Not, in Cochin China, that dysentery could be produced or arrested at will by using or not using certain waters. In China the water of certain rivers is notoriously dangerous to health, and produces dysentery. Thevenat, in his work on " Diseases of Euro- peans in Warm Climates," says nothingis so prone to lead to disorganization of the large intestine as infected water. Improper Food-supply and Indigestion.-The occurrence of dysentery has long been associated with errors in diet, and with indigestion and food decomposition in the in- testinal canal. Acute indigestion, after taking food in excess, or when it is unfit for use, may lead to diarrhoea or dysentery. Fermentative changes in the intestinal canal reach their maximum low down, and there pro- duce their greatest irritation. The acrid matters, which were dwelt upon by the Greeks as causes of dysentery, arise from the putrefactive changes in the intestinal con- tents, and are, without doubt, agents in exciting inflam- mation. The bile is not, however, a cause of dysentery, as has been thought by modern as well as ancient writers ; it is antiseptic, and, when in normal quantity, prevents intestinal decomposition. The so-called bilious dysen- tery derives its name from an excess of bile which is in nowise to be considered an etiological factor, nor is por- tal congestion to be considered as a cause. Individual Predisposition.-Age. No age is exempt from dysentery. It is asserted by Zimmermann that in- 548 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysentery. Dysentery. fants w'hose mothers have dysentery are born with it. Young children, in the hot season in temperate climates, are prone to it, but not to the same extent as to diarrhoea. Recruits from nineteen to twenty-one years of age, newdy arrived in India and Algeria, are more liable to contract the disease than older soldiers. In the French navy the same predisposition has been noticed among the young apprentices. In the old, dysentery is a common and fatal affection. Sex.-Dysentery is more prevalent among males than among females. Race.-All races and nations are subject to sporadic if not to epidemic dysentery. The natives as well as for- eigners are attacked by it, and its fatality is usually greater among the native population. In this country the opportunity is given to contrast the disease as it affects the white and black races. Campbell, of Georgia, has described an epidemic which involved the wdiites only, but this is an isolated observation. In an epidemic in Byhalia, Miss., in 1883, both the masters and servants succumbed to dysenteric symptoms : in a radius of ten miles, out of 100 deaths, 85 were from this cause. A race out of its own habitat is a greater prey to dys- entery, owing to the adoption of a mode of life and diet which are unsuited to the necessities of the climate. Condition and Habits of Life.-Poverty, which entails a life of hardship, without comforts or necessities, predisposes to dysentery. It is more fatal among the poor than among the rich, and it is especially fatal among the poorly clothed and badly fed. Over-fatigue, loss of sleep, and anxiety favor the inroads of the disease. Indulgence to excess in alcoholic liquors is thought to be a cause in hot climates, but as errors of diet, exposure, fatigue, and a general disregard of the rules of health ac- company alcoholic indulgence it is probable that alcohol alone is not a very active cause. Influence of Other Diseases.-The relation of scurvy to dysentery has been much dwelt upon. During the Civil War in this country the concurrence of diarrhoea, dysen- tery, and scurvy was frequently noted. All followed prolonged deprivation of vegetable food, the hardships of camp life or exposure in the field, but that there is no causal relation between scurvy and dysentery is abun- dantly proved by experience everywhere. Of fifty cases of scurvy admitted into the European General Hospital, Bombay, in 1863, only one had dysentery. In epidemics of cholera, a transition of the choleraic into dysenteric symptoms has sometimes occurred, and in fatal cases of cholera lesions similar to those character- istic of dysentery have been found. A very general belief has prevailed as to the close asso- •ciation of malaria and dysentery. In the Southern and Southwestern States the coincidence of " bilious " fever and dysentery, the two diseases frequently appearing in the same individual, and arising apparently under the same conditions, has led to the opinion that both diseases are due to one and the same poison, developed in the decompo- sition of vegetable matters. But the geographical history of dysentery shows that a moist soil and vegetable de- composition are by no means necessary to its origin. Dysentery and malaria prevail independently of each other when there are the same conditions of season, soil, and climate. An epidemic of dysentery occurred in San Joaquin Valley, Cal., in May, June, and July. Ma- larial fever prevailed in August, September, and October of the same year. In Trenton and Gibson Counties, Tenn., in the autumn of 1881, a maximum of dysentery was reached while there was but little malarial disease. In 1874 and 1875, when intermittent fevers were so rife that there were not well persons enough to care for the sick, there was scarcely one case of dysentery. It cannot be denied that the two diseases often attain their maxima of intensity at the same time and under the same conditions, and we cannot but give heed to the opinion of those who have had the opportunities to study the two diseases side by side. W. K. Bowling, of Ken- tucky, writing in 1843, says : " It is in climates most ob- noxious to bilious fever, and at seasons and in localities favorable to the rapid generation of malaria, that dysen- tery is rife. Indeed, for a number of years, I have regarded dysenteric phenomena as nothing more than adventitious manifestations superadded to the suite of symptoms usually characteristic of bilious fever." Dysentery complicates various acute and chronic dis- orders, and these, with former attacks of dysentery, and all previous states of ill-health, maybe regarded as predis- posing to its development. Thus it supervenes during the progress of typhoid and typhus fevers, in phthisis, cancer, and Bright's disease. Constipation has been thought to bring about dysen- tery, the hardened fecal masses acting as foreign bodies in the colon and rectum. Cullen held that the griping, frequent stools, and tenesmus wrere caused by their pres- ence. But the infrequency of the disease among those who are constipated habitually, and the fact that pro- longed fecal retention does not induce dysentery, throw much doubt on the supposed effect of constipation. Moreover, the preliminary diarrhoea in the early stages of the attack, or the purgation to which most dysenteric cases are subjected, would be more immediately curative if this alone were the active cause. Contagion.-Great diversity of opinion prevails as to the question of the specificity and. transmissibility of dysentery. Has it a specific virus which is transmitted directly or indirectly from the sick to the well, or is the infectious principle generated outside of the individual and independently of him, or is it non-contagious and non- infectious ? Belief in its specific nature is based upon the rapid spread of the disease from a single focus and its apparent propagation by contact. Degner attributed the epidemic in Nymegen, to the arrival in that city of a dysenteric case; he thought that the disease spread by contact from house to house and street to street. Gilberet, in his account of the diseases which attacked the Grand Army in Russia and Poland in 1806 and 1807, says : " It is impossible to conceive of the rapidity with wdiich dysentery communicated itself from one patient to those near him. The straw which had been used was contagious ; the privies were centres of this miasm : phy- sicians contracted the disease after a moment's careful in- spection of the stools." Military surgeons have published records of epidemics arising in unaffected localities by the arrival of troops suffering from dysentery. Ilaspel has noticed this in Algeria, and he, moreover, states that cases brought from Algeria to France have kindled an epidemic there. The history of the transplantation of dysentery has been studied by Bergeron, Tissot, Latour d'Orleans, and others. The theory of the specific nature of dysentery and its contagiousness is supported by Selle (1797), Kreysig (1799), Zimmermann (1767), Pringle (1752), Lind (1792), Cullen (1769), Pinel (1798), Desgenettes (1802), P. Frank (1807), Voght (1859), Stille (1864), Niemeyer (1868), Jac- coud (1873), Heubner (1874), and Bartholow (1880). Many authorities do not give unqualified assent to the doctrine of contagion, but believe that under conditions favorable to the growth of the poison it acquires viru- lence. For them the virus resides in the stools of dysen- teric patients. Heat and moisture favor its active growth, and the exposure of individuals, otherwise predisposed to illness from previous disease, poverty, overcrow'ding, or destitution, to the emanations from such sources of infec- tion, develops in them the characteristic symptoms of dysentery. Numberless instances and recorded facts might be adduced in support of this theory. Opposed to the doctrine of specificity there is a great deal of testimony to which due attention should be given. Colin saw several epidemics of dysentery ; in none did he ever observe any case of undoubted transmission. In 1859 the military hospitals of France were crowded with dysenteric patients, but no instance of the spread of the disease among physicians or nurses was observed. The transfer to Germany of soldiers suffering from dysentery contracted before Metz did not cause any outbreak among the civil population. Annesley knew of no instance, in his experience, of the propagation by contagion in India. In the Southern States dysentery was very common on the plantations in the days of slavery. It was noticed 549 Dysentery. Dysentery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. frequently that the negroes on one plantation would be attacked, while those on a neighboring one would escape. In 1851 a planter in Mississippi lost twenty-five negroes, but on the adjoining plantation there were no cases. In June, July, and August, 1852, Bonnell, of Lowndes County, Miss., lost two overseers and twenty negroes, every one attacked dying ; but the disease did not spread beyond his premises, although there were people living within half a mile, and no precautions against contagion were taken. In the military hospitals during the civil war in this country, dysenteric cases were treated side by side with others, and when these hospitals were removed from the surroundings under which the disease originated, no cases of contagion happened among the physicians and hospital attendants. Nor is there any record of a local outbreak among the civil population which could be connected with the return of the thousands of soldiers suffering with dysentery to their homes. In conclusion, it may be said that while in the tropics, and in epidemics elsewhere, there are many reasons for believing that infection and contagion exist, depending upon a specific virulent germ, probably originating or acquiring virulence in the dysenteric stools, yet it must be believed that in sporadic dysentery of temperate cli- mates there is no contagium mum; or, if there is, it is too much lacking in virulent energy to become an agent in spreading the disease. Morbid Anatomy.-The bodies of those who have died from acute dysentery are generally emaciated ; ecchy- moses are seen chiefly on dependent parts ; the extremi- ties are sometimes oedematous, but not so commonly as in the chronic form ; and in cases of long standing there are bed-sores over the sacral and ischial prominences. On opening the abdominal cavity, the appearances are found to vary with the intensity and extent of the intesti- nal inflammation. The mesenteric vessels are distended with blood. The exterior wall of the intestine is of a dark-red or violet color, the areas of discoloration corre- sponding to the limits of the dysenteric process ; the depth of color depends upon the degree of vascular turgescence and the extent of ecchymotic staining of the tissues. Whitish patches, one millimetre or more in length, which correspond to the more advanced intestinal lesions, are found on the serous surface. The openings of perforated ulcers which may be seen are round or oval in shape, with smooth, sometimes ir- regular, edges; and, although usually single, there may be two or more. In cases of great severity the wall of the intestine may be gangrenous, showing either large ir- regular openings, or else the whole wall falls to pieces when the intestine is lifted. Local or generalized peritonitis accompanies perfora- tion, the deposits of pseudo-membrane being greatest near the opening ; there are local or extensive adhesions, and in the peritoneal cavity are found sero-purulent fluid and matters which have escaped through the perforation. Perityphlitis, periproctitis, perineal abscess and fistulae are lesions which are sometimes met with. The mesen- teric glands are tumefied and softened, and rarely they contain pus. The lesions within the intestine occupy the caecum, sigmoid flexure, and descending colon ; less frequently the transverse and ascending colon and caecum. Occa- sionally the small intestine is involved a short distance above the ileo-caecal valve. The anatomical changes diminish in intensity and extent from below upward; they are more advanced in the rectum and sigmoid flex- ure. 1. As the mildest forms of dysentery rarely prove fatal, it is not often that the chance is offered for determining the lesions in such cases, except where death takes place from other causes. Under these circumstances, the mu- cous membrane is often free from all traces of disease ; the hypersemia pales after death, and the mild catarrh leaves no trace. 2. If the attack is of moderate severity, the mucous lining is covered with a layer of transparent or opaque white mucus, here and there stained with blood. When this is removed, the membrane below is seen to be more red than normal, the redness being unevenly distributed in patches or in lines corresponding to the transverse folds of the colon. Ecchymotic areas add to the depth of color. The mucous membrane is oedematous, swollen, and softened ; the submucous layer is thickened from in- filtration, and the solitary follicles are visibly enlarged. 3. In more severe grades of inflammation, and in the more advanced stages of the form just described, the mucosa is more swollen, is pulpy and soft, and of a deep red color, the redness being greater around the enlarged and projecting follicles. Punctate or diffuse ecchymoses are distributed in the membrane. The surface is coated with a glairy mucus, or with a purulent fluid which is colored red or brown, according to the relative admixture with blood or bile. Fibrinous films coat the surface in patches of varying size and of a grayish color, and if these are removed small superficial ulcers or erosions are found beneath occupying the sum- mits of the rugosities. Small round ulcers are also ob- served, which from their position and shape are recog- nized as being formed by the breaking down of the exposed wall of the closed follicles. On section, the submucous layer is seen to be thickened, and on pressure exudes a serous fluid. The muscular tunic is also thicker than normal. 4. In the most intense forms of dysentery the mucosa loses all the characteristics of normal tissue. The surface Fig. 899.-Acute Dysentery. Rectum, with Sloughing Mucous Mem- brane. (After Woodward.) is rough, with irregular elevations and depressions, form- ing ridges and intervening furrows which have a wave- like appearance, or are like a series of mountain ranges. The color of this tissue is dark, almost black, greenish, reddish-brown, or dark red. In places the overlying tissue which gives rise to these appearances is separable, or has separated from the parts below, and hangs loose in the canal in the form of membranous shreds; these adhere at one or more points, or have sloughed off, leav- ing an ulcerated surface behind. The ulcers are small, oval or irregular in shape, or by the union of several smaller ones large irregular ulcers are formed which cover a considerable extent. Their edges are irregular and ter- 550 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysentery. Dysentery. raced, the bottom of the ulcer being much smaller than the outer opening, and their long diameter is transverse to the axis of the gut. The mucous membrane which forms the borders of the ulcer is sometimes undermined, trices. Those parts of the intestinal mucous membrane which are not the seat of dysentery are inflamed. The stomach is distended, sometimes contracted, and the mu cous membrane is thickened and softened. Pathological Histology.-The minute changes in the tissues of the intestine are primarily those of simple catarrh. The vessels of the mucosa and sub- mucosa are distended with blood; a transudation of serum and oedema follows. Serum also transudes into the intestine, is mixed with mucus, and from rupture of small vessels extravasations take place into the mucosa, while blood and mucus appear on the surface. Lymphoid cells accumulate in the submucous layer and in the interflbrillary spaces of the mucosa, pushing apart and raising to different heights the follicles of Lieberkuhn. The septa between the glands are thus increased in length and thickness. From closure of their outlets the contents of the glands accumulate, forming cysts, which by their coalescence form larger cysts, | to | of an inch in diameter. They also shoot out branches, giving rise to an appearance like that of a racemose gland. The closed follicles enlarge by an increase of their cell-elements (follicular suppuration); they project above the surface, burst, and thus the follicular ulcer originates (see Fig. 901, e). By the union of adjoining follicular ulcers larger ones are formed. So far these histological changes accompany the less intense forms of dysentery, but in the so-called diphtheritic form there is an accumulation in the meshes of the mucous and submucous layers of a new material, composed of dead leucocytes, blood, interlacing fibres, and an abundant granular mass composed of amorphous matter with microscopic organisms. This new material is spoken of as an "exudation," which is "infiltrated" in the inter- stices of the tissues. It acts as a foreign body, com- pressing and causing atrophy and death of the proper elements of the mucosa or submucosa-the blood-vessels, glandular structures, and connective tissue. The exudate and the necrosed tissue together form a homogeneous mass, which constitutes the so-called false membrane. This is finally loosened by reactive suppuration from the non-inflltrated tissue below ; separation takes place, and the ulcer is left (see Fig. 901). Successively deeper layers may be in- vaded by the infiltration, and the ulcer deepens by the sloughing off of necrosed tissue. Lesions in other Organs.-The liver in dysentery is the seat of a great variety of alterations ; among these are hyperaemia, fatty degeneration, abscess (single and Fig. 900.-Cicatrices from Healing of Dysenteric Ulcers. (After Woodward.) and as the destruction extends below the overhanging tissue, being deprived of nutrition, dies and is thrown off ; thus extensive ulcers are formed. The juxtaposition of the depressed ulcers and the undestroyed, raised, red, and soft mucous membrane gives a serpentine appearance to the lines of the surface which is quite characteristic. The serous layer may be exposed, penetrated, and finally perforated. This occurred in 11 out of Woodward's 108 cases. In four cases the perforation was near the caecum, in one in the transverse colon, in one at the junc- tion of the transverse and descending colon. Blecker, in a large number of autopsies, found an ulcer in the duodenum once. He also met with two perforations of the rec- tum which communicated with the uterine cavity. In nearly all there was one perfora- tion, in one case there were two, and in one there were twenty. Extensive gangrene of the whole intestinal wall may be found ; the tissues are dark, black, soft, and re- duced to a shreddy broken-down mass ; the canal may be opened in many places by large irregular rents. Cicatrization of some of the ulcers is seen to have begun in some instances in cases of less intense character. The ulcers are clean, or the destroyed mucosa is replaced by cicatricial tissue, which forms irregular scars if the process is completed. These contract, assume a linear, puckered, or stel- late appearance, and occupy a much smaller space than the original ulcer. Stricture of the intestine may be brought about by the continued contraction of these cica- Fig. 901.-Acute Dysentery. Section of the Colon from a Case of Dysentery, a, mucosa, infiltrated between the crypts; b, submucosa, infiltrated ; c, muscular coat; d, sloughing of mucosa and formation of ulcer; e, rupture of distended follicle and formation of fol- licular ulcer. multiple), perihepatitis, granular atrophy, and nutmeg liver. The following table gives a summary of the relations 551 Dysentery. Dysentery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fever or none at all, but the degree of weakness is out of proportion to the mildness of the attack. The patient improves gradually after a few days, and he is well in one week or ten days. 2. In severer forms, lasting ten, fourteen, to twenty- one days, these same symptoms are intensified, especially the constitutional symptoms ; the pulse is more frequent and feeble, and the temperature ranges from 101° F. to 103° F. The strength undergoes a more rapid reduction, as the effect of the violent and frequent abdominal pains (tormina), and the frequent mucous and bloody stools, which are attended with great straining, and the sensation as if a foreign body were in the rectum. In the begin- ning the discharges are composed of a viscid mucus floating in a serous liquid. On the second or third day, blood is mixed with the mucus, and there is less fluid. After the fifth or sixth day blood is passed with muco- purulent or purulent fluid; the source of which is the ulcerating mucous membrane. Gradually the stools get more abundant, and consist of a dirty white or grayish fluid, of a slightly fetid odor. Their number varies from twenty to forty in the twenty-four hours, being more fre- quent at night, but there is no limit, as many as two hun- dred having been noted. The progress of the attack is attended with fever, with thirst, sometimes with delirium at night, always with rest- lessness and insomnia : the abdominal pains are so severe as to excite cries, and the prolonged expulsive efforts cause great exhaustion and profuse sweating. Vesical tenesmus accompanies rectal tenesmus, and prolapse of the bowel is not infrequent, especially in children. A sensation of op- pression in the epigastrium and vomiting are due to re- flex influences. The loss of strength is rapid, the pulse grows feeble, and the patient lies on one side with the knees drawn up. If recovery is to be the result there is a diminution in the number of the stools and a return of fecal matter. Death is preceded by offensive fluid movements. 3. In the most severe form, diphtheritic dysentery, the onset is more abrupt, or it may be preceded by milder dysenteric symptoms. The tongue is dry, red, or brown, and is glazed or furred ; there is vomiting of bile and intense thirst. With the acute abdominal pain, there is tenderness along the line of the colon, and a general in- tumescence of the abdomen. The mucous or muco-puru- lent and bloody stools change in a few days to a thin, reddish-brown liquid, containing floating shreds or long, membrane-like masses, in some cases having the mould of the large intestine. These are sloughed off pieces of tissue due to deep infiltration and necrosis of the mucosa ; their presence changes the odor of the stools to one that is cadaveric or fetid. All the other symptoms indicate serious illness. The patient is delirious, and very early in the attack is so en- feebled as to be unable to move from the bed. After a variable time-a few days to two weeks-the signs of in- creasing illness and weakness are shown in the rapid and thread-like pulse, the anxious and cadaverous expression, rapid emaciation, and burning heat of skin with cold ex- tremities. At the same time the stools change and become involuntary, painless, and more fetid. Death is preceded by dyspnoea, hiccough, cyanosis, and collapse. The in- telligence is sometimes unimpaired to the end. Recovery may occur even after very grave symptoms ; in this event convalescence is exceedingly slow, or the case may pass into chronic dysentery. Although the attempt has been made to give a typical description of dysentery, yet there are so many departures from the type that authors have attempted to classify cases according to the prominence of certain symptoms, as follows: 1, The simple catarrhal form ; 2, the diphtheritic form ; 3, the haemorrhagic form, seen in tropical dysentery, marked by abundant and fatal haemorrhages ; 4, the gan- grenous form ; 5, the algid form, recognized by great feebleness or absence of the pulse-beat, cyanosis, aphonia, suppression of urine, cold surface, and an early fatal issue, 6, the rheumatic form, the distinguishing characteristic of which rests upon the concurrence of rheumatism and dys- of abscess of the liver to dysentery as deduced from ob- servations in India. Authority. Locality. No. of cases of dys- । entery. No. of cases of ab scess of liver with dysentery. Other alterations in liver. Liver healthy. Per cent, of abscess of liver in cases . of dysentery. Murchison India 102 Horton India .... 55 6 10.9 + Calcutta Hospital. 160 21 13.1 + Dr. McPherson.... Calcutta Med. Col- lege Hospital.... 245 1247 Mr. McGregor India 21 167 Dr. Shanks Madras 96 36 •• 37.5 - Dr. Janis Madras 43 8 18.3 Dr. Monat Madras 61 13 30 18 21.32 Dr. Hamilton Madras 17 0 Dr. Wm. Dix Madras 26 9 .. 34.6 4- Dr. Thompson Madras.... 11 2 18.18+ Dr. McGregor Madras 5 1 20. - 259 69 26.6 Dr. McPherson Bengal 293 46 16 04+ Dr. Morehead 32 13 40.6 + Dr. Stovell Bombay 49 21 42.8 + 81 34 41.9 + Madras, Bengal, Bombay 633 149 23.53 Waring . India 96 Fayrer quotes Moore. 1,663 347 20.87+ Parkes * India 98 43 50 6 43.9 Reynolds Netley Path. Mu- Museum 25 3 12.0 Schneider 1,400 57 385 10 4.07 Beranger-Feraud... . Senegal '411 143 170 98 34.79 Anuesley 29 21 72.41 Haspel 25 13 52.0 Gluck 151 16 10.59 Grand total 4,916 1,028 775 132 20.91 Table A. * Says elsewhere : Have observed 20 cases of abscesses of liver ; 9 primary, 11 secondary to dysentery. Murchison believes the tropical single abscess of the liver in India to be endemic, and that its association with dysentery is accidental. This is not the case with the pysemic multiple abscess. The following changes have also been found in fatal cases of dysentery : congestion of the brain and mem- branes, and subarachnoid effusion ; acute pneumonia, acute pleurisy, gangrene of the lung, pericarditis, fibrin- ous coagula in the cavities of the heart, congestion or softening of the spleen, anaemia, congestion or fatty de- generation of the kidneys, and ulcer of the cornea.. Symptomatology.-Diarrhoea sometimes precedes the outbreak of dysentery. In many cases the onset is sud- den, especially in the epidemic form. Fatal cases have occurred without dysenteric symptoms. J. F. Hammond reported the case of a man who had mania and involun- tary diarrhoea, but no blood or mucus in the stools. The mucous membrane of the rectum and caecum was in a sloughing condition, and the colon was perforated in two places. 1. In the milder forms the attack begins with premon- itory distress in the abdomen and tympanites. Colicky pains follow and the patient yields to the desire to go to stool; the evacuations very soon, sometimes at once, are characteristic of dysentery ; they are small, contain or consist wholly of mucus, and are stained with blood. The griping pains, as the attack advances, recur at short intervals in the region of the umbilicus, in the line of the ascending and descending colon, extending to the left iliac fossa. The urgent desire to empty the bowel fol- lows each paroxysm of pain, and with great straining (tenesmus) a small muco-sanguinolent mass is expelled. The patient sits at stool for some time, continuing his un- relieved expulsive efforts and complaining of burning in the anus. In cases of this kind there may be very little 552 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysentery. Dysentery. entery ; 7, the bilious form, in which there is vomiting of bile with bloody stools and jaundice-such cases are often, no doubt, not dysentery at all, but examples of malignant remittent or intermittent fever ; 8, the malarial form, occurring in malarial regions, accompanies or suc- ceeds malarial attacks. Such distinctions have the value of showing how mul- tiform dysentery is under the influence of different eti- ological influences, and in different localities. Complications.-There is no disease which has a lar- ger number of complications than dysentery. Out of 1,537 cases of diarrhoea or dysentery observed in Egypt, only 406 were uncomplicated ; 1,131 were compli- cated with other more or less severe affections. The fol- lowing list includes many of these, which may occur dur- ing the progress or as sequelae at the end of the disease : Catarrh of the stomach and small intestines, acute bron- chitis, pleurisy, pleuro-pneumonia, gangrene of the lung, albuminuria and anuria, ascites, anasarca, meningitis, thrombosis in the cerebral sinuses, convulsions, cerebral embolism with hemiplegia and aphasia, paraplegia, ab- scess of liver, other lesions in the liver, peritonitis, perity- phlitis, periproctitis, perineal fistula, parotitis, malarial fever, malarial cachexia, typhoid and typhus fever, cholera, scurvy, erysipelas, rheumatism, variola, abor- tion, and premature labor. Perforation and peritonitis occurred in 85 out of 580 cases collected by Beranger-Feraud. Out of 79 cases in the European General Hospital, Bom- bay, in 1863, there was one with perforation, and three cases of peritonitis. Of these, one was from perforation, two from sloughing of the intestine ; all were fatal. Abscess of the liver is a common complication in tropi- cal dysentery, but rare in temperate climates. The tropi- cal single hepatic abscess is endemic, and its occurrence at the same time with dysentery is accidental. The multiple or pyaemic abscess is due to absorption of septic matter, and its transference from the intestine to the liver ; it is more fatal (Murchison). Out of a total of many hundred cases of dysentery in Millbank Penitentiary, during thirty years, there was not one hepatic abscess. • Diagnosis.-The recognition of acute dysentery is not difficult if the characteristic symptoms-tormina, tenes- mus, and muco-sanguinolent stools are present. In haem- orrhoids, blood and mucus are passed, but the haemor- rhoidal tumors can be seen, and the discharge follows a normal stool; the blood, too, is thinner, and greater in quantity. An error of diagnosis is not likely to occur in intussus- ception, although blood and mucus are passed with strain- ing ; but the tumor in the iliac or hypogastric region, the more frequent vomiting and tympanites, and the more rapid collapse are significant symptoms. Sometimes the disease proper may be overlooked when dysentery ap- pears as a complication; this might be the case in ty- phoid or typhus fever. The diagnosis of the nature of the lesion is based upon the general symptoms and the nature of the stools. Slight illness and small mucous and bloody stools indi- cate colitis without infiltration and sloughing ; but pros- tration and serious illness with larger and more liquid stools, which may be offensive, point to infiltration of the deeper layers of the intestinal wall, and to destruc- tion and throwing off of the mucous membrane. The higher up the inflammation is, the more fluid are the stools ; the lowrer down, the more mucus and blood. Prognosis.-The fatality of dysentery varies very much with the conditions under which it appears. The mild form in temperate climates is a self-limited disease, tending spontaneously to recovery. It rarely assumes a formidable nature out of the tropics, except when it is epidemic ; but destructive epidemics are much more rare than formerly in temperate regions. In England the re- duction in the death-rate in dysentery has been marked since 1850. In 1880 the mortality was six hundred and sixty-eight times less than forty or fifty years before. In the United States the total death-rate from dysentery, in 1850, was 20,556, or 6.32 per cent, of the total mortality ; in 1860, 10,468, or 2.65 per cent. ; in 1870, 7,912, or 1.60 per cent. ; and in 1880, out of a total death-rate of 756,893, there were 10,825 deaths from dysentery. The death-rate from dysentery in Europe is six to eight percent. (Hirsch) of the'number attacked. In the gar- risons in France there were seven deaths in 589 cases, or 1.18 per cent. Cases of a higher degree of severity last from three to four weeks, although complete recovery does not take place for two or three weeks later. In diphtheritic dysentery death may occur in three or four days, or at the end of the second week, or later. In individual cases the prognosis depends upon the previous state of health, intercurrent diseases, as scurvy, malaria, etc., and recent residence in the country. Un- favorable symptoms are delirium, distress in the epi- gastrium, dyspnoea, vomiting, lowering of the body temperature, hiccough, cyanosis, cold skin and extremi- ties, with feeble, rapid pulse, offensive thin or bloody discharges, disappearance of abdominal pain with in- voluntary stools, aphtha), erysipelas, gangrene of lung, ulcer of the cornea, or suppression of the urine. In epidemics in temperate climates, the mortality varies from seven to fifteen per cent. From 1841 to 1846, in the epidemics which prevailed in France, one-tenth of those attacked died. In 1836, 1837, and 1838, twenty-five per cent, died, and in 1857, one out of every five died. In tropical epidemic dysentery, the mortality is from twenty to thirty per cent. In Bombay it is nine per cent. ; in Hong Kong, twenty per cent. A mortality of thirty- five to forty per cent., and even one of sixty to eighty per cent., has been reached. Treatment.-The preventive treatment of dysentery consists in avoiding all the known causes, and in living under the best hygienic influences. Measures should be taken looking to the complete drainage of moist soil, the procuring of pure drinking water, the complete removal of all excreta, and the prevention of overcrowding and bad ventilation. In the treatment of the attack attention should be paid to ventilation and cleanliness, and to all hygienic rules governing the sick-room. With the earliest symptoms the patient should be put to bed (and in a single bed for greater convenience). The bed-covering should be warm, and even in warm weather a blanket should be used, with a view of preventing chilling of the surface by diurnal variations of temperature. The feet especially should be kept warm. Sponging the surface of the body with goo! or tepid water, with vinegar, or alcohol gives comfort by remov- ing the sensation of burning heat in the skin. The anal region should be carefully and constantly cleansed with a warm disinfectant solution, and anointed with vase- line or other ointment. Hot hip-baths have been used with advantage in relieving the tenesmus of dysentery. General warm baths and vapor-baths have been advised, but are unsafe, as there is danger from the chilling of the skin after a bath. Hot poultices to the abdomen, or hot fomentations covered with oiled silk, give some comfort to the patient. Venesection over the line of the colon or at the margin of the anus has been employed, but although the method seems a rational one for diminishing intestinal hyperae- mia, it has proved of no great practical value. The diet best suited to dysentery is one which is di- gested, as far as possible, in the stomach, and which has but little waste ; therefore eggs, concentrated broths, beef- tea, and milk should be given in small quantities at inter- vals of two hours. Milk may be given pure or diluted with Vichy water, lime water, barley water, or rice water. To relieve thirst, mucilaginous drinks, as gum arabic water, flaxseed tea, the white of egg drink, are advisable. Orange or grape juice is not objectionable, and in cases of scorbutic taint fruit juice, or even fresh fruit, are posi- tively curative. Alcohol is called for in many cases to sustain the feeble pulse. Diet alone, or combined with rest, will, in many cases of dysentery, bring about a cure in a few days. In severer cases, although we have no specific, yet drugs are of ser- vice in relieving pain and in shortening the attack. 553 Dysentery. Dysentery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The great weight of authority is in favor of the treat- ment by ipecacuanha in the initial stages of dysentery. This remedy is given in doses of fifteen to twenty grains, in bolus or suspended in mucilage; by some as large a dose as one to one and a half drachm has been given. Nausea and vomiting may accompany the abundant per- spiration caused by the remedy, and an alleviation of the symptoms, with an improvement in the character of the pulse, a lessening of the tenesmus and tormina, and a change in the character of the stools, follows. The dose should be repeated in four to eight hours, and if good re- sults follow and the patient bear the treatment well, it can be continued during three or four successive days. The use of purgatives, in the beginning and during the whole course of dysentery, has been recommended by Pringle, Zimmerman, Degncr, Dutronleau, and others. In the early stages, in all cases, a purgative is admissible, and may be beneficial, although it is not often that the disease is aborted by the removal of scybalae. The sa- line purgatives, largely diluted, act well for this purpose, sulphate of soda being preferred; but calomel has many advocates who prefer it to all other laxatives, and recom- mend its repeated administration during the attack. But constant purgation does not relieve the symptoms nor change the character of the stools, and after a fair trial at the beginning of the attack, laxatives should not be continued. It is irrational to expect benefit from in- creased peristaltic movement and irritation of the mucous surface, in cases in which rest seems so important to the process of cure. After the illness has lasted a week or longer, a saline purge seems to hasten recovery by causing a fecal movement. Castor-oil, in children, answers better than salines for the same purpose. In India mercury is used much less than formerly. During the progress of the attack opium is given to re- lieve the intense suffering and to induce sleep, but no drug is more liable to abuse than this. The temptation is to give very large doses. Professor Christison has known a patient to take twenty-four to thirty grains of opium in twenty-four hours with good results. The ad- ministration of morphia hypodermically, at regular inter- vals, accomplishes the end much better than any other method. The digestion is not disturbed and the relief is more complete, but the dose should be restricted or in- creased very gradually. A host of'remedies have been recommended and sup- ported warmly, as possessing curative powers in dysen- tery. Bismuth, in very large doses, is among these, as many as a thousand grains a day having been given. It is only in large doses that it is of any avail. Acetate of lead, nitrate of silver, and other mineral as- tringents, are used to diminish the frequency of the more fluid discharges, but it is only then that they accomplish any good. As far as the dysenteric symptoms are con- cerned, they are worse than useless. The bark of the root of calotropis gigantea (or mudar) has been used in India as an excellent substitute for ipecacuanha, in doses of a scruple to a drachm. The use of aconite in dysentery has been advocated by Dr. William Owen. One minim of the tincture is to be given every fifteen minutes, until eight doses have been taken, and then one minim every succeeding hour ; thirty minims to be given in the twenty-four hours. One hun- dred and fifty-eight cases were thus treated with but one death. Quinia can be given either as a tonic or as an antiseptic, or to reduce temperature, and the dose is regulated by the effect desired. It is of especial value in cases in which there is a malarial cachexia complicating the attack, or in which dysentery accompanies acute malarial disease. The mineral acids-nitric, sulphuric, muriatic, nitro- muriatic-have all been advocated ; they aid digestion, and are tonic in their effects. Upon intestinal ulcers they exert a favorable influence, as in typhoid fever. The vegetable astringents are of but little value. In case of haemorrhage from the bowels, gallic acid, in full doses (10 to 15 gr.), may be of use in checking it, but as far as the effect of these drugs upon the intestinal in- flammation and ulceration is concerned, no dependence can be placed upon them. The bael fruit, which contains a large amount of tannin, is said to be a valuable remedy in scorbutic cases. The treatment by the rectum offers the most rational method of cure, as the remedies can be brought into im- mediate contact with the diseased surface or with a por- tion of it, and experience has shown that a favorable impression made upon the rectal mucous membrane is followed by improvement throughout the colon. In acute dysentery the practice of passing long flexible tubes be- yond the sigmoid flexure has been adopted with success, but the suffering which follows this procedure is often an obstacle to its use. The patient should lie on the back or on his right side, with the pelvis raised and the legs flexed slightly on the abdomen; the tube, which should be soft and smooth, should be introduced slowly, and by injecting water in small quantities as it advances the introduction is much facilitated. From eight to twelve inches of the tube can be easily passed in this way. Warm, hot, or cold water enemata can be given ; each has its advocates, but warm water is more comforting, and by its use the mucous membrane is better cleansed and all detritus washed away. The quantity used should not be less than a pint ; two pints thrown in slowly can be retained for a few moments and then passed. Continued irrigation of the rectum and colon with hot water (90° to 102° F.), allays the pain and reduces the in- tense hyperaemia of the mucous membrane. This can be done with a double tube, or by the introduction of the water through a large soft catheter, while another cath- eter, lying by the side of the first one, provides the de- sired outlet channel. The water, thus used, may be of more service by making it antiseptic with carbolic or salicylic acid, the latter being safer. An additional means of cure is offered by adding to the warm water one drachm of sugar-of-lead or of alum, or five to fifteen grains of nitrate of silver to the pint ; but in the acute form such solutions do not give the same promise of success as in chronic dysentery. The pain excited by the distention of the bowels with a large quan- tity of water is sometimes very great, and it is better then to inject not more than four ounces of starch or barley water with four to six grains of sugar-of-lead, and a small quantity of laudanum. From ten to twenty grains of subnitrate of bismuth in four ounces of water by injec- tion, with or without an opiate, is thought to have a soothing effect on the mucous membrane. Ergot, as an enema, in doses of twelve to fifteen grains in a bland fluid, has been used with the effect of diminishing the blood in the stools. From what is known of the action of cocaine on sensi- tive surfaces, great relief may be expected from the ap- plication of it to the rectal mucous membrane. Chronic Dysentery.-Much confusion prevails in the application of the term chronic dysentery. It should not be used to designate cases of chronic intestinal ca- tarrh with follicular ulceration, but should be limited to those cases of chronic flux which are due to the presence of unhealed dysenteric ulcers. Therefore, there can be no such disease as chronic dysentery which is chronic from the beginning ; in the history of the case the acute attack must necessarily precede the symptoms of persist- ent ulceration. The causes of chronic dysentery are those which have led to the acute illness, and which prolong it beyond the usual duration. Improper treatment during the attack may be one cause, but the cause to which chronic ulcera- tion is chiefly due is an unwise management of the stage of convalescence, which delays or prevents cicatrization of ulcerated surfaces. Imprudence in eating, therefore, or too early exercise, induces relapses, due to the breaking down of young and delicate cicatricial tissue, and the re- opening of ulcers. Chronic dysentery follows, as a rule, the more severe grades of disease, in which the ulcers have been large and numerous. Pathological Anatomy.-The lesions left behind after 554 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysentery. Dysentery. the subsidence of the acute destructive processes of acute dysentery have the chronic ulcer as their essential feat- ure. The ulcers have the same seat as in the acute stage, vary in number from one to so large a number that the whole surface seems to be one extensive ulcer, with inter- vening ridges of thickened mucous tissue ; they have the muscular or serous layer as their floor, and in rare in- stances perforation occurs. The ulcerating process is not stationary, but fluctuates between extension and repair, so that while some ulcers are spreading by undermining and breaking down of the mucosa, others are passing through cicatricial changes. The intestinal tube is dilated, contracted, or irregularly dilated and contracted. The narrowing is due to thick- ening and hardening of the submucous and muscular coats, and is found chiefly in the rectum and sigmoid flexure. The mucous lining, where not ulcerated, is dark-red, brown, slate-colored, light-blue, or green. The greatest variegation of color is found in patches, spots, or streaks, due to areas of inflammation of different intensi- continue to be frequent, semifluid or fluid, differing in color according to the amount of pus and blood which they contain. Sometimes they consist of pus alone, or of pus intermixed with blood. In the worst cases they are dark and offensive. Abundant haemorrhages occasion- ally occur. During the progress of the disease there are many alternations in the amount of diarrhoea and in the character of the stools, due to the healing and reopening of ulcers. Borborygmi and tympanites accompany the diarrhoea, and there is sometimes tenderness over the abdomen. The appetite may be unaltered, but sooner or later is lessened or lost, and the tongue is pale and coated, or bright red and glazed. Emaciation from malnutrition is an invariable accompaniment ; the patient loses strength and flesh until he is confined to bed in the most advanced degree of emaciation. The skin in time becomes hard, dry, pale, or icteroid, and bed-sores may accompany this stage. The heart's action is usually feeble throughout. The Fig. 903.-Mucous Polypi of Colon in Chronic Dysentery. (After Wood- ward.) Fig. 903.-Chronic Dysenteric Ulcers. (After Woodward.) urine is normal or high-colored, and may contain albumen and casts. Death occurs by asthenia or by complications, and is preceded by hectic fever and sweats ; the duration being from six months to two years. Recovery takes place by healing of the ulcers, with slow improvement in all the symptoms. Complications.-General dropsy, oedema of one ex- tremity (from a thrombus in the femoral vein), chronic bronchitis, pulmonary phthisis, acute pneumonia, peri- tonitis with or without perforation, malarial conditions, scurvy, and ulceration of the cornea occur during, or at the end of, chronic dysentery. Sequela.-Even after the ulcers have healed emacia- tion from chronic intestinal indigestion may continue. Constipation from atony of the muscular coat, and ste- nosis of the bowel due to the contraction of cicatrices, are common results. The constitution may be permanently enfeebled, and the individual be unfitted for doing work which requires much mental or physical activity. Diagnosis.-The previous occurrence of acute dysen- tery, and the symptoms which are due to the presence of ties, and to old extravasations. Acute or subacute in- flammation may be added to previously existing chronic disease ; the color in this case is bright red, and acute destructive changes, infiltration, and sloughing of the mucosa are found in conjunction with the chronic lesions. The whole wall may be purplish or black, in- dicating gangrenous processes. The mucous surface sometimes presents a rough, villous appearance, due to numerous polypi, which originate in a process of growth of the undestroyed mucous tissue. Cicatricial contraction around their bases gives them pe- culiar forms ; they are club-shaped, simple, or branched. Almost every organ in the body may be the seat of in- flammatory or degenerative changes in chronic dysentery. Abscess of the liver is directly related to the intestinal lesion. Symptomatology.-When the tormina, tenesmus, and constitutional symptoms of acute dysentery disappear without healing of the ulcers, the intestinal discharges 555 Dysentery. Dysmenorrlioea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a pus-forming and bleeding surface in the intestine, render it an easy matter to make a diagnosis of chronic dysen- tery. In chronic catarrh of the colon, not of a dysenteric origin, the symptoms are much the same, if follicular ulceration is added to the simple catarrhal process. For then, by coalescence of small ulcers, larger ones are formed, and pus and mucus are passed by the rectum. But yet the two diseases are distinct in their nature and origin. If bile is contained in the stools, or if the discharges are thin and fecal, without blood, pus, or fragments of tissue, the disease is not limited to the colon and there are no ulcers. A local examination would reveal cancer as the cause of dysenteric symptoms, and an irritable syphilitic ulcer of the rectum would have the history of syphilis and would be single. Prognosis.-The result of treatment depends very much upon the stage of the disease and the general condition of the patient. The longer chronic dysentery has existed, the less hope is there of cure, and when the constitution has become profoundly altered, and emaciation, debility, anaemia, hectic fever, and bloody and purulent stools have been symptoms of long duration, the chances of success are not great. The disease is always a grave one, and great perseverance is required to effect a cure. Even after complete recovery, death may result from some complicating disease, as abscess of the liver, or pulmonary phthisis. The large number of United States army pen- sioners who still claim chronic diarrhoea as their disabil- ity shows how inveterate are chronic intestinal diseases. Treatment.-Great care in the convalescence of acute dysentery affords the best prophylaxis for the chronic form. The patient should not be freed from the guid- ance of his physician until he has continued well for several months. The general health of the sufferer from chronic dysentery requires that he should be put under the most favorable hygienic regimen. A change of cli- mate, especially to one that is cool and dry, or a sea voy- age, with rest from all mental and physical fatigue, will sometimes bring about a speedy improvement. Thermal baths are of great value in improving the condition of the skin and in diminishing abdominal plethora, and sea bath- ing, in milder cases, is advisable. In more severe cases rest in the recumbent position is a necessary part of the treatment, and should be continued as long as the patient bears it without detriment. A diet of milk, or of skimmed or peptonized milk with koumiss or buttermilk, should be continued for two or three weeks or longer. If the patient tires of this, or if he derives no benefit from it, raw scraped beef, concentrated ani- mal broths, and raw eggs maybe given in addition to the exclusive milk diet. As improvement takes place, rare beef or mutton, raw oysters, sweetbreads, rice, macaroni, and bread can be given. Drugs are of small value compared with rest and the milk diet. Nitrate of silver in pill form (one-sixth to one- fourth of a grain), continued for two or three weeks, is of great use. Bismuth in large doses (15 to 30 grains), sul- phate of copper (J to i grain), the liquid preparations of iron, dilute nitric and sulphuric acids, tannic acid, and other vegetable astringents, oxide and sulphate of zinc, alum, and corrosive sublimate (T^ grain), have all been recommended. No remedy should be abandoned until it has been given for several weeks. The Rockbridge alum water is a valuable aid ; it is mildly and pleasantly astringent, and can be given in place of other astringents. Rectal irrigation is the most rational plan of treatment, and offers the best hope of cure. Cold water may be used alone for its sedative and astringent effect; to the water, alum, sulphate of zinc, or sugar-of-lcad, may be added in the proportion of five grains to the pint. Large injections of weak solutions of nitrate of silver (five grains to the pint) thrown as far into the colon as possible, once or twice a day, are followed by good results in almost every instance. Another course is, after washing out the rectum, to expose its interior with a Sims speculum. The ulcers are then to be well touched with nitric acid, and the rectum washed out with a strong solution of bicarbo- nate of soda. Rest of the bowel should be secured for two days by an opiate suppository, and in one 'week the ulcers should be again treated in the same way. The use of opium is to be condemned, except when it is used to check profuse and frequent liquid stools or to relieve pain, but the continued administration of opiates is hurtful by disturbing digestion, and favoring the retention in the bowels of matters which should be ex- pelled. W. W. Johnston. DYSIDROSIS is an affection of the skin characterized essentially by the retention in the cutaneous follicles of sweat rapidly and freely secreted. The follicles are much distended, and congestion may follow with the formation of bullae, maceration of the epidermis, and sometimes more or less dermatitis (Tilbury Fox). In its slightest form the eruption is confined to the hand, occurring in the interdigits, over the palm, and along the sides of the fingers and on the palmar surfaces-some or all of these parts. The eruption may occur in summer or in winter, affecting usually persons who perspire freely. Pa- tients complain of feeling weak and depressed. The erup- tion is made up at first of minute vesicles imbedded in the skin which do not readily burst, and when fully devel- oped resemble boiled sago grains. They are best seen on the palmar surface of the tips of the fingers, but in severe cases they may occur more or less over the whole palm of the hand as well as on the fingers. Itching and burn- ing are always present. As the disease progresses the vesicles become more distended and raised, eventually yellow in color, running together and forming an ag- gregated mass of small bullae which may develop into a considerable size. The hand is then very stiff and painful. If the vesicles are pricked, a clear fluid, at first alkaline and later acid, runs out. If left undisturbed the vesicles and bullae dry up and the cuticle peels off, leaving a non-discharging, reddened, exposed derma. But the cuticle, especially about the roots of the fingers on the palmar aspect, may become sodden and like wet chamois leather. In slighter cases the disease may not run on to the development of bullae. Dysidrosis is most apt to be mistaken for eczema, but it is not inflammatory, as eczema is, and is unaccompanied by sero-purulent discharge, crusts, etc. The vesicles are not produced by the uplifting of the cuticle by sero- purulent fluid, but by the distention of the follicles by retained sweat. In rare cases, however, eczema may fol- low the disease. Treatment in the severer forms of the disease should be both general and local. Dyspepsia and anaemia are not infrequent accompaniments of the disease. The kidneys should be made to act freely by means of diuretics. Aperients should also be used, and in gouty or acid con- ditions, alkalies. Later quinine, arsenic, and iron are useful. Locally, dilute lead-water and soothing ointments should be kept applied, and if the sweat-glands generally are involved, bran and starch baths may be used. The disease, or a similar one, has also been described under the name " Pompholyx" (q.v.). Arthur Van Harlingen. DYSMENORRHCEA. The term dysmenorrhoea (from the inseparable particle 5us, with difficulty, ^v, a month, and I flow) is used in its strict etymological sense, that of painful menstruation; but it should be applied only to menstruation accompanied by severe pain, as dis- tinguished from the moderate aching usually attendant upon the function. Dysmenorrhoea is commonly con- sidered to be only a symptom, and not a disease, and that view is doubtless true of the generality of cases; but in many instances no structural pathological condition can be discovered to account for it, and it may then be looked upon as a neurosis. Almost all systematic writers divide dysmenorrhoea into several varieties, founding their division upon what they conceive to be its varying pathology ; but a few au- thors will have it that the affection is necessarily due to obstruction to the escape of blood from the uterus. Those who admit a number of forms of dysmenorrhoea 556 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysentery. Dysmenorrlirea. follow a nomenclature intended to express various patho- logical states, such as the neuralgic, the spasmodic, the congestive, the inflammatory, the membranous, the ob- structive, etc.; while others employ names designed to indicate the seat of the fundamental morbid condition, such as constitutional, ovarian, uterine, etc. Both classes of writers enumerate the signs and symptoms by which, as they maintain, the particular forms of the disease may be diagnosticated. Practically, these diagnostic points are not much to be relied upon, and we can only say with certainty: 1. That women who, so far as we can discover, are in perfect health in other respects, both con- stitutionally and locally, suffer from dysmenorrhoea ; al- though it must be admitted that the great majority of sufferers show evidence of a depraved constitutional state. 2. That women of every sort of systemic ill-health escape this ailment. 3. That the affection is found as- sociated with every abnormity of the sexual apparatus. 4. That, except positive occlusion of the uterine canal, there is no condition of the parts concerned that invari- ably gives rise to it. It will be seen from all this that the relations between dysmenorrhoea and its causes are very diverse and but imperfectly understood, that no single theory of its causation will apply in all cases, and that no one of the nosological systems covers the ground, satis- factorily from a clinical point of view. Nevertheless, it is convenient to treat of the affection under some of the various forms that have been assigned to it, whether from pathological or from anatomical considerations. Obstructive Dysmenorrhcea.-Obstructive, or me- chanical, dysmenorrhoea is that form which is supposed to depend upon an obstruction to the escape of the men- strual blood from the genital passages, either from the oviduct, from the uterus, or from the vagina. Prac- tically, we may almost restrict it to some impediment to the escape of the blood from the uterus-either an actual stenosis of the uterine canal, a sharp flexure of the organ, or the valve-like action of a polypus, a clot, or an ex- foliated membrane. It is but a few years since it was generally held that mechanical obstruction was almost, if not quite, the sole cause of dysmenorrhcea; now, how- ever, the prevailing opinion is that it is only one of a number of conditions that may give rise to painful men- struation, and some authors go so far as almost to deny the possibility of stenosis causing dysmenorrhcea. Each of the extreme views mentioned is untenable ; undoubt- edly there is such a thing as obstructive dysmenorrhoea, but it is the exception rather than the rule. The diagnosis of obstructive dysmenorrhoea should not be made from the rational symptoms, however plausi- ble it may sound to say that, in a given case, the pain is paroxysmal, each paroxysm being followed by an escape of blood, liquid or clotted, and that therefore the retention of that blood in the uterus was what caused the pain. The blood may simply have been retained in the va- gina, and cast out as the final step of a spasmodic exacer- bation ; moreover, many sorts of pain are paroxysmal, quite irrespective of their cause. Excepting the tem- porary obstruction that may result from spasmodic or congestive narrowing of the uterine canal, we should diagnosticate uterine stenosis only after a physical dem- onstration of its presence. If the condition known as "pinhole os" is observed; if a small probe cannot be passed into the cavity of the body of the uterus, or can be so passed only with great difficulty (especially with the patient anaesthetized); if a sharp flexure of the uterus is detected ; or if an intra-uterine growth is found so situated as readily to occlude the canal, we may reasonably con- clude, in the absence of any other discoverable cause, that the pain is due to obstruction. It will not do to infer positively from the good results of mechanical treatment that the trouble was caused by obstruction, for we know too little of the collateral effects of such treatment to limit its action to so narrow a field. The treatment of obstructive dysmenorrhcea is direct- ed, of course, toward overcoming the obstruction. The treatment of flexures and polypi of the uterus will be found in the sections of this work which are devoted to those affections, and we have here to deal only with the uterine canal. The procedures that have been prac- tised for the relief of uterine stenosis include dilatation, divulsion (the so-called rapid or "bloody" dilatation), and various cutting operations. Dilatation by means of expanding tents is generally regarded as too temporary in its effects to be considered curative, and too dangerous to be resorted to repeatedly as a palliative. The tupelo tent, however, is less objectionable on the latter score than either the sponge, or the sea-tangle tent, and the tubular tupelo tent, as recommended by Dr. Sussdorf, of New York, is perhaps to be regarded as reasonably free from danger as a palliative. Dilatation by means of grad- uated metallic, or hard-rubber sounds, is safer than the use of tents, and some authors report excellent results from its use. A certain amount of force is allowable in the passage of these sounds, counter-pressure being made upon the uterus through the abdominal wall, or traction upon the cervix with a tenaculum. Still greater success has been stated to have been achieved with divulsion, es- pecially by Dr. Goodell, of Philadelphia, whose experi- ence with the method has been very great. Dr. Goodell prefers an instrument so constructed that the blades remain parallel when they are separated, and have trans- verse grooves on the outer surface of each blade, to pre- vent the instrument from slipping out during the opera- tion. In regard to cutting operations in cases of stenosis at the os externum a simple bilateral nicking is sufficient, and this is a procedure much practised by some gynae- cologists, who hold that the stricture is generally at that situation. Others prefer discission (bilateral incision) of the whole length of the cervical canal, which they ac- complish by means of special instruments-metrotomes or hysterotomes-consisting either of a forceps-like mechanism, the blades furnished with an outer cutting edge, being introduced closed and withdrawn expanded, or of a stem upon which a blade is slid into the canal. Many operators insert a glass or hard-rubber plug after the incision has been made, to maintain the calibre of the canal. In cases of flexion, especially anteflexion, some practitioners prefer the more radical operation de- vised by the late Dr. Marion Sims, for a description of which the reader is referred to the heading Uterus. Inasmuch as cases of obstructive dysmenorrhoea con- stitute the minority, the successful treatment of the affection covers a far wider range than that of over- coming mechanical impediments, and even in cases that appear to be mechanical, palliative treatment is some- times all that the patient will submit to. The first indi- cation is to remedy any defect of the general health, so far as possible. The subjects of dysmenorrhoea are apt to be anaemic, and the sensitiveness of their nervous sys- tem is commonly excessive. Careful attention to hy- giene and the use of such nutritive tonics as cod-liver oil, iron (preferably in conjunction with an alkali, as in Blaud's pills), and especially arsenic, are among the measures on which the chief reliance is to be placed. What is known as " general faradization " is a valuable adjunct. Any abnormal condition of the generative organs that can be discovered should be made the subject of treatment; those that most frequently give rise to dysmenorrhoea being the remains of inflammatory ex- udates which cripple the uterus by preventing its physi- ological increase in volume during menstruation, inter- fere with the ready return of blood from it, or draw it into some unnatural posture or configuration. It is not rare for a prolapsed and tender ovary to be found as the accompaniment of dysmenorrhoea. The management of the various abnormities that may give rise to the affection will be found treated of in other sections of this work. Membranous dysmenorrhoea is a variety sui generis. Its pathology is not well understood. In this form the superficial part of the endometrium is cast off more or less entire at each menstruation, constituting the so- called decidua menstrualis, instead of undergoing the natural process of molecular disintegration. The causes of this phenomenon are wholly unknown, and the ex- planation of its relation to the pain is made doubly diffi- cult by the fact that this exfoliation en masse is not 557 DyMnenorrliwa, Dysphagia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. always painful. Membranous dysmenorrhoea is a par- ticularly rebellious form of the disease, and severe measures have often been resorted to unsuccessfully for its relief. Success has been attained by the application of strong nitric acid to the endometrium, and it has also followed the use of a great number of other applications. Dr. Skene, of Brooklyn, has lately acquainted the pro- fession with his very encouraging results from applica- tions of iodoform, which he credits Dr. Fordyce Barker with having been the first to use in this country. As regards the palliative treatment of dysmenorrhoea, a cardinal point should be to avoid the use of narcotics, except on occasions of special urgency, in order that the patient may not acquire the habit of resorting to them. If possible, the sufferer should maintain the recumbent posture, or at least abstain from active bodily movements, for three or four days before the flow begins, and during its continuance. During this period, especially if the flow is excessive in amount, or if there are signs of undue pel- vic congestion, a hot-water bag or flannels wrung out of hot water should be applied over the junction of the dorsal and the lumbar portions of the vertebral column four or five times a day, for ten or fifteen minutes at a time. The use of hot aromatic drinks is a popular remedy, and one that is not by any means to be despised ; but the resort to gin, "which is far too common, should be discountenanced. Some such preparation as the parsley- water of the Germans may be substituted. Local ano- dynes are best administered in the form of rectal supposi- tories. A suppository containing five grains of iodoform, with or without a sixth of a grain of extract of bella- donna, is very efficient; opium should be used only in case of actual necessity. Many drugs prove of service when given by the mouth, but they are apt to lose their efficiency after a few periods, and this is a strong argu- ment in favor of the neurotic nature of the affection in many instances. One of the most trustworthy is the Viburnum opulus, in the form of five grains of the abstract every three hours, during the painful part of the period. The passage of the faradic current through the pelvis two or three times a week, during the inter-menstrual period, is often of service. Apiol, a preparation made from pars- ley, has been used by many practitioners with success. It is commonly given in the form of capsules. The per- manganate of potassium is another remedy that has lately been recommended. Frank P. Foster. or from malignant new-growths of the pleura, and in the posterior mediastinum. The surgical causative conditions are operations upon, and injuries of, the mouth, tongue, superior and inferior maxillary bones, soft and hard palate and uvula, tonsils, pharynx, larynx, and oesophagus. The neurotic con- ditions most commonly met with are spasm of the pha- ryngeal constrictors, paralysis of the velum palati or pharynx from cerebral lesion, or as a sequel of diph- theria, general paralysis of the insane, progressive mus- cular atrophy, glosso-laryngeal paralysis, hysterical af- fections, and, finally, those rare cases in which the pharyngeal neurosis seems to be reflex, as, for instance, in angina pectoris, due probably to the numerous con- nections between the sympathetic and the vagus, or in pericarditis, not only when the exudation is large enough to cause direct pressure upon the oesophagus, but also with a small amount of exudation, where the dysphagia is probably a symptom of reflex irritation. The disastrous effects of dysphagia will be proportion- ate to the severity and duration of the cause. While the latter must, of course, largely determine the plan of treatment to be adopted in a given case, there are, never- theless, certain general measures of wide and very valu- able application. They depend upon the following prin- ciples', namely, that in conditions which are attended with dysphagia, the act of deglutition will produce (1) pain, either local or reflex ; or (2) mechanical or chemical injury to parts already inflamed or ulcerated, or both. These, and especially the first, not only by interfering with the ingestion of food, but also by the depressing effect upon the nervous system of frequently-recurring pain, may result in (3) impairment of nutrition. The general indications to be met would be, therefore, (1) the securing of rest to the parts, and the avoidance of causes which excite pain; (2) protection of the parts from mechanical or chemical injury ; and (3) the main- tenance of nutrition. It is obvious that the above ends must be met by the administration of highly nutritious food, reduced to so small a compass as to require a minimum number of de- glutitory efforts, and rendered as unirritating and as easily swallowed as possible. Thus, in tubercular or cancerous affections the patient, unable to manage either solids or liquids, will often swallow with success an unbeaten raw egg, a small unseasoned raw oyster, lumps of rennet cus- tard, or some such semi-fluid and yet coherent bolus. The local condition may be temporarily relieved in many instances by the application of morphine, or, better still, of the muriate of cocaine. These means are, however, in a large majority of in- stances inadequate to fulfil the necessary conditions of rest, avoidance of pain, and of injury to the parts, and are, moreover, totally insufficient for the proper nutrition of the patient. Pain and local irritation are steadily aug- mented, and, in the unequal struggle for life, enough food not being taken at any one time to supply the de- mands of nature, the patient surely and steadily loses ground. In acute affections of the throat all nourish- ment will sometimes be declined until the severity of the attack shall have subsided, thus adding to the enfeeble- ment caused by the disease itself, and protracting the period of convalescence ; while in the surgical conditions above referred to the evils of dysphagia are sufficiently evident. Since the act of deglutition is the immediate cause of dysphagia, the most rational means for relieving the dys- phagia would be, obviously, to remove the cause ; in other words, to abolish the act of deglutition. This may be accomplished as follows : 1. When there exist both dysphagia and inability on the part of the stomach to retain food, an invaluable resource lies in rectal alimentation, the utility of which has been so well established that it is only necessary, in the present connection, to call attention to the importance of its adoption early in the history of the case, and before the strength of the patient has been reduced by want of food. 2. When, on the other hand, the condition of the stomach is good, then, granting the desirability of ali- DYSPHAGIA (8vs-(pdya>). Difficulty in swallowing, or in deglutition. Physiologists divide the act of normal deglutition, which is under the control of the medulla, into three stages : The first voluntary, and accomplished by means of the tongue and the buccal muscles as far back as the anterior pillar of the velum palati. The second, involuntary, although certain voluntary muscles are engaged in effecting it, and accomplished by the ac- tion of those muscles whose duty it is to retract the tongue, to lift the larynx, to close the glottis, to contract the fauces and bring the tonsils in contact with the bolus of food, to elevate the soft palate and close the posterior nares, and to raise and contract the pharynx. In the third stage, involuntary, like the second, the food passes into the oesophagus, through which, by an undulatory or peristaltic movement, it is propelled into the stomach. Any impairment of the normal process of deglutition may give rise to dysphagia. Such impairment may be organic, and due either to structural lesion or to surgical derangement, or it may be functional, from direct or re- flex neurosis. The organic derangements which most frequently cause dysphagia are tuberculous, cancerous, syphilitic, and diphtheritic affections of the mouth, phar- ynx. tonsils, larynx and oesophagus ; tonsillitis ; affections of the salivary glands and retro-pharyngeal abscess. In diseases of the spleen, dysphagia may arise from second- ary lymphatic hyperplasia of the tonsils, and the follicles of the pharyngeal mucous membrane. In pressure di- verticula or sacciform dilatations of the oesophagus, also, this symptom is present. Again, it may be caused by di- rect pressure of a thoracic aneurism upon the oesophagus, 558 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysmenorrhoea. Dysphagia. mentation by the natural passages, the indication is, clearly, to remove the obstacle to deglutition or to avoid it. The former may be impossible. The latter, however, may be accomplished in a large number of cases by the use of an oesophageal tube, through which nutritious food, in liquid form, may be injected into the stomach. As suggested by the writer in 1880, the best means for accomplishing this purpose are : (1) the employment of a tube of the smallest possible calibre, and (2) the intro- duction of this tube, not necessarily into the stomach, but merely into the oesophagus and past the point of obstruc- tion, or else past the pharyngeal constrictors. Through the tube the stomach may be made to receive food in almost any amount and variety, without any attempt at degluti- tion, and with perfect protection to the parts. Hence it is evident that by this simple device all of the indications mentioned above may be completely met; for (1) pain is at once done away with, and a maximum of rest to the pharynx is secured ; (2) injury is avoided; and (3) nu- trition is maintained. The apparatus needed for this purpose is exceedingly simple, the essential part of it being an English flexible woven catheter, an open-ended soft rubber catheter, or a small oesophageal tube, attached by means of a piece of rubber tubing to a receptacle for the food. For the latter a glass funnel, or, better still, the simple apparatus represented in the illustration (Fig. 904) will be found convenient. To the great advantage of the catheter over the large and clumsy stomach-tube it is scarcely necessary to refer. Its introduction is much less startling and uncomfortable them will be followed by violent gagging. In such cases a soft-rubber tube may be passed through the nostril and pharynx, and thence into the oesophagus, and thus con- tact with the fauces be wholly avoided. Should the in- troduction of the tube cause dyspnoea, direct the patient to take full breaths. It may also cause nausea when it passes the pharynx, for which Dujardin-Beaumetz ad- vises the administration of bromide of potassium ; and, also, when it reaches the stomach, in case it be inserted so far, for which the introduction of food will quickly bring relief. Of course, the passage of the tube will not always prove an easy or a painless operation. A little practice, however, will render it possible in nearly every instance, while the advantages to be gained far outweigh any ordi- nary objection to the method. As to the special conditions in which dysphagia will call for relief, in none does it play a more important part than in tuberculosis. Although the resources of modern therapeutics have rendered it possible to control, to some extent, the tuber- culous ulcerative processes found in the larynx and pharynx, still no amount of medication can counterbal- ance the evil effects of the local disturbance caused by deglutition ; and, even in cases in which the ulcerations are confined to the anterior of the larynx, beyond the reach of matters swallowed, deglutition is apt to provoke attacks of coughing which not only cause the food already taken to be vomited, but inflict additional injury upon the parts. When the ulcerations are external to the larynx, for example, upon the epiglottis, or in the region of the tonsils, the pain is more intense than in any other lesion of the throat. Thus, nutrition is almost totally arrested at a time when life is most dependent upon it. In cases in which extensive degeneration has taken place in the lungs, and this condition must soon of itself prove fatal, dysphagia stands in the same relation that it does in can- cer ; the symptoms can only be palliated, and with little hope of prolonging life. In many instances, however, extensive ulceration of the larynx occurs long before the pulmonary lesion has progressed beyond control. By proper conditions of climate and nutrition, life may be prolonged indefinitely, so far as the lungs are concerned. But the dysphagia interferes with nutrition ; strength to cope with the disease is not forthcoming ; and so, through a cycle of unfavorable influences, the progress of the pa- tient is from bad to worse, until, finally, he succumbs from inanition. It is in such cases that the results of treatment are most satisfactory, for it will readily appear that, with a full and well-assimilated diet, the conditions under which the patient labors are materially altered, and the possibilities of recovery or of improvement infi- nitely increased. The most unpromising circumstances under which dysphagia is likely to occur will be found in some one of the various forms of cancerous disease which may attack the throat. The extreme liability to destructive ulcera- tion in cancer of the mucous membrane renders dys- phagia an early and prominent symptom. The pain in such cases increases with great rapidity, until a time comes when the dysphagia surpasses the limit of human en- durance, and when the pangs of hunger are less intoler- able than is the agony caused by each attempt to satisfy it. While it may hardly be desirable to prolong life under such circumstances, the patient should still be fed, and his pain relieved, even when there is no doubt as to what will be the final result. In syphilis, also, nutrition plays an all-important part in the successful treatment of the case. Although the danger to life may not be so great as in phthisis, still in extensive secondary or tertiary disease of the throat it is by no means inconsiderable, while dysphagia is often very severe. The earlier the patient can be placed upon a full supporting diet the more quickly will he be likely to respond to constitutional treatment. The importance, therefore, of overcoming dysphagia and its effects is clear. In many cases of diphtheria, dysphagia is not a marked symptom. When, however, it exists, the tube may be Fia. 904.-Apparatus for Artificial Feeding. to the patient, and if the food be properly prepared, highly concentrated preparations being employed, after the manner of Debove, the large tube will be unneces- sary. As a general rule, the irritation caused by the passage of the tube increases with its size. The tube should be introduced in the usual manner, namely, the patient's mouth being opened and his tongue protruded, the catheter should be carried to the base of the tongue, the patient told to swallow, and, as he does so, the cath- eter pushed into the oesophagus, and thence downward as far as may be deemed necessary. The larynx may be avoided with certainty by using the finger as a guide. Before its introduction the tube should be carefully lubri- cated, for which purpose white of egg, mucilage, or even milk, are useful. An excellent plan is to allow the patient to swallow slowly, just before the introduction of the catheter, a drachm or two of pretty thick mucilage. Vaseline, glycerine, and oil are unpleasant to the patient, and should on no account be used. In passing the cath- eter gentleness should be observed, and great care taken to avoid, as far as possible, all points of special tenderness. In many cases the patient himself may be taught to pass the tube much more successfully and comfortably than it can be done for him, since the manoeuvre is not a diffi- cult one, and no one knows so well as he the exact situa- tion of the painful spots. Sometimes, especially with children, the point of greatest irritability is in the pala- tine arches, and any attempt at passing a tube across 559 Dysphagia. Dysuria. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. resorted to, in order that the heart's action may not be in- fluenced by the depressing effects of pain. In all acute inflammatory affections of the tonsils, and in affections of the salivary glands, dysphagia is frequently so distressing that the patient will for several days abso- lutely refuse food. This, of course, adds to the duration and severity of the attack, and protracts the period of convalescence. No one familiar with such cases can have failed to observe the beneficial effects of the first hearty meal which the patient is able to swallow. The inference naturally follows that nutrition should be maintained from the outset. In retro-pharyngeal abscess the same may be said. Although spasm of the pharyngeal constrictors is some- what rare, cases now and then occur in which the hyper- sesthesia is so great that the power of swallowing is, for the time being, lost; so that when the difficulty contin- ues for any considerable length of time, the patient may suffer severely for want of food. A few well-assimilated meals would, from their tonic effect, probably contribute more than any other one thing toward the breaking up of the attack, as well as satisfying the immediate demands of hunger. Faucial paralysis, from any cause, is always a most important and annoying symptom, from the well-known tendency of the food to get into the larynx. In his ex- cellent work upon diphtheria, Professor Jacobi suggests the value of the stomach-tube in diphtheritic paralysis. As to the surgical conditions in which the tube will be of service, it is only necessary to mention them in order to suggest the great utility of the method. In all such cases it will be well to accustom the patient to the use of the tube before the operation, so that he will not be obliged to learn it under adverse circumstances. Mr. Henry T. Butlin, of London, having given the instrument a careful trial at St. Bartholomew's Hospital, states that he is using it in an increasing number and variety of cases, and with marked benefit. In cases of tracheotomy the results have been remarkably good. In stricture of the oesophagus, the frequent passage of even a small tube will, in some cases, be found impos- sible, by reason of the narrowness of the stricture, and the consequent difficulty in conducting it past the obstruct- ing ring. In these instances, fortunately rare, Krishaber has suggested that the tube be passed through the nostril into the oesophagus and stomach, and left in situ, only to be removed for purposes of cleansing. The tube should be made of soft gum, and may be fastened in its place in such a manner as to cause little inconvenience. In the case of one of Krishaber's patients, a tube was worn for one hundred and fifteen consecutive days. D. Bryson Delavan. scarcely justifiable, because almost any obstruction to the entrance of air into the lung also opposes an obstacle to its egress. It is also to be remembered that a slight ob- struction to inspiration may be a serious one to expira- tion, because inspiration is a muscular act, and, therefore, much more powerful than expiration, which, under nor- mal circumstances, is almost entirely dependent upon the resilience of the lungs and thoracic walls. Dr. Hyde Salter remarks (Lancet, August 26, 1865) that "any ob- struction in the air-passages, and telling equally both ways, would find to overcome it a strong inspiratory and a weak expiratory force, and would, of course, tell more on the weak than on the strong." A pure form of inspiratory dyspnoea, and probably the only one, is found in cases of paralysis of the muscles which open the glottis in inspiration, namely, the pos- terior crico-arytenoid. The immediate effect of division of the nerves supplying these muscles is thus described by Dalton : "A serious difficulty in respiration is the im- mediate consequence of this operation. For the vocal chords, being no longer stretched and separated from each other at the moment of inspiration, but remaining lax and flexible, act as a double valve, and are pressed inward by the column of inspired air, thus partially blocking up the passage and impeding the access of air to the lungs." The difficulty of inspiration is "accom- panied by a peculiar wheezing or sucking noise, evidently produced in the larynx, and dependent on the falling to- gether of the vocal chords." The best classification of the different forms of dysp- noea is one that has reference to the causes concerned in their production. On this basis, the following classifica- tion, which corresponds with that adopted by Dr. Hyde Salter, is perhaps as good as can be offered, although all divisions of dyspnoea are necessarily imperfect, from the fact that more than one cause is operative in nearly every case : 1. A greater demand for oxygenated blood than can be supplied by the lungs. 2. Interference with respiration, due to (1), mechanical causes; (2), pain. 3. Interference with the blood-supply to the lungs. The typical form of the first variety is the dyspnoea of muscular exertion in a healthy individual. In this form, the respirations are greatly increased in frequency ; in- stead of sixteen to eighteen per minute, they may reach forty to sixty. The range of respiratory movement is much greater than normal ; the breathing is deep. The post-expiratory pause is abolished. The time both of in- spiration and expiration is shortened, but the former in far greater degree than the latter, so that inspiration, instead of occupying, as in health, twice the time of ex- piration, is now of equal duration with it. Finally, ex- piration, which is normally almost entirely passive, is now converted into an active muscular movement. One or other of the elements of this typical form is to be found in every case of dyspnoea. In the dyspnoea due solely to muscular exertion the lungs are perfectly healthy. More work is demanded from these organs in a given time than they are capable of performing without embarrassment. Precisely similar results are produced when a lesser de- gree of work is demanded from a crippled organ, and the respiratory distress is in proportion to the suddenness with which the damage has been inflicted. The most marked examples of this variety are found in extensive pneumonic consolidation, in hydro- and pneumo-thorax, and in oedema pulmonum. The sound portion of lung has to do its own proper work, plus that of the portion function- ally impaired. As a consequence, the respirations are deeper and more rapid ; the post-expiratory pause is abolished, and the ratio of inspiration to expiration more or less altered. The breath-sounds of the sound portion of lung, when they are not completely masked by those of the part diseased, are identical with the sounds pro- duced by the dyspnoea of muscular exertion ; that is to say, they are puerile, or, to use a more accurate expression, compensatory. The mechanical causes of dyspnoea are very numerous, and most of them will readily recur to the mind of the DYSPNCEA. For the proper discharge of the function of respiration, it is essential that the venous blood and the atmospheric air should be brought into intimate relation. This is accomplished by means of the lungs, two hollow sacs with numerous minute subdivisions, upon which and in the septa separating them the capillary vessels ramify so densely that the width of the spaces dividing them is less than that of the vessels themselves. The air is intro- duced into the lungs through the act of inspiration, which, although muscular, is, under normal circumstances, au- tomatic, and ejected by the act of expiration, which, un- der normal circumstances, is believed by most authorities to be entirely passive, although others consider the inter- nal intercostal muscles to be actively concerned in pro- ducing it. Be that as it may, there is no question that the natural elasticity of the costal cartilages and of the lung tissue is the most important factor in the act of ex- piration. At the close of expiration there is a period of rest which, strictly speaking, forbids the designation of normal respiration as either an act or a movement. Anything that interferes with the proper performance of inspiration or expiration, or prevents the access of blood to the pulmonary capillaries, or hinders its egress through the pulmonary veins, may produce dyspnoea. A division of dyspnoea into an inspiratory and an expiratory variety has been adopted by some writers, but this is 560 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Dysphagia. Dysuria. reader. A certain number have their seat within the air- passages, among which may be mentioned oedema glot- tidis, laryngitis, croup, bronchitis, asthma, and intra- laryngeal growths. Another set acts from without, such as enlarged tonsils, enlarged cervical glands, bronchocele, and aneurism. These mechanical forms of dyspnoea are ac- companied with the highest degree of respiratory distress ; nevertheless, the respiration is often much slower than normal. On account of the narrower aperture for the admission of air, a longer time is required for inspiration, and the same is true with regard to expiration. For the same reasons, also, the respirations are shallow, and the respiratory murmur, when not entirely masked by stridor, abnormally feeble. The post-expiratory pause is abolished, since there is no time to spare for rest. In high degrees of mechanical interference there is a marked depression of the supra-clavicular soft tissues during inspiration, as well as of the soft parts below the ribs. Symptoms of asphyxia become gradually devel- oped ; the lips grow bluish, or even bluish-black; the nose, ears, and finger-nails have a dusky hue, and the ex- tremities are cold. The respirations, it has been already remarked, are often abnormally slow. Dr. Hyde Salter has known them to sink as low as seven per minute in a case of stenosis of the glottis. A group of mechanical causes of dyspnoea produce their effect by impairing the elasticity of the thorax and lungs, and so interfere particularly with the act of expi- ration, which is almost entirely dependent upon this phys- ical property. Examples are furnished by cases of calci- fication of the costal cartilages, emphysema, and phthisis. In the latter affection the elastic tissue of the lung is replaced by an inelastic material. In these varieties ex- piration is prolonged, inspiration is shortened, and the range of movement is slight. The effect of pain is to cause the lung to assume an ex- piratory position, the chest being contracted even during the height of inspiration. The respirations are shallow, the breathing is hurried, and the pause abolished. The character of the respiration affords a clew to the seat of pain. When seated in the thorax, as in cases of pleuro- dynia, intercostal neuralgia, and pleurisy, the chest-walls are motionless, while the abdominal respiratory move- ment is abnormally great, owing to the fact that the res- piration is purely diaphragmatic. On the other hand, when the pain is abdominal, as in peritonitis, the respira- tion is entirely costal. The most frequent interference with the blood-supply to the lungs is due to stenosis or insufficiency of the mi- tral valve. The resulting dyspnoea is often of very high degree, causing the patient to retain an upright position -orthopnoea-both day and night. The breathing is rapid, the range of movement free, the pause abolished, and the respiratory murmur puerile. In short, the char- acter of the dyspnoea is remarkably similar to that of muscular exertion. Several years ago the writer con- cluded the report of a case of cardiac valvular disease with the following words: "Indeed, the condition of a patient with marked cardiac valvular disease, even when at rest, so closely resembles that of a healthy individual making violent voluntary exertion that it would be inter- esting to determine whether the same tissue changes, as indicated especially by the urine, faeces, expired air, and perspiration, do not occur in both instances" (" Path. Soc. Trans.," Philadelphia, vol. vii., 1878). The common un- derlying cause of every form of dyspnoea is congestion of the pulmonary capillaries. In the typical form, that of sudden muscular exertion, more blood is returned to the right heart through muscular pressure upon the veins than can be propelled through the pulmonary circuit. There is an inordinate vis a tergo; the supply is greater than the demand. On the other hand, in dyspnoea of mitral origin, there is an excessive vis afronte. Finally, an imperfect supply of air will produce pulmonary con- gestion in accordance with the law of asphyxia, ' ' that uni- versal law, that whenever the changes that ought to take place in a capillary system do not take place, that capil- lary system refuses, in some way, to give the blood a free passage, and generates at once the congestion of stasis." Of the subjective symptoms of dyspnoea, one is so prominent as to render all others insignificant. It is the sensation of want of breath. This is disagreeable enough when the pulmonary capillaries have been engorged by the transient cause of sudden and violent exertion ; but when the cause continues and its force increases, as it does in many cases of stenosis of the air-passages, the sensation becomes agonizing in the extreme. The feeling of want of breath is not in proportion to the amount of damage which the lungs may have sustained through dis- ease, but is most acute when the supply of air to a healthy lung is interfered with. Thus, in tuberculosis, the lungs maybe so riddledwith cavities, and so indurated from fibroid change, that scarcely a portion of healthy vesicular structure is to be found, and yet the sense of dyspnoea may be very slight. This is due to the fact that the nutritive changes of the body have gradually ac- commodated themselves to the diminished amount of oxy- gen supplied by the imperfectly performed respiratory function ; so much so that the carriers of oxygen, the red blood-corpuscles, are greatly reduced in quantity. It will be invariably found that the sense of dyspnoea is most acute in cases, such as asthma and other forms of stenosis of the air-tubes, in which the supply of air is cut off from healthy air-vesicles, or, in other words, that the " further the mischief is removed from the ultimate lung-substance, the greater the dyspnoea." Frederick P. Henry. DYSURIA. This term is employed, rather loosely, to denote either difficult or painful micturition. It may be caused by, or exist as a symptom in, several different conditions of the urinary organs. There may be a de- fective vis a tergo, or some obstruction may exist in the course of the urethra. In paralysis of the bladder, either partial or complete, the expulsive force is weak and mic- turition is accomplished only with the assistance of the abdominal muscles and diaphragm. A similar condition sometimes exists as a temporary state when the contractile force of the bladder has been weakened by over-disten- tion, as may occur after voluntary retention of urine for a long time. Partial or complete retention may occur tem- porarily from psychical causes, as is exemplified by the fact that many are unable to urinate, at least with full stream, when in the company of others. Painful micturition may also be caused by irritability or spasm of the bladder. The viscus, when in this state, responds to the stimulus of a very small accumulation of urine and contracts violent- ly, expelling its contents and causing pain often of great severity. Painful micturition is caused also by great acidity or alkalinity of the urine, and it is a prominent symptom in the acute stage of gonorrhoea. Difficult and painful urination of very severe type, known as strangury, often follows toxic doses of certain drugs, as turpentine and cantharides, and may also occur as a symptom in inflammation of any part of the genito-urinary tract. Obstruction to the flow of urine may be caused by stone in the bladder or urethra, by an enlarged prostate gland, by stricture of the urethra, either organic or spasmodic, or by a narrowed prepuce. Dysuria may also be caused by pressure on the bladder from the gravid uterus, from ovarian or other intra-abdominal tumors, or from disten- tion of the intestines by gas or accumulated faecal masses. In the treatment of dysuria special attention should of course be paid to the discovery and removal of the causal condition. But beyond this, temporary relief may be ob- tained by certain palliative measures, designed to render the urine bland and unirritating, and to relax spasm of the urethra or of the wall or sphincter of the bladder. To this end demulcent drinks, the spirits of nitrous ether, etc., are to be administered, and cloths wrung out of hot water may be placed over the hypogastrium, or the patient may be placed in a hot sitz-bath. Morphine hypodermically ad- ministered may render good service, or a few whiffs of chloroform or ether may suffice to relax spasm. But if there is retention of urine with a very full bladder, anaes- thetics should never be pushed to the stage of excitement, as in the struggles of the patient the bladder would be in danger of being ruptured. T. L. S. 561 Ear, Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. EAR: ANATOMY OF LABYRINTH. The internal ear, or labyrinth, lies embedded in the petrous portion of the temporal bone. In shape it is very tortuous, and its longest diameter does not exceed 1.75 ctm. It consists of a bony cavity, the osseous labyrinth, which contains a membranous labyrinth. The latter supports the ter- minal filaments of the branches of the auditory nerve, and is an essential structure of the organ of hearing, which, with the nervus auditorius and certain portions of the brain, constitute the "sound-perceiving appara- tus." Animals low in the scale of development, such as mollusca, have no bony labyrinth, but only a simple membranous sac. The Osseous Labyrinth presents three natural di- visions, consisting of (1) a median chamber, the vestibule (Fig. 905, 1) which communicates posteriorly with (2) three semicircular canals (Fig. 905, 3, 4, 5), and anteriorly with (3) the cochlea (Fig. 905, 6, 7, 8). The osseous labyrinth is lined with periosteum, formed by connective tissue containing fine elastic fibres. In the semicircular canals it ex- hibits numerous large nuclei, but it is without an epithelial lining (Ril- dinger, Henle, Hasse). The lumen of the osse- ous labyrinth is only partially occupied by the membranous labyrinth, and the remaining space is filled by a transparent gelatinous fluid, the peri- lymph (liquor Cotunnii.) The perilymph con- tains about 2.2 per cent, of solid matter, chiefly mucin, with sodium chloride and a proteid which is coagulable by acids but not by heat (Dahnhardt2). The membranous labyrinth contains a similar albuminous fluid, the endolymph, which has only 1.5 per cent, of solid matter, with less mucin and no albu- min. These two fluids do not come in contact at any point. Early writers recognized one fluid only, the Aquula Cotunnii (Magendie). The endolymph can reach the subarachnoid space by flowing through the sheath of the nervus acusticus (Hasse). The vestibule is an irregular, ovoidal chamber (Fig. 905), the diameters of which measure 3.4 x 6 mm. It opens anteriorly into the cochlea, and posteriorly by five round apertures into the semicircular canals. On the inner side it communicates through the cribriform plate with the meatus auditorius internus (Fig. 905, 1, 2). The fenestra oralis is an aperture (Fig. 905, 2) leading into the tympanic cavity through the external wall of the vestibule. The base of the stapes is fitted into this fenestra (Fig. 906, o, k), to which it is attached by a delicate articular capsule (Sommering) called the liga- mentum orbiculare baseos stapedis. A layer of hyaline cartilage covers the vestibular surface of the base of the stapes (Toynbee), and over this is continued the lining periosteum of the vestibule. The margin of the fenestra itself is lined by cartilage, which extends in a thin layer for a short distance over the inner surface of the ves- tibule. Between this marginal cartilage and that of the base of the stapes, a layer of elastic tissue is disposed in a plexus which forms two ligaments, whose office is to attach the base of the stapes to the fenestra ovalis so firmly that its mobility is very slight (not over (Helmholtz). These ligaments are called respectively the ligamentum orbiculare baseos stapedis vestibulare, and tympanicum. The joint is thus a sort of amphiarthrosis. From a narrow, bony crest, near the fenestra, arises the musculus fixator baseos stapedis, which is described by Riidinger as antagonizing the action of the voluntary musculus stapedius. It is found in the young, but does not appear to be constant. The nervus auditonus, passing along the floor of the meatus auditorius internus, divides into a cochlear (ramus cochlearis) and a vestibular (ramus vestibuli) branch (Fig. 906, a, c, 1, 2, 3). These branches contain multipolar cells, and they separate into nu- merous fllaments which pass through the per- forations, which are found in groups in the cribriform plate that divides the meatus from the internal ear. At their point of separation is a small ganglion, the intumescen- tia ganglioformis (Scarpa). The ramus vestibuli separates into branches, pres- ently to be de- scribed, one of which enters the vestibule through many minute open- ings, the maculae cribrosae, found in a depression, the fovea hemispherica (Fig. 907, 2) or recessus sphericus in the forepart of the inner wall. The principal and central group of openings forms the macula cribrosa media. Be- hind the fovea is a vertical ridge, the crista vestibuli, or eminentia pyramidalis (pyramis vestibuli), (Henle), be- hind which again is the oblique entrance to the aqueductus vestibuli (Bottcher), (Fig. 907, 4). The aqueductus vestibuli is a small canal reaching to the posterior surface of the pars petrosa. This canal is 5 to 7 mm. long and 0.25 mm. wide (Henle), and it is lined by tessellated epithelium surrounded by nucleated con- nective tissue. It transmits a small vein (Hyrtl) to the sinus petrosus inferior, and the ductus endolymphaticus (described below). Between the fovea hemispherica and the orifices of the semicircular canals is another small fossa, the fovea hemielliptica (Fig. 907, 1), (sinus semi- ovalis, Morgagni), or recessus ellipticus. Large vessels are de- rived from the arte- ria auditiva interna, and proceed from the osseous vestibule into the osseous semicir- cular canals whose curvature they fol- 1 o w. The arteries and veins do not lie very close together. The osseous cochlea (cavitas cochleata, ductus spiralis) is a tapering bony tube, which in process of development be- comes coiled around a central pillar by two turns and a half (rarely 2£ Henle). The turns are from left to right in the right ear, and from right to left in the left ear. The length of this helical osseous tube is 28 to 30 mm. and its greatest width is 2 mm. (Henle) at its commencement, but only 1.5 mm. throughout the greater part of its length. The modiolus is the central column formed by the in- ner wall of the tube (Fig. 908, Md). It is conical, and measures 2 mm. in breadth at the base and 0.5 mm. at the apex. From its whole length a spiral osseous lamina (septum osseum cochleae) projects half-way into the Fig. 906.-Perpendicular Section through Right Ear. Diagrammatic (Czermak). «, Nervusacus- ticus; C, cochlea ; <8 V, scala vestibuli; 8 T, scala tympani; r, fenestra rotundus ; s r, sac- culus rotundus ; s e, sacculus ellipticns ; am, ampulla ; fc, semicircular canal; o, foramen ovale ; ci, nervus cochlearis ; 1, 2, 3, branches of vestibular nerve; k, stapes; pl, lamina spiralis. Fig. 905.-Right Osseous Labyrinth from Outer Side (Siimmering). 1, Vestibule; 2, fenestra ovalis ; 3, superior semicir- cular canal; 4, horizontal canal; 5, posterior canal; *, *, *, ampullae of semicircular canals; 6, first turn of cochlea; 7, second turn ; 8, apex ; 9, fenestra rotunda. Fig. 907.-Interior of Left Osseous Laby- rinth (Sommering). 1, Fovea hemiellip- tica; 2, fovea hemispherica; 3, common opening of superior and posterior semicir- cular canals; 4, opening of aqueductus vestibuli; 6, superior, 6, posterior, 7, ex- ternal semicircular canal; 8, scala tym- pani; 9, orifice of aqueductus cochleae ; 10, lamina spiralis. 562 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. liar, liar. lumen of the tube (Fig. 908, Ls), thus partially divid- ing it. The lamina spiralis ossea measures 1.5 mm. at the base and 0.5 mm. at the apex (Fig. 908, ft) of the cochlea. At its attachment to the modiolus it is 0.3 mm. thick, and at its free margin 0.15 mm. At the base of the cochlea it forms almost a right angle with the modiolus, but it gradually becomes more and more perpendicular. Near its margin it gives attachment to two membranous laminae, the la- mina spiralis membranacea, and the membrana Reissneri, which proceed to the outer wall of the cochlea and thus complete its division into three passages, the upper one of which is called the scala vestibuli, and the lower or basal one is the scala tympani (Fig. 907, 8). The third passage, called the scala media, or canalis cochlearis, is smaller than the other two, and is formed by the diver- gence of the two membranous laminae in a manner pres- ently to be described. The spiral made by the cochlea forms a blunt cone (Fig. 905, 6, 7, 8), with an altitude of 0.65 cm. and a base of about the same diameter. The base is directed toward the internal auditory meatus, and the apex points outward, forward, and downward (Quain). The first turn of the spiral is much larger than the rest (Figs. 906, 908), and it bulges a little into the tympanic cavity, form- ing there an elevation known as the promontory or tuber cochleae. The apex or cupola of the spiral is closed (Fig. 908, ff). Both the mo- diolus, or columella cochleae, and the lami- na spiralis ossea are of somewhat dense struc- ture upon their exter- nal surfaces, but in the centre they are spongy and admit of the pas- sage through minute anastomosing canals of the branching ves- sels and the nerve- fibres of the ner- v u s cochlearis, which after entering the broad base of the modiolus (Fig. 906, ci), pass at right angles into the lamina spira- lis ossea. The largest of these canals is the canalis centralis modi- oli. It has a diameter of 0.3 mm. A small canal which winds around the modiolus, close to the lamina spiralis, is called the canalis (or tubulus, Krause), spiralis modioli (habenula ganglionaris, Corti; canalis ganglionaris, Claudius). This canal contains nerve-fibres with bipolar ganglion cells. The osseous lamina terminates at the cupola in a hook- like process, the hamulus (Fig. 908, H), or rostrum, which partly surrounds the helicotrema (hiatus of Scarpa). The helicotrema is the name of an opening which has been described (Breschet, Henle) as establishing the only communication between the scala vestibuli and scala tym- pani. Recent investigation throws doubt upon the ex- istence of this opening (Buck), which must be very minute if it occurs at all. The veins from the cochlea empty into the superior petrosal sinus (Quain). The scala vestibuli is narrower than the scala tympani, and it communicates with the cavity of the vestibule through the wide apertura scalae vestibuli. The scala tympani (Fig. 907, 8) starts at its basal end from the fenestra rotunda (Fig. 905, 9), an aperture which leads into the tympanic cavity, but which is closed by a membrane, membrana secundaria tympani (Scarpa), formed of three layers, two of which are derived respec- tively from the periosteal lining of the cochlea and tym- pani, and a middle fibrous layer. This membrane is concave toward the tympanic cavity. The fenestra ro- tunda is smaller than the fenestra ovalis. Near to it is a small bony lamina which projects inward from the first turn of the cochlea. It is called the lamina spiralis se- cundaria, or lamina spiralis ossea externa (Bendz). The aqueductus cochlew is a small canal (Fig. 907, 9), whose orifice is found in the scala tympani near the fenestra rotunda. It extends downward and inward through the petrous bone, and it contains a small vein (Hensen, Henle) which empties into the bulb of the vena jugularis, and a fibrous process from the dura mater. Hasse claims to have also discovered in it a ductus peri- lymphaticus which conducts the perilymph fluid away to the fossa jugularis, near which it opens (v. Bezold, Schwalbe, Weber). The aqueductus cochleae is both longer and broader than the aqueductus vestibuli. The osseous semicircular canals lie in planes nearly at right angles to each other (Fig. 905, 3, 4, 5). As compared with the axis of the body, the superior or an- terior vertical canal is vertical and transverse, and it reaches higher than the rest of the labyrinth to form a smooth, rounded elevation on the upper surface of the pars petrosa. The posterior vertical canal is vertical and longitudinal. It is longer than the others. The external canal is the shortest, and it lies horizontally. The canals are somewhat compressed laterally (Fig. 907, 5, 6, 7), and each is bent to form about two-thirds of a circle. The longest diameter of each canal is 1.2 to 1.7 mm., and the shortest 1.0 to 0.8 mm. (Ranke, Henle); but one end of each canal, where it joins the vestibule, forms a dilata- tion or ampulla which is 2.5 mm. in diameter (Quain). The length, which increases somewhat with the age of the individual, varies between 22 and 15 mm. The canals have but five openings into the vestibule, because the end of the posterior vertical canal nearest to the anterior vertical canal is not dilated, but joins the latter, and has a common orifice with it (Fig. 907, 3). The horizontal canal has two separate orifices. The periosteal lining of the canals presents an uneven surface and has numerous large nuclei, but no squamous epithelium (Rudinger). The Membranous Labyrinth.-The membranous labyrinth is not loose within the osseous labyrinth, but is Fig. 908.-Section through Osseous Cochlea. (Henle.) Md, modiolus ; Ls, lamina spi- ralis ; H, hamulus; +, trans, sect, through lamina spiralis; ++, termination of lamina spiralis in the cupola ; Fee, fenestra coch- leae. Fig. 909.-Membranous Labyrinth (Waldeyer), Diagrammatic. LI, utri- culus with semicircular canals; 6', sacculus; Ji, aqueductus vestibuli, with a division for the sacculus and another for the utriculus; Cr, canalis reuniens; C, ductus cochlearis; V, caecal pouch; Jt, cupola. fixed by bands of fibrous tissue which support blood-ves- sels. Its walls are largely composed of connective tissue which resembles the cornea in structure. The vestibular membranous labyrinth is divided into two sacs: (1) the oblong utricle (Fig. 909, U), or sacculus hemiellipticus (common sinus), which lies in the fovea hemielliptica (Fig. 907, 1), and communicates with all the semicircular canals ; (2) the sacculus rotundus (Fig. 909, S), or sacculus hemisphericus, which lies in the fovea hemispherica (Fig. 907, 2) above mentioned, and commu- nicates with the ductus cochlearis through a small canal, canalis reunions (Hensen). The sacculi are closely con- nected, but they do not open directly into each other ; they communicate, however, through a Y-shaped canal, the saccus endolymphaticus (Bottcher, Retzius ; recessus labyrinthi, Reissner), which occupies the aqueductus ves- tibuli(Fig. 909, R) and presents a small cul-de-sac near the posterior surface of the pars petrosa. This canal is attached to the periosteum. Its diameter is 1 mm., and it is lined with tessellated epithelium. Henle thinks that 563 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the vessels in its walls supply fluid for the endolymph. It certainly forms a portion of the membranous laby- rinth. The two sacculi occupy two-thirds of the cavity of the vestibule, and they are not completely surrounded by perilymph, but are in contact with the osseous vestibular wall at certain parts, where they are held in place by nu- translucent or vitreous tunica propria (Fig. 910, 2); (3) a pa- pilliform layer (Fig. 910, 3, 6); (4) an internal single layer of squamous epithelium. The latter is of uniform thickness, but the other layers are relatively thin on the side where the canal touches the internal osseous wall, at which point the fibrous layer becomes continuous with the periosteum, and contains pigment cells (Fig. 910, 5). At the extrem- ities of the oval transverse sec- tion are fibrous bands, the ligamenta labyrinth! canalicu- lorum (Figs. 910, 7; 911, 5), which stretch across from the free wall of the canals to the periosteum, and support coarse plexuses of blood-vessels (Fig. 911, 2, 3). The thickness of the entire wall of each mem- branous canal varies from 0.016 mm. at its free curvature to 0.028 to 0.08 mm. at the attachment of the ligaments (Riidinger). Excepting at the attached margin of the canal the tunica propria (Riidinger), presents a dozen or more pa- pillae or papilliform processes. The papilliform processes, which resemble transparent spheroids, project into the lu- men of the canal (Fig. 910, 3, 6). They are covered with irregular, nucleated, tes- sellated epithelium (Riidinger). It has been suggested (Riidinger) that if the endothelial lining secretes the en- dolymph which fills the canals, as it probably does, the papillae increase the secreting surface ; but they are ab- sent in the foetus and the new-born. They are without nerves, and they are wanting in the sacculus and am- Fig. 910.-Transverse Section of Membranous Canal. (Rudinger.) Greatly magnified. 1, Outer fibrous layer ; 2, tunica propria ; 3, 6. papill® with epithelial layer ; 5. fixed thin side of canal, without papillae ; 7, fibrous bands passing to periosteum. cleated fibrous ligamenta labyrinthi sacculorum (Ruding- er). The sacculus rotundas is less firmly attached than the utricle. Neither of the sacculi touch the base of the stapes (Rudinger). The vestibular nerve divides into three branches, as stated above (Fig. 906, a, 1, 2, 3). They are : 1, a ramus superior, which goes to the maculae cribrosae and divides into three branches, one of which goes to the utricle, and the two others supply two of the ampullae ; 2, ramus media, which passes to the maculae cribrosae, and thence to the sacculus; 3, ramus inferior, which passes to the remaining ampulla (Henle). Ranke says, however, that a nerve for the septum sacculi etutriculi is given off from the nervus cochlearis, and that three nervi ampullares are given off from the ganglion at the point of separation of the nervus cochlearis and nervus vestibuli. The nervi ampullares run in minute grooves, and are associated with ganglion cells (Hasse, Leydig). The branches for the utricle and superior and external ampullae enter the vestibule at the crista vestibuli; the fibres for the sac- culus rotundus enter at the fovea hemispherica (Fig. 907, 2), and the branch for the posterior ampulla enters just behind the sacculus rotundus nerve. Where all these branches extend there is a close vascular plexus. Larger arterioles enter with branches of the vestibular nerve and form coarse plexuses in the loose connective tissue which lies between the bony vestibular wall and the walls of the sacculi. Upon the latter the vessels become smaller and form fine plexuses (Rudinger). Large arterioles also pass from the vestibule into the semicircular canals. The Membranous Semicircular Canals. - The membranous semicircular canals occupy about one-third of the lumen of the osseous semicircular canals, to the inner curvature of which they are attached by the fibrous ligaments. In the ampullae they are thicker and more opaque, and they nearly fill the lumen of the bony cavity ; and here also the ligamentous tissue receives and supports the blood-vessels and nerves which enter from the vesti- bule. The nerves are not continued into the canals be- yond the ampullae, where they form flat, forked expan- sions (Leydig, Hasse) in the crista acustica (see below). The membranous semicircular canals are best observed in transverse section (Figs. 910, 911). The sections are oval, and their long diameter measures 0.5 to 0.58 mm., and their short diameter 0.3 to 0.4 mm. The transverse sections of the ampullae measure 2.25 x 0.57 mm. (Huschke). The canals are composed of (1) an external nucleated fibrous layer (Fig. 910, 1,); (2) a homogeneous Fig. 911.-Transverse Section of Entire Semicircular Canal, Osseous and Membranous. (Riidinger.) Greatly magnified. 1, Osseous wall ; 2, fibrous bands, including vessels, united at 3 with periosteum ; 4, membranous canal ; 5, short fibrous bands (with intervening spaces) uniting membranous canal to periosteum ; 6, union of outer layer with periosteum. pullae. The walls of the sacculus rotundus and utricle and ampullae have essentially the same structure with the semicircular canals, but where they are attached to the osseous walls the yellowish tunica propria is much thick- ened, and forms a rounded eminence, which in the am- pullae is called the septum transversum (Scarpa, Steifen- 564 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. sand), or crista acustica, and in the sacculi the macula acustica (Schultze). The crista and macula acustica are all surrounded by modified epithelium, which consists in part of (1) a long columnar variety (Fig. 912, c), and forms a layer two or three times thicker than the epithelium elsewhere. These cells have large nuclei. Between them are (2) more num- erous nucleated spindle or fusiform cells (Fig. 912, sp) and other (3) pyramidal elongated cells (Hasse), which rest by a broad base upon the tunica propria, or, accord- ing to M. Schultze, they rest upon a structureless base- ment membrane which borders the tunica propria (Fig. 912, b). They serve to support the columnar cells be- tween which they project. Riidinger denies the exist- ence of the third class of cells. M. Schultze and Hasse also describe stellate and pigmented cells appearing be- tween the columnar cells. In the ampullae the epithelial layer is thicker than in the sacculi, and the latter have more spindle-cells. As- sociated with these various cells are delicate, tapering ciliae (Fig. 912, h). The cilia, or auditory hairs (Schultze, Ecker, Reich, Leydig) do not vibrate spontaneously. They are bathed by endolymph. The difficulty is great of observing the cells anil hairs, for they are only 90 mm. long (Hartmann), and doubt exists as to their exact relations. Retzius and Hart- mann think that the hairs spring from the columnar "auditory" cells, and that they may be split into several still finer fibres. M. Schultze and Riidinger main- tain that they spring from the spindle-cells between the colum- nar cells (Fig. 912, h, sp). The nerve-fibres which enter the tu- nica propria from the external fibrous tissue lose their medul- lary sheath (Schultze, Odesius), and the axis cylinders then break into fine fibrils, which form a plexus around the bases of the spindle-cells (Fig. 912, n). The plexus presents numerous swell- ings, which are described by Reich as ganglion cells. Riiding- •er denies the existence of this plexus, and with Hasse claims that the nerve-sheath is often continued into the epithelial cells. Retzius, Riidinger, Hart- mann, Kolliker, Ranke, believe that some of these fibrils then pass through the cells and be- come continuous with the audi- tory hairs. Analogy with cer- tain gustatory, olfactory, and •cochlear cells w'ould seem to favor this view. The membrana tectoria is an exceedingly delicate membrane (Prichard, Lang) which covers the auditory hairs. Sometimes the hairs appear to be sur- mounted by little caps (Leydig), which Riidinger and Schultze re- gard as epithelial cells detached from the crista acustica or crista macula, as the case may be. The function of the hairlets is undecided. Otoliths.-Lying near the epithelial cells, and also scat- tered less abundantly through the cavities and along the walls of the sacculus rotundus, utricle, ampullae, and membranous canals, and on the periosteum of the osseous semicircular canals (Henle, Kolliker), and in the fluid of the cochlea (Hyrtl), are small bodies called otoliths, oto- conia, or lapelli. They consist of from 74.5 to 77.5 per sent, of mineral matter, which is mainly calcium car- bonate. The organic remainder resembles mucus (Diihn- hardt), but by Henle it is termed "otolith cartilage." The otoliths occur as granular, amorphous particles, or, more commonly, as arragonite crystals, which are usu- ally rhombic, octahedral, or hexahedral. They vary greatly in size. Sometimes, and in certain animals, they assume quite fantastic shapes. Their extremities are often very sharp. They may occur grouped in bunches, enveloped by a delicate, structureless, cuticular sac (Kol- liker) fixed in the viscid endolymph. Their function is not understood. Waldeyer suggests that they may have a sort of damping action upon the vibrations of the hair- lets. The Membranous Cochlea. - The membranous cochlea, like the membranous semicircular canals, is a tube lined by epithelium and tilled with endolymph. The external thin margin of the osseous lamina of the cochlea gives attachment to a membrane, the membrana basilaris, which stretches across to the opposite external curvature of the spiral cochlea, where it is attached to a projection of the periosteal lining known as the spiral ligament (Fig. 913, Lig.). The spiral ligament was formerly regarded as a muscle. The retiform connective-tissue cells of which it is formed are many of them much elongated, and they have an outward radiating direction. The peculiar firm tissue of which the membrana basilaris is composed breaks into fibres which pass into the ligament. The membrana basilaris is strong and elastic (Hux- ley ; inelastic, Quain), and upon its upper surface it sup- ports the organ of Corti (see below). On its under sur- face is a layer of connective-tissue fibres derived from the periosteum of the scala tympani, which lie across the fibres composing the rest of the membrane. Spindle-cells also occur here. The membrana basilaris increases in breadth, while the osseous spiral lamina diminishes, from base to cupola. From the upper surface of the lamina spiralis ossea, at a little distance from its free margin, arises another membrane, the membrana Reissneri, which is also attached by its other extremity to the periosteum of the outer wall of the cochlea. The membrana Reissneri (Fig. 913, R) is formed of ho- mogeneous connective tissue, continuous with the peri- osteum of the scala vestibuli. This layer is covered on the vestibular surface by flat epithelioid connective- tissue cells, and on its opposite surface by a single layer of true epithelial cells with round nuclei, sometimes containing fat corpuscles. A few capillaries have been traced into this membrane. The triangular space thus divided off by the membrana basilaris from the scala tympani, and by the membrana Reissneri from the scala vestibuli, and bounded externally by the external curva- ture of the cochlear wall, is called variously the scala media, scala cochleae, canalis cochlearis, ductus coch- learis, canalis membranosus (Fig. 913, Cc.). At the cupola of the cochlea the canal ends in a cul-de-sac, which partly bounds the helicotrema (Reichert). At its other extremity there is also a small cul-de-sac which extends in front of the floor of the vestibule, and near which is a small passage through a short, narrow tube, the canalis reunions (Fig. 909, Or.), (Heusen, Henle, Reichert), which forms almost a right angle with the canalis cochlearis and leads through the wall formed by the membrana Reissneri into the sacculus. This minute canal is attached to the periosteum and is lined by short columnar epi- thelium. Its length is 0.7 mm., and its diameter 0.22 mm. (Heusen). There is thus a free passage filled with endo- lymph leading from the canalis cochlearis through the canalis reunions into the sacculus, through the branching saccus endolymphaticus into the utricle, and thence into any one of the semicircular canals (Fig. 909). The detailed structure of the canalis cochlearis, like that of the membranous semicircular canals, is best studied in transverse section. The periosteum lining the portion of the cochlear wall which forms the external boundary of the canalis coch- learis bulges slightly into that canal at a point near the ligamentum spirale. This thickening is produced by retiform connective tissue which supports numerous Fig. 912.-Diagram of Audi- tory Epithelium and Mode of Termination of Nerves of Ampullae. (M. Schultze.) c, Columnar epithelium ; sp, spindle-cells supporLingaudi- tory hairs A; b, basal Sup- porting-cells ; n, two nerve- fibres passing through tunica propria to join the plexus in the epithelium ; I, limit of tunica propria. 565 Ear, Klar. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vessels forming the stria vascularis. One of the arteries is especially prominent ; it is the vas prominens of Henle, and it is supported by a small elevation of ligamentous tissue, the ligamentum spirale accessorium. Between this elevation and the basilar membrane is a groove, the sulcus spiralis externus. The retiform tissue is covered by a basement membrane supporting a single layer of cuboidal epithelial cells, which are very small toward the membrane of Reissner, but become more prominent toward the ligamentum spirale (Fig. 913, 7). Many of ternal (Pritchard, Winiwarter), and at their point of con- tact they fit by rounded enlarged extremities (which present large oval nuclei) into corresponding concavities on the ends of the internal series. The internal rods oc- casionally have small nuclei. Small masses of proto- plasm containing nuclei are also found near the bases of the rods. Similar structures sometimes cover the floor of the tunnel, lying upon the membrana basilaris. The rods, especially the external series, are striated, and the fibrilla; may be traced into the basilar membrane. The inner rods are estimated at 6,000, the outer at 12,000 (Retzius), or 4,500 (Waldeyer). Claudius says that there are always three inner to two outer rods. The inner rods are closely set and are in contact throughout their length. The outer rods only touch each other at their enlarged extremities. At the heads of the rods peculiar appendages are seen, which have received the name of the capitular lamina (Waldeyer). Little collections of granular proto- plasm are found at both the heads and bases of the rods (Bottcher). Internal to the inner rods, that is, toward the sulcus spiralis, is a sin- gle row of epithelial cells (Fig. 913, 3), which are broader than the rods, and are in contact with them throughout their length. These cells are tipped with a cluster of delicate, short, cylindrical (Kolli- ker), stiff cilise, and surmounted by a ring of intercellular tissue which is extended to little elevations on the heads of the inner rods (Quain, Waldeyer). They rest on a row of small, round, granular cells (Bbtt- cher, Waldeyer). The cochlear nerve, after entering the modiolus, sends out branches at right angles between the plates of the osseous lamina (Fig. 914). Toward the edge of this lamina, beneath and internal to the limbus, is situated a ganglion (Fig. 913, G.) containing numerous large multipolar cells, through which the nerve-fibres pass. They then extend along the lower part of the osseous lam- ina until they reach its tip (Fig. 913, N), and their termi- nal varicose filaments are said to become continuous with the elongated lower extremities of the ciliated epithelium just described (Waldeyer, Gott- stein, Lavdowsky, Retzius). M. Schultze also describes spi- ral nerve-fibres that run to the bases of the inner hair-cells of Corti. In the membrana basilaris, beneath the outer rods of Corti,aprom- i n e n t arte- riole has re- ceived the name of vas spirale. External to the outer rods of Corti, i.e., to- ward the ligamentum spi- rale, three or four (usually four in man) rows of epithe- lial cells are arranged (Fig. 913, 5). Cells of the same row are in contact with each other, but the rows are separated by endolymph. These outer cells, like the inner series, are tipped by stiff hairlets, which project from a thickened extremity. The middle part of the cells is flattened, and the lower extremity is rounded, usually nucleated, and it sends a long, thread-like- process into the basilar membrane (Lavdowsky). Deiters regards these processes as special cells (Deiters' cells). The nuclei may, however, be in any part of the cell, and one Fig. 913.-The Canalis Cochlearis, Cc; Ligamentum Spirale, Lig., and Margin of Osseous Lamina, Los. (Minot.) Greatly magnified, p.os, periosteum; G, ganglion; N, nerve; Or, crista; Mt, membrana tectoria; R, membrana Reissneri; i, n, varicose nerve fibrils ending in outer hair-cells ; 2, epithelium of sulcus spiralis; 3, inner hair-cells; 4, tunnel beneath rods of Corti; 5, external rows of hair-cells; 6, external epithelial cells tapering off to join columnar cells lining ligt. spirale, 7. these cells contain pigment granules (Quain). The free edge of the lamina ossea spiralis is thin in macerated specimens, but in the recent specimen it is surmounted by a thickening, the limbus laminae spiralis or zona cartila- ginea of Huschke, formed of connective tissue contain- ing some fibres and corpuscles which vary in size and distribution. The external edge and surface of the limbus, labium vestibulare (Huschke), present a layer of elongated epithelial cells which are continuous with the epithelium of Reissner's membrane (Fig. 913, 1). The edge of the limbus has a number of tooth-like projections, auditory teeth of Huschke, which extend between the epithelial cells and give it an uneven, highly refracting surface. These processes are composed of the osteo- genous tissue of the crista (Fig. 913, Cr.) (Waldeyer). The limbus projects into the canalis cochlearis and its edge forms a crest, crista spiralis, which overhangs a spiral groove, sulcus spiralis internus (Waldeyer), or semicanalis spiralis (Huschke) (Fig. 913, 2.) The sulcus is lined by several layers of cuboidal epithelium, part of which lines the under surface of the limbus or labium tympanicum. The organ of Corti is so named after the anatomist who first described it. It is peculiar to mammals (Bell). It is a curiously modified epithelial structure, which is developed from the involuted epithelium of the canalis cochlearis (Kolliker). It lies in the centre of the floor of canalis cochlearis, which is formed by the membrana ba- silaris, and it receives the terminal filaments of the nervus cochlearis (Fig. 913, N). In the centre of the organ of Corti are the rods of Corti (Fig. 913, 4). The rods of Corti are firm elongated bodies, whose bases rest upon the membrana basilaris. These rods are ar- ranged in two parallel rows, external and internal. They are thinner in the centre. Their enlarged bases are sepa- rated by some distance, and their apices are in contact, so that a bridge is made, the passage beneath which forms a minute triangular tunnel filled with endolymph. The external rods are somewhat longer and larger than the in- Fig. 914.-Mode of Distribution of Cochlear Nerve. (Quain, greatly magnified.) 566 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear, Ear. cell may exceptionally have two nuclei. Varicose nerve- filaments run across the sulcus spiralis and join these outer rows of cells in a manner similar to the inner ones. The ciliae project through rings which exist in little cu- ticular structures, some of which resemble phalanges (Dieters), while others resemble rings (annuli, Bottcher). The rings are more abundant than the phalanges. The phalanges and annuli, as they are termed, join the tips of the external rods of Corti, and each other, and form a sort of network which is the reticular lamina (membrana reticularis, Kolliker). The structure of this lamina is described as consisting of a kind of cement substance (Lavdowsky). It also contains clear brown pigment cells. Long threads of cuticular substance often hang down from the phalanges between the hair-cells (Quain). The epithelial cells which adjoin the rows of ciliated cells above-described become shorter and shorter, and slope off, on the inner side, toward the epithelial lining of the sulcus internus, and on the outer side toward the liga- mentum spirale and sulcus externus, where they become continuous with the cuboidal epithelium lining the peri- osteum. A thick fibrillated membrane of gelatinous con- sistence (Henle), the lamina tectoria (Fig. 914, mt.), (or membrane of Corti, Kolliker; membrana tectoria, Clau- dius), extends from the crista, which it overlies, outward over the sulcus spiralis internus (Fig. 914, 2), (which it thus converts into a canal) as far as the most external row of ciliated epithelium (Fig. 914, 5). Its lower surface rests upon the hairlets of the outer rows of cells. Waldeyer regards it as a damper to prevent too extensive vibration of the hair-cells. The organ of Corti has the same general structure throughout the length of the cochlea, but the epithelium varies in size and in closeness of attachment. The span of the bridge formed by the rods of Corti increases a lit- tle from the first turn of the cochlea toward the cupola (Hensen). The inner rods are 30 long in the first turn, and 34 to 50 in the upper turn. The outer rods are 47 f<. and 69 long, respectively. The hair-cells number from 16,400 to 20,000 (Hensen, Waldeyer). Their length varies from 18 to 48 p. The hairlets are only 4 long (Waldeyer). of the ectoderm ; the ear-passages and ossicles arise by modifications of certain of the branchial arches and clefts of the embryo ; the concha, again, has an independent de- velopment. Accordingly, we must divide our subject into three sections, to agree with the natural tripartition. I. Development of the Membranous Labyrinth. -The membranous labyrinth is developed from a simple otocyst, which is at first a spheroidal sack of epithelium, and arises as an invagination of the ectoderm (epidermis) just over the first visceral or branchial arch. In the history of the labyrinth it is convenient to distinguish the follow- ing stages : 1, appearance of the invagination ; 2, closure of the invagination to form the otocyst; 3, first appear- ance of the recessus labyrinthi s. vestibuli; 4, commence- ment of the semicircular canals ; 5, outgrowth of the cochlea ; 6, separation of the sacculus from the vestibule ; 7, the cochlea becomes spiral. During all these changes the otocyst or labyrinth is a closed sack or cavity, with a continuous epithelial lining. The process of differentia- tion may be considered twofold: 1, the gradual conver- sion of the simple otocyst into a very complex one ; 2, the specialization of certain areas of the epithelium (ma- cula acusticw, etc.). 1. The ear arises as a lateral pit, lying somewhat dor- sally and opposite about the middle of the medulla oblon- gata, and just above the first gill cleft. The pit is an in- vagination of the outer germ layer (ectoderm), and is at first wide open. This stage has been observed by His in a human embryo of 2.4 mm. (Fig. 915, A). In the chick the first sign of the future auditory organ is a local thick- ening of the ectoderm, usually after thirty hours' incu- Bibliography. Biittcher: Bau u. Entwickelung <lcr Schnecke, Virch. Jahresb., 1869, S. 40.; Ueber den Aqueductus Vestibuli, Du Bois Reymond's Arch., 1869. Buck : Diag. and Treatment of Ear Diseases. 18S0, pp. 12, 13. Dahnhardt: Endolymphe u. Perilymphe, Arbeit d. Kieler Phys. Insti- tuts. p, 103-106. Deiters : Lamina Spiralis Membranacea, Zeitsch. f. Wissenschft. Zoolog., Bd. X., S. 1. Deiters : Lamina Spiralis Membranacea, Bonn, I860, 8. Gottstein : Beitr. zum feineren Bau der Gehiirschnecke, Centbl. fur Med. Wissenschft., 1870, No. 40. Henle : Anatomic des Menschen, Bd. II., S. 790-855. Hensen: Functionen des Labyrinths, in Hermann's Hdb. d. Phys., Edi HL. S. 66-75. Hyrtl: Untersuch. uber das inncre Gehiirorgan des Menschen u. der Siiugethiere. Kolliker : Hdb. der Gewebelehre. Labyrinth ; Entwickelungsgeschichte des Menschen u. der hiiheren Thiere. Leydig: Lehrbuch der Histologie, Labyrinth. Lowenberg : Beitr. zur Anat, der Schnecke, Arch. f. Ohrenheilk., Bd. I., S. 175. Odenius : Epithel der Macula? Acusticae beiin Menschen, Arch. f. Mikros- Anat., 1867. Quain : Anatomy, Internal Ear or Labyrinth. Reichert: Beitra. zu feineren Anat, der Gehiirschnecke, Berlin. 1864. Reissner: Kenntniss der Schnecke im Gehiirorgan des Menschen, etc., Muller's Arch., 1854, S. 420. Retzius: Riidinger: Ueber das hiiutise Labyrinth im mensch. Ohre, Aertz. In- telbit., June, 1866; The Membranous Labyrinth, Stricker's Histology. Schultze, M.: Endigungsweise d. Hiirnerven im Labyrinth, Muller's Arch., S. 343, 1858. Waldeyer : The Auditory Nerve and Cochlea, in Stricker's Histology. Fig. 915.-Sections of Human Embryos, showing the Otocyst. (After His.) A, embryo of 2.4 mm. ; B, embryo of 4 mm. ; ot, otocyst; N, nervous system ; Md, mandibular arch; 2, hyoid arch; ch, chorda dorsalis. A, X 40 diams.; B, X 20 diams. bation ; this thickened area is afterward invaginated and forms the lining of the otocyst. In fact, the difference between the newly-arisen auditory vesicle and the ecto- derm, in respect of the thickness of the two epithelia, is very striking, and the character of the otocystic epitheli- um is very important, because it exhibits an analogy be- tween it and similar rudimentary sense organs which are related to the succeeding gill-clefts as the ear is related to the first. As suggested by Froriep, there is probably a true serial homology in this case ; and the ear is one of a series of organs extending in a longitudinal lateral line, none of which, except the ear, persist in man save during early embryonic stages. Moreover, this lateral line probably extended in the ancestors of vertebrates the whole length of the body, and was characterized by the presence of sense organs in each segment. In fishes and amphibia the existence of the lateral line is unmistakable. In short, the derivation of the complex membranous laby- rinth of man from the specialization of one of a long series of general sense organs in lower ancestral forms is extremely probable. This view, first suggested, I believe, by Mr. Beard, we can only allude to here, as it would be out of place to enter upon a lengthy discussion, such as would be indispensable to fully explain and justify the hypothesis. 2. The mouth of the pit very soon closes over, and the invagination becomes a closed sack, which quickly loses its connection with the ectoderm, making a separate sphe- roidal vesicle, the otocyst Fig. 915, B, ot. The sack is lined by a quite thick epithelium, which contains the William Gilman Thompson. EAR, DEVELOPMENT OF. Morphologically the ver- tebrate ear consists of two entirely distinct parts, 1. The auditory organ proper, or the so-called membranous laby- rinth ; 2, the accessory parts, the meatus auditorius ex- ternus, the tympanum and ear bones, and the Eustachian tube, to which we may add the external ear, or so-called concha. The development of these two parts is very dis- tinct ; the membranous labyrinth arises as an invagination 567 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nuclei scattered at various levels (Fig. 916), and is built up apparently of slender columnar cells, bellied out where each cell contains its nucleus. As yet the embryonic con- nective tissue (mesoderm) has formed no envelope around the epithelium, but later the cells about the vesicle con- dense around it and constitute a sub-epithelial membrane. 1 he recessus vestibuli rapidly enlarges, and its upper end becomes dilated (Fig. 918, A, se'), to form the saccus endolymphaticus, the narrower portion, se, becoming the ductus endolymphaticus of authors. The ductus subsequently becomes greatly elongated, and reaches through the whole pars petrosa, so that the saccus lies within the skull in the dura mater. Kolli- ker, in his " Entwickelungsge- schichte," pp. 744, 745, gives a fragmentary series of measure- ments of the recessus in mam- malian embryos of various ages. 4. The semicircular canals arise next from the walls of the primitive vestibule, and rapidly acquire great prom- inence, while the cochlea grows out slowly. Each canal first appears as a nar- row fold (Fig. 919), ss, se, a wide but thin evagination. In the middle of each evagination the opposite walls meet and coalesce, leaving only the rim of the ori- ginal flat pouch ; this rim is the per- manent semicircu- lar canal. The fur- ther development of the canal consists in the gradual as- sumption of the adult form and size, the ampullae ap- pearing quite early. The embryonic connective tissue about the organ, as a whole, is gradually converted into cartilage and ultimately ossifies. The con- nective tissue (mesoderm) immediately about the otocyst has a different history, which may be readily followed in connection with the study of the semicircular canals, and hence may be mentioned now. In Fig. 920, the epithe- lial semicircular canal, m, I, is seen surrounded by a carti- lage, c, but separated from it by a thick layer of gelatinous tissue, g, and the fibrous perichondrium (future perios- teum), f. Later, the layer g is sepa- rated into a thin subepithelial layer, which persists, and a main or gelatinous layer proper, which atrophies, thus leav- ing the peri-lymph- atic space about the canal. The gelatin- ous layer consists of anastomosing con- nective-tissue cells, with, according to Kolliker, a liquid matrix. The mesh- es of the network gradually increase in size, until finally only a few threads are left, the condition in the adult. As far as known, the whole of the perilymphatic spaces are formed in this manner, including, of course, the scala tympani and the scala vestibuli of the cochlea. The ampulla} of the semicircular canals appear quite early as enlargements of the canals, and develop each a Fig. 918, A.-Sagittal Section of the Labyrinth of a Rabbit Embryo of Sixteen Days, se', Saccus endolymphaticus; se, ductus endo- lymphaticus ; pa, common stem of the poste- rior and upper semicircular canals; p, part of posterior canal; u, utriculus ; s, external semicircular canal (?); c, cochlea. Fig. 916.-Horizontal Section of the Otocyst of a Chick of the Third Day. Ot, otocyst; Ep, epidermis; Br, walls of the brain (medulla); r, v, blood-vessels. The epithelium retains its cylindrical form over and im- mediately on the borders of all the areas where the sensory hair-cells, or so-called auditory cells, are developed ; over all the remaining portions it thins out, becoming either a cuboidal or a pavement epithelium. In fishes there are seven, in amphibians, reptiles, and birds eight, in man only six of these areas of sensory cells. It is desirable to call attention to this thinning out, because it is usual to find it stated that a thickening arises, when in reality it is the thinning of adjacent parts which effects the differ- entiation, and though there may be an absolute thicken- ing also, yet the thin- ning round about is the principal factor. 3. The otocyst next loses its spherical form by the development of a prolongation on the dorsal side in conse- quence of which it ac- quires somewhat of a pear-shape. The upper tapering end is the com- mencement of the re- cessus vestibuli, or aque- ductus. The lower por- tion soon changes its configuration, and in a human embryo of four weeks was found by Kolliker, as shown in Fig. 917. A new rounded protuberance, v, has appeared behind and a little outside the base of the recessus, and marks the situa- tion of the future vestibule ; some traces, cs, of the semi- circular canals are already indicated; the lower end of the pear is somewhat elongated, c, preparatory to the out- growth of the cochlea. Fig. 917.-Right Otocyst, Human Embryo of Four Weeks, enlarged. (After Kiilli- ker.) A, from behind; B, from outside; rv, recessus vestibuli; V, primitive ves- tibule : c, commencement of the cochlea; a and cs, commencing evaginations of the vestibule. Fig. 919.-Transverse Section of Otocyst of a Cow's Embryo, 18.7 mm. long X 30. (After Kblliker.) ch, Chorda dorsalis; sh, cavity of the skull; sr, commencement of saccu- lus rotnndus ; rv, recessus vestibuli; ss, superior, se, external, semicircular canal; v, vestibule ; c, cochlea. 568 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. macula acustica, which is stated by Kolliker to be found in older embryos covered with a delicate cuticula of con- siderable thickness, the membrana tectoria of Hasse, the cupula terminalis of Lang. 5. The cochlea is the third part to grow out from the primordial otocyst (sheep embryo, 1.6 mm.). It grows from the lower side of the vesicle downward and inward (Fig. 920, c), as a canal flattened in its vertical diameter, and therefore oval in transverse sec- tion. It soon pro- longs itself and be- comes curved (Fig. 921, A, c, c); on its concave upper side appears the com- mencement of the future ganglion spirale G. In this stage it closely re- sembles the condi- tion found in adult monotremes, and also the lagena (cochlea) of birds. By further elonga- tion and coiling the canal gradually as- sumes the final shape of the scala media; in man there is one complete coil by the eighth week, and by the twelfth week all the coils are formed. Our knowledge of the histogenesis of the cochlea rests principally upon the elaborate investiga- tions of Bottcher, which have been confirmed by Gott- stein, Kolliker, Pritchard, and others. The histological development of the cochlea is the same throughout its entire length, but progresses most rapidly at the base, or the stretch nearest the vestibule. We append here the complete history of the cochlea. The first change in the epithelium is in the height of the cells-those upon the upper side thin out; in other words, that portion of the epithelium decreases in thick- ness, remains a per- fectly simple col- umnar epithelium, and forms the lin- ing of one side of Reissner's m e m - brane, and of the outer wall of the scala. The lower portion of the epi- thelium, which remains thicker, forms the crista, sulcus, and Corti's organ. The two divisions of the epithelium are not sharply separated, but pass gradually into each other. The second change is that the loss in thickness of the epithelium is continued on the under side, or the wall next the scala tympani, so as to leave two thick epithelial ridges of very unequal dimensions (Fig. 922, e', e"). The larger ridge, m, lies nearest the columella, and becomes the thick lining of the sulcus spiralis. It very early ac- quires a thick cuticula, the beginning of the membrana tectoria. The smaller ridge, e", lies nearer the ligamentum spirale, and is metamorphosed into the organ of Corti, including the supporting cells, the inner and outer hair- cells, and Corti's rods. Very soon after the two ridges are distinctly formed, the lamina spiralis, sp, begins to grow up between the sulcus or broad inner ridge, and the axis of the cochlea to develop into the crista. The epi- thelium on the crista is thus maintained with its upper surface even with that of the sulcus, e'. Over both parts stretches the cuticula, in, which gradually thickens into the fully-developed tectorial membrane, which proba- bly has at no time any histogenetic connection with the organ of Corti,1 although it grows out so far as to over- hang it. The membrane always remains firmly attached to the crista, but is loosely united to the epithelium of the sulcus interims, and in the adult it is probably entirely separated from the sulcus, and attached only to the crista. From some unknown cause the lower boundary of the epithelium of the crista becomes indistinguishable. The cells in the sulcus apparently assume an oblique position, so that in sections there seem to be several layers of cells. Middendorf and others have been misled to describe a stratified [mehTschichtiges) epithelium in the sulcus. The smaller ridge, e", is made up of four sets of cells, disposed in longitudinal row's. The two rows nearest the sulcus internus are composed each of a single line of cells. The third row is in most mammals three cells, the fourth or outermost row several cells wide. The first row forms the inner hair-cells ; the second, Corti's rods ; the third, the outer hair-cells ; the fourth, the supporting cells. The development of these parts is followed best in trans- Fig. 920.-Transverse Section of the Semicircu- lar Canal of an Embryo Rabbit, Twenty-four Days. X 41.5. (After Kolliker.) in, I, Epithe- lium of the Canal; g, gelatinous tissue; c, cartilage ; f, fibrous perichondrium. Fig. 922.-Transverse Section of the Scala Media Cochleae of an Embryo Calf of 8.4ctm. Length, p, p, perichondrium of the cartilaginous cap- sule , t, b, embryonic connective tissue filling the scala tympani; v, embryonic connective tissue filling the scala vestibuli; r, connective- tissue layer of Reissner's membrane; g. ganglion spirale ; sp, future lamina spirale ossea ; cc, canalis cocldearis; e, e', e", e'", epithelium of the same; e', epithelium of sulcus; e", commencement of Corti's organ ; m, first trace of the membrana tectoria. verse sections of the ridge, and in the following descrip- tion reference is made to the appearances seen in such sections. The inner cell slopes toward the centre of the ridge, has a broad base and narrower top, and originally has a single, clear, oval nucleus at its basis. The upper part becomes the inner hair-cell, with a distinct nucleus of its own, a somewhat coarsely granular protoplasm, and a horseshoe of hairs upon its free upper surface, and a tapering base, which last is really the constricted middle of the original cell. When the auditory cells or Corti's organ are viewed from the surface, the hairs are seen to mark out a horseshoe on the top of each cell. The open end of the horseshoe always faces inward, i.e., toward the columella. The base of the cell also acquires one, or, according to Bdttcher, two nuclei, becomes finely granu- lar, and corresponds to Waldeyer's Kornerschicht. The structure of the fully-developed inner cells is still im- perfectly understood. The second cell is likewise broadest at the base, where lies the spherical nucleus. The base widens out rapidly (immediately after birth in dogs) until the whole cell be- comes triangular in outline, and the width of the base exceeds the height. Meanwhile, the nucleus divides, and the two daughter-nuclei place themselves near the Fig. 921, A.-Section of the Inner Ear of a Sheep Embryo of 20 mm. (After Biittcher.) Ji V, recessus vestibuli; VB, vertical canal; HB, horizontal semicircular canal; cc, coch- lea ; G, ganglion. 569 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. two lower angles of the cells. Next, the cell becomes striated : first, along the inner side; second, along the outer side of the triangle. These striated lateral por- tions form the two Corti's rods in the restricted sense. The triangular space between the rods and the basement- membrane is filled with protoplasm. Very soon the cen- tral portion is hollowed out, thus forming the tunnel un- der the arching rods. The protoplasm is next reduced to small nucleated masses, one at the base of each rod. The further development takes place principally by the growth of the rods, until they assume their ultimate shape and size. Recent investigators have added little to the account of the structure of Corti's rods given by Waldeyer in Stricker's " Handbuch," 1872, pp. 931-934. The third band, which is three cells wide, forms the outer hair-cells. Like the other cells, they first acquire two nuclei-a larger oval one above, and a smaller one below. This was first observed by Pritchard. The two parts around the two nuclei early become separated into an upper cell (the Corti's cell, or absteigende Ilorzellen) and a lotver cell (Deiter's cell, or aufsteigende Horzellen). The base of the upper cells is at first rounded off, but subsequently a fine process extends down to the mem- brana basilaris, and the base tapers gradually into the process. The cells become slenderer, and acquire an oblique position about the time of birth. The rod (Stab- chen or Haupthaar) and the horseshoe of hairs are de- veloped upon the free ends of the cells during the later stages of foetal life. The lower cells taper at their upper ends, which are continued by a fine process. They are found united in the adult with the upper cells, thus forming twin- cells, which have been most fully described by Lav- dowsky and Nuel. The development of these twin-cells is by no means clearly understood yet. The upper and lower cells appear distinctly separate in new-born and young animals. The upper cells enlarge at the expense of the lower. The nucleus becomes smaller, and is placed near the top of the cell. The rod (Haupthaar) disappears. The horseshoe of hairs opens toward the Corti's rods, as can be best seen in silver preparations. The hairs are more like short rods, vitreous, with rounded ends, and are parts of the cell, not of the membrana reticularis. The basal process of the upper cell is enclosed by (Lav- dowsky), or fused with (Nuel), the body of the lower cell. The tops of the upper cells (Corti's, absteigende, or Stabchenzellen, Lavdowsky), occupy the rings, the tops of the processes of the lower cell occupy the phalan- ges of the membrana reticularis. The lower part of the united cells appears as their common body, and contains the lower nucleus. The nerve-fibre unites with the cell at the side near the lower nucleus. The twin-cells end below by a single basal process. The above account is mainly from Lavdowsky. Nuel agrees with him in the main, but the latter's paper I know only from the abstract in Hofmann's and Schwalbe's " Jahresbericht." Connected with the outer hair-cells are various struct- ures, which are probably to be grouped under the gen- eral head of intercellular formations. Of these, the most important are the Stutzfasern (supporting fibres) and the membrana reticularis. The latter is generally re- garded as the exposed edges of the intercellular substance, the rings and phalanges being the spaces where the free ends of the hair-cells are exposed. The " Stutzfasern " form a network underneath the tunnel, and also a finer network between the outer hair-cells. They were dimly recognized by Bottcher, clearly seen by Nuel, and elabo- rately described by Lavdowsky. The fourth row of cells undergo no striking differentia- tion, but decrease generally in height from the hair-cells outward, so that they pass gradually into the low cells of the zona pectinata. Klein states that in the guinea-pig the supporting cells do not form, as is usually the case, a simple continuation of the last row of the outer hair-cells, but ride upon the sides of the hair-cells. According to the preceding summary, the cochlea is a tubular extension of the lower side of the primitive ecto- dermal otocyst; upon one side of this tube are two ridges : a larger one, which forms a thick cuticula, the membrana tectoria; and a smaller one, which, through complicated differentiations, becomes the organ of Corti. The nerves grow to the hair-cells. 6. The separation of the sacculus has been studied prin- cipally by Bottcher. There is first developed a con- stricted tube, the canalis reunions, between the base of the cochlea and the central otocystic cavity. Afterward ap- pears a ring-shaped constriction around the main cavity (primitive vestibule, Kolliker) by which it is divided, in most mammals, into two cavities connected by a narrow canal, into which opens the recessus labyrinthi (ductus endolymphaticus of Hasse); hence, the recessus appears to have two legs, derived from the canal ; one leg leading into the upper secondary cavity, the adult utriculus, and the other into the lower cavity, the adult sacculus rotundus. These relations, as well as the other essential dispositions of the parts of the labyrinth, are sometimes all recognizable in a single fortunate section, as in Fig. 923. Fig. 923.-Section through the Internal Ear of a Sheep Embryo, 28 mm. (After Bottcher.) D.M., dura mater; R. K, recessus vestibuli; K. V.B., posterior vertical canal; U, utriculus; K.B., horizontal canal; a,/, the constriction between sacculus, S.R.. and utriculus; b, canalis re- unions ; cc, cochlea ; KK, and KB, cartilage; ch, chorda dorsalis. In man, however, the relations are somewhat different in that the ductus opens directly into the sacculus (Fig. 924, de). The developmental process resulting in this dis- position has not yet been followed out. The maculae acusticce of the sacculus and utriculus arise as circumscribed areas, where, as before stated, the epi- thelium remains thick, and is differentiated into auditory cells of elongated form, with hairs on the free ends. 7. The coiling of the cochlea has already been de- scribed under 5. Of the otoliths the development is unknown. Kolliker says, merely, they " appear as quite small punctiform bodies, and remain a long time in that form, until they finally increase in size, and gradually assume a crystalline form" ("Entwickelungsgesch.," 1879, p. 735). The development of the definite form of the inner ear is, as we learn from the investigations of Retzius, nearly complete by the end of the sixth month of foetal life, as shown by the accompanying Fig. 924, which represents the isolated right labyrinth of a six months' human em- bryo, seen from in front and the outside. In the figure the most conspicuous parts are the semicircular canals, the cochlea, and the nerves stained dark by the osmic acid with which the preparation had been treated. The cochlea is a long spiral, commencing with a central blind end, I, and making two and one-half turns, and continu- ing off tangentially toward the posterior ampulla, ap, to 570 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear, Ear, end in a small blind pouch, vb, the Vorhofsblindsack of lietzius. At the base of the pouch springs a small canal, esc (canalis sacculo-cochlearis), canalis reuniens Henseni, II. Development of the Auditory Passages.-The auditory canal is developed from the first visceral cleft of the embryo. His has shown ("Arch. f. Anat. u. Entwicke- lungsgesch.," 1881, p. 319), that the clefts are not open as in the lower vertebrates, but closed by a thin membrane. This has since been confirmed for both birds and mammals by Kblliker and Born. The clefts arise as a series of ento- dermal pouches (outgrowths), opposite each of which the ectoderm forms a separate pouch (ingrowth); between each inner pouch and the outer one related to it there persists a thin membrane ; it is probable that in the first cleft this membrane is permanent, being en- larged and specialized to form the membrana tym- pani. The meatus audi- torious externus then is homologous with the ec- todermal invagination of the first gill-cleft. The entodermal portion, wdiich is inside or inte- rior to the membrane, becomes the Eustachian tube and the tympanum, and may be called the tubo-tympanal canal. Both portions of the cleft have at first a nearly horizontal course (Fig. 925, me, me', and t). The tubo-tympanal canal, t, early formsan expansion, which extends upward, outward, and backward. The expansion is wide in the sagittal direction, but narrow as seen in frontal sections; in short, the outer end of the canal forms a flattened cavity which may already be termed the tympanum. By looking at the figure it will be seen that between the tympanal cavity and the inner end of the external meatus, me', is a triangular space in the midst of which lies the em- bryonic malleus, m. This space is, for the rest, filled Fig. 924.-Isolated Right Membranous Labyrinth of Human Embryo of Six Months, seen from in front and out- side, magnified about eight diameters. (After Retzius.) ca, Anterior semicircular canal; ce, external semi- circular canal; cp, posterior semicircular canal; aa, anterior, ae, exterior, ap, posterior, ampullie; cr, crista ampullae ; rac, ranulus ampullae communis ; mu, macula utriculi; f, nervus facialis ; ms, macula acustica sac- culi ; I, lagena cochlearis ; mb, membrana basilaris ; Is, ligamentum spirale; rb, ranulus basilaris of the cochlear nerve ; esc, canalis sacculo cochlearis, or reunions Henseni; vb, Vorhofsblindsack of Retzius ; rap, nerve of the posterior ampullae : cr', crista acustica of the same ; ss, sinus utriculi superior; de, ductus, endolymphaticus, with its internal opening, cus ; rec, recessus utriculi. which affords direct communication with the sacculus. In the cochlea (as shown in the figure) we can distinguish the ligamentum spirale, Is; the membrana basilaris, mb; and the braches, rb, of the cochlear nerve. The three semicircular canals-anterior, ca ; external, ce ; and pos- terior, op-together with their respective ampullae, aa, ae, ap, are easily identified. The anterior and posterior canals have a common stem, ss, which leads into the wide utriculus, u ; from the utriculus a second canal leads into the posterior ampulla, ap ; finally, from the upper portion of the utriculus arise a wide caecal evagination, rec, the recessus utriculi, the development of which has not been yet followed out, so far as I am aware. The canalis reunions, esc, leads into the sacculus rotundus, which has on one side a large macula acustica, ms, and on the other communicates with the ductus endolymphaticus, de, of which only the commencement is shown in the figure ; in reality it extends clear through the pars petrosa, and ter- minates in the dura mater with a blind enlargement. It is noteworthy that the ductus opens into the sacculus rotundus, and not, as in many mammals, into the canal between sacculus and utriculus. The last-mentioned canal may be seen in part between the points lettered mu and ms in the figure. From this description it is evident that the labyrinth is merely an otocyst of extremely complex form and is still a closed epithelial sac, continuous through all its parts. The acoustic nerve reaches the neighbor- hood of the labyrinth in company with the n. facialis, which, of course, passes on. The acoustic nerve divides first into two branches, one, the posterior, rac and mu, and the other, anterior, a, which supplies the cochlea and also gives off a few small branches to the macula acustica sacculi, ms, and a more considerable branch, rap, to the posterior ampulla. The labyrinth has only six sensory areas ; two, namely, the macula neglecta and the papilla acustica lagenae, be- ing wanting. These two are found in amphibia, reptiles, and birds. The six present in man are : 1, 2, 3, in the three ampullae ; 4, in the recessus utriculi; 5, in the sac- culus ; 6, in the scala media cochleae. Fig. 925.-Frontal Section of the Head of a Sheep Embryo of 27 mm.r through the Region of the Ear ; enlarged 10.5 diam. (From Kolliker.)' mo. Hind brain ; o, occipital cartilage, with notochord; c, cochlea ; t, tuba : me, me', meatus auditorius externus; m, malleus ; c, superior semicircular canal ; eC, external semicircular canal ; s, sacculus ; st, stapes ; f, nervus facialis ; a, auricula ; v, alveus communis ; av, aqueductus. vcstibuli. by embryonic connective tissue. After birth the tissue around the flat tympanum atrophies, while in the same measure the cavity expands and grows around the bones of the ear, hammer and anvil, so that these ossic- ula apparently lie within the cavity, but arc of course 571 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. covered by the tympanal epithelium, and therefore, strictly speaking, outside the cavity, just as the intestine is mor- phologically outside the peritoneum. Another result of the expansion of the tympanum is that only a thin lamina of tissue remains between it and the inner end of the meatus, and becomes the tympanal membrane of the adult, to which the malleus is attached. The details of the expansion of the tympanum have not yet been worked out, nor can we expect to have perfectly clear concep- tions of the process until a series of models of the tym- panum at successive stages shall have been constructed. One result of the described mode of development of the membrane is, that it at first occupies a nearly horizontal position, it being parallel to the meatus externus ; after birth the membrane gradually changes its position to that of the adult stage. The inner end of the tubo-tympanal canal is trans- formed into the tuba Eustachii. It becomes small in di- ameter, and has a small opening into the pharynx, just behind the root of the soft palate ; it widens out grad- ually into the tympanum. Its lumen is obliterated for a time, presumably, simply by concrescence of the epithe- lial walls. The cartilage of the tuba appears during the fourth month, as a plate of hyaline cartilage on the medial side of the upper end of the tube (Kolliker). The meatus auditorius externus is at first shallow, but gradually deepens, becoming a long horizontal tube ; the diameter of this tube very early diminishes, and its inner end soon loses its lumen, Fig. 925, by the con- crescence of the epithelium ; the occlusion continues till after birth. The wax-glands appear during the fifth month, and are developed, according to Kolliker, after the type of the sweat-glands. A special bone arises, as the so-called annulus tympanicus, around the margin of the tympanum, and subsequently extends itself outward around the meatus ; the ring, however, is incomplete on the lower anterior side, and so remains for several years after birth. The fenestra rotundas and the fenestra oralis are spots where the tissue between the labyrinth and the tympanum is transformed into the incus. The second piece is sepa- rated off later, and becomes the malleus (Fig. 926, Ml.), a bone which finds its homologue in the quadrate of lower vertebrates. Curiously, the end of Meckel's cartilage, after the splitting off of the incus, gradually assumes the characteristic form of the malleus, and the cartilage of the hammer does not become distinct from Meckel's rod until later. The origin of the malleus has long been known, and was originally discovered by Reichert. The develop- ment of the incus remained under debate until Salensky established its real history ; before that it was usually re- garded, especially by English writers, as the metamor- phosed end of the cartilage, not of the first, but of the second arch. Both hammer and incus begin to ossify from the periost during the fourth or fifth month, and it is doubt- ful whether the cartilage ever entirely disappears from the hearts of these ossicula. III. Development of the External Ear.-Pro- fessor W. His has traced out very fully the history of the form of the external ear (" Anatomic Menschlicher Em- bryonen," Heft iii., pp. 211-221). Before the end of the first month there appear around the external opening of the first gill-cleft a series of six tubercles (Fig. 927, A) ; Fig. 926.-Meckel's and Reichert's Cartilages of a Sheep Embryo of 2.4 ctm. (After Salensky.) Me., Meckel's cartilage; Re., Reichert's car- tilage ; Ml., malleus; Inc., incus. is so much reduced that only a thin membrane is left over each spot. In connection with the latter arises the stapes. The tissue where the fenestra ovalis subsequently is formed is pierced by a small artery, arteria perforans sta- pedis, which has been traced to a connection with the in- ternal carotid. Kblliker thinks it is a branch of the stylo- mastoid. Around this artery, opposite the fenestra ovalis, condensed tissue is formed as the first trace of the stapes ; this tissue subsequently ossifies, according to Rathke, from three centres ; the artery atrophies in man, leaving the perforated bone, but persists in many mammals. It is still an open question whether the stapes is an ossifica- tion of the fenestra, or whether it is derived from the upper end of the cartilage of the second visceral arch, or, as suggested by Kblliker, is the uppermost end of the first or Meckel's cartilage separated off very early. For the present the first alternative may still be preferred. The first or mandibular arch contains a long, cartilag- inous rod, known as Meckel's cartilage, the upper end of which lies just outside and below the membranous laby- rinth, and between the inner end of the auditory meatus and the embryonic tympanum. According to Salensky, two pieces are separated off from this rod ; the first, com- prising the extreme proximal end, is separated off before the cartilage has become histologically differentiated ; it Fig. 927.-Development of the Human External Ear. (After His.) A, Embryo of one month; A, six weeks ; C, eight weeks ; D, ten weeks ; E, fourteen weeks. The six primitive tubercles are numbered 1 to 6; the primitive ridge is marked c; 1, is the tragus ; 4, the anthelix ; 5, the antitragus ; 6, the tcenia lobularis ; 2, 3, and c form the helix. two in front on the hind edge of the first visceral (or the mandibular) arch ; one above the cleft and three behind it. A little later a vertical furrow appears down the middle of the hyoid arch in such a way as to mark off a little ridge (Fig. 927, A, c), which joins on to tubercle 3 and descends behind tubercles 4 and 5. The second stage is reached by the growth of all the parts ; the fusion of tubercles 2 and 3, and the growth of the ridge down be- hind tubercle 5 to become continuous with 6. After these changes it is not difficult to identify the parts (Fig. 927, 2?). 1, is the tragicum; 2 and 3, together with the arching ridge, represent the helix; 4 is the anthelix; 5, the antitragicum; 6, the tania lobularis. The deep pit bounded by 1, 2, 3, 4, and 5 is the/ossa angularis. Dur- ing the latter part of the second month the ear changes its proportions somewhat, becoming more slender ; tubercle 2 projects farther backward toward the helix, making the separation between it and the tragicum more marked, and also rendering the fossa angularis more irregular. The third stage begins with the third mouth. The 572 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. upper and posterior part of the concha rises from the surface of the head and gradually, but rapidly, bends over forward, so as to completely cover the anthelix, B, 4, and the upper portion of the fossa angularis (Fig. 927, C). It is during this stage that in mammals the assumption of the pointed form of the ear commences. The anteversion lasts only a short period, probably not much over a fort- night. The ear now unfolds and shows the anterior tubercle still more projecting than before (Fig. 927, B), and the upper part of the/essa angularis very much re- duced. The fourth stage commences with the fourth month. The tuberculum anterior encroaches still more upon the fossa angularis, and reduces the lower part of it also to a fissure, hence the tuberculum, 2, itself almost touches the anthelix, 4, and the antitragicum, 5. There now appears a ridge which grows out from the second tubercle and unites it with the anthelix (Fig. 927, E, cr. h.\ and divides the upper part of the fossa from the lower, which latter becomes the opening of the meatus. Shortly after the first ridge a second appears which unites the second tuber- cle with the antitragicum (Fig. 927, E, Cr. s.\ Finally, the sixth tubercle becomes pendent and appears distinctly as the taenia lobularis. These changes are completed by the end of the fifth month. The further development is very gradual, and is partly post-natal. Of the two ridges, the first formed is permanent, and is the crus or spina helicis, while the second (crus supratragicum, His) be- comes nearly obliterated ; the subdivision of the tragi- cum, already indicated in Fig. 927, E, 1, becomes more marked ; the concha enlarges, and its cavity grows more evident. By these and other subsidiary changes the adult ear is developed. The differences in the ears of adults are mainly the product of secondary modifications. Literature.-The most important memoir is that of Bottcher,' a beautiful research, and next must rank the observations of Kolliker.5 On the development of the middle ear, see especially Moldenhauer,1 Urbantschitsch,15 and Zuckerkandl.17 On the ossicula, Reichert,11 Salen- sky,13 and Fraser.2 On the concha, see the very full history given by W. His.4 Charles Sedgwick Minot. 1 Bottcher, Arthur: Ueber Entwickelung und Bau des Gehorlaby- rinthes nach Untersuchungen an Saugethieren. Nova Acta L. C. Acad., xxxv., 1869. Abbd. v., p. 203. Tafn. xii. 2 Fraser, A. (Development of the Ossicula): Proc. R. S. London and Phil. Trans., 1881. 3 Hasse, C.: Zur vergleichenden Morphologic und Histologie des hauti- gen Gehdrorgans der Wirbelthiere. Leipzig, 1873. 4 His, W.: Anatomie menschlicher Embryonen. Heft iil., 1885 (De- velopment of Concha, pp. 211-221). 6 Kolliker, A. von : Entwickelungsgeschichte des Menschcn, etc, 1879, pp. 704-755. 6 Meyer, P.: £tude histologique sur le labyrinthe membraneux, etplns specia lement sur le limacon, chez les reptiles et les oiseaux. Strasbourg et Paris. 1876, p. 189, Taf. i.-iv. 7 Moldenhauer, W.: Die Entwickelung des iiusseren und mittleren Ohres. Gegenbaur's Morphol. Jahrb., iii. 106. 8 Nuel: Beitrage zur Kenntniss der Saugethierschnecke. Arch. f. mikros. Anat., viii., 200. 9 Pritchard, Urban: The Development of the Organ of Corti. Journ. of Anat. Physiol., xiii., 99-103, Pl. I. 10 Reissner: Deauris internre formatione. Dissert. Dorpati, 1851. 11 Reichert, C.: Ueber die Visceralbogen der Wirbelthiere. Muller's Arch., 1837. 12 Retzius, Gustav: Die Gestalt des Membranoren Gehiirorgans des Menschen. Retzius Biol. Untersuch., ii., 1-32, Taf. i., ii. 13 Salensky, W. : Beitrage zur Entwickelungsgeschichte der knorpeli- gen Gehorknochelchen bei Saugethieren. Gegenbaur's Morphol. Jahrb., vi., 415-431. 14 Urbantschitsch, V.: Schenks Mittheilungen, I., 1; ii.. 131. 15 Urbantschitsch, V.: Ein Beitrag zur Entwickelungsgeschichte der Paukenhohle. Sitzungsber. Wiener Akad. Wiss., 1873. 18 Waldeyer: Stricker's Handbuch der Lehre von den Geweben, 1872, 931-934. 17 Zuckerkandl zur Entwickelung des iiusseren Gehororgans. Mo- natschr. Ohrenheilk., 1873, No. 3 (Cf., also, same journal, 1876). diagnosis the use of which is indispensable to the reach- ing of such a conclusion. The symptomatology and the pathology of diseases of the ear will not be discussed ; neither is it proposed to treat of all the known varieties of diagnostic apparatus, nor yet to describe exhaustively such methods as are at times adopted for the more pre- cise or scientific determination of the singular, and often imperfectly understood, anomalies of hearing which are occasionally met with in the practice of an otological specialist. These matters are in part discussed in other articles, which are to be found in the pages of this Handbook ; and to such other articles, as well as to special treatises upon diseases of the ear, the reader desirous of attaining a knowledge of them must be referred. To give, as it were, an introductory supple- ment to some of the other otological contributions in the Handbook, and more particularly to set down in concise form such rules and directions respecting the ex- amination of a case of ear disease as may be found practi- cally useful for reference to the general practitioner, is the sole purpose of the writer of the present article. To the otological specialist who has been properly trained by experience in the diagnosis and treatment of ear dis- ease this article imparts, or should impart, but little information. To him who is reasonably experienced in the treatment of diseases of the ear much information respecting the probable nature of a particular case of such disease will often be conveyed by the account of symp- toms volunteered by, or elicited from, the patient who applies to him for treatment. Nevertheless, it may be laid down as a rule to which there are no exceptions, that a properly conducted physical examination of the ear should in no case be omitted; such examination is always necessary for the attainment of anything ap- proaching to a really accurate diagnosis. To test the hearing of the patient is the first thing that the physician has to do after listening to an account of the symptoms. Although it is perfectly true that a cer- tain number of those who will apply to him for treatment will have no complaint to make in respect to their power of hearing, and although, in many other cases, a restoration of the hearing power may be the least important part of the object of such treatment, nevertheless, the ear is the organ of hearing, and every disturbance of its normal function should receive attention on the part of the phy- sician, and should, if possible, be removed. Certain of the methods necessarily adopted for the complete diag- nosis of a case of ear disease may materially alter the capacity of the ear for hearing sounds, and for this rea- son the testing of the hearing had better in all cases precede every other diagnostic procedure. For all practical purposes, and in all ordinary cases, a sufficient degree of accuracy in estimating the patient's hearing power may be attained by the use of three sources of sound production, which are within the reach of any physician. These are : (a) the human voice, (b) the watch, and (c) the tuning-fork. The last mentioned of these three is chiefly serviceable as a means of testing the ca- pacity of the ear for appreciating sounds transmitted to it by bone conduction. The watch may also be used for this same purpose, but it is a far less satisfactory instru- ment than the tuning-fork when so used, and should, therefore, be considered as an apparatus for testing sim- ply the power of the ear for appreciating sounds trans- mitted through the air. When the voice is used in testing the hearing it is im- portant that the patient should either close his eyes, or should be placed in such a position that he cannot see the movements of the speaker's lips. He should also be instructed to repeat exactly the words addressed to him. The speaker should, of course, stand so as to face the ear which is to be tested, and the opposite ear should be kept closed during the examination; unless, indeed, it should happen to be the ear which is the more seriously deaf of the two. In a quiet room the words used by the speaker may be uttered in a whisper. Where the room is not a particularly quiet one, or when the patient is decidedly deaf, it is necessary that the tone adopted in ordinary con- versation should be the one employed. The selection of EAR, EXAMINATION OF, FOR PURPOSES OF DIAGNOSIS. The object set before him by the writer of the present article is to present, within the compass of a few pages, a brief account of the methods which it is necessary for the physician' to pursue in order to arrive at a correct conclusion concerning the pathological con- ditions existing in any case of ear disease which he may be called upon to treat. Necessarily included in this subject must be some description of those instruments of 573 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the words used is by no means a matter of indifference, both because of the varying degree of intelligence and of education possessed by patients of different ages, or be- longing to different walks in life, and also because of the very great difference of resonance existing between the vowel and the consonantal sounds of which such spoken words consist. This matter will be found more fully treated in special works on otology. The names of num- bers are perhaps as good a class of words as can be selected for use by the speaker, especially such numbers as consist of three or more figures ; as, for example, ' ' three - hundred - and - eighty- six," ' ' two-thousand-one- hundred-and-twenty-three," etc., etc. For younger chil- dren shorter numbers, or simple words, had better be employed. The watch is used in testing the hearing at short range. The patient, in this case, must be directed to speak out and tell the examiner that he hears the tick- ing sound just as soon as lie perceives it. Whether the voice or the watch be employed as the source of sound- production, the rule should be followed of beginning the process of testing with an interval between the ear and the source of the sound greater than the estimated prob- able hearing distance of the affected ear for that particular sound, rather than to begin with the source of the sound held close to the ear and afterward removed to a greater and greater distance from it. lu using the watch the patient's eyes should be kept closed, and the sound should occasionally be interrupted, either by covering the watch, with the examiner's hand, by suddenly removing it to a much greater distance from the ear, or to a position be- hind the physician's back, or, better still, by arresting its action, as may be done in the case of a stop-watch. In estimating the hearing distance two units of measure- ment are commonly adopted, the foot for cases where the voice is employed as sound-producer, and the inch where the watch is so employed. In recording the result of an examination the most convenient method is that first suggested by Dr. Prout, of Brooklyn, which consists in writing the result in the form of a fraction, whose de- nominator shows the average distance at which the sound is heard by persons having normal hearing, while the numerator indicates the distance at which the sound is heard by the ear of the patient examined. In testing by the watch the letter C is frequently written as the numerator of the fraction, to indicate that the ticking sound is only heard by the patient after the watch has been brought into actual contact with his ear. When any means of treatment, or of diagnosis, are adopted at the physician's office which are likely to effect an immediate alteration in the patient's hearing power, it is advisable to test the hearing both immediately before and immediately after the employment of such means. The result of all such tests should be immediately recorded. Of the tuning-fork nothing will be said in this place ; for information respecting its use the reader is referred to the article entitled Tuning-forks. A discussion of the comparative merits of the different methods of test- ing the hearing, it is hardly proper or necessary to give in such an article as this ; neither does it strictly pertain to a brief essay upon diagnostic procedures to do more than barely refer to the value of what may be called " home tests," in estimating the degree of benefit which is being derived from a course of treatment. Informa- tion on such subjects as these may either be found in some of the articles describing the special forms of ear disease, or else in the pages of standard works on otology. The preliminary testing of the patient's hearing having been accomplished, and the result having been recorded, the next thing in order for the physician is the ocular ex- amination of the ears. We say of the ears, and not of the ear, because upon the occasion of a first visit both ears should always be examined. The nature of the light employed in making this ex- amination is by no means a matter of indifference. Dif- fused daylight is preferred by some, and it has one slight advantage over every form, of artificial light in that under its use the parts appear of their natural color. Daylight, however, varies greatly in intensity, according to the hour chosen for the examination, the position of windows, etc., and the state of the weather ; it is therefore highly advisable for the physician to accustom himself to the use of some form of artificial light. A sufficiently power- ful light of this kind can be obtained from any form of round-wicked kerosene lamp, or from an Argand gas- burner. The writer himself employs an Argand drop-light mounted upon an upright stand of the same shape as, but rather taller and heavier than, that of the well-known Fig, 928, common German student s lamp, and having its base heavily loaded with lead, so that it is practically an im- possibility for the apparatus to be upset. As the hori- zontal arm carrying the burner may be raised and low- ered upon the vertical standard bar, and can be firmly fixed (by a screw) at any desired elevation, and as the length of the rubber-tubing of the drop-light is suffi- ciently great to allow of very considerable shifting of the standard itself in a horizontal direction, this form of light-giving apparatus is, in the writer's opinion, much more convenient, both for ear and for throat work, than are the adjustable, elbowed wall-brackets, which are so commonly employed, and which are figured in many treatises upon dis- eases of the ear and of the throat. This form of lighting apparatus is by no means original with the writer, and is described thus minutely merely because, in his opinion, it is one which should be more generally known, and because mention of it in this place may prove to be a con- venience to some readers of the Handbook, to whom it may not be familiar. To throw the light into the patient's ear some form of concave reflecting mirror is indispensable. This mir- ror should be secured to the exam- iner's head, so as to leave both his hands free. Lack of space forbids in this place a description of the va- rious contrivances by which this se- curing of the mirror to the examin- er's head may be effected ; and the faults of construction, common to most head-mirrors which are to be found exposed for sale in the instrument-makers' shops will, for the same reason, receive no specific mention. Instead of this we shall merely introduce a couple of illustrations (Figs. 928 and 929) which, together with a partial quotation of the ex- planatory text accompanying them in the work from which they are taken (" Diagnosis and Treatment of Ear Diseases," by Albert H. Buck, M.D.), will serve to Fig. 929. 574 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. set before the reader a very excellent type of such a mir- ror. The forehead-plate of this mirror consists of a piece of hard rubber, about three and three-fourths inches long and one inch wide at its broadest part, " a trifle more than one millimetre (one twenty-fifth inch) in thickness, and curved flatwise, so as to lie at all points in firm contact with the forehead. This concave side should not be padded, partly for reasons of cleanliness, and chiefly be- cause such padding materially diminishes the stability of the mirror when once adjusted to the observer's forehead." The band which encircles the head ' ' should be made partly of undyed leather, and partly of elastic material. The leather portions should begin at either end of the forehead-plate, and should extend to a distance of twelve or thirteen centimetres (four and three-fourths to five inches) from these. Beyond these limits an elastic band of any material or color may be used. The adjustment of the band to the size of the head is effected by means of a buckle." » The nickel-plated brass shanks attached to the forehead- plate, and by which the mirror, when in use, is held sus- pended from the latter, are about two inches in length. As will be seen from an examination of the two plates (Figs. 928 and 929), each shank is fastened to the fore- head-plate by a single rivet. The object of this method of securing the upper extremities of the shanks to the fore- head-plate is the attainment of a limited amount of pivotal motion at their upper extremities, which is necessary in order that they may be unhampered in exercising their function as forceps-like graspers of the brass ball pro- jecting from the back of the mirror. The lower extremity of each shank is hollowed out, so as to convert their junction with this ball into a ball-and- be dispensed with when the mirror is worn in this manner. A near-sighted observer, if he do not wear glasses, will, however, find some difficulty in so using the mirror, and may prefer to place it directly in front of one or the other of his eyes, in which case the possession by the mirror of such a central aperture will be of course a matter of necessity. When the mirror is thus worn in front of the observer's eye, the source of illumination should be placed a little above the level of the eye and at a moderate distance behind, and to one side of, the pa- tient's head. When the right eye is used the light is most conveniently placed somewhat to the right of the patient's head ; when the left eye is the one used the light falling upon the mirror should come from the left. In either case the angle formed by the observer's axis of vision, and a line drawn from the centre of the mirror to the source of illumination, should be as acute as possible ; care, of course, being taken to insure that the rays of light incident upon the mirror be not intercepted by the patient's head. Experience alone can teach each ob- server the management of these details. As already stated, the exact position of the light will be a matter of comparative indifference to an observer who wears his mirror in the way depicted in Fig. 930, and such an one will be much less liable to be inconvenienced by having his light suddenly obscured from being intercepted either by the head of the patient, or by the movements of his own hands during the examination. In all cases, how- ever, the eye of the observer, and the source of light must be upon opposite sides of the patient's head ; that is, upon opposite sides of an imaginary vertical plane drawn so as to bisect the latter. As stated by Dr. Buck (op. cit., p. 26), ' ' the light must occupy such a position that when the observer's face is directed toward the ear that is to be examined, he can see the flame or other source of il- lumination by simply turning his eyes in the proper direc- tion. If he is obliged to turn his head, however, in order to see the light, it is certain that he will not be able, by means of his mirror, to reflect any of it into the patient's ear. " One other little practical hint, and then we shall have done with this the driest portion of our subject. Throughout the examination, in reflecting the light into the patient's ear the observer should rely simply upon ro- tation of his mirror, and should never attempt to supple- ment this by rotation of his own head. A sufficient amount of properly directed light having been once thrown upon the ear, it is sometimes possible to obtain a good view of the drum-membrane and of the deeper part of the external auditory canal, without resort- ing to any further procedures. Ordinarily, however, two other steps must be taken by the observer ere he will succeed in obtaining a sufficiently distinct view of these deeper-lying parts of the ear. The first of these two steps consists in an effort to overcome the natural tortuosity of the canal by resorting to gentle manual traction of the auricle. The direction in which this traction must be exerted will vary with the age of the patient under ex- amination : in the case of an adult the back part of the auricle must be pulled outward, backward, and upward ; while in the case of an infant such traction should be exerted more directly outward, a little backward, and rather downward than upward. In addition to the exer- cise of such moderate traction upon the auricle it will usually be found necessary still further to straighten the axis of the canal by the introduction of some variety of rigid-walled and tubular speculum. Probably the best variety of such specula is that first invented by Dr. Wilde, of Dublin, and called by his name. Owing to its conical shape, this speculum not merely serves to straighten the canal, but also, in some degree,-to increase its calibre by moderate dilatation of the outer (cartilagin- ous) portion of the canal. In attempting to introduce any form of speculum the beginner cannot too carefully bear in mind that the bony portion of the canal (occupy- ing in the adult nearly two-thirds of its entire length, and beginning therefore at an average depth of about half an inch from the external meatus) is quite incapable of dilatation, and also that the walls of the deeper part Fig. 930. socket joint. Their grasp upon the ball of the mirror is rendered sufficiently firm by means of the screw shown in the illustrations. The brass ball has a diameter of about three-eighths of an inch. The stem by which it is attached to the back of the mirror should be seven milli- metres (0.275 inch) long, and "should be fastened to the mirror at a distance not exceeding seven millimetres from its circumference." The object in view in putting the ball so close to the margin of the mirror, and in making its stem so long, is to increase the range of mobility of the mirror beyond the limits which are commonly possible, and in this way to render the exact position of the observer, with reference to the source of light, a matter of comparatively little importance. This ob- ject is also more easily attained by wearing the mirror in the manner depicted in Fig. 930 ; and unless the pro- portions observed in arranging the attachment between the mirror and the forehead-plate be such as have just been described, it will be found impossible satisfactorily to wear the mirror in the manner depicted. The mirror itself should have a diameter of about two and three- fourths inches, and a focal distance of about eight inches. When intended to be worn, as in Fig. 930, the focal dis- tance of the mirror may well be made greater by several inches : the circular aperture in its centre may also 575 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the canal are exceedingly sensitive. Inasmuch as the exact proportions of a really good and serviceable ear- speculum are a matter of no small importance, and in- asmuch as the Wilde's specula of our instrument-makers are extremely apt to be clumsily and improperly con- structed, we shall not only place before the reader a cut (Fig. 931) illustrating the proper shape of such a specu- lum, but shall also give directions as to the proper pro- portions of each one of a set of such specula, so explicit that their literal following on the part of an intelligent maker of surgical instruments cannot fail to result in the production of what may justly be considered a model set of these specula. The notched border surrounding its wider mouth is a very im- portant feature of the specu- lum, as it steadies the grasp of the observer's lingers upon the instrument when held in position ; but its consideration in no degree pertains to the still more important matter of the proper proportions of the speculum as to length, diame- ter of outer and inner mouths, and thickness of wall. Below the illustration, which shows approximately the proper shape of the in- strument, we have inserted five groups of figures (lettered respectively A, B, C, D, and E) to indicate the exact proportions of each one of a set comprising five such in- struments. The top figure in each group gives the length of the speculum, the second figure gives its diameter at the larger end, and the third figure its diameter at the smaller end. These are all inside measurements, and the unit of measure adopted is the millimetre (= 0.03937079 inch). The thickness of the wall is the same for all the instruments, and may be most accurately appreciated by the reader when he is told that it is equal to the thickness of two leaves of this Reference Handbook held pinched tightly between the fingers. The chief fault in all ' ' ready- made " specula is that their walls are made altogether too thick. Commonly the balance between the other propor- tions is not well preserved, so that the slope of the walls is either too great or too little, while in point of length also the instrument is not infrequently deficient. The material of which these Wilde's specula are made should be coin silver, and both the inner and outer surfaces of the instruments should be well polished, the outer surface in order to facilitate their introduction into the ear, the inner surface in order that it may serve as a re- flector to increase the illumination of the deeper parts of the canal during the exami- nation. Another variety of speculum which is occasionally useful in examining the ear (although for operative procedures greatly inferior to Wilde's), is the hard-rubber, funnel-shaped speculum of Dr. Adam Politzer, of Vienna (Fig. 932). The spe- cial class of cases in which this Politzer's speculum may be found serviceable are those where, in the presence of considerable swelling and great tenderness of the outer part of the canal, it is desirable to introduce a non-dilating tube of small calibre, in order to get a view of the deeper- lying portions of the canal and of the drum-membrane. The introduction of an ear speculum is to be effected as follows: (1) The ear should be well illuminated and should be kept thus illuminated throughout the entire procedure ; (2) traction upon the auricle should be made (in the manner already described) by the fingers of one of the operator's hands (preferably the left hand); while (3) with the thumb and index finger of the other hand the speculum is grasped at its wider end, and (4) its nar- rower end is gently introduced into the auditory meatus, the long axis of the instrument being made to correspond as closely as possible with that of the auditory canal, while exactly coinciding with the observer's axis of vis- ion. Two general rules will indicate the essential things to be borne in mind during this procedure, viz., that nothing be done in the dark, and that nothing be done by main force. To these may be added a third rule, viz., that when once a good view of the drum-membrane has been attained, the observer should discontinue the process of introduction. The advance of the speculum along the canal may be facilitated by communicating to it a slight, and always slow and gentle, ro- tatory motion. Should it be found desirable, in order to get a more cpmplete and comprehen- sive view of the deeper-lying parts, to shift the position of a speculum thus introduced, such shifting should be ac- complished by moving the entire specu- lum in a lateral direction (that is, in a direction at right angles to the axis of the canal), and not by causing the outer and inner extremities of the speculum to move in opposite directions, after the manner of a lever, around the short axis of the instrument. In other words, to put it in homely phrase, the specu- lum should not be wiggled about in the patient's ear, at the risk of hurting the sensitive walls of the bony portion of the auditory canal. The speculum once introduced, it may be held in posi- tion by the thumb and forefinger (or by the thumb alone), of the same hand which is used in maintaining traction upon the auricle ; thus leaving the ob- server's other hand free for the ma- nipulation of any other diagnostic or operative apparatus. For purposes of examination, still more when operative procedures are called for, it should be borne in mind that the larger the size of the speculum which is employed the more perfect will be the view obtained. Of course, however, it will not do to try and force a large speculum into an ear that will only accommodate a small one. We have spoken just now of the use of the Politzer speculum in an ear having its canal greatly diminished in calibre by swelling of its walls. In the hands of a skilful, patient, and painstaking examiner the same object may be at- tained by the use of a small-sized Wilde's speculum, supplemented perhaps by gentle dilatation of the stenosed canal through the bougie-like action of lubri- cated, cone-shaped, or olive-shaped cot- ton wads, wrapped firmly about the tip of a cotton-holder. The rules applicable to the introduc- tion of sounds into the male urethra will be found ser- viceable to him who desires in this way to effect a passage between the walls of a greatly swollen auditory canal. Very often the physician will find his view of the drum-membrane and of the deeper walls of the canal ob- structed by foreign bodies, by accumulations of cerumen, by scale-like particles of exfoliated epithelium (or by a compact and laminated mass of such scales), by purulent or other pathological excretions, etc. These, of course, must all be removed, and for their removal various ap- pliances have been devised. Many of these appliances and their uses will be found elsewhere described and dis- cussed. A few. however, call naturally for special men- tion in this place as constituting an essential part of the A. 34.5 15.66 7.0 Fig. 931. B. 35.0 15.0 6.0 C. 35.5 14.5 4.66 D. 35.5 14.0 4.0 35.5 13.5 3.5 Fig. 933. Fig. 932. 576 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear, Ear. physician's armamentarium of diagnosis; such are the slender cotton-holder, the common ear-syringe, the cu- rette (Fig. 933), the angular forceps (Fig. 934), and the blunt-hook. For the removal of fluid, or of trifling accumulations of semi-fluid substances, the cotton-holder, armed with a small wad of absorbent cotton, will be found the most generally useful instrument. Solid bodies, including ob- structing plugs of impacted cerumen, or of laminated epithelium more or less intimately mixed with cerumen or with pus, etc., as well as considerable accumulations of any semi-solid material, had better be removed by the syringe, unless the observer has acquired by experience a good degree of operative skill. In the hands of a skilled examiner, however, the curette, the forceps, and the blunt-hook may very often be chosen for the removal of this class of obstructions, and may be used either in- dependently of, or in conjunction with, the ear-syringe. Very small foreign bodies (especially if they be angular rather than rounded in outline) which lie in the outer portion of the canal may safely be re- moved by for- ceps, curette, blunt-hook, or even by the cotton-hold- er ; provided that the examiner be the possessor of a moderately steady hand. The method of using the syringe and the blunt-hook will be found dis- cussed in the article entitled Auditory Canal, Foreign Bodies in the. Concerning the method of using absorbent cotton wrapped about the end of the cotton-holder, nothing, of course, need be said. Respecting the proper handling of the curette and the forceps, no adequate verbal instructions can well be given. The special function of the curette is to act as a loosener of bodies lying in contact with the wall of the auditory canal, and as a means of so shifting the position of bodies as to insure their easier extraction by the forceps or blunt- hook, or their expulsion by the syringe. An abundant experience, both among aural speci- alists and among general practitioners, has clearly shown the absolute necessity of a proper training to insure success, and to avoid damage in the handling of all these varieties of what may be called solid exploratory apparatus. The unskilled would do well to let the curette, the blunt-hook, and especially the forceps se- verely alone in all their explorations of the deeper part of the auditory canal, and to confine them- selves solely to the employment of the syringe and of the armed cotton-holder. The same remark applies also in the case of the exploring-probe, an instrument of great diagnostic value to him who is experienced in its use, but not devoid of danger to him who knows it not, and of still greater danger to his patient. So far we have spoken only of the removal of obstacles to vision lying external to the drum-membrane. In a case where perforation of this membrane exists, and such obstructions to vision lie wholly or partially within the cavity of the tympanum, it is manifest that still greater care in the choice and in the handling of instruments em- ployed for their removal will be demanded. A few words may properly be said in this place concerning the shape of the instruments represented in Figs. 933 and 934, and of the ear-probe (which is pictured in Fig. 935), as well as respecting the materials of which these instru- ments should be constructed. The proportions of the curette (Fig. 933) are fairly well shown in the illustration. The total length of the in- strument, however, should be about half an inch greater than it is there depicted. It is well to have two sizes of this instrument, that is, two, in one of which the ter- minal ring is rather larger than it is in the other. These terminal rings should have flattened and not rounded mar- gins ; but they should have their edges made smooth and blunt, being intended for use as a sort of minute spade or spatula. The smaller ringed of the two curettes should have its shank made of malleable steel for a short distance (say half an inch) back from the terminal ring; the other instrument should be constructed throughout of tem- pered or non-pliable metal. The handles of both are eight-sided, so as to afford a firm and steady grasp for the fingers. The general shape of the angular forceps is shown in Fig. 934. The bend of such a pair of forceps should be 2-j7^ inches distant from the extremity of the handle, and 2-,^ inches from the tips. The aver- age width of the blades, beyond the bend, should be a trifle less than one-sixteenth of an inch ; their width at the tips about one-forty-eighth of an inch. The blades should be notched on their inner surface for a distance of about half an inch back from the tips ; or, if preferred, they may interlock at the tip, after the manner (characteristic of the so-called " rat- tooth " forceps) shown in the cut. The probe should be made of silver. Its proportions and dimensions are fairly well shown in the illustration (Fig. 935), but its total length should be about half an inch greater, while the diameter of the terminal bead-like point should be rather less than it is represented to be in this figure. The handle end of the probe should be four-sided rather than round or octagonal. The uses of the probe in aural surgery are precisely the same as they are in general surgery. It may not inaptly be termed the examiner's sixth finger. One special use it has, however, which perhaps it may be well to refer to in this place. Not only may it be em- ployed to touch those objects which are in the direct line of the observer's vision, but, by converting its extremity into a short-armed blunt-hook, we have at our command an apparatus which in certain cases may serve to bring unseen objects within this line of vision. As, for example, a case in which small pedunculated polypoidal growths exist in the upper and posterior portions of the drum cavity. For testing the degree of permeability to air pos- sessed by the Eustachian tube, the examiner must re- sort to one or the other of three methods of inflating this tube. Such inflation of the Eustachian tube and of the drum cavity will also be of service in testing the degree of mobility possessed by the drum-mem- brane, and, in some instances, may be required for the detection of a minute perforation in this mem- brane. When the Eustachian tube is fairly perme- able, that is, when but little pressure is required to force the air along it and into the tympanic cavity, the method of inflation which is known as Valsalva's method may be resorted to; and as it requires for its performance no artificial apparatus whatever, this method will often prove serviceable to the un- assisted physician who desires to keep his eye fixed upon the drum-membrane during the inflation. To insure a proper performance of this (Valsalva's) method of inflation, it is merely requisite that the patient shall make a strong expiratory effort while hold- ing both his mouth and his nose firmly closed. When- ever decided pain exists in the ear, neither this nor any other method of inflation should be adopted for diagnos- tic purposes. Concerning their employment as a means of treatment in such a case, it does not behoove us to speak in this place. The two other methods of inflation referred to above have this in common, that the pressure by which the air is forced into the Eustachian tube is not exerted by the patient, but by the physician, the compressing force nec- essary for the production of the requisite amount of sud- den atmospheric condensation residing in the muscles of the hand and forearm of the physician, and not in the Fig. 934. Fig. 935. 577 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. respiratory muscles of his patient. The force-pump, in both these methods, consists simply of a strong, flexible india-rubber bag, just sufficiently large to be steadily grasped by the thumb, palm, and fingers of the exam- iner's hand. The shape of such an inflating-bag is cor- rectly represented in the accom- panying wood-cut (Fig. 936), which is copied from the catalogue of Herr Josef Leiter, a celebrated in- strument-maker in Vienna, and represents the strong black rubber bag used by Professor Adam Polit- zer, of that city. The nozzle of this bag, and the cap to which it is affixed, are made of hard rubber. The total length of the apparatus is six inches ; its width across the broadest portion of the bag proper is three inches; the thickness of its flexible rubber walls is about one- eighth of an inch. The apparatus has no aperture, save that existing at the tip of its nozzle, differing in this respect from certain other va- rieties of inflating-bag, which are provided with a valve intended to facilitate a refilling of the apparatus with air after each act of compression. The two methods of inflation by means of such a bag differ in respect to the contrivance adopted in each case for establishing a communication between the nozzle of the bag and the orifice of the Eustachian tube. In that one of the two methods which was first adopted by Profes- sor Politzer, and which is called by his name, this com- munication is brought about as follows: The nozzle of the bag, armed with some variety of nose-piece, is gently introduced into one of the patient's nostrils, and over the nose-piece thus introduced the nostrils are firmly compressed by the thumb and forefinger of the ex- aminer's left hand. The nasal and naso-pharyngeal space is then closed posteriorly by an act of swallowing performed by the patient; which same act of swallowing also pulls open the pharyngeal orifices of the Eustachian tubes. The interior of the inflating-bag, the nasal and naso- pharyngeal space, and a greater or less length of the two Eustachian tubes (and drum-cavities), being thus momen- tarily converted into a common air-chamber, and shut off from communication with the external atmosphere, a sudden compression of the bag will necessarily result in compressing the air contained within that portion of this common cavity, which lies inside the patient's head. Should the Eustachian tubes be stenosed at any point, such compression will tend to dilate the stenosed por- tion, and to drive the air past this point and into the drum-cavity. The greater or less degree in which this result is accomplished, and the greater or less effort re- quired for its accomplishment, will be some measure of the extent of such stenosis. In cases where little or no ste- nosis of the Eustachian tube exists, the effect of increased atmospheric pressure thus suddenly brought to bear upon the walls of the tympanic cavity, including the inner surface of the drum-membrane, may be used to demonstrate the degree of mobility possessed by a drum- membrane which is intact, or to show the existence of a perforation in one which is not so. That the air actu- ally does enter the cavity of the drum may be proved in one of five ways: 1, By the sound and sensations ex- perienced in the ear by the patient himself ; 2, by observ- ing through the speculum the excursion performed by the drum-membrane during the inflation (or in a case where a perforation exists, by observing the projection of pus or bubbles through such perforation); 3, by compar- ing the appearance of the membrane immediately before, with its appearance immediately after the inflation ; 4, by noting any difference in the results of two tests of the patient's hearing, made respectively, the one just be- fore, and the other just after, the inflation ; 5, by the sound generated in the patient's ear during the inflation, and conveyed therefrom to the ear of the examiner through the medium of an auscultating tube. The exact steps to be followed in attempting to inflate by Politzer's method are as follows : First, the physician will do well to make a cursory ex- amination of the anterior portion of the patient's nostrils, that he may select for the introduction of the nose-piece that one of the two which, by its larger size and greater freedom from hypertrophied tissues, is capable of afford- ing the better facilities for the easy and completely pain- less introduction of the nose-piece. When no great dif- ference exists between the two, the patient's left nostril is the one to be selected for the introduction of the nose- piece. Second, the patient is directed to take about a teaspoon- ful of water into his mouth and to retain it there until he receives the signal to swallow it. Third, the physician grasps the inflating-bag with his right hand, and with the fingers of the same hand, as- sisted by those of the left, he gently introduces the tip of the nose-piece for a distance of about three-fourths of an inch along the floor of the nostril, and in such a position that it shall lie in the outer and lower corner of the nostril. Fourth, with the thumb and index finger of the left hand both nostrils are compressed, and at the same mo- ment the patient is told to swallow, while the inflating- bag is emptied by a firm and rather sudden act of squeez- ing, to be performed, so far as possible, solely through the action of the muscles of the operator's hand and fore- arm. The operator should not relax his grasp upon the bag until the nose-piece has been removed from the nostril, and has been carefully wiped dry upon a towel. Of the nose-piece, already so frequently referred to, several varieties are to be found. None of these are bet- ter, and few, if any, are so good as the one depicted in Fig. 937. The proportions of this nose-piece (including the proper degree of its curve) are well shown in the illustration. Its length from tip to curve is about three-fourths of an inch ; the portion below the curve is some two inches long, and for about half its length is inserted into the extremity of a close- ly-fitting, thick-walled piece of black-rubber tubing of medium size. When in use the other end of this piece of tubing is pulled tightly over the nozzle of the inflating-bag. The nose- piece should be made of hard rubber. Its total diameter should not exceed three-six- teenths of an inch, while its calibre should be as large as is consistent with a proper strength of its walls, and should not be less than one- tenth of an inch in diameter. The length of the piece of rubber tubing used to connect the nose-piece with the bag is about ten inches. The other method of forcing air into the Eustachian tube and drum-cavity by means of an inflating-bag, is that in which the nozzle of the bag is brought into direct contact with the pharyngeal opening of the Eustachian tube through the medium of the so- called Eustachian catheter. This instrument, which is preferably made of hard rubber, is shown further on in Dr. Roosa's article. The proportions and proper degree of curvature of the instrument are sufficiently well shown in the wood-cut. Its length from the expanded end to the tip should not be less than six and one-fourth inches. The expanded end just mentioned is made so as to tit over the nozzle of the inflating-bag. These Eustachian catheters are made of varying sizes as to the diameter of their narrower portion, and it is well for the physician to be possessed of several sizes of the instrument. The external diameter of the shank in an instrument of aver- age size is three millimetres (about one-tenth of an inch); its calibre should be large in proportion to the total di- ameter, and should measure about two millimetres (one- fifteenth of an inch) across. To bring the tip of the catheter into apposition with the mouth of the Eustachian tube, several methods of pro- cedure have been devised. Each has its peculiar advan- tages and disadvantages, and all require an amount of manual skill which is only to be acquired by clinical Fig. 936. Fig. 937. 578 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. training and experience. The comparative merits of these different methods will not be discussed in this place. The employment of the Eustachian catheter is very seldom a matter of necessity in forming a correct diagnosis of a case of aural disease. Most of the methods adopted for the introduction of the instrument are described at con- siderable length in the pages of each of the larger special treatises upon Otology. None of these methods should be attempted by the physician who is not sufficiently in- terested in otological practice to be the possessor of at least one such work. Neither does the writer flatter him- self that he can, within the compass of this brief general article, improve upon the description of the method or methods of introducing the catheter given by the respec- tive authors of these lengthy and special treatises. Con- sequently, he will not attempt to describe any one of these methods. In the hands of the unskilled operator, the in- troduction of the catheter involves an unnecessary amount of pain and discomfort to the patient; it may inflict con- siderable damage upon the lining membrane of the nose and upper pharynx ; it may, occasionally, lead to the pro- duction of a dangerous submucous emphysema involving the larynx; and, finally, it will be exceedingly apt to fail of its object. The aver- age general practitioner, or the imperfectly trained specialist, is therefore advised to leave the instrument lying quietly in his case and to confine himself, in diagnosis or treatment, to Politzer's method of inflation. Three modifications of this latter method may well be described in this place, as they are especially applicable in the examination of young children, and occasionally are service- able in the examination of older persons. Instead of compelling the patient to swallow water during the insufflation, it will not infre- quently suffice to have him suddenly inflate his cheeks with air at the moment when the in- sufflating bag is compressed. This method is, in reality, a combination of the Valsalva and of the Pohtzer methods. Or the patient may be directed to phonate instead of swallowing, using prefer- ably for this purpose some short word ending in a guttu- ral consonant, such as the word ' ' hie. " This is the method commonly employed by Dr. Josef Gruber, of Vienna. Or again, in the case of a young child, it may be and generally is, sufficient simply to perform the act of insuf- flation. It is not necessary to compel the child to swal- low, to blow, or to phonate ; but the operation is in some degree facilitated in case the child should cry out during the insufflation. It is, perhaps, superfluous to add that an infant usually does so cry out. Finally, for infants and for persons having especially tender nostrils, we may substitute, in place of the nose- piece pictured in Fig. 937, a smooth-edged, conical nose- piece, which will of itself sufficiently occlude one nostril, while the opposite nostril is held compressed against the nose-pfiece and the intervening septum nasi. This variety of nose-piece is shown in Fig. 938. lleference has already been made to the auscultating tube, or so-called otoscope of Toynbee. A view of this simple con- trivance is presented in Fig. 939. The instrument consists merely of two ear- pieces inserted into opposite ends of a piece of rubber tubing (about three feet long). One of these ear-pieces is to be placed in the meatus of the ear which is under examina- tion, the other goes into the ear of the examiner. For facility of distinguishing them apart, one of these ear- pieces is either surrounded by a little metallic ring, or else is colored differently from the other. The physician need hardly be reminded, however, that both ends of the instru- ment should be kept scrupulously clean. The auscultatory diagnosis by the physician of stenosis in the Eustachian canal, of a minute perforation of the drum-membrane, or of the existence of fluid within the tympanum, is most satisfactorily effected during insuf- flation by catheter or by the Politzer method. As al- ready remarked, if the physician be not provided with an assistant he will ordinarily find the method of Val- salva most satisfactory whenever he desires to keep his eye fixed upon the drum-membrane during the insuffla- tion. The Eustachian catheter once properly introduced, insufflation by this method is unquestionably the most satisfactory for auscultatory diagnosis, because the force of the air-current is expended upon a single ear rather than upon both (as is the case when either Valsalva's or Politzer's methods are adopted), and also because sounds generated within the Eustachian tube and drum-cavity are far less liable to be masked by any other sounds hav- ing their origin in the naso-pharyngeal space. Never- theless it is very rarely necessary to resort to the use of this instrument. A very serviceable little apparatus for occasional use is that shown in (Fig. 946) Dr. Green's article, farther on in this volume, and known as the pneumatic speculum of Siegle. The instrument consists essentially of a cylin- drical hard-rubber box, closed at one end by a plate of glass which is set obliquely in such a manner that the direction of its plane surface forms an angle of forty-five degrees with an imaginary plane drawn horizontally across the lumen of the instrument, and having an open- ing at its opposite extremity and another and smaller opening, provided with a nozzle, at its side. To the opening at the unglazed end of the cylinder may be screwed hard-rubber specula of various sizes. A soft rubber tube is slipped over the nozzle mentioned above. The speculum fastened to the unglazed end of the cylin- der is to be covered externally with soft rubber. When this rubber-armed speculum is introduced into the au- ditory canal it should apply itself so closely to the walls of the latter that no air can pass between the two. The distal end of the rubber tube is either to be held in the observer's mouth or else is to be slipped over the nozzle of a small inflating-bag or syringe. By his mouth, or by means of this bag or syringe, the observer can alternately compress or rarefy the column of air contained within the apparatus (and the external auditory canal) after the speculum is introduced into the meatus. Special in- formation can be derived, by the use of this instrument, concerning the degree of mobility possessed by the drum- membrane and, in particular, concerning the relative mobility of different portions of the latter. In conclusion, it should be added that an examination of the patient's pharynx and naso-pharyngeal space should never be omitted in a case where any degree of obstruction of the Eustachian tube has been actually discovered or is surmised to exist. The details of such an examination belong rather to an article treating of diseases of the upper respiratory tract and to their diagnosis, and will not, therefore, be given in this place. The reader desirous of further information concerning any of the points which have been touched upon in this article, and in particular concerning the method of employing the Eus- tachian catheter, may be referred to some of the other otological contributions contained in this Handbook, and to the pages of the larger special treatises upon otology. A short list of good works of this class is herewith subjoined for convenience of reference. Fig. 938. List of Works of Reference. Charles H. Burnett, A.M., M.D.: A Treatise on the Ear. D. B. St. John Roosa, M.D., LL.D.: Treatise on the Diseases of the Ear. Albert H. Buck, M.D.: Diagnosis and Treatment of Ear Diseases (Wood's Library of Standard Medical Authors). Oren D. Pomeroy, M.D.: Diseases of the Ear. Dr. Adam I'olitzer : Lehrbueh der Ohrenheilkunde (an English edition of this work is in the market). Dr. Josef Gruber: Lehrbueh der Ohrenheilkunde. Dr. Arthur Hartmann: Die Krankheiten des Ohres und deren Behand- lung. Dr. Victor Urbantschitsch ; Lehrbueh der Ohrenheilkunde. Fig. 939. Iluntington Richards. EAR: GENERAL THERAPEUTICS. In the treat- ment of aural affections we are usually at liberty to choose between a variety of means for the attainment of the end desired. Those who have not learned by per- 579 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sonal experience what remedies or what remedial meas- ures they should choose by preference in treating a given case or a given form of disease, are apt to be very much confused, in reading the therapeutic portions of the text- books, by the multitude of remedies recommended. In their desire to do justice to other authorities, and partly also in the fear that they may be accused of inordinate conceit, authors of practical treatises on diseases of the ear are sometimes very generous in their enumeration of the different ways in which a particular therapeutic effect may be obtained. The beginner is apt to draw the in- ference, after the perusal of a chapter such as I have described, that the writer of it is himself in the habit of employing indifferently any of the various measures recommended. In the majority of instances such an inference would not be correct. It is probably the truth that those who have a great deal to do with the treatment of diseases of a special organ, and who have, therefore, ample opportunities for watching the effects of certain remedial procedures upon these diseases, soon settle down into a routine plan of treatment. They find that they can depend with confidence upon a compara- tively few drugs and procedures, and they stick some- what closely to these. Furthermore, I believe that the routine practice of one careful worker in a special de- partment will not differ very materially from that of his associates in the same department. It seems to me, therefore, that if the beginner is to derive much benefit from the experience of those who have explored the ground thoroughly before him, he should begin building up an experience of his own by first adopting-on trial -these well-established routine methods; and in the present article it shall be my aim to prepare an outline sketch of what I consider to be the simplest and most effective, means of relieving certain symptoms and of arresting certain pathological processes in the domain of the ear. If I stop occasionally on the way to criticise certain therapeutic procedures, I trust that in so doing I may not be thought to be lacking in courtesy toward my colleagues, who have joined with me in the endeavor to present in a compact form such information in re- gard to the nature and treatment of ear diseases as will be really useful to the profession at large. This article, I take pains to state, has been written without a knowledge of the contents of the other articles in this series ; hence, if my criticisms happen to apply to any doctrines and views therein expressed, I trust that I may be absolved from the charge of taking an unfair advantage of my editorial privileges. In full sympathy with the old motto, " Nullius addictus jurare in verba magistri," I have simply allowed myself that liberty of opinion which I have endeavored to emphasize through- out the Handbook by assigning, in not a few instances, the same topic to different writers who hold different views in regard to it. In discussing some of the more important reme- dies I shall consider them only from the standpoint of their comparative virtues in relieving individual symp- toms and conditions, and shall make no attempt to set forth in detail all the therapeutic peculiarities of each remedy in turn. In accordance with this plan I shall first discuss the comparative merits of the different remedies and procedures which relieve pain in the ear -which involves necessarily the consideration of those which relieve the higher degrees of congestion. In the next place, I shall consider those which possess the power of diminishing the milder but more persistent degrees of congestion of the tympanic mucous membrane. I shall then consider those which tend to arrest a discharge from the ear, and shall so continue on through the list of symptoms and conditions, or at least a part of them. I. Measures for Controlling Pain.-1. When Due to Acute Inflammation Developing in a Previously Healthy Middle Ear.-The decision as to what measures are best to employ for the relief of. pain which is dependent upon inflammation of the drum cavity and adjacent parts, will depend very much upon the condition ascertained to exist upon an examination with the speculum and re- fleeted light. Thus, for example, if we find that an exu- dation has already taken place in the tympanum, and that it is pushing the tympanic membrane outward,-in other words, that an undue degree of pressure is being exerted not only upon this membrane, but also upon the entire mucous membrane of the drum cavity,-our safest course will be to make a free opening in the membrana tym- pani, and so afford escape to the pent-up fluids. The condition just described is that which is ordinarily to be found in cases of acute inflammation of the middle ear of recent origin, and developing in an ear which has been previously healthy. But there are cases-some of them of comparatively recent origin, and others repre- senting a condition in which an acute inflammation has supervened in an ear previously much altered by disease -in which such operative interference is not so clearly indicated. In these cases there will be a widespread in- filtration of the parts, with no distinct pushing outward of the drum membrane, or the tissues may indeed be so swollen and deformed as to render a clear recognition of the relations of the parts simply impossible. Under such circumstances we may use the knife boldly and freely, and yet fail to afford the relief from pain which may be almost counted upon with positiveness in the class of cases previously described. From these remarks I would not have the reader draw the inference that the knife is not to be used in the latter class of cases,-for I believe fully that incision of the membrane contributes much to- ward hastening the ultimate recovery of even such cases, -but simply that he must be prepared to frequently ex- perience disappointment, so far as the immediate results of the operation are concerned. It will not be out of place to say a few words here in re- gard to the operation. In the first place, a long, slender, spear-pointed knife will be found to answer well the de- sired purpose. Some prefer to have the slender shank of the instrument bent at an obtuse angle, at the point where it joins the handle, while others like to have a bayonet- like jog interposed between the handle and the shank ; in both patterns of knife the object being to get the opera- tor's fingers and hand out of the way, in order that they may not rob him of any of the light which is reflected from his hand- or forehead-mirror upon the drum mem- brane. My own preference at the present time is decid- edly in favor of the perfectly straight instrument, but my recollection is, that in 1870, when I first performed paracentesis of the drum membrane, I found the bent in- strument-viz., the so-called "paracentesis needle" set in a Blake's snare apparatus-easier to manage. The pos- terior half of the membrane is more easily reached than the anterior, and it is here that the incision is usually made. A vertical linear incision is generally all that is required. The point of the knife should be introduced at a spot midway between the handle of the hammer and the periphery of the membrane, and perhaps at a distance of a millimetre above a horizontal line running through the tip of the handle of the hammer. It should pierce the membrane, and then it should be carried straight downward almost to the lbwer border of the membrane, or until the slit in it measures fully three or four milli- metres in length. We need feel no anxiety about the point of the blade reaching the opposite wall of the drum cavity, nor in regard to the likelihood of its piercing the membrana tympani secundaria in the round window. The mucous membrane covering the bony promontory is exceedingly thin in its normal state, and when the parts are inflamed, only good will result from such an acci- dental incision, provided the cut in the drum membrane it- self be sufficiently long to permit the free escape of any clots of blood that may follow the operative interference. Then, on the other hand, the membrane of the round window is well protected against injuries of all kinds by its secure position behind a hood of strong bone. There is only one danger connected with the operation, and that is the possibility of injuring the stapedio-incudal joint or the parts immediately surrounding the foot-plate of the stirrup. To avoid this, we must constantly have before the mind a picture of the relative positions of the different structures of the middle ear. We shall then ap- 580 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. predate how important it is not to penetrate the mem- brane at too high a level. While there is perhaps no very serious reason why the incision should not be made in the anterior half of the membrane, if for any reason one should prefer to adopt this course, it must be remembered that, opposite to that part of the drum membrane which is commonly the seat of the "bright spot," lies the rounded elevation of the tympanic extremity of the Eustachian tube. A prick of the knife point might give rise to some haemorrhage from this highly vascular part of the mucous membrane ; and while this loss of blood would be insignificant in all other respects, it might greatly interfere with the success of the operation by developing a clot in the vicinity of the slit in the membrane, and so obstructing the escape of fluids through it. This provoking accident rarely complicates an incision in the posterior half, and then only when the knife is carried too far downward, at which point the tympanic mucous membrane is generally much thicker and more vascular than on that part of the inner bony wall known as " the promontory." It is not often necessary or desirable to convert the linear into a crucial or H-shaped incision. A marked de- gree of infiltration of the tissues composing the mem- brana tympani furnishes an adequate reason for the se- lection of this form of incision. I must confess that, while I have occasionally thought it best to make such a crucial incision, I have not yet satisfied myself that a linear in- cision would not have answered* the desired purpose equally well. Immediately after the membrana tympani has been in- cised, it is a good plan to fill the external auditory canal with warm water, and to apply hot fomentations. Now and then, as in the case of a nervous or " spoiled " child, I find it necessary to produce a partial state of gen- eral anaesthesia before I can safely, and comfortably, I might add, perform this operation. In the great majority of instances, however, neither a general nor a local anaes- thetic is required. As regards the use of cocaine for this operation, I may say that while I always go armed with the drug, in the expectation that I may find it useful, I am still waiting for the first case to arrive in which I can, upon grounds which seem to me to be reasonable, make use of this remedy. The mere statement that the operation will cause no pain will not enable the surgeon to perform paracentesis of the membrana tympani in a nervous or unruly child, or, perhaps, even in a nervous and timid adult. Such patients need to be rendered temporarily unconscious, and for this purpose ether or chloroform is the best agent. In the case of those who are not espe- cially nervous, but yet are afraid that they may not be able to remain sufficiently quiet during the actual cut- ting, I have rarely failed to persuade them that an anaes- thetic would not be necessary by assuring them that the immediate pain of the incision was of such short duration (not longer than a full second) that they would experi- ence no difficulty in maintaining the head in a quiet posture. It may happen that, for some reason or other, it will not be practicable to resort to the use of the knife, and the question will then present itself, What other means should we employ for the relief of the pain ? In answer to this I would say that the best means of alleviating this symp- tom, in cases of acute inflammation of the middle ear, is the persistent and thorough irrigation of the inflamed drum membrane and deeper parts of the external audi- tory canal with water at a temperature of about 100° F. For this purpose a fountain-syringe or douche with a capacity of at least two quarts will be found by far the most perfect apparatus. By means of it, if its long tub- ular outlet is armed with a slender nozzle of such a pat- tern that it may safely be introduced a sufficient distance into the external auditory canal, we may keep a stream of warm water playing for an indefinite length of time upon the inflamed parts. No other measure, with the exception of paracentesis of the drum membrane, affords so much relief as this does. I have observed, however, that in many instances, especially where I have simply given verbal instructions, and have not taken pains to at least supervise the first steps of the procedure, very little or no relief has resulted from the use of the douche. On investigation I have generally found that the nozzle at- tached to the instrument was of such a pattern that only a person skilled in such manipulations could be reason- ably sure of effecting the object which should be held clearly in view, viz., to keep a stream of warm water actually playing upon the drum membrane. To remedy this difficulty, I induced the instrument-makers to manu- facture a hard-rubber nozzle of slight diameter, with nicely rounded tip and armed with prongs which pre- vent the introduction of the instrument too far into the auditory canal. By means of this nozzle, which is at- tached to the instrument now sold in the market under the name of Angelo's Ear Douche, no difficulty will be experienced in effecting a thorough irrigation of the in- flamed parts. In using this instrument it is essential that the nozzle should be pushed into the canal as far as the prongs will permit, otherwise one cannot be sure of really carrying the stream of water down upon the drum membrane. As soon as the relief from pain has been ob- tained in this way, it is well to continue for some time the application of warmth, either dry or moist, to the ear and its vicinity. Furthermore, the patient should not attempt to go about for at least several hours after the pain has been subdued, as a little exercise, or jarring of the body, or even mental excitement, may bring it back again in its full force. While the fountain-syringe is probably the most per- fect instrument that we can employ for the accomplish- ment of the purpose desired, there are other ways in which we can apply heat and moisture to the drum mem- brane. A very simple and effective method is to pour w'arm water from a teaspoon into the external auditory canal,-the patient's head being inclined toward the oppo- site side,-and then, immediately afterward, to lay a flax- seed-meal poultice, or cloths wrrung out of hot water, over the ear and surrounding parts. To prevent the too rapid loss of heat it will be found advantageous to place a light woollen shawl, or a light blanket, over the poultice. As soon as it is evident that these dressings have lost much of their heat, they should be removed and the water should be allowed to escape from the audi- tory canal. Then the various steps just described should be repeated as soon as possible ; and in this manner an almost continuous poulticing of the membrana tympani may be kept up for as long a time as may be necessary to secure relief from the pain. Here again, I feel con- strained to call attention to the frequent failures which are reported as following the employment of this or simi- lar methods of applying heat and moisture to the in- flamed parts. Undoubtedly, in some of these instances the failure is genuine in character-that is, the method is really inadequate to control the violence of the inflamma- tion ; but in a still larger proportion of instances I am confident that the fault lies not with the method, but with those who attempt to carry it out. If successful re- sults are to be obtained, some' one person must devote himself or herself to the task of carrying out the details of the operation carefully and persistently. The patient, furthermore, should be in the lying-down posture, pre- ferably in bed, and he should play as nearly a passive part in the business as he possibly can. Of the remaining therapeutic methods which may be employed for the relief of pain dependent upon inflam- mation of the middle ear, I shall speak but briefly. Local blood-letting, by means of leeches, oftentimes proves a very efficient means of relieving the pain. This procedure, like those already enumerated, has this merit to commend it: it aims to relieve the pain by diminish- ing the underlying pathological process. According to the age, sex, and physical vigor of the patient, from one to three, or even four, leeches should be applied to the skin immediately in front of, and in close proximity to, the tragus. A leech-tube (see under Blood-letting) is al- most indispensable if we wish to make the leeches bite at certain fixed spots. It is also advantageous to apply them in the order from below upward. After they have 581 Ear, Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gorged themselves with blood they will drop off sponta- neously, and then, according to circumstances, we may either promote a certain amount of after-bleeding by sponging the bites with tepid water containing a little bi- chloride of mercury (1 : 2,000), or we may proceed at once to check the further loss of blood by laying small pledg- ets of borated cotton upon the bites, and applying firm pressure over them. Usually this will suffice ; but if the bleeding continues we may apply styptic cotton. The anaesthetic properties of cocaine have led many practitioners of late to employ it freely in cases of acute inflammation of the middle ear, as a means of relieving the pain. While the fact cannot be denied that it often proves entirely successful in subduing this symptom, the practice is nevertheless not to be commended. The ob- jections to it are these : It exerts no curative effect upon the disease, but simply deadens the pain ; and it provokes a certain amount of irritation of the dermoid surface of the drum membrane and neighboring canal. If the case happens to be one of a mild type, it is probable that the effects which I have just mentioned will not prove to be objectionable in any important respect; but, on the other hand, if the disease be of a more active type, the deaden- ing of the pain, and the production of a swollen and in- filtrated condition of the drum membrane, produce ef- fects which are decidedly objectionable, viz., they conceal the true state of the case from the physician, and so post- pone the employment of more directly curative measures until the disease has gained considerable headway, and has, perhaps, even involved the neighboring mastoid cells to a marked degree. Furthermore, at this advanced stage of the disease the curative measures already de- scribed prove far less effective than they do at the onset. For example, an ordinary linear incision of the mem- brana tympani will then no longer be found competent to establish a free outlet for the inflammatory products in the middle ear, owing to the great increase in swelling which has taken place in the meantime. In a word, then, the employment of cocaine is not to be commended under the circumstances which we are now considering. If the legitimate measures fail, and it still seems desirable or necessary to allay the pain, opium in some form may be given internally. In this way the pain may be dead- ened without at the same time aggravating the swelling of the drum membrane and adjacent parts. In a lesser degree these same objections apply to the instillation of laudanum into the external auditory canal. Warmed vaseline is often employed with success in these cases of acute inflammation of the middle ear, and I believe that its employment is to be commended. It is apparently free from the objectionable features which sometimes characterize olive-oil; that is, it does not favor the development of vegetable fungi in the auditory canal as sweet oil is apt to do, nor does it ever become rancid and so prove a great source of irritation, if allowed to re- main for some time in contact with the inflamed parts. Glycerine is not to be used, as it is irritating to the in- flamed as well as to the normal membrana tympani. Recapitulation : If an examination with the speculum and reflected light shows that the disease has not gained much headway, and that there is as yet no bulging of the membrana tympani, apply heat and moisture persistently by means of the fountain-syringe armed with a pronged hard-rubber ear-nozzle ; but if this cannot be done, pour warm water into the ear and make such additional out- side applications as will promote the retention of heat in the water that fills the canal. Heated vaseline will prob- ably answer the purpose just as well as water. If the pain continues, and the drum membrane presents a bulg- ing condition, it should be incised freely. If for any reason the operation cannot be performed, the next best thing will be to apply a suitable number of leeches in front of the external orifice of the auditory canal. Be- yond this point we shall probably find that the disease calls for measures which will not be discussed in this place-Wilde's incision of the mastoid integuments, per- foration of the mastoid process, etc. However, if the physician who has charge of the case is called to see it in its early stage, and does not hesitate at the right time to incise the drum membrane freely, lie will rarely fail to quiet the pain and to check the activity of the inflamma- tion. It is claimed by some that the internal administration of such remedies as sulphide of calcium, spirits of tur- pentine, and perhaps one or two others which do not now occur to me, is competent to check the progress of an acute inflammation of the middle ear, and in this manner to allay the pain. I am not able to say from per- sonal experience whether this claim is a valid one or not. Some practitioners, in whose opinion I should have entire confidence, have given one of these drugs (the sulphide of calcium) a fair trial in suitable cases, but have failed to obtain the happy results which others claim to have obtained. A bulging membrana tympani means a de- gree of pressure upon all the soft structures of the middle ear which threatens serious damage. In the presence of such a state of things it seems to me to be worse than folly to administer internally any drug now known to medical science, with the expectation that it will remove this dangerous pressure and will turn back the tide of disease. The indication for the use of the knife seems to me to be so unmistakably clear that I have never once felt the slightest desire to consider seriously the idea of resorting to this or any other internal remedy. The conditions in a painful inflammation of the middle ear are not unlike those which characterize a felon or paronychia. Who, let me ask, would seriously expect to quiet the pain of such a swollen and throb- bing finger, and to materially alter the course of the disease, by administering to the patient sulphide of cal- cium, turpentine, or any other remedy ? 2. When due to Changes which may Occur in the Course of a Chronic Suppurative Inflammation of the Middle Ear.-In cases which belong to this category we may always safely assume that the pain is due to an obstruction of the channel through which the discharge from the middle ear habitually finds its way into the external auditory canal. An opening in some part of the drum membrane is the most common outlet for the discharge. If it be small in size, even a moderate degree of inflammatory swelling of the tympanic mucous membrane may suffice to completely close this outlet. In the mean- time the formation of pus goes on uninterruptedly, and the degree of intratympanic pressure steadily increases. The severity of the pain will be proportionate to the degree of this pressure, and the aim of our treatment should be to restore a free outlet for the discharge and so remove the pressure. The various ways of accomplishing this have already been set forth in sufficient detail in the pre- vious section. In another class of cases we shall find that crusts, or laminated masses of epithelium, have formed in sufficient quantity, either on the inner or on the outer side of the drum membrane, to obstruct or even completely arrest the outflow of pus from the middle ear. The proper treatment for this state of things is to soften the crusts with a warm solution of bicarbonate of soda and remove them either with the syringe or with suitable instruments. If the obstruction exists on the inner side of the mem- brana tympani it will probably be found that it consists of a mass of laminated epithelium which can only be re- moved by the employment of a certain degree of force. Under such circumstances our best plan is to introduce the curved end of a slender silver probe through the opening in such a manner as to exert a prying force upon the impacted mass. In the great majority of cases the mass will be found to occupy the upper portion of the tympanic cavity. Our manipulations will, therefore, have to be made with great caution and with a thorough knowledge of the anatomical relations of this region, or serious damage may be done to the ossicular connections, provided these parts have not already been destroyed by previous ulcerative disease. When the impacted mass has been loosened by these manipulations we can usually extract it by means of slender angular forceps, either piecemeal or, at times, as a single leathery mass. In some cases excellent results may be obtained by directing a stream of warm water upward toward the roof of the 582 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear, Ear. tympanic cavity by means of a slender glass or silver can- nula, attached to a bulb syringe or a gravity douche, and sharply curved at its free end. (See accompanying cut, •copied from Hartmann's "Die Krankheiten des Ohres.") This plan does good service in those cases in which the laminae of epithelium are separated from each other by a certain amount of cheesy material. From time to time during the progress of the operation it will be found necessary to stop the work of irrigation and extract with the forceps some larger mass, which has been dislodged by the stream of water and has become impacted in the opening. Sometimes several sittings will be found necessary before we can be reasonably sure that the tympanic cavity has been thoroughly cleared of all such offending material. When once this has been accom- plished it will be found a good plan to introduce a liberal supply of iodoform into the cavity. The after-treatment should consist of the daily use, by the patient, of the douche with a saturated solution of boric acid, and from time to time the physician should examine the ear and make sure that no fresh masses have got lodged in the find an easy escape. Experience has shown that the most perfect drainage of the antrum can be effected by boring or chiselling a channel through the bony mastoid process. This operation will be discussed fully in another part of the Handbook, and I shall, therefore, simply make the remark here that we are not to wait for the development of external evidences of mastoid disease-redness, swelling, and tenderness of the skin behind the ear-before we pro- ceed to the establishment of such an opening in the bone. The long-continued inflammation of the antrum is almost invariably associated with chronic proliferative inflamma- tion of the mastoid cells which lie between that cavity and the outer surface of the bone. Hyperostosis and ob- literation of the cells are the ultimate results of this chronic inflammation. In other words, those channels which, in comparatively recent cases of mastoid inflam- mation, serve as paths along which the inflammation may travel to the soft parts covering the bony process, are in this class of cases obliterated by the increased growth of the bone. The inflammation cannot possibly spread through a mass of ivory-like bone, and we are thus de- prived of a very valuable danger-signal. This very im- portant fact should not be lost sight of, or we may let slip through our fingers the opportunity of rescuing a life which otherwise will succumb to the progress of an ul- cerative disease of the antrum. 3. When Due to Inflammation of the External Auditory Canal.-A diffuse inflammation of the external auditory canal is rarely associated with pain, and then it is only paroxysmal and comparatively mild in character. The use of the douche with warm water generally sufiices to quiet it. On the other hand, furuncles in the meatus (otitis externa circumscripta) are sometimes characterized by pain of great severity. This is especially true of those which develop in the outer, cartilaginous portion of the canal. The skin in this region is united to the underlying cartilage by a dense and unyielding connec- tive tissue. A cross-section of this part of the ear would be correctly represented by three concentric rings-an outer one of bone, an intermediate one of cartilage, and an inner one of skin and dense connective tissue. These anatomical relations afford an ample explanation of the facts, that furuncular inflammation is apt to be particu- larly painful in this locality, and that incisions often afford but slight immediate relief, although they probably in all cases shorten the course of the disease. Hot flax- seed-meal poultices sometimes afford the patient consid- erable relief, and at other times they seem to only aggra- vate the pain. There can be no reasonable do.ubt, however, that poultices hasten the formation of a circumscribed collection of pus, and to this extent, at least, they may serve a useful purpose. Local blood-letting is equally untrustworthy. In fact, I am disposed to believe that it is better not to apply leeches in this form of disease, but rather to trust to poultices until the time arrives when the development of the circumscribed tumor shows clearly the exact spot where pus has already formed, or is about to form. Then we may reasonably expect to shorten the period of pain by making a free and deep incision into the swelling. Lack of space prevents me from discussing here sev- eral points which have a practical bearing upon the after-treatment of the disease. I will, therefore, merely allude to one or two of the more important ones. In very many cases we are justified in attributing the localized inflammation, near the orifice of the canal, to the flow of an irritating secretion emanating from the deeper part of the canal, over the part where the furuncle is situated. It is, therefore, good practice to recommend the use of the douche, with a saturated solution of boric acid, once or twice a day for a period of a week or ten days after the abscess has broken spontaneously, or has been artificially opened. This will rob the secretion of its irritating properties, and will in this way prevent relapses, which are so common in this affection. In another class of cases, which are, indeed, comparatively rare, the abscess is simply the outward manifestation of a circumscribed death of the cartilage. In these cases the disease may drag on for weeks, unless we ply the patient vigorously with cod- opening in the tympanic membrane. At these visits he will do well to introduce a fresh supply of iodoform. The manipulations described above should not be un- dertaken by any person who does not already possess a certain familiarity with the locality of the disease, with the use of reflected light, and with the manipulation of probes and forceps in exceedingly contracted quarters. In the cases which we have just been considering, it has been assumed that the obstruction exists either on the outer side of the membrana tympani, or within the tym- panic cavity proper; and, in the latter case, that the open- ing in the drum membrane is sufficiently large to permit the introduction of various instruments. But it occasion- ally happens that the opening is quite contracted in size and, as is very apt to be the case, is located, not in the drum membrane itself, but in the soft parts which form the upper and posterior boundary of the membrane. These are precisely the conditions in which epithelial masses and cheesy and decomposing pus are apt to go on accumulating in the mastoid antrum, until the narrow outlet channel into the tympanic cavity proper becomes completely obstructed. It is of the utmost importance that the physician should recognize the gravity of these cases, of which not a few terminate fatally through an extension of the disease to the neighboring lateral sinus, or to the brain itself. If such therapeutic measures as I have already described fail to relieve the pain, no time should be lost in restoring an adequate and direct outlet by way of which the decomposing pus in the antrum may Fig. 940. 583 Kar. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. liver oil and some preparation of cinchona bark (prefer- ably Huxham's tincture). Finally, a deep excavation, with, perhaps, a mass of redundant flesh at its mouth, sometimes persists for a long time, and resists the meas- ures which are commonly employed for the purpose of causing it to heal, viz., excision of the granulation-tissue and cauterization of the cavity with nitrate of silver. The first of these steps is certainly necessary, but the sec- ond is very apt to prove unavailing. It is far better to apply strong nitric acid freely to the walls of the cavity. The effects of one such application are sometimes almost magical, and the pain produced by the operation is usu- ally slight-oftentimes, indeed, slighter than that pro- duced by nitrate of silver. II. Measures for Arresting the Different Forms of Catarriiae or Non-suppurative Inflam- mation of the Middle Ear and Eustachian Tube. -There are three different classes of cases which may properly be considered in this section. The first class comprises those acute attacks which, although they begin in precisely the same manner as do those which terminate eventually in suppurative inflam- mation of the middle ear, with perforation of the mem- brana tympani, stop short at the stage of congestion and swelling of the mucous membrane, with slight serous effusion, or, at most, a mucoid or muco-purulent secre- tion. In this condition our aim is to alleviate pain and to check the further progress of an acute inflammation. The treatment, therefore, should be essentially the same in these cases as in those which have been described in a previous section ; and, accordingly, the remarks made in that place in regard to the means which may be employed to attain these ends, apply here with equal appropriate- ness, and therefore need not be repeated. The second class comprises those cases which, after be- ginning in an acute fashion, subside into a condition of chronic, painless congestion and swelling of the mucous membrane of the middle ear. The process of getting well from the acute attack goes on until a certain stage is reached-which stage varies in different cases-and then, for weeks, or even months, the condition of the middle ear remains at a standstill. In the third class may be placed a large number of cases which differ from each other in not a few respects, but which all have these features in common, viz.: the demonstrable lesions are strikingly insignificant in com- parison with the amount of impairment of the hearing ; and catarrhal disease at the vault of the pharynx either coexists with the deafness, or forms a part of the previous history of the case. I might add that they possess a further feature in common-they are practically incurable. In view of the limited space at my command, I may be permitted to restrict my remarks to the therapeutics of the second class alone. What, then, is the task set be- fore us in these cases ? As I understand the nature of the pathological changes, they consist in a congested and infiltrated condition of the mucous membrane lining the entire system of cavities known, technically, as the ' ' mid- dle ear ; " and with this may be associated some effusion upon the free surface of the mucous membrane (an ac- cumulation of serum or mucus in the tympanic cavity). So long as the drum membrane remains intact, there is but one way in which we can bring remedies to bear directly upon the affected mucous membrane-that is, through the Eustachian tube. Air, vapors, spray, and free fluid can be made to pass through this narrow chan- nel into the middle ear. The possibility of doing these different things has led to the adoption of a variety of intratympanic therapeutic procedures. I believe that they are all, with a single exception hereafter to be men- tioned, either useless or positively harmful. The bene- ficial results which competent and trustworthy authorities claim to have obtained by the employment of these meas- ures, are, I believe, to be attributed to the simple intro- duction of air under pressure, or to other therapeutic measures which were carried out at the same time. The forcible introduction of air is oftentimes beneficial, and I have no reason to believe that, under proper restrictions, it produces harm. This forcible introduction of air forms a necessary part of the intratympanic injection of remedial agents, whether they be in the form of a spray, in that of a mere vapor, or in that of a free fluid. Such remedial solutions or vapors can be used safely only when they are quite weak-too weak, it has always seemed to me, to be of any use. When they are of greater strength they tend to aggravate the already existing irritation. Aside, then, from the single method of forcing air (by Politzer's, and not by the objectionable Valsalva's method) into the tympanum, I am disposed to consider all direct treatment of the middle ear (with intact drum membrane) as more or less objectionable. Among the indirect methods of exerting a curative effect upon the diseased mucous membrane of the middle ear, I unhesitatingly give the first place to the systematic application of ni- trate of silver to the vault of the pharynx, and particu- larly to the regions bordering upon the orifices of the Eustachian tubes. It is a matter of great surprise to me that some excellent authorities should speak of this rem- edy in terms of positive condemnation. As is true of all powerful remedies, care, skill, and good judgment must be exercised in the employment of this one. It requires, some skill to prevent the solution employed from travel- ling downward to the larynx, or forward into the nasal passages. The quantity which it is well to use in the naso-pharyngeal cavity of one individual will be found excessive in that of another. The strength of the solu- tion which answers admirably in one patient, will pro- duce a violent reaction in another. A careless and indis- criminate manner of applying the remedy will be sure to inflict upon the patient a vast amount of bodily discom- fort. In a word, then, it is quite conceivable that ni- trate of silver is not a remedy which can safely be placed in the hands of every practitioner ; and it is, perhaps, on these grounds that the authorities referred to above have- condemned its use. While, therefore, I have no doubt that many of those who, on the strength of my remarks, may resort hopefully to the employment of nitrate of silver, will probably soon abandon it as both inefficient and very disagreeable to the patient, I can in the most positive manner assure those who will handle the remedy cautiously, and with the exercise of some judgment, that they will obtain better results with it than with any other remedy known to me. There are various ways of bringing a solution of silver- nitrate in contact with the walls of the naso-pharyngeal cavity. At one time the preference was given to the so- called posterior nares syringe ; but it was soon found that, the solution, when thus injected into the vault of the- pharynx, occasionally found its way to neighboring cavi- ties, where its presence produced exceedingly disagree- able symptoms. I believe that it is now employed by comparatively few physicians. Spray apparatuses, which are at the present time in great favor, are certainly far superior to the posterior nares syringe. But this method of applying nitrate of silver is also, as it seems to me, open to serious objections. The action of the spray can- not be confined to the naso-pharyngeal cavity proper, and the strength of the solution is often neutralized by the coating of mucus which is generally spread out over the affected mucous membrane. The third plan of ap- plying this remedy to the affected mucous membrane of the naso-phhryngeal cavity is the simplest and, I think, the most effective of all the methods. The end of a metal rod, or probe, is armed with a small mop of ab- sorbent cotton, and then bent at a right angle. When the cotton has been saturated with the silver solution, and after the excess of fluid has been carefully pressed out, the mop may be introduced high up behind the soft palate, and be rotated from one tubal orifice across to the other, thus at the same time wiping off any mucus that may be present and bringing the remedy in thorough con- tact with the diseased mucous membrane. If an unusual amount of mucus is found to be present, it is a good plan to prepare a fresh mop and make a second application to the affected region; or the saturated mop may be intro- duced only after the mucus has been thoroughly removed by means of dry cotton. It is important to observe carefully certain precautions 584 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. in making these remedial applications. They are briefly stated as follows: 1, The mop should not be too highly saturated, lest the contraction of the muscular walls of the naso-pharyngeal cavity cause some of the solution to drop down upon the vocal chords, or to be swallowed ; 2, the patient should be told to draw in a long breath be- fore the mop is introduced behind the soft palate; and finally, 3, the solution used on the occasion of the first application should not exceed a strength of twenty grains to the ounce of water. Solutions of greater strength (up to sixty grains) may be used later, if deemed necessary. The method described above is in every particular the same as that which I learned from Dr. Robert F. Weir, of this city, in 1870. Those who prefer to do so, may substitute the tincture of iodine, or Lugol's solution, or a solution of alum, or ferric alum, or one of some other preparation of iron. My own experience with these drugs does not lead me to say much in their favor. During recent years I have found myself placing more reliance upon the treatment of the naso-pharyngeal con- dition, and less upon the method of inflating the middle ears. I have repeatedly satisfied myself that my cases made as rapid a recovery without the accessory inflations as with them. In a few instances, indeed-those charac- terized by aerial bulging of the membrana tympani-I became convinced that the inflations were positively harmful. As a general rule, it will be found best to make the reme- dial applications to the vault of the pharynx not oftener than three times a week. As regards the inflations, it is a good rule to abstain from employing them so long as the patient experiences any pain in the ear. Furthermore, it is never quite safe to employ them until we have first ascertained the condition of both drum membranes. While that of one side may be in such a condition as to render inflations desirable, or at least perfectly safe, that of the other side may be in a cicatricial, or highly atro- phied, state, in which case the inflations will be very likely to rupture the imperfect membrane. By means of the Eustachian catheter the inflations may, of course, be readily confined to the particular ear which needs them. Under ordinary circumstances, however, it is not neces- sary to resort to the employment of the catheter for ther- apeutic purposes. This statement may strike the reader as being little short of rank heresy. I admit that it is not in accordance with the teachings of many excellent au- thorities, but as my statement is simply the expression of what I candidly believe, and of what my own personal experience has taught me, I need not hesitate to make it. General therapeutic measures are often found to be im- portant adjuncts in the treatment of this class of cases. In young individuals, cod-liver oil and Huxham's tincture of bark may be prescribed with great advantage to the patient. In older persons we may find it necessary to re- sort to other measures. Excessive smoking, and es- pecially the practice of forcing the smoke of cigarettes out through the nasal passages, should be checked ; for these habits tend to keep up the very pathological condi- tion which it is our chief aim to mitigate, viz., the ca- tarrh at the vault of the pharynx. In other cases we may find that the habit of sleeping in a room with an open window is promoting the continuance of the naso-pharyn- geal catarrh. Finally, in still another class of individu- als, this catarrhal irritation seems to be dependent upon what may be termed a gouty condition. In such cases we usually find that a great increase in the amount of physical exercise, to be taken daily, is what the patient stands chiefly in need of. He should walk not less than four or five miles every day, if he wishes to keep himself in good condition. III. Measures for Arresting a Discharge from the Ear.-A discharge from the ear comes as a rule from the tympanic cavity, and finds its way into the external auditory canal either through an opening in the drum- membrane proper, or through the soft parts situated be- tween the bone above and the membrana tympani below, or, finally, directly through a sinus situated in some part of the bony wall of the auditory canal. In a smaller number of cases the discharge owes its origin to a dis- eased condition of the auditory canal alone, the tympanic cavity participating very little or not at all in the morbid process. When the discharge comes from the cutaneous walls of the auditory canal, the employment of the douche, from one to three times a day, with a warm saturated solution of boric acid (about two teaspoonfuls to the pint), often suffices to put an end to the discharge in the course of a very few days. After such an ear-bath it is a good plan to have the patient introduce vaseline, or a weak mixture of oil of Cade and vaseline (one drop to one drachm), into the canal. As soon as the discharge seems to have been arrested, the douche should no longer be used. The inner end of the meatus may then be dusted with iodoform ; and if, at the end of three or four days, it be found that the discharge has really ceased, all further treatment may be dispensed with. Now and then, however, this simple treatment will not suffice. The instillation of a few drops of a strong solu- tion of nitrate of silver (from forty to eighty, or even one hundred and twenty, grains to the ounce of water) may then be tried. Such strong solu- tions should not be allowed to remain in the ear longer than two or three minutes, and if they seem rather to aggravate the disease, as sometimes happens, we may rightly begin to suspect that our diagnosis is at fault, and that the disease is in reality an affection of the tympanic cavity, or that an undiscovered spot of caries exists-prob- ably close to the membrana tympani, in the ante- rior cul-de-sac of the canal. When the skin of the canal is found to be in a granulating condition, the actual granulating spot calls for the same therapeutic procedures as are appropriate for granulations in any other part of the body. I have not sufficient space for the dis- cussion of these procedures ; and furthermore, I am confident that they are fully discussed in one of the next articles. The same remarks apply to polypoid growths and localized caries, conditions which are occasionally observed independently of any coexisting disease of the middle ear. The treatment of an otorrhoea which owes its continuance to disease of the middle ear, must vary according to the conditions ascertained to exist in each individual case. The sim- plest conditions are these: A subacute inflammation of the tympanic mucous membrane, from the free surface of which a purulent or sero-purulent fluid is constantly escaping ; a perforation, not less than half a millimetre in dia- meter, in the central or lower part of the membrana tympani; and a con- stitution free from the taint of tuberculosis or syphilis. The first thing to be sought in our local treatment is local cleanliness-to prevent the pus from undergoing too rapid decomposition, and from lying (while in this decomposed state) in contact with the drum- membrane. The frequent use of the douche, with the warm satu- rated solution of boric acid, will very soon rob the discharge of all its irritating prop- erties. Dusting the drum-membrane and inner half of the auditory canal, from time to time, with powdered iodoform, will also conduce to the attainment of the same object. In many cases these simple measures will suffice. Generally, however, an otorrhoea of several weeks' duration requires the employment of additional therapeutic measures. The most effective plan that I know of is to inject a weak solution of silver nitrate (gr. ij. to the ounce of water) through the perforation into the tympanic cavity. This may be accomplished by means of a slender glass or metal tube, attached to a tightly fitting elastic rubber cap (see Fig. 941); or, if the physician does not feel warranted in undertaking manipu- Fig. 941.-Middle Ear Pi- pette, for injecting reme- dial solutions into the drum cavity. 585 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lations which certainly require a certain degree of manual skill, he may fill the auditory canal with the solution, and then, by pressure, force some of it through the opening in the membrane into the middle ear. Such intratym- panic remedial applications may be made two or three times a week. If they fail, a very small mass of burned alum may be pushed through the perforation into the tympanic cavity. In not a few cases attention will have to be paid to the condition of the vault of the pharynx, and also to the general state of health, before a cure of the aural disease can be effected. Cod-liver oil is par- ticularly valuable in these stubborn cases. but it is generally possible, however young the subject, to determine whether or not an inflammation of the tympanum exists. 1. Pain.-This is often the first symptom that is ob- served. Children old enough to speak awake suddenly at night, crying, "My ear!" Adults find themselves, sud- denly seized with an agonizing pain. Persons with good habits of observation, when attacked by such a pain, usu- ally recall the fact that the pharynx feels thickened and full, and the throat Sore, for a few hours before the onset. This is not always the case, however. The pain is usu- ally sudden in origin, and if unrelieved goes on increasing in intensity until suppuration and rupture of the mem- brana tympani occur. 2. Fulness in the Ear.-A marked sense of fulness or stuffiness of the tympanum is another subjective symp- tom that is very trying. This symptom very often lasts long after the pain has passed away. It is also a symp- tom, when unattended by pain, of subacute and chronic inflammations. 3. Tinnitus Aurium.-This symptom, common to all affections of the tympanum, is a violent one in acute in- flammation. In the first stages it is usually of a puffing or blowing character. 4. Resonant Sound of One's own Voice.-This symptom, sometimes called autophony, is somewhat annoying, but hardly painful. It belongs to the stage of the disease im- mediately after the severe pain. Patients at this time also speak of the conveyance of vibrations to the ear, in walk- ing, for example. This symptom is due to the increased capacity of the tympanum as a resonator, from its being stuffed with mucus. 5. Vascular Injection of the Membrana Tympani.- There is sometimes a pinkish hue to the whole surface of the membrane ; again it is only upon the periphery of the membrane, and along the handle of the malleus, while the other parts of the membrane are of a normal color. Spots of redness are sometimes seen in a drum-head, thickened and opaque from a former inflammation. In extreme cases, the membrane is so injected as to present an evenly red color. In mild cases the drum-head has a moist, dull appearance. 6. Impairment of Hearing. - This is not always a marked symptom in the early stages, that is, the first few hours of an acute catarrh of the tympanum ; but it soon occurs, and with it an increase of the bone-conduction over the aerial occurs, ■when a C2 tuning-fork is used. Sometimes, however, the pressure upon the fenestra oralis is so great as to cause an increase of the aerial conduc- tion. 7. Bulging Outward of the Membrana Tympani.-After the first forty-eight hours, even if the pain be fully re- lieved, this symptom may usually be observed in adults. In children it is difficult to make out the bulging, for there is apt to be great hyperaemia and sometimes swell- ing in the auditory canal, even in the initial stages of the disease. In very rare cases the imperforate membrana tympani may pulsate synchronously with the heart. 8. Pharyngitis and Tonsillitis with ar without Coryza.- All these symptoms may exist together, or the coryza only may be marked. 9. Fever.-Increase of temperature usually exists, cer- tainly in all severe cases. The temperature of the external auditory canal, with that of the general surface of the body, may be heightened. Causes.-Undue exposure to cold, especially through a draught, is one of the chief causes of acute catarrh of the tympanum. Ducking and diving under water, and carelessness in surf-bathing-that is to say, allowing the wave to strike the side of the head-are frequent causes of the disease. It is also often a consequence or accompani- ment of constitutional diseases, such as scarlatina, mea- sles, pneumonia, parotitis, small-pox, whooping-cough, syphilis, or cerebro-spinal meningitis. Coryza, however caused, may give rise to acute catarrh of the tympanum. The origin of the disease is chiefly to be found in the faucial extremity of the Eustachian tube, and not in the auditory canal, but inflammation of the tympanum does In a second set of cases the conditions are the same as in those which we have just been considering, except in regard to the size of the perforation. The latter is of such small dimensions that injections cannot well be made through it into the tympanic cavity. These cases are often very stubborn. In a third set of cases the discharge persists despite our best efforts to arrest it, and despite anatomical condi- tions which are very favorable to thorough intratympanic medication (viz., an auditory canal of full size, and a comparatively large perforation in the membrana tym- pani). The failure of our therapeutic efforts in these cases can generally be traced to the existence-in some concealed part of the middle ear-of a polypoid growth, or of a circumscribed area of bone caries, or to the fact that the mastoid antrum-a side cavity of the middle ear which is practically beyond the reach of local treatment -is the chief seat of the disease. Frequently repeated cleansings of the tympanic cavity will sometimes cause a circumscribed caries to heal, or at least to dry up for a longer or shorter period. In a few cases we may have the good fortune to bring a concealed polypoid growth into view by careful manipulations with a slender probe. The removal of the mass with the wire loop of a Blake snare may then effect a complete and permanent cessa- tion of the discharge. Finally, in a fourth set of cases, the discharge escapes entirely through an opening in the soft parts which lie immediately above the membrana tympani, or even, in some instances, through a fistulous canal in the bone which forms the upper and posterior wall of the osseous ■external auditory canal. The discharge in these cases is usually foul-smelling - an almost sure indication that there is stagnation and consequent decomposition of pus in the deeper recesses of the ear. In some instances the fistulous opening is of such breadth that effective cleans- ing procedures can be instituted and a comparative cure effected. In others, however, this is not practicable, and the disease then continues its course until an intercurrent acute attack reveals the danger of the situation, and leads to the establishment of an adequately broad counter-open- ing in the mastoid process. Albert H. Buck. EAR: NON-SUPPURATIVE INFLAMMATIONS OF THE TYMPANUM. I. Acute Inflammation of Tym- panum.-The term inflammation of the tympanum is more comprehensive than it seems to be, for there is scarcely an inflammation of this part that does not involve the mastoid cavity and Eustachian tube as well. It will be understood, then, in writing of an inflammation of the tympanum, that one of the middle ear is meant. The chief seat, however, of an inflammation of the middle ear is usually the tympanic cavity. Most of the serious symptoms arise from lesions in this part. Inflammation of the tympanum, however it may pro- gress, generally begins as a catarrh. In many instances the stage of acute catarrh is very brief, and suppuration is the first process recognized both by the physician and the patient. Acute catarrh of the tympanum or middle ear is a veiy common affection in the northern and middle zones. It is generally known among the laity as "earache." It is safe to assume that nine-tenths of all painful affections of the ear result from acute catarrh or suppuration of the tympanum. Symptoms.-In the adult these are unmistakable. In very young children the diagnosis is sometimes difficult, 586 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. at times originate with the auditory canal, either from a draught of air, or the violent entrance of water into it. Water sometimes enters the tympanum in the treatment of the nose by means of the nasal douche, the posterior nares syringe, or even when water is drawn into the nos- trils by the patient himself. The nasal douche (Weber's) is, however, the only one of those means of treatment that may be said to be so dangerous as to be wholly dis- carded. Treatment. - An acute inflammation of the tym- panum usually requires active treatment, especially in adults. The practitioner should at once combat the strik- ing symptom, that is, the pain. The first means to be tried is the hot douche. Water of the temperature of from 90° to 100° F. should be allowed to run into the ear, from a fountain syringe or the like. The stream of water should be continuous, hence, the piston syringe is of no use. This instrument is only valuable as a means of cleaning the ear, or of removing a foreign body. In case the warm douche fails to give relief in a few min- utes, and the patient be not an infant or a very young child, from one to four or even six leeches should be ap- plied upon the tragus, according to the severity of the symptoms and the age of the patient. In addition to this the patient should usually be confined to his room, and be in bed, while the general indications of the disease, the condition of the bowels, the skin and pharynx, are met by appropriate treatment. Usually the leeches will soon subdue the pain, and appropriate hygiene, without drugs, will allow the case to go on to recovery. It will some- times be necessary to repeat the leeching and to continue the use of the douche for some days ; opium may also be required, but opium without local blood-letting will be of little or no service. Some authorities speak well of the instillation of a solution of sulphate atropia, gr. ij. ad |j.,and of hydrochlorate of cocaine in a four-per-cent, solution, instead of the warm douche, but these remedies will not avail, except in mild cases. Hot vapors are some- times of service. An old remedy is a poultice applied in the canal. The " heart " of a hot onion is especially used. Such a poultice will quiet the pain in many cases, but since it favors suppuration, and may lead to suppuration of the drum-head, its use is not generally proper. When there is bulging of the drum-head, and perfect relief from the agonizing pain is not secured by the use of leeches and the hot douche, paracentesis of the drum-head should be performed. Bulging with- out pain may be recovered from without an open- ing, although such a drum-head will usually per- forate sooner or later. It is better to anticipate the slow process of nature by making an artificial opening, when we have good reason to believe that one will occur. Paracentesis should be performed with a good illumination of the drum-head, and while the patient's head is well supported. It is undecided, as yet, whether the preliminary instil- lation of cocaine lessens the pain from this op- eration. It is, however, not great in a distended membrane. Various needles, some of which are angular, some straight, have been invented for this operation. In case of need, an oculist's cataract needle or narrow knife (Graefe's) will serve very well. The accompanying figure shows the instru- ment I usually use. The perforation should be made at the point of greatest bulging. Politzer's method of inflation should be practised daily as soon as the acute symptoms have sub- sided, and the pharynx should be freely washed by a saturated aqueous solution of warm chlorate of potash, Vichy, or the like. In the case of young children and infants, inflation is of use in lessening the pain in sub-acute cases, and should be prac- tised at once. This treatment should be persisted in until the hearing-power becomes normal, as tested by the watch, tuning-fork, and the human voice. If acute inflammation of the tympanum occur in connection with serious general disease, the symptoms are not apt to be as violent as when it occurs as an apparently local affection, but the practitioner should nevertheless follow the above treatment, in gen- eral, and, if possible, prevent acute suppuration of the tympanum. Infants and very young children rarely recover from acute catarrh of the tympanum without a perforation of the membrana tympani, but occasionally this may be recognized so early as to enable the practitioner to secure by the use of the hot douche, or the instillation of co- caine, resolution without suppuration. A case of acute inflammation of the tympanum, promptly recognized and treated, usually terminates in full recovery. In less favorable cases suppuration occurs, but this also, when properly treated, is a tractable dis- ease. It is unfortunately the case, however, that death has occurred from acute inflammation of the tympanum even where the cases have been at once made out and promptly and properly treated. Such cases have usually occurred in adults who could not be induced to believe that their disease was a serious one, and who would not conform to the advice of the physician as to mental and bodily rest. The adult who is seized with acute inflammation of the tympanum should be placed under close observation, and be kept from harassing or fatiguing occupations, until all the acute symptoms are fully sub- dued ; for inflammation of the membranes of the brain is not a rare consequence of what is sometimes thought to be an insignificant affection. As Troltsch wisely said years ago, " Each inflammation of the lining membrane of the tympanum is essentially a periostitis." II. Sub-acute Non-suppurative Inflammation of the Tympanum.-Some German authorities have ob- jected to the classification of acute inflammation into acute and sub-acute. But there is such a large number of cases that are neither acute in severity of symptoms, nor chronic in duration, that I think the arrangement of the various types of tympanic disease into acute, sub- acute, and chronic is exceedingly convenient. Sub-acute catarrh of the tympanum, although occur- ring at all ages, is more common in children and young persons than in adults. Symptoms.-The absence of pain, or at least of severe pain-that which will prevent the patient from sleep at night-is the chief means of distinguishing acute from sub-acute non-suppurative inflammation of the tympa- num. The chief subjective symptoms are as follows: The patient is frequently very hard of hearing, but usually only for a few days; but the attacks occur so frequently that the school-life of children who are sub- ject to them is seriously interrupted. Such patients are apt to be rather delicate children with catarrh of the nostrils and pharynx, and enlarged tonsils. Yet this inflammation may occur in vigorous children and young persons, but they usually have an unhealthy naso- pharyngeal mucous membrane. Objectively, the mem- brana tympani is found to have lost its transparency, and is often vascular. The light spot is either absent or smaller than usual. The hearing is markedly impaired, and the bone conduction, except in exceptional cases, when pressure is made upon the labyrinth from the tympanum, is better than the aerial when tested by a C2 tuning-fork. It is a very suspicious thing when a child does not seem to hear perfectly well, and before malingering or stupidity are assigned as causes, such a child should be carefully examined as to the condition of the ears. It would be well if careful examination of the hearing power of chil- dren in schools were regularly made, for a frequently re- curring or persistent non-suppurative inflammation of the tympanum unfits a child for the proper appreciation of its studies or surroundings. Causes.-The general condition will usually be found to be the point of origin of these cases. Improper habits of life, or care, lead to naso-pharyngeal disease, which ex- tends to the mucous membrane of the tympanum. For example, children are not properly and regularly fed; they are not sufficiently clad ; their nutrition and vigor are so impaired that they easily take cold. In the case of boys, especially, frequent and prolonged bathing or swimming, with immoderate indulgence in ducking and Fig. 942. 587 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. diving, is a frequent source of non-suppurative inflam- mation of the tympanum. Treatment.-Hygienic regulation of the general con- dition will generally be the first indication in the treat- ment of this disease. Patients have recovered with this treatment alone ; but since the invention of Politzer's method of inflating the tympanum, we have the means at our command of at once relieving the most prominent symptom in these cases, the impairment of hearing. This is an advantage in treatment not to be overestimated, for in many cases a timely use of this method enables the patient to discharge his daily duties while the gen- eral treatment, which may prevent future attacks, is be- ing carried on. It is not necessary to use the Eustachian catheter in very young children, but in adults the use of the catheter renders the subsequent inflation by Politzer's method more thorough and effectual. In the absence of an air-bag a bit of rubber tubing, through which air is blown from the lungs of the surgeon, becomes an efficient means of inflating the ear (James Hinton). In young children its use is better than that of the air-bag, as it is usually less alarming. It is not necessary that they should swallow anything given to them, in order to suc- cessfully inflate the ears. If they cry or struggle a little the Eustachian tube will be sufficiently open to allow the air to be forced through it. It will sometimes be neces- sary to remove enlarged tonsils, and to systematically treat the naso-pharynx, in order to prevent recurrences of the disease, although not to restore the temporary loss of hearing ; but the practitioner will be wise to be on his guard, and not to rely too completely upon active local treatment of the mucous membrane of the nostrils and pharynx. In most cases, cleansing the nostrils and pha- rynx with mild solutions of common salt, chlorate of potash, or the like, with applications of tincture of iodine dissolved in glycerine, applied to the nostrils and pharynx by means of a cotton-holder, will be sufficient to improve the condition of the usually hypertrophied mucous mem- brane. In other cases astringents, such as sulphate of zinc, gr. ij. or § j., will be useful. For cleansing, a solu- tion known as Dobell's, a mixture of carbolic acid, soda bicarbonate, soda biborate, glycerine, and water, is very efficient. It is best used by means of a coarse spray from one of the numerous nebulizers or atomizers now generally employed. The pathological condition of the middle ear in these cases is probably an hypertrophy of the lining membrane, with collection of mucus in the faucial orifice of the Eustachian tube, or in the calibre of the tube or the tym- panum itself. The inflation removes the mucus and re- stores the mobility of the ossicles, hence the instantaneous improvement to the hearing from inflation. III. Haemorrhagic Inflammation of the Tym- panum.-This is a rare affection, but it is one that oc- curs in a constant proportion in any large number of aural cases.1 In one institution for the treatment of dis- eases of the eye and ear, it was seen in 10 cases out of a total number of 7,812 aural cases observed in twelve years; and since the first case was reported, in 1872,2 several cases have been published. The disease is characterized by very severe pain, which lasts at the most but a few hours, and then terminates with a haemorrhage through the membrana tympani. Pus does not usually form after this, but the blood is gradually removed and the membrana tympani is restored to its normal condition. The opening in the drum-head is usually circular. Haemorrhagic inflammation of the tympanum is simply an acute inflammation of the tym- panum or middle ear, which has an unusually violent and rapid course, so that the walls of the vessels are broken through. The perforation probably occurs from the dis- tention of the tympanum, and of the membrana tympani. If cases likely to become haemorrhagic are seen at a very early stage, that is to say within a few minutes after the onset, they might possibly be aborted by the use of leeches. This would be proper treatment, but it is con- jectural whether treatment would effect this, since all the cases have been seen by physicians after the perfora- tion has occurred. Haemorrhage into the membrana tympani without per- foration of this membrane has been observed. It some- times occurs after the use of the nasal douche. It is usually attended by severe pain, and requires the ordi- nary treatment for acute inflammation of the tympanum. Haemorrhage into the tympanum has been seen in the course of Bright's disease, and also in old persons simul- taneously with haemorrhagic retinitis. Such an affection requires no especial treatment. The auditory canal should be very gently and carefully freed from blood when there is sufficient quantity to clog it, but, as in traumatic haemorrhage into the canal, great care should be exercised that no injury be done to the lining membrane of the canal or the drum-head in the re- moval of the blood. It is generally better to remove it by means of absorbent cotton upon an ordinary cotton- holder, the cotton being moistened with some bland fluid. In reporting a case of otitis haemorrhagica, McBrides explains the occurrence of the haemorrhage by the phys- ical conditions of the tympanum. After alluding to the fact that the early changes of inflammation are character- ized by dilatation of the arteries, he assumes that an in- flammation of the tympanum " occurs on a surface which is under less pressure than any other part of the body," and then concludes that haemorrhagic inflammation of the tympanum is one that has been aborted by rupture of the distended arterioles. IV. Chronic Non-suppurative Inflammation of the Tympanum (chronic non-suppurative inflammation of the middle ear).-This is one of the most frequent of all the affections of the ear, although of late years it is probable that a small proportion of cases of disease of the internal ear have been improperly included in this category. Be this as it may, chronic non-suppurative in- flammation of the tympanum still remains the most com- mon form of disease of the ear. It is, however, to be be- lieved that the recent advances in the diagnosis and treatment of diseases of this organ, leading as they do to the proper care of subacute and acute inflammations of the tympanum as well as of diseases of the naso-pharyngeal mucous membrane, will finally lessen the numerical pro- portion of what is usually an incurable disease. Chronic non-suppurative inflammation of the middle ear may be divided into two varieties : 1, catarrhal; 2, proliferous. It is not well to make subdivisions of inflammations of the drum-head, the tympanum, or of the Eustachian tube. It is doubtful if such divisions actually occur in disease of the ear. The Eustachian tube, the tympanum, and the inner layer of the membrana tympani are all parts of the middle ear, their diseases seldom occur independently. On the other hand, diseases of the middle ear in time ex- tend not only to the auditory canal, but also to the laby- rinth. Symptoms.-Those who suffer from chronic catarrhal inflammation of the middle ear usually complain of feel- ings of stuffiness in the ear, of a sensation as if something were in the ear. Sometimes, although not generally, of vertigo, and especially of noises in the ear, or in the head, tinnitus aurium. This latter-named symptom is com- mon to both the catarrhal and proliferous forms of non- suppurative inflammation, and it is generally a most an- noying and distracting symptom. Persons have been known to commit suicide on account of it. On the other hand, distinguished and successful men and women have suffered from it all their lives, without allowing it to in- terfere with their duties. The character of the sounds of which the patients speak are described with a vividness that varies according to the subject's mental powers, oc- cupation, musical education, and so forth. The roar of the sea, the hum of a tea-kettle, musical notes, the chirp- ing of birds, are often compared to tinnitus aurium. Such sounds are in some instances pleasant, and never as troublesome as ringing and thumping sounds. Besides subjective tinnitus aurium, there are also cases in which the sound may be heard by the examiner as well as by the victim himself. This is usually inter- mittent, and the sound is what is known as crackling. This kind of tinnitus probably depends upon spasmodic action of the muscles of the tympanum or Eustachian 588 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Kar. Ear. tube, or both. It generally occurs in catarrhal cases of a pronounced type, and the subjects do not appear to be persons of well-balanced minds. They soon learn to produce this crackling sound at will, and make themselves more unhappy by constantly repeating it when there is considerable catarrh of the middle ear. The sound may be caused by moving the lower jaw rather rapidly. There is also a venous murmur in the ear transmitted by the jugular vein in certain cases of anaemia, and also a pulsating sound in aneurism, coming from the internal carotid as it takes its sinuous course through the apex of the petrous bone. The cause of tinnitus aurium is probably to be found in a disturbance of the intra-tympanic pressure (Field4). The pharynx is very much complained of by many pa- tients with chronic catarrh of the middle ear, while others, who suffer quite as much apparently from increased naso-pharyngeal secretion, do not speak of this symptom. Neuralgic pains in the ear are often spoken of by suf- ferers from chronic non-suppurative inflammation, but the symptom seems to appear only at intervals, and then only for a short time. The objective symptoms of chronic catarrh of the tympanum, or middle ear, are well marked 1. Impairment of Hearing.-This is usually very evi- dent, for the cases seldom come under the notice of the physician until both ears are affected. It may be distin- guished from the impairment of hearing from disease of the nerve, by the fact that it is not good in any range, and that it is better in a noise, especially in such a noise as that of a railway train, or that of machinery. Hear- ing better in a noise is a symptom common to the various forms of tympanic disease when the affection is on both sides, but it is particularly noticed by those who suffer from chronic and advancing affections. This improve- ment of the hearing in a noise was once referred to in- creased susceptibility of the acoustic nerve, but the more probable explanation is to be found in some mechanical effect (increased vibration ?) made by the great din upon the ossicles of the tympanum, and especially upon the ar- ticulation of the stapes with the fenestra ovalis. 2. The tuning-fork, C2, when placed upon the mastoid process or other bones of the head, is heard better through them and for a longer time than when placed in the air in front of the meatus. For the sake of brevity in de- scribing this symptom, it is said that bone conduction is better than aerial. 3. Changes in the Membrana Tympani.-Opacities and alteration of the shape of the light spot in the membrana tympani do not always indicate that there is disease of the tympanum at the time they are seen. They may be, and often are, the result of old inflammations which have run their course without materially, if at all, injuring the hearing power. A normal membrana tympani is of a neutral gray or dark blue color. The lustre and transparency vary ex- ceedingly. The light spot is of the shape of an equilat- eral triangle, the apex of which is found at the extremity of the handle of the malleus. ' Such a membrane as this is seldom found, even in persons with good hearing power. The normal light spot is found but in a very small proportion of cases of non-suppurative disease of the middle ear. It is sometimes entirely absent, generally it is small. Changes in the curvature of the membrana tympani, its rigidity, the retraction of the hands of the malleus, are positive evidences of disease of the tympanum and Eus- tachian tube. They indicate that adhesions have occurred in the tympanum between the joints of the ossicles. In some cases adhesive bands have been found stretching across the tympanum. Siegle's otoscope, with a syringe attachment for exhausting the air (Pinkney, Ely), is a good means of testing the mobility of the drumhead. A sunken drumhead has, ever since the publication of Sir William Wilde's writings on the Ear, been generally re- cognized as a prominent symptom of chronic non-suppu rative aural inflammation. It results from the retraction of the chain of ossicles, and from the exhaustion of the air in the tympanum. Proliferous inflammation of the tympanum reduces the size of the air-chamber of the ear very markedly. It has been found actually plugged with neoplastic material. 4. Changes in the Eustachian Tube and Naso-pharyngeal Region.-In cases of catarrhal non-suppurative inflamma- tion these changes are positive. In the proliferous form they are not at all marked. The faucial orifice of the tube is red and swollen. It is often difficult to get air through the tube into the tympanum. Sometimes the patient does not experience any sensation of air passing into the tympanum, when the redness of the membrana tympani, or an alteration in the curvature of the mem- brane, show that it has actually entered. In such cases it is' possible that morbid changes in the tympanum have led to atrophy and want of sensibility of the mucous membrane. The changes in the naso-pharyngeal mucous membrane are often marked. They are usually of a hypertrophic character. Yet there are large numbers of cases of naso- pharyngeal catarrh with no affection of the ear. The tonsils are sometimes enlarged, chiefly in young subjects. In older ones they often show that they have been the seat of frequent abscesses, and are cicatricial and shriv- elled. The pharynx is rough and granular, adenoid veg- etations are seen in youth. They are usually removed by absorption before middle life. Increased secretion of the mucous membrane of the nostrils and pharynx is the most constant of the symptoms that accompany chronic catarrhal inflammation of the middle ear. Many authorities attach importance to the sounds heard in the passage of air into the tympanum through the Eustachian catheter. For the purpose of hearing them a tube of india-rubber is placed by one tip in the external auditory canal of the patient, while the other rests in a similar way in the ear of the examiner. The symptoms of the proliferous form of chronic non- suppurative inflammation of the middle ear differ essen- tially from those of the catarrhal variety only in the fact that there are no changes in the naso-pharyngeal region. There is no catarrh of these parts, nor of the tympanum, while there may be evidences of atrophy of the mucous membrane. The drumhead is usually more sunken, the tympanum less sensitive to the entrance of air or fluid, while the tinnitus aurium is more distressing, and there are no considerable variations in the hearing. This vari- ation in the hearing capacity is very marked in some ca- tarrhal cases. Some patients hear better on clear, dry days, and correspondingly worse on damp ones. Climate has much influence upon such cases. Pathology.-The following named changes have been observed in chronic catarrhal inflammation of the tym- panum : 1. Collections of mucus or serum distending the tym- panic chamber. 2. Hypertrophy of the mucous membrane. 3. Filling up of the cavity with lymph. In the proliferous variety, and in the cases in which the two forms are mingled, the following changes have been found : 1. Connective-tissue formations. 2. Dense,, fibrous tissue covering the walls of the tube and filling up the tympanum. 3. Hypertrophy of the bony walls. 4. Anchylosis of the foot-plate of the stapes bone. _5. Exostoses of the ossicles. 6. Anchylosis of the malleus and incus. 7. Bands of adhesions in the mastoid cells. 8. False membrane on the tendon of the tensor tym- pani muscle. 9. Adhesion of the membrana tympani to the walls of the labyrinth. 10. Atrophy, and fatty and fibrous degeneration of the tensor tympani. 11. Pseudo-membranous growths, sometimes filling the whole cavity with an irregular network, and sometimes covering the fenestra rotunda and the tympanic orifice of the Eustachian tube.6 Causes.-The causes of this disease are exceedingly numerous and are not easily classified. We may say in 589 Ear. Ear, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. general terms, however, that they are all to be sought for in those influences known to predispose to catarrh. In this manner, inherited or acquired syphilis, phthisis pulmonalis, bronchitis, among diseases, and especially defective hygienic management, become causes of chronic non-suppurative aural inflammation. The Eustachian tube and tympanum are affected in very many cases of naso-pharyngeal inflammation, how- ever occurring. Repeated attacks of acute inflammation of the middle ear probably leave morbid changes- especially if the acute disease be not adequately treated-which predispose to the insidious progress of chronic disease. This insidiousness is one of the marked features of the disease now under discussion. Patients have often lost a great deal of hearing power, especially of one ear, before they are aware that their hearing is impaired, or at least, in some cases, before they admit that their hearing is not entirely perfect. This disposi- tion to conceal a loss of function is especially marked in persons suffering from chronic aural disease. It is prob- ably due to the knowledge that, in the community at large, persons who are partially deaf are shunned and not pitied. The syphilitic catarrh, or "snuffles," of infants, some- times leads to an incurable proliferous inflammation of the tympanum. The disease of the eye which generally accompanies the interstitial keratitis is often com- pletely recovered from, but if intra-tympanic adhesions occur and the membrana tympani be greatly retracted, the hygienic and specific treatments which seem to effect so much for the disease of the cornea, often accomplish nothing, and the subjects become deaf. Chronic proliferous inflammation of the tympanum is specially apt to begin during a first pregnancy, and to receive an impetus at each succeeding one. At the menopause, the tinnitus is often much worse if chronic non-suppurative inflammation exist when that period be entered upon. But an affection of the acoustic nerve is more apt to occur during the change of life, than one of the middle ear. Cerebro-spinal meningitis is a prolific source of non- suppurative disease of the middle ear. During the early stages of the disease the tympanum is sometimes affected. Either with or without a disease of the labyrinth, ad- hesions occur between the ossicles, the tympanum may be filled up, and complete deafness, in young subjects deaf-mutism, results. The deafness from a blocking-up of the tympanum and the ossicles may be so profound that no sounds conveyed through the air alone are heard, while they may be still heard if the vibrating body touch the bones, or the vibration be conveyed to the ear through a tube in the auditory canal. Parotitis also may cause a proliferous inflammation of the middle ear, although from our present knowledge it is probable that disease of the labyrinth is more frequently caused by mumps. Scarlet fever and measles are much more apt to cause suppuration in the tympanum than non-suppurative inflammation. Treatment.-The treatment of chronic non-suppura- tive inflammation of the middle ear is not satisfactory, for the reason that in a very small proportion of cases, and those in young subjects, is complete recovery known to occur. We have not yet found, in the numerous varie- ties of remedies and modes of treatment that have been proposed, any means that are even tolerably certain to cure a well-defined and established case of the disease. Even to arrest it, is often an exceedingly difficult, and always a doubtful, task. With these reservations the ap- proved treatment of to-day is here given. Constitutional treatment by means of hygienic directions is of the utmost importance. In the first rank among these stands care of the skin, by daily bathing and rubbing, with attention to the proper clothing of the body. A change from a rigorous climate to a mild one is also of great service in some cases, especially in relieving the distressing tinnitus. In our country the climate of Southern Georgia, and of some parts of North Carolina, is especially favorable to patients with chronic catarrh of the ear; while that of Colorado is not adapted to the alleviation of this disease. In Europe, the south of France and such places as Meran, in the Tyrol, seem to be well adapted for winter residence of patients suffering from non-suppurative aural inflammation. Some authorities (Theobald) advocate the use of mer- cury in alterative doses in chronic non-suppurative in- flammation. I am not sure that I have seen any effect from specific medication of any kind, in a case of chronic non-suppurative disease of the middle ear, when uncom- plicated by syphilis. The practitioner will find much to do in a general way to prevent the steady advance of this distressing disease. Applications to the naso-pharyngeal spaces are of the first importance in catarrhal cases. Above all, excessive secretion should be removed. This may be accomplished by the Davidson syringe, the posterior nares syringe, or a coarse spray producer. Salt and water, solutions of chlorate of potash, tar-water, and mixture of glycerine, soda biborate, soda bicarbonate, and carbolic acid (Dobell's solution) are es- pecially valuable for cleansing the nos- trils and pharynx. Sometimes it will be necessary to remove enlarged tonsils, or hypertrophied nasal mucous mem- brane. The nasal douche is a danger- ous means of cleansing the nostrils ; many cases of serious damage to the ears from its use have been reported, even when all precautions are taken to prevent the entrance of fluid into the tympanum. The treatment of the Eustachian tube and tympanum by inflation is one of the most important means now used for the alleviation and arrest of chronic non-suppurative inflammation. The Eustachian catheter and the air-bag (Politzer) are the chief means of carry- ing on this treatment. The Eustachian catheter is best made of hard rubber. The cut here given shows the curve and actual size of such instrument. The method of using it is fully de- scribed in the text-books. Atmos- pheric air is the agent most fre- quently used through this instrument, even in the treatment of chronic dis- ease. The vapor of iodine and cam- phor is useful, especially in the cases in which the catarrhal symptoms are not marked, or in the proliferous form. A convenient apparatus for the use of this vapor is delineated in Fig. 944. The camphor and iodine may be used in the proportion of 3 ij. of gum camphor to § iij. of tincture of iodine. After inflating the tympanum by the catheter, it is well to use Politzer's method three or four times. In cases of advancing inflammation of the mid- dle ear, the treatment by inflation should be used daily for about three weeks, or every other day for double that time. This local treatment should be usually undertaken twice a year, as long as the disease appears to be progressive. The treatment of the nares and pharynx may be constantly required for years. It may be left to the patient himself, while that of inflation should usually be carried only by a surgeon. In catarrhal cases, sulphate of zinc, gr. v. ad 3 j-, may be injected through the catheter into the mouth of the Eustachian tube, and perhaps, in some cases, into the tympanum itself. A few drops of the solution are placed in the distal extremity of the catheter and forced into the tube by means of an air-bag. Other agents, such as iodide of potassium, two to five grains to the ounce ; sul- phate of copper, one-fourth to one grain to the ounce. Fig. 943.-Eustachian Catheters. (Roosa.) 590 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. may also be used in the same way. In cases where sim- ple air cannot be felt in the tympanum, or does not seem ton, is a useful means of lessening the retraction of the drum-head in some cases of chronic non-suppurative in- flammation. Tinnitus is the symptom usually relieved when benefit occurs from this method of treatment. The plug should be oiled and placed hermetically in the meatus on retiring at night. D. B. St. John Roosa. 1 Report of Brooklyn Eye and Ear Hospital, 1883. 2 Transactions of the American Otological Society, 1872. 3 Archives of Otology, vol. xiv., p. 99. 4 Diseases of the Ear. p. 208 et seq. 6 Toynbee: Catalogue, London, 1857. Archiv fur Ohrenheilkunde; Monatschrift fur Ohrenheilkunde; Guy's Hospital Reports ; Gruber's Lehrbuch; Transactions American Otological Society; Moos's Klinik der Ohrenkrankheiten. Schwartze: Pathology of the Ear, translated by Orne Green. EAR: PURULENT INFLAMMATION OF THE TYM- PANUM. Synonym: Otitis media purulenta seu perfo- rativa. I. Acute Purulent Inflammation of the Tym- panum.-Of 5,135 patients with disease of the ear, seen at the Boston City Hospital, this disease wras found in 11.5 per cent., and the sexes were nearly equally divided. This percentage is larger than that shown by most European and American institutions (six to seven per cent.), per- haps partly to be accounted for by climatic influences and partly by the fact that many acute inflammations of the ear occurring in the course of acute diseases in a large general hospital appear in the aural department of that institution. Pathology.-The disease is characterized by hyper- aemia of the tympanic mucous membrane, cellular and serous infiltration of the connective-tissue stroma of that membrane, and the exudation of many pus-cells into the tympanic cavity, with which are occasionally mingled granular corpuscles, granules, epithelium, and detritus, and often, also, more or less mucus. The mucous membrane appears in most cases bright- red, swollen even to a thickness of one or two millimetres, and deprived of epithelium. The chief exception to this is when the disease appears in the course of tuberculosis ; then the marked congestion and great swelling are often wanting, but the other appearances are the same. Per- foration of the drum-membrane occurs in the majority of cases. Occasionally the exudation is tinged with blood, owing to a rupture of some of the capillary blood-vessels. The anatomical changes usually extend over the whole mucous membrane of the tympanum, Eustachian tube, and mastoid cells. Schwartze1 has found that the swell- ing is greatest over the tympanic roof and promontory. The free anastomoses between the blood-vessels of the tympanum and labyrinth often lead to hyperaemia and serous infiltration of the labyrinthine structures, and oc- casionally to a purulent inflammation of these parts. Etiology.-The disease may appear primarily as the result of cold upon the meatus and drum-membrane, as from wind, cold injections, cold sea and river bathing; or, secondarily, from extension of an inflammation of the naso-pharynx to the tympanum, or from traumatism, di- rect, as in the case of wounds in the ear, or indirect, from blows upon the cranium or upon the ear itself. It is also very common in the course of scarlatina, measles, small- pox, abdominal typhus, tuberculosis, and diphtheritis, but whether in these diseases it is merely an extension of inflammation from the naso-pharynx, or whether it is an expression of the specific disease in the tympanic struct- ures has not yet been determined satisfactorily. It is not uncommon in pneumonia, influenza, and whooping- cough. According to Politzer it is rare as a result of non-scarlatinal pharyngeal diphtheritis, but very com- mon with scarlatinal naso-pharyngeal diphtheritis. The disease is very common in children. Symptoms, Subjective.-The accession of the dis- ease is marked by sharp, lancinating pains, referred by the patient to the depth of the ear usually, but in some cases shooting over the wdiole side of the head from the ear. Occasionally, even in the beginning of the inflam- mation, the pain, instead of being referred to the ear, radiates over the temporal and parietal bones. These pains are usually remittent, but rarely completely inter- Fig. 914.-Apparatus for Introducing Vapors into the Middle Ear. (Roosa.) to enter, a very few drops of chloroform (Prout) on a sponge, in the box used for injecting vapors by Politzer's method, will be effective. The chloroform seems to have some curative power in cases of proliferous inflammation. Bougies for dilating strict- ures in the Eustachian tube are still used by some au- thorities, but I have found no cases in which they are useful, chiefly because, as I believe, when strictures have occurred, the neoplas- tic changes in the tympa- num are also great and pre- clude much benefit from a dilatation of the tube. There is excellent author- ity, however, for using bougies in chronic non- suppurative inflammation Operationsup- on and through the membrana tympani, divis- ion of the ten- don of the ten- sor tympani, re- moval of one or more ossicles, have been prac- tically aban- doned in Great Britain and the United States in the treatment of chronic non- suppurative dis- eases of the tympanum. Exhaustion of the air in the au- ditory canal, by means of a carefully fitted plug of cot- Fig. 945.-Method of Using Politzer's Apparatus (with box for containing iodine or other evaporat- ing substance). 591 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. mittent, and are apt to be worse at night. In exceptional cases, however, pain is entirely absent, and the fulness, noises, and deafness are the first symptoms noticed by the patient. This absence of pain is often noticed when the disease occurs during tuberculosis and fevers. After the pain subjective noises are the most common symptom ; they are the accompaniments of the increasing congestion and exudation; are variously described as roaring, hissing, singing, pounding, and metallic ringing. They are due either to exudation pressing upon the sec- ondary labyrinthine fenestrae, or to hypersemia and serous exudation within the labyrinth. A high-pitched metallic ringing is characteristic of serious involvement of the labyrinthine structures. As the tissues of the ear begin to swell there is a feel- ing of fulness in the ear and side of the head, and as the disease progresses there may be marked febrile reaction, with a temperature of 101° to 103° F. The fever, how- ever, is by no means always present; in strong, healthy adults it is often entirely wanting, while in children and in debilitated persons it is usually found. An acute tympanic inflammation will not infrequently explain the marked rises in pulse and temperature which occur dur- ing convalescence from scarlatina, abdominal typhus, and other fevers. The functional disturbances in the earlier stages of congestion are so slight as to be unnoticed; but as this congestion is succeeded by swelling of the tissues, the vibratory power of the drum-membrane and ossicles is diminished and a certain degree of deafness is perceptible. As the pus is secreted and the tympanic cavity becomes filled the deafness increases, and if rupture of the drum- membrane does not soon occur, the pressure of the secretion may so force the secondary membranes inward as to partially or wholly paralyze the auditory nerve within the labyrinth. Aside from the ordinary tests with the watch and voice, the transmission of the sounds from which will be found to be very defective, the vibrating tuning-fork on the forehead and teeth affords valuable aid in diagnosticating the condition of the labyrinthine structures. If the deaf- ness is due to immobility of the conducting mechanism only, the tuning-fork on the forehead will be heard loud- est in the affected ear; if the perceptive power of the nerve is seriously affected, however, the fork is heard loudest or entirely in the unaffected ear. The nerve- paralysis from pressure of the tympanic secretion is rapidly relieved by evacuation of the tympanum, and the tuning-fork will show the change in the reappearance of bone-conduction ; if, however, after such evacuation of the tympanum the tuning-fork is still heard in the good ear, there exists something more than paralysis from pressure ; that is, there exists either infiltration or actual suppuration of the labyrinth. The differential diagnosis between labyrinthine infiltration and suppuration cannot be determined ; the former is very common, the latter very rare. From the former a very fair or even perfect recovery may take place; from the latter it is rarely, if ever, that the delicate structures of the labyrinth improve so far as to leave a useful ear. The functional disturbances of the ear may be said to increase up to the time of rupture of the drum-membrane, and from that point gradually decrease again, the hearing improving as the inflammation subsides. It will be found that the hearing improves more rapidly for the voice than for the watch, and on that account the voice is the better test. The swelling of the membrana tympani is very slow in disappearing, even when the inflamma- tion is subsiding satisfactorily, and several weeks, and sometimes two or three months, are necessary for its complete disappearance, and as long as any swelling re- mains some deafness is noticeable. Accurate testing of the hearing for the watch is, in young children, impossible, and with them testing for the voice alone has to be depended upon ; with a little care this, however, is perfectly satisfactory if they are required to repeat the words or sentences, or to answer some direct question. Symptoms, Objective.-(a) Inspection.-(1) Color. As the disease comes on, the first appearance noticed is a slight congestion along the manubrium, three or four reddish lines of capillaries showing themselves just be- hind and along the manubrium. Soon after this minute capillaries are noticed on the periphery of the drum- membrane and on the walls of the osseous meatus. These capillaries then extend from the periphery and from the manubrium toward the centre of the membrane as radi- ating lines, which finally unite, covering the surface of the membrane with a net-w7ork of red lines. Serous in- filtration of the tissues follows, with a loss of the lustre of the membrane and the disappearance of the manubrium beneath a solid, reddish swelling. The net-work of capil- laries changes to a mass of red over the whole membrane, which increases often to a bright scarlet, and in some cases almost to a purple, when the inflammation is very intense. 1 The epidermis becomes loosened in small flakes, giving a whitish mottled appearance over the red mem- brane, and when this loose epidermis is excessive it often completely conceals the redness. The retrogressive stage of the inflammation gives exactly the reverse of these appearances. If, after secretion is poured out in the cavity, the drum-membrane is subjected to great pressure, the intense redness may be diminished where the pressure is the greatest. (2) Translucency of the drum-membrane begins to dis- appear with the first serous infiltration, is wholly lost as the redness comes on, and is the very last normal charac- teristic of the membrane to return as the inflammation subsides. In many cases, however, it never returns, be- ing permanently destroyed by thickening, fatty degenera- tion, or calcification of the fibrous tissue. (3) The position of the membrane in the earlier stages of the disease is not altered. As the serous infiltration comes on it is probably flattened, but this is scarcely appreciable. As the pus collects behind it there is either a distinct flattening of the membrane throughout its whole extent, or, as is often the case, cir- cumscribed bulgingsappear in cer- tain portions. These appear as rounded prominences in any part of the membrane, more common- ly in the posterior lower segment, are paler in color than the sur- rounding membrane, and often distinctly yellowish at the apex. (4) The mobility of the mem- brane and conducting mechanism is always affected, and usually very much so ; this is due to the great increase in weight of the membrane and to the embedding of the ossicles in the swollen tissue. The increase of tension must also be an important factor in diminishing the mobility. (b) Auscultation.-As the secretion begins to form in the tympanum, distinct, moist rales can be heard on aus- cultation if the Eustachian tube is open ; later in the dis- ease, however, as the whole mucous membrane becomes involved, the Eustachian tube is generally so closed by swelling that all auscultation is impossible. As the swelling subsides later, the tube regains its permeability, and coarse, moist rales and bubbles are heard, and if per- foration exists and the cavity has been cleared from secre- tion, the air will be heard passing out through the per- foration with a distinct whistle, known as the perfora- tion-whistle. The course of acute purulent inflammation of the tym- panum varies somew'hat according to its cause, intensity of the inflammation, and the constitution of the patient, being prolonged when accompanied by serious naso- pharyngeal disease or by a debilitated state of the general system. The time at 'which perforation occurs varies also according to the resisting power of the drum-mem- brane and the rapidity with which the secretion is formed. It generally takes place in from a few hours to three or four days, but in rare cases does not occur till the inflammation has continued for three or four weeks. In most cases the perforation seems to be the result of Fig. 9-16.-Protrusion of the Posterior Upper Quadrant from Collection of Exuda- tion in the Cavum Tym- pani. (Schwartz.) 592 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear, ■simple rupture from internal pressure, but occasionally of softening and ulceration on the inner surface of the membrane, and exceptionally of ulceration on the outer surface, probably caused by defective nutrition produced by the pressure of the pus. The power of resistance of the drum-membrane varies; when perfectly normal the rupture occurs readily, but if the membrane is thickened from some previous disease the rupture is slow in taking place, and particularly in these cases there is danger to the labyrinth and brain from the retention of the pus. In certain cases no perforation takes place, due either to the lesser severity of the inflammation, to the small amount of secretion formed, or to a thickened drum- membrane. In these cases the pain is continued longer, and recovery is slower. The course of this form of the disease is usually increasing pain up to the beginning of the formation of secretion, when a certain amount of re- lief is experienced, followed again by increased pain as the secretion distends the cavity. As the inflammation subsides the swelling diminishes, the secretion is ab- sorbed, the pain and subjective noises gradually disap- pear, the latter more slowly than the former. The fever, fulness in the head, and giddiness, all pass off slowly, but there is more apt to remain an affection of the hear- ing, owing to permanent tissue-changes in this non-per- forative form of the disease, than in the more common forms accompanied by perforation. Perforation occurs in the majority of cases, and is the more favorable issue. It is often felt by the patient as a distinct bursting, and is always followed by profuse dis- charge. In many cases the pain ceases immediately, and the sense of fulness is greatly relieved ; in other cases the pain subsides gradually after the rupture, while occa- sionally no distinct relief is experienced, and the pain only ceases as the inflammation subsides. The general febrile symptoms, if such existed, are generally relieved by the evacuation of the secretion, as are also the fulness in the head, giddiness, and general nervous irritability. After perforation the secretion continues for some time profuse, but slowly diminishes as the inflammation sub- sides ; the membrana tympani loses its redness entirely, and slowly passes through the reversed appearances it showed as the inflammation came on. The discharge having ceased, or nearly so, the perfora- tion begins to close ; if a simple small rupture, by adhe- sion of its edges ; if it had become oval, by a gradual con- traction of its edges ; while if quite large a plastic material is thrown out by its edges, and this material unites into a cicatrix which closes the opening. In the first two forms of healing no sign of the perforation remains ; in the lat- ter, however, a well-marked cicatrix, destitute of any fibres of the membrana propria, continues through life, a fact which may be of importance in a medico-legal inves- tigation. The first form of healing takes place very rap- idly, for as soon as the diminution of the discharge allows the edges to fall together they unite, often in one night; in the second form the healing is more gradual, while in the last it is comparatively slow. The membrana tympani now appears grayish and des- titute of lustre ; the position of the manubrium is marked by a reddish swelling which conceals the bone ; the seat of perforation, after healing, is marked by red lines of capillaries radiating from it; if a cicatrix has formed this appears grayish-white and depressed below the plane of the membrane. Slowly the drum-membrane regains its normal appearance and translucency, the lustre of the membrane being the last characteristic to return ; but in many cases the normal translucency is never regained, opacities, general or circumscribed, due to thickening and degeneration of its fibres, continuing through life, or else calcifications or circumscribed atrophies appear and remain as permanent deformities. The duration of the disease to the closure of the per- foration is very variable ; in exceptional cases, where perforation occurs very early, the duration may be only a few days ; as a rule, where the perforation is not large, about four weeks is the average ; where, however, the perforation is large, the inflammation subsides, the dis- charge ceases, and the disease is apparently at an end long before the perforation is closed ; in these cases three, or even four, months being required to fully close the opening. Often, after healing has taken place, a long time is necessary to restore the hearing fully, and not in frequently a simple catarrhal inflammation is left in the tympanum; that is, there is an abnormal amount of mucus secreted from the tympanic mucous membrane. This catarrhal inflammation is especially apt to remain in those cases in which no perforation occurred. As has been said, the hearing for the voice usually returns more rapidly than that for the watch. The above, which may be called the common course of the disease, is liable to be interrupted (1) by constitutional causes, (2) by inflammation of the mastoid, (3) by otitis externa, (4) by granulations, (5) by extensive ulceration, (6) by meningitis. A low state of the general system from any cause- cachexia, scarlatina, and typhoid fever especially-may greatly prolong the disease. Inflammation of the mastoid is occasionally a serious complication, tending to keep up the tympanic inflamma- tion, and becoming itself the prominent feature in many cases. To avoid repetition the reader is referred to the section upon Mastoid Inflammation, later on. Otitis externa is occasionally developed secondarily to the tympanic inflammation, and more commonly in' the later stages of the disease. It consists generally of a dif- fuse inflammation of the soft tissues of the meatus, which are swollen, often so much so as to almost close the pas- sage. For a full description of otitis externa, the reader is referred to the article on Diseases of the Meatus ; in this place we are concerned merely with its recognition and with its influence on the tympanic disease. It can be recognized by the swelling of the walls of the meatus, sometimes directly at the orifice, sometimes a short dis- tance within the orifice, and also by marked tenderness on moving any part of the cartilage of the auricle ; this latter in itself is distinctive of the disease, arid upon it would depend the differential diagnosis between the swelling of the meatus which accompanies inflammation of the mastoid antrum and the swelling of an otitis ex- terna. Sometimes an otitis externa produces such inflam- mation of the tissues around the ear, particularly behind the auricle, as to strongly resemble an external mastoid periostitis, but the extreme sensitiveness on moving the cartilage, and the absence of tenderness of the mastoid bone on deep pressure, would distinguish it from true mastoid inflammation. The course of an otitis externa under appropriate treat- ment is usually from eight to ten days, but by neglect of cleanliness the epidermis may be destroyed and the whole meatus turned into a granulating and suppurating sur- face, in addition to the existing tympanic disease. Its influence on the tympanic disease is to prolong the latter by keeping up the congestion, and by interfering with the free drainage and thorough cleansing of the cavity, thus favoring ulcerative destruction. Granulations are occasionally developed in the course of an acute purulent inflammation, and as they serve to keep up the disease, their recognition and treatment is necessary. They are found sometimes on the edges of the perforation, sometimes on the walls of the meatus, and appear as red, fleshy masses, generally of small size, projecting from the surface, and are readily recognizable after the ear is thoroughly dried. Extensive loss of substance from ulceration sometimes occurs in the acute disease, destroying a large part, or the whole, of the drum-membrane, and loosening the ossicles by destruction of their ligaments. Rapid de- struction is particularly liable to take place in the disease when it occurs during scarlatina and diphtheria, and the drum-membrane, and any, or all, of the ossicles are sometimes lost in a few days, apparently by enormous sloughing due to the intensity of the inflammation. In other cases a more gradual ulceration occurs, extending from the edges of the perforation. The possibility of a meningitis from acute tympanic in- flammation should always be borne in mind, although it is a rare disease. As it, however, is much more common 593 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as the result of chronic tympanic suppuration, it will be discussed later, and the close connections of the tym- panum with the meninges will be then pointed out. The diagnosis of acute purulent inflammation depends largely on the appearances upon inspection, which have been already described. In its earlier stages, before per- foration has taken place and the otorrhcea become estab- lished, it may be mistaken for a severe catarrhal inflam- mation, but the distinction between the two diseases is largely one of intensity of inflammation, and compara- tively unimportant. Probably the most common mistake is in considering the disease in its earlier forms merely as a neuralgia-an error frequently made by those unfamiliar with or unable to appreciate the appearances seen with the otoscope. The well-known congestion, swelling, and other phenomena of inflammation seen upon inspection afford the only means of perfectly distinguishing one dis- ease from the other. The diagnosis of perforation can in most cases be made from the appearances alone by the expert eye, but the perforation-whistle on inflation is an absolute proof of the opening, and will often reveal its existence wdiere the in- experienced eye has been unable to make it out. In young children, however, inspection often fails to reveal the perforation on account of the difficulty of getting a full view of the membrana tympani. This difficulty is due to the position of the drum-membrane relatively to the meatus. In the infant at birth the mem- brana tympani lies almost horizontally, and as a conse- quence the walls of the meatus lie almost in- contact. At this age, also, the osseous meatus is entirely wanting. In order to get a view of the membrane in young in fants it is necessary, instead of straightening the meatus by drawing the auricle upward and backward, as is done in adults, to draw the auricle downward and outward, and in using the otoscope to look upward ; in this way a very fair view can often be obtained. As the skull of the infant develops, not only is an osseous meatus formed, but the drum-membrane is brought more and more perpendicular, and after several years-the exact time is uncertain-it assumes its normal position. In young children the rapidity with which the secre- tion forms is another serious and sometimes an insur- mountable obstacle to a clear view of the drum-membrane and perforation ; but the character of the secretion is often a great help in making the diagnosis. The pres- ence of distinct clumps of mucus is characteristic of perforation, as mucus is only formed within the tym- panum ; the presence of pus, however, may occur with or without perforation. By syringing the discharge from the ear and collecting the water in a vessel valuable aid can thus be obtained in diagnosticating perforation. Prognosis.-In healthy persons the prognosis of acute purulent inflammation is favorable under proper attention. It is slightly less favorable where there is marked pre- disposition to catarrhal affections, especially of the naso- pharynx, although even in these cases it is generally good. In tuberculous, scrofulous, and cachectic persons there is greater liability to destruction of tissue, and the amount of this destruction determines the ultimate result. In severe general diseases the prognosis is doubt- ful, and it is especially doubtful in scarlatina and diph- theria, particularly if inspection shows an intense degree of inflammation of the drum-membrane, as in such cases great loss of substance is apt to result. The course of the disease is of assistance in forming the prognosis, which is favorable if the perforation occurs early and with relief to the pain ; if the discharge rapidly diminishes the subjective noises decrease steadily, and the hearing gradually improves; it is less favorable when the course of the disease is irregular in any of the ways described. The prognosis in regard to the hearing is favorable when the disease runs its regular course in a healthy person, is doubtful when its course is irregular, and al- ways doubtful when there is a decided hereditary ten- dency to deafness, as the disease is in such cases apt to leave behind a sclerosis of the mucous membrane. Treatment.-Whether any abortive treatment of acute purulent inflammation of the tympanum is of use is very questionable. Some have raised such a claim for calcium sulphide (0.006 every half hour, or every hour), but the diarrhoea and strangury occasionally produced by the drug in sensitive persons, even in the quantity of 0.12 to 0.24 in twenty-four hours should make one careful in its administration. In a few' exceptional cases free leeching during the first twenty-four hours of an attack has seemed to check an inflammation which from the ap- pearances and from the severity of the symptoms bade fair to become a suppurative inflammation. In all of these cases, however, there is the possibility of a mistake in diagnosis, for the lesser-non-suppurative-inflamma- tions sometimes come on with symptoms fully as severe as those accompanying a purulent inflammation. In some cases, particularly in those in which the Eustachian tube is closed very early, the use of Politzer's inflation during the first few hours of pain has certainly produced relief, and occasionally has seemed to check the progress of the disease. It may be used if the patient is seen during the first twenty-four hours of the disease ; after that time it is of no use, and if persisted in may increase the pain. After the disease is fairly started the treatment must be, at first, palliative. In cold or inclement weather, or if the febrile disturbance is very marked, the patient had better keep in the house or even in bed ; a saline cathartic may be necessary, and sudorifics-spiritus etheris nitrici, ammonise acetas, or pulvis ipecac, compositus, are often useful. A light diet and avoidance of wine, spirits, mental and physical exertion, stooping, and everything tending to produce congestion of the head should be insisted on. The pain is usually the most prominent and distressing symptom ; this can sometimes, if of moderate degree, be controlled by aconite (tincturae aconitae radicis, gtt. iij. to v.) which seems to act specially on the fifth nerve, and which is also useful for the febrile disturbance. In the milder cases the bromides soothe the irritated nerves, and, in young children especially, chloral hydrate (1-5 grains; 0.06 to 0.30 Gm.) is often sufficient to insure rest. Various local applications for the alleviation of pain are often useful, and of these heat is the principal factor. Hot vapors and heavy poultices applied continuously are, however, to be avoided, as they both tend to increase the congestion of the deeper parts, to macerate the tissues, and favor excessive suppuration and ulceration. Dry heat applied by resting the affected ear on a flat rubber bottle full of hot water, or on a bag of hot salt or bran, is sometimes very soothing, and Politzer finds a warm fo- mentation, made by dipping a piece of linen, folded sev- eral times into tepid water, or into tepid water and lau- danum (200 to 2), applied over the ear, and covered first with oil-silk and then with a dry silk handkerchief, of excellent service if changed several times a day. Where the pain is moderate and paroxysmal in character, Polit- zer advises the use of a few drops of narcotic oil (olei olivae, 10.0 ; morphiae acetatis, 0.2), applied to the meatus on cotton-wool; and for the rapid alleviation of an at- tack of pain he recommends twenty to thirty drops of equal parts of olive-oil and chloroform, to be dropped on cotton-wool and applied over the ear. When the pain is of a severe character-continuous, and disturbing the sleep-it must be acknowledged, however, that these milder remedies, both local and internal, are often insufficient, and recourse must be had to opium internally, or by subcutaneous injection, and to local bleeding. That local bleeding by leeches, natural or artificial, has any decided effect on the pathological process is doubtful, but its action in diminishing the severity of the pain is in many cases very marked. It should not be resorted to in cases where there is great debility, as the depletion may increase the sensitiveness of the nerves ; but in robust persons it can be used without risk. The point of appli- cation of the leeches is of much importance, for if care- lessly applied at a distance from the ear no good will result. As the object is to deplete the vessels of the tympanum, and as the venous drainage of that cavity outw'ard is along the lower and anterior walls of the meatus, the leeches should be applied either at the lower 594 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. edge of the meatus within the concha, or else on the in- ner side or close in front of the tragus. In a strong adult, four or live should be used ; in less robust persons, two or three, while in young children rarely more than one is advisable. Heurteloup's artificial leech can be sub- stituted for the natural one, and gives rapid depletion ; but as it cannot be applied within the concha it has seemed to me less effective. When either is used the meatus should be firmly closed with cotton to prevent the en- trance of blood and the irritation resulting from a hard, dry blood-clot. Silver nitrate or some of the iron styptics may be necessary to check the bleeding if a vein has been opened. When the disease is fully established it has a definite course to run, as has been already shown, and it is only when thus fully established that treatment directed to the pathological process is of any avail. If it is evident from the continuance of the pain, fulness, increasing deaf- ness, throbbing and noises, and from the increasing red- ness and swelling of the drum-membrane, that suppu- ration must occur, the formation of the secretion can be very materially hastened by the use of moist heat applied directly to the drum-membrane ; this can be best done by using the ear-baths, as recommended by Troeltsch, which are given by filling the meatus with ■water as hot as can be borne (108° to 112° F.), and allowing it to re- main till it begins to cool, usually from five to ten min- utes, and repeating this at intervals several times a day, taking care to cover the ear warmly after each applica- tion, to prevent an exacerbation of the pain from the air chilling the moistened surface. When the secretion once begins to form in the tym- panum it is often poured out so rapidly that between two visits rupture occurs, and an otorrhoea is established. If, however, it is secreted less rapidly, or if perforation is delayed from an unusual resistance in the drum-mem- brane, as from previous thickening, the accumulation can often be recognized by an increasing bulging out- ward of the membrane. As soon as this can be deter- mined a paracentesis tympani should be performed, in order to more rapidly relieve the patient, and to diminish the risks of ulceration. A paracentesis tympani consists in incising the drum- membrane, thus giving exit to the confined secretion, and is best performed with a lance-shaped paracentesis needle. The point of selection for the incision should be at the spot of most prominent bulging, if any such exists, but of course care must be taken not to injure the ossicles and tendons of the tympanum. In these cases, as a rule, the greatest projection of the membrane occurs in the pos- terior segment. Under good illumination, so that the whole field of operation is distinctly seen, the paracentesis needle is passed in to the upper edge of the intended in- cision, thrust steadily through the membrane, and then carried downward till the opening is of the required length; as the lance is withdrawn it should be turned somewhat sideways, to thoroughly separate the edges of the wound, which without this manoeuvre will lie in con- tact and adhere with the first drop of blood which is poured out. The inexperienced hand sometimes finds the same difficulty with this as with other operations within the tympanum, namely, an uncertainty in judging of the distance to which the needle has penetrated, owing to the monocular vision under which the operation is done, and consequently there is hesitation as to when to make the final thrust through the membrane. This diffi- culty can be overcome by keeping the point of the needle in slight motion as it is passed into the deeper meatus, and when the membrane is reached this movement will be seen and felt to have ceased, and the remaining steps of the operation can be completed. When the whole surface of the drum-membrane is equally prominent, the point of selection for puncture should be at the posterior lower quadrant, as behind this portion of the membrane lie no important structures, and, moreover, an opening at this point affords the best drain- age of the tympanic cavity. Anaesthetics are, as a rule, unnecessary, except in the case of extremely nervous pa- tients, who cannot be depended upon to hold the head still. The pain of the operation varies considerably. If the pus has been confined long enough to have produced great pressure upon the membrane, the sensitiveness of the membrane is often so reduced that absolutely no pain is felt; in other cases a sharp prick is felt, followed by a dull aching for some minutes ; the severest pain is felt in those cases in which the incision is made in the upper posterior quadrant, just behind the short process of the manubrium, this, as experience shows, being the most sensitive portion. The length of the incision had better be from one-third to one-half of the vertical diameter of the membrane. Perforation of the drum-membrane being effected, cither naturally by rupture, or artificially by paracentesis, the tympanic cavity should be thoroughly cleared of secre- tion by inflation, either by Politzer's method or by the cath- eter, which forces the pus into the meatus, whence it can be wiped or syringed out. The after-treatment, from this point, must depend, on the course of the disease. If the dis- charge is so profuse as to seriously inconvenience the pa- tient, and especially if the pain continues after the estab- lishment of the otorrhoea, douching with a warm (100° F.) carbolic solution (1 to 80) two, three, or four times a day, according to the rapidity with which the secretion forms, will be a great comfort; at the same time the ear should be cleared by inflation daily. If the discharge is slight and there is no pain, thoroughly cleansing by infla- tion and wiping with absorbent cotton, without the use of water, is preferable, and this should be followed by the insufflation of boric acid in fine powder, which makes an antiseptic coating over the inflamed membrane. For the first few days of the otorrhoea nothing more than this is necessary, but after that time, if the discharge continues abundant, means can be taken to check the se- cretion either by astringents or antiseptics. Whichever method is used, care must be taken that the ear is thor- oughly cleansed, and afterward carefully dried, as other- wise the medicament will not come in contact with the diseased surfaces. The tympanum having been cleansed by inflation, and the secretion thoroughly removed by syringing and douch- ing with warm carbolic solution (1 to 80), or by wiping with absorbent cotton, the drum-membrane should then be dried and the application made immediately. Astrin- gent aqueous solutions, zinc sulphate 1 to 300, zinc sulpho- carbolate 1 to 300, alum 1 to 100, should be applied by directing the patient to lie down with the affected ear up, and a few drops of the solution, slightly warmed, should then be poured into the meatus and retained for about ten minutes. But little can be said about the choice of the astringent, except that lead salts, formerly much used, had better be avoided, as they are apt to form insoluble compounds with the secretions. The frequency of these applications must depend on the amount of the discharge ; if this is profuse they can be made twice, or even three times a day, but not oftener ; if less abundant, once a day is sufficient. As the inflammation subsides and the for- mation of the secretion is less rapid, the frequency of the applications should be diminished, and as the perforation begins to contract the less interference the better, pro- vided the tympanum is kept tolerably clear. In regard to antiseptics, it must be remembered that an antiseptic dressing, in the strictest sense, to a suppurating tympanum is an impossibility, on account of the com- munication of the tympanum with the air of the Eusta- chian tube and mastoid cells. The best that can be done is to bring the antiseptic in close and frequent contact with the suppurating surfaces, and to partially exclude the air from the meatus. This can be done by cleansing the tympanum, as already described, by inflation, syring- ing, and drying, and then blowing into the meatus pure boric acid in an impalpable powder; but a small quantity should be used at each insufflation, and the application should be repeated five or six times till the deeper parts are thoroughly covered. Care should be taken that the powder used is thoroughly impalpable. If the tympanum and perforation have been well cleansed and dried, a small quantity of the powder penetrates to the tympanum either directly or by dissolving in the secretion, and the remain- 595 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ing powder forms an antiseptic coating which lasts for hours. The meatus should then be closed with absorb- ent or borated cotton. When the discharge is profuse, this dressing should be applied daily by the surgeon in a thorough manner, and the patient should be instructed as well as possible in making intermediate insufflations, if such are thought necessary. Powdered antiseptics, other than boric acid, are also of use: resorcin, or resorcin and boric acid in equal parts, or a mixture of an antiseptic and astringent, such as boric acid triturated with tincture of calendula or other vegetable astringent tinctures. Liquid antiseptics are recommended by some: carbolic solution (1 to 60), boro- glyceride (1 to 2), corrosive sublimate (1 to 1,000), applied in the same way as the liquid astringents. The powders have one great advantage over all liquids, that being destitute of moisture they have no tendency to macerate the delicate structures, as all aqueous solutions will do if left in the ear till they become heated. Pow- ders also very much diminish the risks of a secondary in- flammation of the meatus, which is not uncommon from the irritation of the discharge. The same rules, in regard to diminishing the frequency of the antiseptic dressings, should be used as with the astringent solutions, and especial care must be taken not to check the final closure of the perforation by injudi- cious interference. In regard to the choice between astringents and anti- septics, it may be said that many cases do equally well under either form of treatment; but when there is very great redness of the tissues in the earlier stages of the in- flammation astringents are preferable, and as the redness diminishes antiseptics should be substituted. Where, however, there is great oedema, antiseptic powders are best. The perforation having healed, there remains a marked degree of infiltration in all the parts of the middle ear, which disappears slowly, and until this is gone more or less dulness of hearing and subjective noises continue. In addition to this, the mucous membrane of the tympanum rarely passes directly from a stage of suppuration to its normal, slightly moist, condition, but a hypersecretion of mucus is kept up for a considerable time, gradually diminishing till the normal condition is reached ; in other words, there is apt to be a catarrhal inflammation left in the tympanum for some time after the suppuration has ceased. This infiltration of the tissues requires only time for its removal, and, if the drum-membrane stands out freely from the inner wall in its normal position, no treat- ment is now necessary. Certainly, for a few days after the closure of the perforation, the parts had better be left at rest in order that the cicatrix may become firm. If, at the end of that time, the drum-membrane is found re- tracted, or if the hearing is not improving, and distinct rales are heard in the tympanum on inflation, inflations by Politzer's method, at intervals of two or three days, had better be used till the mucus has disappeared. In ex- ceptional cases, this secondary catarrhal inflammation of the tympanum requires a good deal of attention ; this occurs particularly when the constitutional condition is bad, or when there is chronic disease of the naso-pharyn- geal mucous membrane-both of which conditions may require appropriate treatment. It should be remembered, however, that these late stages of a suppuration are gen- erally slow in disappearing, and where the improvement is steadily progressive much can be left to nature. When, in addition to the perforation, there has been an extensive loss of substance in the drum-membrane, the same treatment should be adopted as in the simpler cases ; but when the suppuration has ceased, the ear should be left at rest, but protected from cold drafts, and should only be examined occasionally to be sure that no new secretion has formed and dried in such a way as to inter- fere with the healing process. It will often be found, after some weeks, or even months, that such perforations, even when quite large, have closed by a firm and very usefid cicatrix. If, in the course of the inflammation, granulations de- velop, as sometimes happens, on the edges of the perfo- ration, they serve to keep up the inflammation and pre- vent healing. When such are found to exist, they should be touched with silver nitrate; this can be done most effectually and safely by fusing the salt on the end of a probe and applying it to the growth, slightly if the granulation is small, more heavily if it is large, and re- peating at intervals of two or three days till it has shriv- elled nearly to the surface of the membrane. Such granulations are usually soft, and but few applications are necessary. An otitis externa, secondary to a purulent inflamma- tion of the tympanum, is a troublesome complication on account of the increase of pain which it produces, and is sometimes dangerous from the hinderance to the free drainage of the tympanic cavity caused by the great swelling of the tissues of the meatus. If the walls of the meatus are so swollen as to close the passage, special care must be taken to evacuate the confined pus. This can best be accomplished by passing an elastic tube beyond the swelling, and syringing or douching through this ; a piece of elastic tubing, or of a small elastic catheter, can be used for this purpose. The inflammation of the meatus itself should be treated by moist antiseptic fomentations and by pressure ; both of these indications can be well fulfilled by dipping a firmly rolled pledget of absorbent cotton in the solution, passing it firmly into the meatus, so as to create as much pressure as can be well borne without producing irritation, and leaving it for several hours. If the sensitiveness is great, pain is produced after two or three hours, and I order it removed immediately that this is noticed, and re- new it on the next day. If no pain is produced it can be kept in continuously, being renewed whenever it becomes saturated with discharge. For the solution, all of the non-irritating antiseptic oils are useful, such as olei oli- vae and acid, carbolic. (10 to 1), glycerine and boric acid (10 to 1). The oily solutions do not dry as aqueous ones would, and the heat of the meatus quickly makes the application a moist fomentation which relaxes the tension of the tissues, while the pressure promotes absorption. If distinct fluctuation occurs an incision may be neces- sary. When there is much swelling around the ear ex- ternally, a horse-shoe, or crescent-shaped, poultice will greatly help in the resolution of the inflammation, but it had better not be kept on more than one-third or one-half of the time, and the auricle itself should never be covered by the poultice. Occasionally, as the result of otitis externa, granula- tions in the meatus appear on any part of the walls ; if such are found after the swelling subsides they require the same treatment as granulations on the drum-mem- brane, cauterization with silver nitrate. The moderate degree of tenderness of the mastoid ac- companying most acute purulent inflammations of the tympanum requires no direct treatment; it usually sub- sides as the tympanic disease improves, but if it becomes decided, if the pain is largely referred to that spot, and especially if the skin begins to show redness and slight oedema, it requires active measures (ride Mastoid Inflam- mation, later). Meningitis preceded by aural symptoms, however slight, should lead to a thorough examination of the ears, and if secretion is discovered it should be evacuated im- mediately, and the ear kept clear by inflation and syring- ing as already directed ; and the same rule should be fol- lowed if an otorrheea has been established. The mastoid should also be carefully watched and actively treated if any indications of disease in that part show themselves. Recovery from an undoubted meningitis directly follow- ing the establishment of an otorrheea in an ear previously unsuspected is by no means an uncommon history, es- pecially in children. Of the treatment of the meningitis itself it is unnecessary to speak here ; it does not differ from that of an idiopathic meningitis. II. Chronic Purulent Inflammation of the Tym- panum is developed sometimes from an acute purulent inflammation, the chronicity being due to neglect in some cases, and in others to constitutional causes ; some- times it has no acute stage, but develops primarily with- 596 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. out pain or the other symptoms of acute inflammation ; in rare instances it is developed secondarily to an inflam- mation of the meatus, as, for instance, chronic eczema, and occasionally it occurs from injuries. Of 5,135 aural patients at the Boston City Hospital, chronic purulent inflammation of the tympanum was found in 22.3 per cent., and the sexes in this disease, as in the acute inflammation, were nearly equally divided. The disease is found at all ages, but is especially common in children. Pathology.-Perforation of the drum-membrane is present in almost all cases. Very exceptionally no per- foration exists, but the pus is discharged down the Eu- stachian tube, or through a fistula in the bone into the meatus. Some years ago I had an interesting prepara- tion of the disease sent me, in which the membrana tym- pani was entire, but the bone on the upper wall of the meatus was perforated by caries, and through this per- foration the pus was discharged into the ear-passage ; the patient died from abscess of the cerebrum, due to another carious perforation of the tympanic roof. A somewhat similar case was previously described by Schwartze,1 with death from basilar meningitis, and undoubtedly other cases of undoubted chronic purulent tympanic inflamma- tion without perforation could be found in the literature of the subject, although the absence of perforation is very rare. With the perforation there is, in the majority of cases, more or less destruction of tissue. The pathological changes in the tissues have been most thoroughly described by Politzer, from whom the fol- lowing account is taken: " The most important change in the mucous membrane in chronic suppuration of the middle ear consists of in- crease in bulk, caused by excessive infiltration of round cells, and enlargement and new formation of vessels. While in this process the periosteal layer of the mucous membrane is either wholly or partially preserved, the subepithelial layer, stripped of its epithelium, is so re- placed by round cells that a suppurating granulation- surface, traversed by many vessels, takes its place. The mucous membrane appears red, or yellowish red, of several times its original thickness, smooth or glandular, and frequently so proliferated that the air-spaces of the middle ear, the depressions in the walls of the tympanic cavity, or a great part of the space of the tympanic cavity, are filled by the hypertrophied mucous mem- brane." 2 ' ' The results of suppuration of the middle ear depend to a great extent on the ultimate fate of the infiltrated round cells ; (1) the hypertrophy of the mucous mem- brane may subside by fatty metamorphosis and degenera- tion of the round cells, but the tissue of the mucous membrane, even in the slighter forms, will scarcely again assume its normal character, as it does after acute in- flammation of short duration ; (2) by partial hyperplasia of the infiltrated mucous membrane circumscribed ele- vations are developed in the form of granulations, or of pedunculated new formations, which are called polypi of the tympanic cavity ; (3) the purulent process leads to destruction of the tissue, to ulceration and wasting of the mucous membrane, which is eaten away to the bone, in which case the ulceration may extend to the bone ; (4) by transformation of the round into spindle-shaped cells there occurs a formation of a firm connective tissue, similar to cicatricial tissue, in the form of diffuse tendin- ous calcareous thickenings of the mucous membrane, or of bridges and thick scars which lead to abnormal ad- hesion between the membrana tympani, the ossicula, and the walls of the tympanic cavity. The new formations of connective tissue may be permanent, or in the subse- quent course of the disease shrivelling and sclerosis, cal- cification, or ossification of the new formation, more rarely atrophy of the mucous membrane, may result." " The changes in the middle ear enumerated here may be developed one after the other at different periods of the suppurative process, or they may exist simul- taneously. In this way, in the same ear, besides granu- lations on the mucous membrane, a firm, organized, new formation of connective tissue, and in other places again an ulcerative defect, extending to the bone, may be found. The epithelium of the mucous membrane, which is wanting in the excessively suppurating places, in other portions so proliferates that the cavity of the middle ear is partially or wholly tilled by large epidermic layers, which are frequently interwoven (otitis desquamativa). " " The membrana tympani almost always suffers a loss of its continuity in chronic suppuration of the middle ear. Cases in which the suppurative process runs its course without perforation of the membrane are so exceed- ingly rare that the assumption that perforation of the mem- brana tympani is not characteristic of chronic suppuration of the middle ear appears entirely unfounded. While in acute purulent inflammation of the middle ear, as a rule, only a disturbance in the continuity of the membrana tympani takes place, we have here to deal with loss of substance produced by absorption of the tissue of the membrane at the margins of the perforation. In this instance all the layers of the membrane are not always uniformly attacked by the destruction, as would appear from the inspection of the living ; for when examining the dead body the dermic layer, or the layer of mucous membrane, will frequently he wanting to a greater ex- tent than the substantia propria. The margins of the perforation, which in the living almost always appear sharply defined, are often found to be jagged, fringed, and irregular at the pathological examination." "The destruction attacks, as a rule, the portions of the membrane situated midway between the periphery and the handle of the malleus. Even in the case of very extensive losses of substance, in the majority of in- stances the peripheral portion of the membrane is still found preserved in the form of a detached sickle-shaped ledge. This is not always formed by the tendinous ring, as is generally believed, but, as I have convinced myself by several post-mortem examinations, by the dense, peripheral, circular, fibrous bundles of the membrana tympani. The portions of the membrana tympani situated in front of and behind the short process also resist for a long time the destructive influence of the suppuration." "The remnant of the membrana tympani is subject to many pathological changes in the suppurative pro- cess. Sometimes the membrane is uniformly thickened and tumefied, sometimes the layer of mucous membrane alone shows an excess of growth toward the tympanic cavity, or that layer and the substantia propria only change slightly, but numerous papillary villous growths and granulations develop on the dermic layer as in myringitis granulosa. Lastly, a polypoid degeneration of the membrana tympani (see Troeltsch) may take place, in which the original elements of the membrane can be traced in the new formation. Sometimes, near the per- foration, one or more small swellings exist in the dermic layer, which spread as far as the substantia propria and form the basis of partial atrophied thinnings of the membrane." ' ' After suppuration has ceased, either the margins of the perforation are covered with epithelium, and a permanent aperture in the membrana tympani remains, or the orifice is closed by a deposit of a yellowish-gray plasma on its margins, out of which there very rapidly develops a deli- cate and thin cicatricial tissue, in which the elastic fibres of the substantia propria are wanting. The cicatrix con- sists either of fibrous connective tissue, or of an almost structureless membrane which is covered on both sides with epithelium in large plates. The remains of the membrana tympani are either thickened by a growth of connective tissue, calcified, ossified, or atrophied, and its inner surface sometimes adheres more or less to the inner wall of the tympanic cavity, and sometimes does not." " In conclusion, we will indicate those pathological changes which, in chronic suppuration of the middle ear, are developed in the osseous tissue underlying the mucous membrane. It has already been mentioned that numer- ous blood-vessels, accompanied by prolongations of con- nective tissue, penetrate from the mucous membrane of the middle ear into the osseous wall, by means of which 597 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pathological changes occurring in the mucous membrane spread to the bone. Indeed, on microscopic examination it will frequently be found, even in those cases in which the bone is apparently normal after the mucous membrane has been detached, that those prolongations of connective tissue and osseous spaces are infiltrated with round cells, and that the vascular spaces are dilated ; in a word, that the phenomena of inflammation of the bone are more or less strongly pronounced. This leads either to condensation of the osseous tissue, to hyperostosis and the formation of osteophytes, or to caries and necrosis of the temporal bone and of the ossicula, with all the con- sequences with which we shall become acquainted in the course of this division." 3 Etiology.-Scarlet fever and scrofula are the most com- mon causes of chronic purulent tympanic inflammation ; after them come typhus abdominalis, morbilli, variola, diphtheritis, tuberculosis, and anaemia. In many cases, however, none of these general diseases have existed, and the suppuration is merely a purulent inflammation of the tympanum, originally acute, which has become chronic owing to retention and decomposition of pus in the mid- dle ear, or else owing to disease of the nose and naso- pharynx, which keeps up the tympanic inflammation. Subjective Symptoms.-These are chiefly discharge, and a variable degree of deafness ; pain is rarely, if ever, present in the uncomplicated form of the disease. The discharge is often profuse, but sometimes very slight in quantity, and its existence is occasionally denied by the patient, when, from its consistency or from drying in the meatus, it fails to moisten the outer part of that passage. It is either distinctly purulent, or, more frequently, muco-purulent; occasionally it is tinged with blood, gen- erally due to granulations ; in very rare cases it assumes a blue color, owing to the presence of abundant vibrios (Bacterium termo, Zaufal). The discharge is often very foetid, even when no caries exists, owing to retention and decomposition of pus and the mixture of the glandular secretions of the meatus, the acidity of which, Schwartze thinks, increases the foetor. The retained pus often forms offensive caseous masses with which are mixed epidermis and cholesterine. The deafness may be moderate or extreme in degree, depending on various conditions : on the amount of loss of tissue in the membrana tympani and consequent change in its tension and power of conduction; on the amount of swelling of the tympanic mucous membrane ; on the mobility of the ossicula and secondary mem- branes ; on the amount and position of the secretion within the tympanum. Total deafness never exists from the simple tympanic disease, but is only found where there is disease of the nervous apparatus. Disagreeable head symptoms are by no means rare in chronic tympanic suppuration ; patients complain of a sense of weight in the head, with mental depression, and sometimes of an obstinate headache, when the disease is unilateral, referred to the side of the affected ear ; a slight dizziness is often spoken of also. All of these symptoms are due either to intralabyrinthine pressure produced by the collections, swelling and hypersemia in the tym- panum, or else to a hyperaemia of the meninges of the brain, it being an established anatomical fact that the vessels of the diploe of the temporal bone communicate freely with the brain sinuses. Subjective noises are less common and less irritating in this disease than in chronic tympanic catarrh or tympanic sclerosis; when present they are usually more or less intermittent, and are rarely of great intensity. Diminution or loss of taste on the anterior two-thirds of the side of the tongue, and occasionally also on the side of the soft palate corresponding to the ear-disease, are by no means uncommon. This is not always confined to the chorda tympani, nervus lingualis trigemini, but extends to the region of the glosso-pharyngeus, and is referred by Carl to the fact that fibres of the nervus glosso-phar- yngeus pass through the nervus tympanicus to the plexus tympanicus, and from this to the lingualis, partlyglirough the nervus petrosus superficialis minor, partly Through the ramus communicans cum plexu tympanico to the ganglion geniculi, and from there to the chorda tympani (Schwartze).4 Pain cannot be said to be a symptom of chronic puru lent inflammation ; when complained of, its most common cause is a subacute exacerbation of the tympanic disease, due either to changes of temperature affecting the ex- posed mucous membrane, or to irritation from decompo- sition of retained pus. Occasionally it is due to a furun- cle of the meatus. When constant and severe, with marked exacerbations (and when at the same time there is a free exit for the secretions), it is almost always char- acteristic of some of the complications of which more will be said later. Objective Symptoms.-The appearances of the ear on inspection vary very much according to the many conditions which are found in this disease ; an exact determination of these condi- tions, however, is all-important in deciding upon the treatment, but can only be made out by first taking care that the ear is thoroughly cleansed and perfectly dried. Often the meatus and deeper parts are covered with crusts of dried secretion, or layers of loose epidermis ; if these are very adherent it may be advisable to soften them by soaking, which can be done best by instillations of glycerine and water, to which a little soda bicarbonate has been added, and then removing them with a probe, ring-curette, or by syringing. Careful drying should succeed the removal of these masses, for a thin film of liquid can obscure or distort the appearances in a wonderful degree. When the suppuration has been profuse the epidermis of the meatus is often swollen and white from the continued maceration, and occa- sionally it is ulcerated. Sometimes there is a decided, but rarely an extreme, stenosis of the membranous canal from inflammatory thicken- ing of the cutis, and often small granulations are seen on any part of the walls either of the membranous or osseous meatus, lying singly or in groups, of a bright red color, and bleeding slightly on being touched. These granulations are hypertrophies of the papillae of the cutis. In the osseous meatus stenoses are also not un- common in old cases, due to hyperostosis of the bone; when they exist of a size sufficient to interfere with the free discharge of the pus, they constitute a most serious and dangerous complication. These exostoses appear of two forms, a pedunculated small prominence from the size of a pin's head to that of a pepper-corn, usually at- tached to the upper and posterior wall, or a non-pedun- culated growth with broad base growing from any part of the osseous meatus and attaining any size, even suf- ficient to wholly close the passage ; these latter are not infrequently mul- tiple from different portions of the walls. Either form may exist without the presence of any caries, being prob- ably caused by chronic c i r c u m - scribed periostitis. Both forms appear of a pale color, with perhaps a slight tinge of redness around their bases, and are readily re- cognized from their appearances alone ; but if any doubt exists the probe will demonstrate their immobility and extreme hardness. An exact determination of the pathological changes in the drum-membrane and tympanic cavity, so far as they are open to inspection with the otoscope, is absolutely necessary in many cases for deciding upon the appropri- ate treatment, anil although offering many difficulties to Fig. 947. - Blunt Ring- curettes. Fig. 9-18.-Exostoses of the Meatus. (From Schwartze.) 598 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. prominence, showing the edges of the opening very dis- tinctly. Occasionally, however, certain appearances on the membrane so simulate perforations as to easily de- ceive the observer, such as flat bits of adherent cerumen, dark foreign bodies, and ecchymoses. Much help can often be obtained in such cases by keeping the otoscopic mirror in slight motion during inspection, and closely following along the plane of the membrane as the light varies with the motion, and it will thus become evident that there is no solution of continuity. Where the whole drum-membranes and ossicles have been lost, uncertainty will sometimes arise as to whether the surface seen is an inflamed and swollen drum-mem- brane or the tympanic mucous membrane. The outline of the promontory and the niches for the oval and round fenestrte, if seen, prove the loss of the drum-mem- brane ; but if they are obscured, as is often the case when the mucous membrane is swollen, the use of the probe will readily prove that the visible membrane is lying against the bone. In case all other means fail, inflation either by Val- salva's or Politzer's method, or by the catheter, when followed by an escape of air known as the perfo- ration-whistle, is indubitable evi- dence of an opening. The appearances of the mucous membrane are various ; sometimes it looks dark-red, or even bluish-red, cedema- tous, and much swollen; sometimes pink, smooth, and delicate as normal, and often granular in spots or through- out its whole surface. Occasionally it is so much swol- len as to reach the plane of the drum-membrane, or even project beyond this through the perforation. The de- gree of swelling can often only be determined with the probe, when, by touching the end of the instrument on the membrane, and then slightly moving it, the amount of swelling can be made out, and the oedema becomes evident by the slight pitting. In children under three years of age it is difficult, and occasionally impossible, to make out the exact conditions in a chronic otorrhcea, but the presence of mucus in the discharge is conclusive evidence of the existence of a perforation. This mucus can readily be seen by mixing the discharge with water, when its flocculency immedi- ately determines its character. The inexperienced eye sometimes finds it difficult to distinguish between an open perforation and one which has been closed by a cicatrix, as the cicatricial tissue is so thin as to readily escape detection ; and the edges of the opening, especially if somewhat thickened, contrast so strongly with the delicate cica- trix as to give the impression of an opening. In such cases the slight movement of light spoken of above will often enable one to trace the tissue from the true mem- branp on to the apparent perfora- tion ; a lense of about ten diop- trics held in front of the speculum is often of assistance, and when neither of these methods suffices a small probe can be passed to the doubtful spot, when any slight movement of the cicatrix, as the probe touches it, is sure to bring it into view, if well illuminated at the moment. Auscultation is of no practical value in chronic purulent inflammation, except in giving us the whistle characteris- tic of perforation, which is dry if there is no secretion, but is accompanied by rattling and bubbling as the air passes through discharge. In tessting the hearing different degrees of deafness will the inexperienced eye, these can be overcome by practice and by a knowledge of the minute anatomy and relations of the parts. In the very exceptional cases in which a chronic puru- lent inflammation of the tympanum exists without per- foration of the drum-membrane, the appearances of that membrane cannot be said to be determined, as so few cases have ever been accurately recorded during life. The very fact that no perforation occurs is almost con- clusive proof that the membrane is abnormally resistant, and it would probably be so opaque from fibrous thickening, or calcification or swell- ing, that no glimpse could be ob- tained of the interior of the cavity. Possibly a slight glimmer of the yellowish secretion within might suggest retained pus. The mem- brane itself would probably be more or less congested and swollen, especially along the manubrium, and might be flattened from the pressure upon its inner surface. The osseous meatus, particularly near the tympanic ring, would be expected to show a deep and diffuse congestion. Perforations occur in all parts of the drum-membrane, and also in the membrana flaccida Shrapneli; they are most frequent in the anterior lower quadrant of the drum-membrane, midway between the manubrium and tympanic ring, and are least common close to the manu- brium and tympanic ring, as at these points the tendinous fibres of the membrana propria are so heaped upon each other, and are so abundantly nourished as to offer great resistance to rupture and destructive processes. The size of the perforations varies from that of a needle's point to complete loss of the whole membrane. The perforations may be single or. multiple ; they usually appear round, oval, elliptical, or kidney-shaped. Anatomy teaches that the parts of the membrane most abundantly supplied with blood-vessels are along the manubrium and the tympanic ring, while clinical experience shows that in extensive de- structions these portions of the membrane are often left when all the rest has been destroyed, and we then have a V-shaped remnant of the membrane running downward along the manubrium, together with a narrow rim of the tympanic ring. The manubrium is often left after ab- solutely the whole membrane has been destroyed, and is then drawn inward by retraction of the tensor tyinpani muscle, which in this condition is no longer coun- terbalanced by the resistance of the drum- membrane ; the bone now appears very much foreshortened, and sometimes even lies so horizontal that it is concealed be- hind the short process, and its lower end may actually touch and become adherent to the promontory. Caries sometimes attacks the lower end of the manubrium, and a portion of it is lost. The above are the appearances in the more common forms of the disease, but in the severer forms still greater destruc- tion is found; any or all of the ossicles may be lost by ulceration of their ligamentous attach- ments ; this occurs most frequently with the malleus and incus, much less often with the stapes. The cavity of the tympanum is then fully exposed to view, and if the mu- cous membrane is not excessively swollen, all of the ana- tomical landmarks of that region can be made out-the promontory with its sharply defined posterior edge, the niche of the fenestra rotunda, the osseous rugae of the tympanic floor, and often also the niche of the fenestra ovalis with the head of the stapes in position. The recognition of perforations is generally not diffi- cult if care is taken, as already said, to have the ear thoroughly clean and perfectly dry. Usually the rem- nants of the drum-membrane are of a lighter color than the perforation, and the contrast brings the latter into Fig. 949.-Double Perfora- tion of the Drum-mem- brane. (Schwartze.) Fig. 951.-Central Perfora- tion ; anteriorly and pos- teriorly caleareous depos- its in the drum-mem- brane. (Politzer.) Fig. 950.-Destruc- tion of the Right Drum-membrane; the manubrium laid bare and de- tached ; a small perforation in the upper part of the remnant of the membrane. (Po- litzer.) Fig. 952.-Large Perfora- tion in the Hight Drum- metnbrane; in the supe- rior quadrant of the field of view the inferior ex- tremity of the long pro- cess of the incus is seen, and in the posterior infe- rior quadrant the niche of the fenestra rotunda. 599 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. be found, according to the condition of the conducting and perceptive apparatus, and the results of the tests are generally perfectly explicable on simple physical and physiological laws. A certain degree of deafness accom- panies every case ; but if the perforation is small, interfer- ing but little with the tension of the membrane, if there is but little swelling or thickening to diminish the mobility of the drum-membrane and ossicles, if the stapes is freely movable in its annular membrane, and if the nervous structures are intact, the loss of functional power is com- paratively slight. On the other hand, if the conducting mechanism is deeply buried in swollen tissue, seriously thickened or adherent to adjacent parts, its vibratory power is very seriously interfered with and great deaf- ness results. Where the drum-membrane is wholly de- stroyed, the amount of deafness depends, provided the nervous parts are intact, upon the condition of the stapes and its membrane ; if these remain delicate a very fair degree of hearing is left, while if they are rigid from swelling of the mucous membrane, thickening, calcifica- tion, adhesions, or retraction of the muscles, transmis- sion of the waves of sound is seriously impeded. Total deafness is only found where the labyrinthine structures are involved-not necessarily, however, always by exten- sion of suppuration to the labyrinth, but sometimes by the pressure exerted on the intra-labyrinthine fluid from the tympanum, and probably also by congestion and se- rous infiltration of the structures themselves. The per- ceptive power of the auditory nerve, even for sounds of slight intensity, is generally retained in uncomplicated chronic purulent inflammation of the tympanum, and a vibrating tuning-fork placed on the forehead or teeth is usually heard loudest in the affected ear. The course of chronic purulent inflammation of the tympanum depends chiefly on the local changes in the ear, which are of great variety, on the condition of the mucous membrane of the naso-pharynx, and on the general health. For convenience of description we may divide all cases into three classes : (1) simple suppuration of the tympanic mucous membrane only ; (2) granular suppuration of the mucous membrane; (3) cases with complications, retained secretion, desquamative products, polypi, caries, necrosis, mastoid and labyrinthine inflam- mation. In the simple cases, in healthy constitutions or where the mucous membrane of the naso-pharynx, previously inflamed or granular, becomes gradually healthy, as is not infrequent, months or years after the exanthematous fevers which originally caused the disease, the aural sup- puration may cease of itself ; in scrofulous, tubercular, or the worst forms of scarlatinal cases the suppuration may continue indefinitely for years, or through life. As the inflammation subsides, naturally or under treatment, the discharge gradually ceases over the whole surface of the tympanum and drum-membrane. Granular suppuration runs very much the same course as the simple variety, except that it less commonly gets well of itself, and, when it does, its course is more tedious. The granulations undergo a retrograde process, slowly disappear, and the case becomes one of simple suppura- tion. In the third class of cases, the complications of retained secretion, polypi, caries, and necrosis absolutely preclude a natural cure so long as they exist, and the same may be said of almost all mastoid and labyrinthine inflammations, although in very exceptional cases the tympanic disease is cured, leaving the mastoid diseased. These complica- tions must first be gotten rid of by appropriate treatment and the case reduced to one of simple purulent inflamma- tion before any cure can result, and the recognition of those complications becomes therefore a matter of ex- treme importance, which will be discussed later. The case being reduced to a simple inflammation the suppuration from which has ceased, the further course of the disease depends upon the condition of the perforation. If the skin of the outer surface of the drum-membrane has united with the mucous membrane of the tympanum over the edges of the perforation, no closure is to be expected, and the opening is permanent. We have, then, as the result a cure of the otorrhoea, but an ear crippled in its function and extremely liable to relapses of inflammation ; for the permanent exposure of the tympanic mucous membrane renders it liable to be affected by external influences, such as winds and dampness, and it also seems particularly lia- ble in this condition to an extension of inflammation from the naso-pharynx. If, however, no such permanent open- ing has been formed, a plastic material may be thrown out from the edges of the perforation, and this gradually ex- tends across, and, uniting with the opposite side, closes the perforation with a cicatricial tissue. A loss of two-thirds of the drum-membrane, or even more, may be replaced in this way by a cicatrix. This restoration of the drum- membrane by cicatrix is the most perfect cure obtainable, such cases rarely relapsing if the new tissue once becomes firm and sound. The time occupied in the formation of such a cicatrix is very variable, and occasionally the per- foration closes only several months, or even one or two years, after the cessation of the otorrhcea. The position of the perforation is of influence in the healing ; if the loss of substance extends to and has destroyed the tym- panic fibrous ring, the probabilities of healing are much less than if this ring has not been destroyed ; perforations in the posterior portion of the drum-membrane heal more readily than in the anterior portion, as the healing process is less disturbed by air passing up the Eustachian tube. If left to itself, any of the varieties of purulent inflam- mation may pass into another variety, the simple sup- puration becoming granular, or vice versa, or developing any one or several of the complications spoken of. Cases are seen in which a suppuration continues simple for twenty or thirty years, or through life ; in other cases there may be a rapid development of granulations within a few weeks, and the same may be said of the other com- plications. The general constitutional condition is un- doubtedly of influence, and in the scrofulous, tubercular, and syphilitic the worst forms are more apt to appear ; but this is by no means always the case, for the worst complications are occasionally seen in persons of perfect constitutions. In many cases the closure of the perforation by a free (non-adherent) cicatrix does not take place. Where but a small rim of the periphery of the drum-membrane re- mains, the plastic material may be deposited, and, falling inward, rest upon and become attached to the tympanic mucous membrane, and then extend till it covers the whole exposed surface, giving a closure of the perfora- tion, but without any air-cavity behind the cicatrix. For a full description of the many varieties of cicatrices and their attachments, the reader is referred to Politzer5 and Schwartze.6 If no portion of the drum-membrane is left from which a cicatrix may start, or if the external and internal edges of the perforation have united, making a permanent open- ing, the tympanic mucous membrane, as the inflammation subsides, becomes paler and paler till, ceasing to secrete, it assumes either its thin, delicate structure and whitish appearance, or else it is left more or less thickened from an increase in its connective-tissue elements, but of its natural whitish appearance. In other cases, and par- ticularly in the granular variety, the epithelium of the mucous membrane seems to undergo a gradual transfor- mation into epidermis, just as occurs in the mucous mem- branes of other parts exposed to the air. When this occurs, a small spot of grayish appearance is seen, gen- erally near the centre of the exposed surface, and this slowly extends till it covers the whole. It secretes at first quite freely, but gradually becomes firm and dry ; it is, however, liable to secrete again from any slight irritation, as cold, but in the course of months becomes hardened, and then cannot be distinguished on inspection from other cicatricial formations. It is probably a transfor- mation of the ciliated epithelium of the mucous membrane to a dry pavement epithelium, although this has not yet been proven by dissection, so far as I know. Retained secretion in the form of cheesy masses are- often found during a chronic purulent inflammation, and such masses constitute serious complications, the recog- 600 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear, nition and removal of which is often imperative. The cheesy masses are very offensive, soft, greasy, grayish ac- cumulations of inspissated secretion, with which often much epithelium, cholesterine, fat-globules, detritus, and micrococci are mixed ; they are met with most commonly in the mastoid cells and antrum, and in the upper portion of the tympanum proper ; they especially predispose to caries and necrosis of the bone, either owing to their irri- tating nature or else to their mechanical pressure which causes ulceration. They have been considered by some authors the origin of tuberculous infection. Desquamative products, as compact masses of epithelial cells, are also formed in some cases of chronic purulent inflammation, and these, when retained in the cavities of the ear, constitute another source of danger from the re- tention of secretion behind them, and from their pressure causing ulceration and absorption of the bone. They are formed of closely packed lamellae of epithelial cells from the mucous membrane, mixed with cholesterine and fat, and occasionally have a nucleus of cheesy pus ; they are most common in the declining stages of a purulent in- flammation, or in cases in which the discharge is slight. Politzer found them especially in individuals affected with scrofula and tubercle. They correspond in almost every particular writh the cholesteatoraatous tumors of the older authors, and it is now a question whether many of the cholesteatomata of the temporal bone, so often de- scribed, are more than these retained inflammatory prod- ucts. Wendt,1 who made a most thorough investigation of them, gave the process the name "desquamative in- flammation." He says the microscopic examination of the masses showed "that they consisted of flattened polyg- onal cells, often without nuclei, of the size from 0.02 to 0.026 mm. in diameter, which in their form, size, and arrangement corresponded exactly with scales of epi- dermis. These cells were grouped in parallel layers, be- tween which were embedded drops of fat, generally small, and some cholesterine crystals. Where the layers overlaid each other thickly, he found a fibrous, striped appearance, due partly to folds of the thin, delicate ele- ments, and partly to an optical effect from layers of flat- cells seen edgewise. The coarser lamellae, composed of the simpler layers heaped upon each other, lay in general parallel to each other. A concentric, tubular, or glob- ular arrangement of the masses, either in whole or in parts, was not observed." Politzer8 found the mucous mem- brane in these desquamative cases sometimes cicatricially thickened, sometimes so thinned that it almost seemed to be wanting, and sometimes it had wholly disappeared; several times he saw smooth epithelial globules, from the size of a pin's-head to that of a pepper-corn, enclosed in mucous membrane in the upper part of the tympanic cavity, which he thought might arise from the epithelium of the glandular depressions in the proliferating mucous membrane, these depressions probably becoming closed at their surface by pressure, and the epithelial layer con- tinuing to proliferate in the enclosed space. Microscop- ically the masses from desquamative inflammation consist of large, round, or polygonal epithelial plates, often non- nucleated, between which numerous granules and fat- globules, cholesterine crystals, and bacteria are often found, and more rarely nucleated giant-cells (Lucas).9 The size of these desquamative accumulations varies from that of a pin's-head to masses filling up the w'hole temporal bone ; they may be quiescent in a part of one of the natural cavities for years, or increasing in size may, by pressure and ulceration, cause enormous destruction of the bone, penetrating outward into the meatus, or through the outer surface of the mastoid, or, by penetrat- ing inward, lead to a fatal issue from meningitis, cerebral abscess, or thrombosis of the sinuses. Not infrequently they fill cavities previously made by caries, the desqua- mation arising from the cicatricial tissue lining the cavity. The diagnosis of these desquamative products is often difficult, and not infrequently impossible, and many cases undoubtedly die from the complications produced by them which might have been saved by appropriate treat- ment if their presence had been recognized. The same is undoubtedly true also of the other varieties of retained secretion, although in a less degree. When the masses project into the meatus, or lie in its immediate neighbor- hood, they can be seen on inspection or found by explor- ing the tympanum with a bent probe which displaces small particles. Often the syringe brings out small masses where inspection failed to develop any, and if this recurs several times the diagnosis is confirmed. Careful inspection after an ear has been thoroughly cleansed and dried, will not infrequently show whitish shreds project- ing into the meatus, either through the perforation of the drum-membrane, or, where that membrane is entirely de- stroyed, from the upper and posterior part of the tym- panic cavity, and on displacing these with a probe or forceps, a much larger mass than was suspected will be brought into view. The presence of these collections, or of inspissated pus, may be suspected when an apparently simple suppuration obsti- nately persists in spite of treatment, and also where, in such cases, an unusually pungent and offensive odor is noticed in the dischange, in spite of persistent and frequent cleansing. A constant sense of oppression or pain on that side of the head is often complained of in these cases. The results on the hearing of a chronic purulent inflammation of the tympanum, after the suppuration ceases, depend en- tirely upon the condition in which the conducting mech- anism and the perceptive power of the nervous struct- ures are left. Where the perforation closes by a cica- trix, and the subsidence of the inflammation leaves the membrana tympani delicate and free from adhesions, the ossicles and secondary membranes with full vibratory power, and when the nervous structures have escaped injury, but little impairment of the functions of the ear is produced. This result is sometimes attained even in cases of long standing. Where the drum-membrane has been largely destroyed, and no reparation by cicatrix occurs, the hearing is im- paired ; but if the foot-plate of the stapes and its sur- rounding membrane and the nerve are in good condition, a very useful ear for practical purposes is obtained, the hearing for the voice being relatively much better than that for the watch. If, however, the conducting mechanism is limited in its vibratory power by adhesions, calcifications, perma- nent hyperplasia of the mucous membrane, or if the per- ceptive power of the nervous structures is diminished or destroyed from their having been involved in the inflam- mation, as may occur from a small- cell infiltration and subsequent or- ganization of these cells, or from suppuration of the labyrinth, the hearing is much injured or totally lost. Adhesions may form between the inner surface of a cicatrix and the labyrinthine wall of the tympa- num, between the remnants of the drum-membrane and this same wall, or the ossicles, or from one ossicle to another, or from any of the ossicles to the tympanic walls. Calcifications of any size may form in any part of the inflamed tissue, but are especially common in the fibres of the membrana propria of the drum-membrane ; they may, however, be developed in many parts of the mucous membrane, and if around the foot-plate of the stapes, fixing that bone immovably, produce the most extreme degree of deafness. Hyperplasia of the mucous membrane is due to a trans- formation of the round-cell infiltration into spindle-celled connective tissue, which, being liable to contraction like cicatricial tissue, may draw together and bind down parts which, for good hearing, should vibrate freely to waves of sound. Fig. 953.-Retract- ed Cicatrix of the Drum- membrane Adherent to the Labyrinth - wall. A diagrammatic section. (Polit- zer.) Fig. 954.-Large Cicatrix in the Posterior Half of the Drum-membrane; round perforation with calcified edges and two calcified spots. (Politzer.) 601 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It is only possible here to point out grossly the causes of deafness resulting from the inflammation. For the more thorough investigation of the details the reader is referred to the works of Politzer and Schwartz10 for descriptions of the very many and curious changes which have been found in the conducting apparatus, and to the section on Physiology of Hearing for the part played by the different parts of this mechanism in hearing. The cicatrices found in the drum-membrane, being destitute of meinbrana propria, seldom stretch tightly across the opening, but are more or less relaxed, and generally fall inward toward the tympanum. This loss of tension in the membrane is probably also a cause of more or less deafness when no other changes are left by the inflam- mation, and of course varies with the size of the cicatrix. The hearing, in almost all cases of purulent tympanic inflammation, is improved by the subsidence of the in- flammation and the cessation of secretion, which reduces the immobility of the conducting parts; but in rare and exceptional cases the reverse is found to be true, the ces- sation of the otorrhoea being followed by a decided loss in hearing power. This occurs in cases in which there is great hyperplasia of the mucous membrane, which, with the cessation of discharge becomes dry, hard, and under- goes contraction, while as long as the discharge con- tinued, the hyperplastic tissue was more or less infiltrated with serum, which kept it moist and mobile. A diminu- tion in hearing, it might be mentioned, is occasionally seen immediately after cleansing and drying out a secreting tympanum, due to the fact that the discharge happened to lie in such a position as to constitute a temporary arti- ficial membrane ; any such use of the secretion is but accidental and not to be considered in the treatment of the case. Prognosis. - Chronic purulent inflammation of the tympanum may be described as a serious disease in the same sense as, for instance, a pneumonia is serious ; many cases are light and yield readily to treatment, but while the disease continues it is liable to accidents or complications which endanger life, and some of which are almost necessarily fatal. The prognosis may be considered in three relations : (1) in relation to checking the otorrhcea ; (2) in relation to hearing ; (3) in relation to life. In regard to the first, if the case is simple, in the sense in which this term has been used heretofore, if the gen- eral health is good, and if the mucous membrane of the naso pharynx is in, or can be brought into, a healthy state, the inflammation can almost always be reduced and the discharge checked. The closing of the perforation is a matter of greater uncertainty, for it is impossible to de- cide whether the edges of the perforation have become covered with skin and thus rendered incapable of throw- ing out cicatricial tissue. If the perforation closes, the cure may be considered complete ; if the perforation re- mains open, there is always danger of relapses from fresh irritation of the tympanic mucous membrane, either from external injuries, as cold winds, or from extension of in- flammation from the naso-pharynx, The predisposition of the patient to catarrhal affections is an important ele- ment. It should be stated, however, that many cases of permanent perforations remain free from relapses of in- flammation through life, and even when there exist very marked catarrhal tendencies. In the granular suppuration the prognosis is somewhat more doubtful. Large numbers of these cases do per- fectly well, and the same influences are of importance here as in the simple cases ; but the condition of the gen- eral system is an important factor, and in considering the prognosis those cases of simple suppuration which have become granular merely from long continuance and the irritation of retained secretion should be distinguished from those cases depending on scrofulosis, tuberculosis, anaemia, or on a chronically granular pharynx. The former do nearly as well as the simple cases ; the latter are more tedious, more doubtful in result, and show much less healing power. In tubercular cases, particu- larly, the prognosis in regard to checking the discharge is very doubtful, although such cases have beeu known, exceptionally, to heal even in the later stages of tuber- culous disease. In the complicated cases the prognosis depends largely on the character of the complication and our ability to get rid of it. Polypi, caries, and necrosis absolutely preclude recovery till they are gotten rid of ; they are produced by the inflammation, but once formed they keep it up. Re- tained secretion and desquamative products usually act in the same way, but, exceptionally, they dry in sitv, and the recovery may then be completed without their re- moval. The prognosis for the hearing depends upon the condi- tion in which the parts of the ear are left, as has been already shown, and cannot be foretold with certainty, although it can be said that in the majority of cases an improvement in hearing results from the reduction of the inflammation. The deafness produced by serous in- filtration, inflammatory swelling of the tissues, and the presence of obstructive discharge, which constitute the more common causes of the deafness, will be greatly im- proved by reduction of the inflammation. Cicatricial retraction of the mucous membrane and calcification upon parts acoustically important may occasionally diminish the hearing after the inflammation ceases. In regard to life, so long as the inflammation and dis- charge continue there is the possibility of some of the fatal complications-meningitis, phlebitis, and thrombosis of the sinuses, or pyaemia-setting in. The risks of these is greater in some forms of the disease than in others. With active ulceration either of the soft parts or of the bone, ■with an obstruction to free drainage, as in a small perforation or in great stenosis of the auditory meatus, the risks are much greater than in a simple purulent in- flammation, or in a case in which the drainage of the affected parts is perfectly free. The involvement of the labyrinthine cavity in the suppuration affords a direct channel to the brain membranes. In addition to these conditions, which can be more or less certainly diagnosti- cated, there are other possibilities of fatal complications which can never be foretold ; these are arrests in develop- ment of the bony walls of the tympanum, which are known to occur occasionally in the roof of the tympanum, and then the dura mater lies in juxtaposition to the mucous membrane of the tympanum, or in the inner wall of the mastoid cells, when the mucous membrane lining these cells is in direct contact with the walls of the lateral sinus. We have also the anatomical fact that off- shoots of the tympanic mucous membrane, in the form of fibrous bands and minute vessels, penetrate the bone and connect directly with similar structures from the dura mater. It may be stated, however, that very extensive caries and necrosis of the temporal bone is often separated from the brain by an inflammatory thickening of the dura mater, which serves to protect the brain from injury. The petroso-squamosal fissure, which is open in children and filled merely with fibrous tissue, exposes them to greater risk of extension of the inflammation to the brain than is the case in adults where this fissure is nearly closed. Treatment.-In the treatment of chronic tympanic suppuration, the first and most important indication is thorough and systematic cleansing of the cavity ; this is necessary to prevent the retention of matter which de- composes readily, and then acts as a great irritant; and secondly, to expose the diseased surface so that applica- tions may reach it freely and thoroughly. For the removal of the secretion, the use of the syringe or douche is often sufficient to cleanse the tympanum very well. As a rule, the syringe is to be preferred to the douche, as the force of the current can be regulated by the rapidity with which the piston or bulb is worked, and a certain amount of force is often necessary to displace thick and adhesive pus. The piston syringe should be of good size, holding at least forty cubic centimetres, and may be two or three times that size with advantage ; it should be perfect in the action of its piston, as otherwise bubbles of air entering the ear with the water are not only disagreeable, but ofteu painful from the blows they 602 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Ear. Ear. inflict. The Davidson bulb-syringe is an extremely use- ful instrument, and very common in this country, but an almost infinite variety of others exist, all of which are very good in the practised hand, but utterly useless in unskilled fingers until instruction is given in their use. In using the syringe the outer ear should be grasped be- tween the two outer fingers of the left hand, and the ear drawn upward and backward as far as possible ; this straightens the ear-passage; the point of the syringe should be inserted in the orifice of the ear-passage, and then fixed between the thumb and finger of the same left hand, and the syringe worked with the right hand, the stream being directed slightly backward against the pos- terior wall. The water can be caught in a surgical pus- basin held just below the ear against the neck, or in any similar shallow vessel with a sharp edge. The amount of force to be used varies with the character of the dis- charge, but caries is a contraindication to the use of much force, and with caries the douche is often preferable to the syringe. Whatever fluid is used it should be slightly warm (100° to 105° F.) ; dizziness, often very severe, fol- lows the use of decided cold or heat in the tympanum, and also results from the use of too great force. Solutions of carbolic acid (1 to 80), or of thymol (1 to 500), are useful for cleansing, but many other antiseptic solutions are in use ; acid, boric. (1 to 30), corrosive subli- mate (1 to 1,000), resorcin (1 to 25). As disinfectants none are equal to carbolic acid. Modern antisepsis requires that the water of which the solutions are made should have been boiled, to destroy any micro-organisms it con- tains. Dry cleansing is favored by some authors, on the ground that the use of any fluids tends to increase the suppura- tion ; this dry cleansing is accomplished by carefully wip- ing out the tympanum and meatus with absorbent cotton, borated or salycilated, while the parts are illuminated by the otoscope. Success by this method requires an expert eye and hand, and even then is unsuccessful in thorough cleansing in many cases, owing to the irregularities and concealed cavities of the ear, where the pus forms dry crusts, beneath which mischief is liable to occur. Any evil effects from the use of fluids can be prevented by im- mediately drying out the ear by means of absorbent cot- ton on a cotton-holder, and this should always follow the use of the cleansing solutions. In many cases, however, even when the drum-mem- brane has been wholly destroyed, syringing or dry cleans- ing are insufficient to bring away all secretion, and these methods must be supplemented by inflation of the tym- panum through the Eustachian tube, which tends to drive the secretion into the meatus, whence it can readily be re- moved. If the Eustachian tube is fairly open, the patient himself can usually inflate the tympanum by Valsalva's inflation, which Was suggested by the great anatomist himself for this very purpose, and when the disease is bi- lateral this method can safely be adopted, if marked con- gestion of the head is avoided ; when, however, the dis- ease is unilateral, the inflation of the opposite ear, which occurs at the same time, may injuriously stretch and re- lax the drum-membrane of that side. Where the Eusta- chian tube is obstructed, inflation by Politzer's method or by the catheter may be necessary. Valsalva's and Polit- zer's methods are both open to the objection of inflating both ears at once, but the action on the healthy ear can be reduced by tightly closing it with one finger. If the Eustachian tube is tightly closed, it may be necessary to treat that by injections and bougies before the tympanum can be fully cleansed. Suction applied to the meatus is occasionally a useful method of withdrawing secretion from the deeper parts, especially when retained by some of the irregular depressions and cavities of the tympanum not influenced by inflation and syringing. This is best applied by means of a Siegle's speculum, which enables the operator to see the effect through the external glass of the instrument. The disadvantage of this instrument is the increased congestion it produces, and on this ac- count it should not be used with much force or for more than a few seconds. There still remain cases in which, owing to the caseous nature of the retained secretion or to the position and small size of the perforation, neither of these methods suffices, and it may be advisable to pass the point of a syringe directly into the tympanum, in order to displace and remove the secretion. This can be done by attaching a fine cannula, some three inches long, to a syringe, and passing the end within the perforation, or the elastic tym- panic catheters can be used in place of the cannula." If the cannula is made of soft silver, it can be bent to adapt it to different cases, which is a great advantage. Still another method of washing out the tympanum, Politzer has found to be occasionally useful. This con- sists in syringing through the Eustachian tube. The cath- eter used should have a longer beak than usual, be of as large a size as can be inserted, and its outer end should hermetically fit a syringe capable of holding eighty to one hundred grammes. Through this, he asserts, the stream can be driven into the Eustachian tube and tym- panum, and out of the meatus, a portion, however, always being lost in the nose and pharynx. When difficulty is experienced in getting the fluid through, owing to inspis- sated masses or swelling, the elastic tympanic catheter of Weber-Liel can be passed through the Eustachian cathe- ter and tube fully into the tympanum, and the cavity then syringed through this. In either of these methods of syringing care must be taken that there is a free exit for the fluid into the meatus, as otherwise violent dizziness, pain, and injury of the labyrinth, or even brain in cases of caries, may result. The middle-ear syringe is specially adapted for the re- moval of secretion in the posterior part of the tympanum, Fig. 955.-Siegle's Pneumatic Speculum. while injections through the tube are applicable when the retained secretion is in the anterior portion and can- not be removed by inflation, or when the Eustachian tube is granular. The cleansing of a suppurating tympanum can only be entrusted to the patient after the most minute and thor- ough instruction has been given him, and in many cases it is absolutely necessary that the surgeon take charge of it himself. Desquamative products often require to be loosened from their position by a blunt probe or ring, till they can be seized with forceps and removed. The probe or ring should be kept close to the bone, and gradually worked under the mass. If this is done, the deepest layer of epi- thelium, which is strong and resembles an eveloping cap- sule, is loosened, and the whole mass removed at once; while the more superficial layers, when seized, are so friable that they generally come away piecemeal. In- deed, the presence of this strong, glistening lamella is the surest indication that the whole mass has come away. Some cases of chronic suppuration of the tympanum can be entirely cured by simple cleansing in some of the methods above described. The frequency of the applica- tions should depend on the rapidity with which the mat- ter is secreted; if rapid, they may require to be done daily, in other cases every second or third day is suffi- cient, and as the secretion diminishes the frequency of the applications should be reduced. Every syringing of the ear should be immediately fol- lowed by careful and thorough drying with absorbent cotton, and the ear should be closed by a small, loose pledget of the same. 603 Bar. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Many cases, however, notwithstanding that the tym- panum is perfectly and regularly cleansed, will continue to secrete, and in these local medication, to reduce the inflammation and check the suppuration, is absolutely necessary. The medicaments in use for this purpose are of three forms-liquids, powders, and medicated cotton. The use of all of them presupposes previous cleansing and drying, a point which cannot be too strongly insisted on, as otherwise the applications are made, not to the dis- eased tissues, but to the secretion only. The liquids are applied either by instillation, the head being bent so that the application can be poured into the ear and held there as long as is desirable, or by syring- ing or painting with a small brush or swab. Powders are used by insufflation, being blown in from any form of insufflator. The medicated cotton is applied directly to the affected parts by a forceps or probe. All liquids should be slightly warmed before application, to prevent pain and dizziness ; where the perforation of the drum-membrane is large, they readily penetrate to the tympanum ; where the perforation is small, they can be forced in by filling the meatus and then pressing the tra- gus over the orifice firmly, which forces the drops through the perforation, and often down the Eustachian tube to the naso-pharynx. Marked dizziness is an indica- tion for stopping the pressure. The different forms of treatment in use for chronic purulent inflammation of the tympanum are divided into antiseptic, alcoholic, caustic, astringent, and dry treatments. Each has its advocates, and the indica- tions and contraindications are not always fully estab- lished. Sometimes a case not relieved by one method is cured by another ; sometimes, if the case is tedious, a change from one to another is of advantage. Some cases change their character under one treatment, and require a consequent change of treatment. In simple uncomplicated cases the antiseptic treatment is often very satisfactory. Pulverized boric acid is the most common and useful antiseptic, but care must be taken that the powder is impalpable. The ear being cleansed and dried, a small amount of powder is blown over the ex- posed surface, and this is to be repeated several times till the deeper parts are thoroughly covered ; the ear is then to be stopped with cotton. In profuse suppuration this should be repeated two or three times in the day ; but as the suppuration diminishes, the frequency of application should be reduced, and when all secretion has ceased, the powder should be left covering all the parts. The actual filling of the osseous meatus, as advised by Bezold, who fitst introduced this valuable remedy, I have not found necessary, and prefer a moderately thin covering only, which can be readily inspected. A great advantage of boric acid is the fact that it is followed by no irritating reaction, and is a safe remedy to entrust to the patient himself ; it is also soluble in the secretions and in water. The efficacy of the boric acid is thought by Politzer to be increased by the addition of carbolic acid (gtt. j. to Oj.), and when the secretion is blennorrhagic he adds a few drops of spirits of turpentine. Resorcin, pure or mixed with boric acid in equal parts, is used in the same way as simple boric acid. Many authors advise the use of fluid antiseptic solu- tions by instillation, but whether they possess any ad- vantages over the dry powders remains to be proven. Granting that they are equally antiseptic, they lack one property possessed by the dry powders in a marked de- gree, namely, that of absorbing moisture from the tis- sues, and thus reducing the oedema which accompanies many cases of tympanic suppuration, and for which, be- fore the introduction of antiseptics, simple indifferent dry- ing powders were used, often with excellent effect, such as talc and chalk. Liquids, on the other hand, by remain- ing in the ear become heated, and then act, more or less, as poultices, tending to increase rather than diminish the existing oedema. The alcohol treatment, first recommended for tympanic suppuration by Loewenberg,11 is an extremely valuable addition to our materia medica. In its action it coagulates the mucus and albumen on the surface, it diminishes the congestion, reduces the oedema, owing to its affinity for water, and especially shrivels up the proliferating mucous membrane ; in addition to these properties it is a power- ful antiseptic. It is most useful on the granular mucous membrane, or when there is any other form of prolifera- tion ; it is less efficient in reducing oedema than the anti- septic powders. It may be contraindicated when an open ulceration exists, on account of the pain produced by its application, but this is by no means always the case. It is applied by instillation, diluted with an equal amount of water, and held in the ear for from ten to fif- teen minutes, the applications being made twice a day, or less often, according to the amount and rapidity of the secretion, and always preceded by cleansing and drying as already described. It is rare that a solution of this- strength produces more than a slight warmth, and as the inflammation subsides the strength of the solution can be increased. When I can have the patient under my own observation I have found a combination of the alco- hol and boric acid treatment very effectual by painting the mucous membrane several times, at each sitting, with a saturated solution of boric acid in deodorized alcohol (ninety-five per cent.), and on top of this using insuffla- tions of a powdered boric acid, repeating the process, daily, or every second or third day, according to the amount of the discharge. The stinging of the solution, often quite sharp for one or two minutes at the first ap- plication, is much alleviated by driving a current of air upon it from a Politzer's bag. The effect of the alcohol can be seen in an immediate diminution in the redness and swelling of the membrane. The insufflation of the- powder upon the moistened surface of the membrane produces a coating which remains larger and is more thoroughly applied than the simple dry powder. The caustic treatment, brought into general use by Schwartze, consists in a cauterization of the diseased mucous membrane by argentic nitrate. This is applied either in warmed solution (1-30 to 1-10) by instillation, or by painting, or in substance by fusing either the lapis mitigatus, or pure nitrate, on the end of a probe and rub- bing the suppurating surface lightly. When used by in- stillation, Schwartze advises the neutralization of the superfluous nitrate by syringing with a solution of sodic muriate as soon as the nitrate is removed from the ear. Politzer considers this neutralization superfluous, and thinks the insoluble argentic chloride thus formed a serious obstacle to subsequent cleansing. The action of the caustic is to produce a reduction of the congestion and swelling. The eschar is usually thrown off in from one to three days, and not till this occurs should the ap- plication be repeated. The efficacy of the application is usually apparent after from five to ten trials, and if not then seen the alcohol and boric acid treatment had better be substituted. With uncomplicated tumefaction of the mucous mem- brane, and when the perforation is large, the caustic treatment often acts well, but it is contraindicated in sub- acute exacerbations of inflammation, with caseous and desquamative collections, and with caries ; also when the perforation is small, so that the eschar cannot be thrown off, or when the reaction from the application is severe. It cannot be entrusted to the patient, but requires the strict supervision of the surgeon, and while open to the disadvantage of occasionally producing more irritation than is desirable, it undoubtedly is a valuable supplement to the antiseptic and alcohol treatments when a case of simple suppuration is peculiarly obstinate. In the use of the solid nitrate the suppurating surface should be touched lightly; if pressed at all heavily its action ex- tends deeper than is desirable, and the whole epithelial layer being destroyed, granulations may spring up. The astringent treatment, formerly in universal use, but now largely superseded by more modern methods, is still favored by some excellent authorities in chronic sup- puration of the tympanum. The astringents are used in solution by instillation, or in powder by insufflation. The solutions in common use are zinc sulphate (0.2 to 0.4 in 20.0), plumbic acetate (0.2 to 0.4 in 20.0), and alum (0.3 in 604 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. 20.0). The most common powder is crude alum. The objections to the mineral astringents is that the solutions remaining in the ear and becoming warm tend to macer- ate the tissues ; and all the mineral salts, either solutions or powders, tend to form compounds with the albumen which are but slightly soluble ; on this account they should never be used except when the patient is under the constant supervision of the surgeon. Crude alum in powder is probably the most useful of these astrin- gents, and Politzer has found it particularly advan- tageous after the caustic treatment has been used for a time. The so-called dry treatment consists in dry cleansing without the use of any fluids, as has been already de- scribed, and in the application of an antiseptic tampon against the diseased surface. The cleansing is effected by wiping with absorbent cotton and by inflation, and then a soft tampon of salicylated, carboiated, or borated cotton is inserted down to the drum-membrane or tym- panum itself, if that is largely exposed. The tampon re- quires to be changed every twelve or twenty-four hours. The dry treatment thus used may be supplemented by covering the inflamed surfaces with boric acid before inserting the tampon. The omission of the syringing prevents the patient from following this method by himself, for careful inspec- tion of the ear is necessary in cleansing to be sure of thoroughness-a great disadvantage in tedious cases. Another disadvantage of this method is the difficulty of thorough cleansing, even by the surgeon; as Troeltsch well says: "Nothing cleanses like water." The method is indicated when the discharge is watery or blennor- rhagic, and especially when the suppuration, as in ex- ceptional cases, tends rather to increase from the use of the syringe. It is contra-indicated when the tympanum is sensitive to pressure and when the discharge is offensive. The granular suppuration of the mucous membrane, characterized by papillary growths over circumscribed areas, or over the whole typmpanic membrane, is pecu- liarly obstinate. The essential features, so far as treat- ment is concerned, are the hyperplasia and the oedema ; the former must be gotten rid of either by destruction or by shrivelling, the latter by reduction of the inflamma- tion and by applications which have an affinity for water. It is a rule to which there are but few exceptions, that the granulations must be removed before the suppuration will cease. The destruction of the growths may be accomplished by mineral caustics, by galvano-caustic, or by instrumen- tal removal. The shrivelling is best brought about by the alcohol treatment. The choice of agents will depend somewhat on the character of the growths ; if very soft and succulent the alcohol treatment, or the alcohol and boric-acid treatment described, is indicated ; if firm, quite hard, evidently con- taining much fibrous tissue and covering a large space, caustics are best; if present only singly or in small groups, and projecting a good deal, their removal by in- strumental means is often the most rapid method of get- ting rid of them. Nothing need be added to what has been said of the alcohol treatment; if acting favorably, the granulations will be seen to become smaller and smaller till the mem- brane is quite smooth. The caustics are applied in solu- tion by instillation, by painting, or better still, in substance directly to the growths. Of all the forms I prefer the argentic nitrate fused on the end of a probe, and applied directly to each granulation if there are but few, or rubbed over the whole exposed surface if the whole mucous membrane is granular. According to the con- sistency of the growth the caustic should be rubbed lightly over the surface or pressed for a considerable time firmly onto the granulation; lightly if the growth is rather soft, firmly if it is composed of much fibrous tis- sue. The next application should be made very soon after the slough from the previous one has come away, and this is repeated several times ; I then wait two or three days after the eschar is removed to watch the effect, and if the granulations prove to have been destroyed down to the level of the mucous membrane I substitute the antiseptic or alcohol treatment. Crystals of ferric chloride, chromic acid, and many other caustics have been more or less extolled, but the freedom from too deep a destruction makes the argentic nitrate preferable, in my opinion, to all other forms of caustic, and rarely is it insufficient if properly and thoroughly applied. Of the galvano-caustic it may be said that, while more rapidly destructive, it requires very delicate instruments and the nicest manipulation to avoid injuring neighboring parts ; and a slight burn of the mea- tus may, by its swelling, so close the passage that all treatment must be suspended. The instrumental removal of granulations can be adopt- ed when they exist singly or in isolated groups, and time is thus gained over the caustic treatment The in- struments used are a fine wire snare or a sharp curette, Fig. 956.-Blake's Modified Wilde's Snare. the former when the granulation is so prominent as to be more or less pedunculated, the latter when it has a broad base. The snare being passed over the growth to its base, the pedicle is cut by withdrawing the wire with- in its cannula. The sharp curette is used to scrape away the growth. Whichever instrument is used, there is risk of a recurrence of the growth from the raw surface, un- less the operation is followed by appropriate treatment of the inflammation in some of the ways already indicated, and this possibility of recurrence of the granulation con- tinues till the cut surface is thoroughly healed. Granu- lations which appear on the remnants of the membrana tympani or on the walls of the meatus must be treated on the same principles as those on the mucous membrane. In all cases of chronic suppuration of the tympanum the Eustachian tube requires attention as well as the tym- panum ; it may be closed by simple swelling of its mu- cous membrane, by a marked stenosis due to fibrous thickening produced by an organization of the cellular infiltration, or by a granular condition of its mucous lin- ing similar to the granular inflammation of the tym- panum. When the closure is produced by simple inflammatory swelling it will often disappear during the inflation used for clearing the tympanum, or, if not from this, it will go down as the inflammation of the tympanum subsides, and if these inflations by Politzer's or Valsalva's methods are kept up it is rarely necessary to do anything more with this form of tubal closure. If, however, the closure is so firm as to require the use of the catheter for inflating the tympanum, the inflation had better be accompanied by an injection into the tube. For this purpose solutions of ammonia muriate (0.30-0.60 to 30.0), sodic bicarbonate (0.60 to 0.30), or alum (0.25 to 30.0) may be used, a few drops being inserted in the catheter and blown quite for- cibly into the tube. A fibrous stenosis of the tube can be best overcome by passing a capillary bougie through the stricture and allowing it to remain for from five to fifteen minutes at a sitting, repeating at intervals of a few days, but carefully avoiding any inflammatory reaction. The granular Eustachian tube is occasionally an obsti- nate complication of the tympanic inflammation, serving to keep up the tympanic disease ; in such cases carbolic or slightly astringent injections through the Eustachian tube into the tympanum, or from the meatus and tym- panum down the tube are of great value. The injection of the tympanum from the Eustachian tube has already been described. The injection in the opposite direction, from the meatus inward, can be done, if the closure of the tube is not unusually firm, by inserting the nozzle of the 605 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. syringe air-tight into the meatus, and then forcing the liquid in. The air-tight closure is produced very simply by fitting a perforated rubber cork, so called, tightly over the nozzle of the syringe, and the soft rubber can then be inserted in the meatus without injury of its walls. In using this method care must be taken to inject the fluid slowly, and to cease as soon as the patient complains of dizziness. The syringe should hold from thirty to sixty grammes. As the fluid penetrates the tube it is felt by the patient running toward the pharynx, and soon drops from the external nostril; if well borne the pressure can be con- tinued till a continuous stream runs from the nostril, often bringing with it masses of muco-pus. An inflamed me- atus, caries of the bone, or a very firm closure of the Eus- tachian tube, are absolute contra-indications to the adop- tion of this method, and in every case it must be used with caution. Instillations of any desired medicament may also be forced down the Eustachian tube, in the cases under consideration, by filling the meatus with the solu- tion, and then pressing the tragus firmly over the orifice as already described, and such instillations are indicated where the antiseptic syringing proves insufficient to allay the inflammation. The most useful of these instillations are diluted or absolute alcohol, alone or combined with boric acid, a mixture of alcohol and water in equal parts being used first, and the alcohol being gradually increased in strength if the membrane is not too sensitive. Operations other than those described are occasionally necessary during the course of simple chronic suppuration of the tympanum, as an aid but not a substitute for suc- ceeding treatment. These are: (1) enlargement of a small perforation ; (2) the establishment of a second perforation. The first is indicated when free escape of the secretion is impossible on account of the small size of the existing perforation, or when granulations exist in the tympanum and cannot be reached through the existing opening; also when necessary for the removal of caseous or des- quamative products, and when the use of the tympanic syringe is desirable, but the opening is too small to ad- mit the cannula. The operation is done with the paracen- tesis needle already described, which is passed into the perforation, and an incision made of the desired size and in the desired direction ; in exceptional cases, when a large gaping perforation is necessary, it may be desirable to make a second cut at right angles to the first. The establishment of a second perforation may be neces- sary when the secretion collects in such a position within the tympanum that it cannot be removed by the existing opening. This is most likely to occur when the original perforation takes place in the extreme anterior portion of the drum-membrane, and especially when it is in the ex- treme upper anterior quadrant. The operation is dis- tinctly indicated when, with such perforations, the mem- brane is pressed outward, and so remains in spite of the most thorough cleansing and inflation, and also when re- tention of pus is probable from recurring pain or from the suppuration obstinately continuing. The edges of this second perforation require to be separated frequently by a probe to keep them from uniting, and the use of the tympanic syringe though this second opening may be in- dicated to cleanse and treat the mucous membrane with- in the cavity. The importance of recognizing the special pathological condition of the ear in chronic suppuration of the tym- panum has been sufficiently dwelt upon ; it is necessary in every stage of the treatment, and attention to the mi- nutiae of cleansing, drying, and thorough application of remedies is the key to successful treatment, and these often require the personal attention of the surgeon. The diffi- culties are those inseparable from a deep-lying and com- plicated organ, readily to be overcome, however, in most cases, by a knowledge of anatomy and physiology, and by delicate manipulation. The duration of treatment can hardly be defined, so much depends on the condition of the ear, the method of treatment adopted, the skill in manipulation of the pa- tient and the surgeon ; it may vary from two or three weeks to many months. One point should be emphasized, that so long as the tympanic mucous membrane is exposed by an open per foration there is risk of relapse from irritation of the same, either from without or from the naso-pharynx, and after all suppuration in such cases has ceased the patient should be warned to protect the ear from cold wind, dust, and water, and, in case of relapse, to immediately begin treatment; if this is done, a few days often suffices to check the renewed inflammation. Cicatricial tissue across the perforation or over the mu- cous membrane when the opening is excessive, sometimes requires several years in its formation, even while pro- gressing steadily. A covering of the exposed membrane by boric acid, or by painting with a saturated solution of boric acid in alcohol, may afford a certain amount of protection, and I always make a final application of one of these remedies, after the suppuration has ceased, which is left in position. The influence of the mucous membrane of the naso- pharynx, especially about the orifices of the Eustachian tubes, must not be lost sight of in treating a suppurating tympanum, as disease in that membrane may keep up the tympanic inflammation. It is sufficient in this place to call attention to the fact, and to refer to the discussion of diseases of the nose. Finally, in all cases the general health requires consid- eration, for while chronic purulent inflammation of the tympanum is often a purely local disease, very severe forms of which are found in persons of excellent health and constitution, many cases are influenced by constitu- tional causes, which require correction where this is possible. Anaemia and debility, scrofula and syphilis, when present, should receive appropriate treatment by iron, potassic iodide and iron, mercury or iron, and also by tonics. In many cases the general treatment is abso- lutely necessary, especially in a syphilitic naso-pharynx, which will keep up the otorrhoea by continuity of tissue even although the ear-disease is not specific. When tuberculosis is present the prognosis of the otorrhoea is ex tremely doubtful, for the ear-trouble is usually kept up by the general disease. In regard to diet, but little need be said; anything tending to cause congestion of the head is to be avoided, and particularly stimulants in excess. The bowels should be kept sufficiently free. Smoking, especially in catarrhal patients, may act injuriously by keeping up an irritation of the mucous membrane. Any occupation tending to produce congestion, such as heavy lifting, continuous, bending of the head, as in careful writing, may delay or check the cure. Some cases are greatly influenced by climatic changes, and not always by the same changes ; one is worse from dampness in the atmosphere, another from cold* and if the study of a tedious case shows this climatic influence to be very marked, a change of climate will often be of very great benefit. Treatment oe the Deafness.-After the suppura- tion of the tympanum has ceased the degree of hearing depends upon the condition in which the conducting mechanism ii left, as has been already shown in speaking of the pathology of the disease, and is dependent upon well-known physical and physiological laws. It is im- possible in this place to call attention to all of these con- ditions ; some of them can be improved by treatment after the suppuration has ceased, others are irremediable. If the conducting mechanism (drum-membrane and ossi- cles) is in an abnormal position by being drawn inward, its restoration to the natural position may greatly improve the hearing, and if adhesions have bound it down, the separation of these adhesions will improve its vibratory power. The use of inflation through the Eustachian tube, or of rarefaction of air in the meatus, as already de- scribed, if used for cleansing will do much to prevent these accidents, and is an additional reason for their em- ployment ; but occasionally it happens that the use of them after the suppuration has ceased still further im- proves the hearing, and if such is found, on trial, to be the case, they should be continued at intervals as long as improvement is noticeable. These applications should not, however, be used too frequently, twice or thrice a 606 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. week being sufficient, and care should be taken that their use is not interfering with cicatrization, if such is taking place, for the firm and perfect closure of the tympanum is of more importance than an immediate gain in the hearing. The artificial drum-membrane in a very small propor- tion of cases is of great value in improving the hearing. Of the different forms suggested I have found that made from cotton, first introduced by Searsley, the best, as less irritating, more free from crackling on movement of the jaws, and, on the whole, most useful. The action of the artificial membrane is not yet deter- mined. Erhardt considered it due to pressure, which brought the loosely articulated ossicles into firmer con- tact ; Knapp, that the pressure exerted on the short pro- cess of the hammer brought the ossicles, previously drawn inward, nearer their normal position ; others have referred the beneficial effects merely to the closure of the opening. The exact class of cases in which the artificial mem- brane will be of use cannot be determined beforehand. The only course is to try its effect, and several trials are often necessary to get it into the position produc- ing the best result. The membrane can be easily pre- pared by taking a small quantity of absorbent cotton, flattening it out of an even thickness to a round surface a little smaller than a silver quarter of a dollar, then gathering the edges together roll them till a pear-shaped mass is made, terminating in a sharp, firm handle. The mass is then held in forceps by the firm end, the cotton moistened in glycerine or vaseline and passed down to the tympanic membrane ; the forceps are then withdrawn, and with a blunt probe the cotton is pressed firmly against the deeper structures all around. Each fresh adjustment of the cotton should be followed by tests of the hearing, and in a small proportion of cases a decided improvement will be noticed. If the case proves to be adapted for the use of the arti- ficial membrane, the patient must be instructed in its in- sertion and will soon apply it much better than the sur- geon. He should then gradually accustom himself to its use, wearing it at first only for one or two hours at a time, and gradually lengthen the time till it can be borne all day. It should always be removed at night. Patients who have thus learned the method of application carry a small probe with them always, by which they can read- just the cotton in case it becomes displaced. Unfortu- nately, all forms of artificial membranes are foreign bodies, and many cases which are much benefited by their use are so irritated by the presence of the foreign body that an inflammation is set up and the artificial aid has to be abandoned. The risk of irritation can, perhaps, be di- minished by covering the cotton, before insertion, with boric acid. The indications for the use of the artificial membrane are extremely limited, and are confined to those cases of extreme deafness, from disease of both ears, where the loss of hearing is so great as to render it impossible for the patient to carry on his business, and where an im- provement of the hearing for the voice, by two or three metres, will compensate for the inconvenience of its application. It is contra-indicated when it produces dizziness and when irritation follows its use, as hap- pens, unfortunately, in the majority of cases. Its use is superfluous when only one ear is affected. Operations for the relief of the deafness after all sup- puration has ceased are proposed by some authors, and claimed to be of value. They have for their object (1) the separation of adhesions in the conducting mechanism, (2) to produce a cicatrix over an open perforation, (3) to keep a perforation open, (4) to increase the tension of a relaxed cicatrix. They may all be said to be as yet in their in- fancy, and the indications for them and their value not fully established. For a full discussion of them, the reader is referred to Politzer.12 The indications for the separation of adhesions which seem to promise the most satisfactory results where infla- tion and the pneumatic speculum are not sufficient to re- lieve them are given by Politzer as follows: (a) In the case of adhesions between the membrana tympani and the inner wall of the tympanum, when pitted depressions and thickened bands are visible on the surface of the membrane ; (b) when there is a strongly projecting fold behind the membrana tympani and simultaneous retrac- tion of the handle of the malleus ; (c) when there is thick- ening and inflexibility of the posterior segments of the membrana tympani ; (d) when the lower end of the man- ubrium or the drum-membrane near the umbo has be- come adherent to the wall of the promontory ; (e) when there is a firm cicatrix in the posterior superior quadrant, by which the motion of the stapes is impeded; (f) when the incus is adherent to the stapes. If in chronic purulent inflammation of the tympanum any of the complications-caries or necrosis, polypi, laby- rinthine or mastoid inflammation-are present, these com- plications become an important element in the case, the recognition and proper treatment of which are absolutely necessary for the relief of the tympanic disease. In re- gard to caries and necrosis and polypi, it may be said that so long as they are present a cure of the tympanic suppuration is wholly impossible ; with labyrinthine and mastoid inflammation the same is generally true, although in very rare instances the tympanum may be cured, while the inflammation of the mastoid still continues active. Caries and Necrosis is produced by ulceration of the inflamed mucous membrane of the tympanum, which, ex- tending to the deeper layers of that membrane, which act as the periosteum on the inside of the osseous cavities, finally attacks the bone itself. Politzer, whose anatomi- cal and microscopical opportunities have been very great, describes the process as an infiltration of round cells into and around the fibrous tissue which penetrates the sub- stance of the bone as offshoots from the mucous mem- brane. These round cells may undergo three transforma- tions : they may break up and be absorbed, they may be converted into connective tissue in which depositions of lime take place, and we then have a thickening of the bone, or they may, by degeneration and erosion, pro- duce an ulcerative osteitis (caries and necrosis). This ulceration is due to constitutional taint, to retention and decomposition of secretion, or to the catarrhal ulceration and wasting of the mucous membrane already described in speaking of the pathological changes produced by tym- panic suppuration. All parts of the temporal bone are liable to caries and necrosis; the most common situations are the mastoid and posterior walls of the meatus, next the roof of the tym- panic cavity and the surface of the promontory, and least frequently the pars petrosa and the anterior wall of the meatus. The extent of the disease varies from a small spot not larger than a pin's head up to tlie entire tem- poral bone. Several different spots may be affected at the same time. In addition to the walls of the tympanum, the ossicles may be affected, and we may have caries and necrosis of any or all parts of these bones ; and in some cases caries of the ossicles is found without caries of the other osseous structures. On the malleus, the most common seat of caries is the malleo-incudal articulation, from which point the disease may extend to the interior of the head of the hammer and to the incus. When the drum-mem- brane is largely destroyed, destruction of more or less of the lower end of the manubrium may take place. On the in- cus, the long process, the body, and the malleo-incudal ar ticulation are the parts generally affected; on the stapes, the head and crura, rarely the base, may be diseased. The subjective symptoms of caries and necrosis are by no means so well marked as to be readily distinguished from the common symptoms of tympanic suppuration. When the caries is very circumscribed in extent, there are abso- lutely no subjective symptoms except those of the general tympanic disease ; but if the amount of diseased bone be extensive, there is very often pain in the depth of the ear, frequently intense and persistent. This pain is most decided during the earlier stages of an osteitis, and often, though not always, ceases entirely with the formation of a sequestrum. In other words, severe pain is apt to ac- company the decay of the round-cell infiltration of the bone, and when a chronic purulent inflammation of the 607 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tympanum, which has been running its course quietly, suddenly develops severe pain which continues persist- ently for days or weeks, and examination shows no reten- tion of pus, there is very strong reason for suspecting caries. With extensive caries there is very often a de- cided irritability of the general nervous system, sleepless- ness, and often an acceleration of the pulse and increase of temperature toward evening. The objective symptoms of caries are in some cases very marked, in others obscure. The lesser circumscribed spots of caries of the tympanic walls are accompanied by changes in the mucous membrane, and, if within view, that membrane is seen to be ulcerated and to have spongy granulations over and around the ulceration ; sometimes the darkly discolored bone is seen and with the probe felt to be denuded and rough. If caries attack the mastoid antrum or the anterior por- tion of the mastoid cells, there is apt to soon follow a dif- fuse swelling and infiltration of the cutis in the upper and posterior portion of the meatus, which may go on to a suppurative periostitis which closes the meatus. This swelling is sometimes intermittent, but generally persist- ent, and slow in its development; at first hard and firm, but if pus form, it becomes soft and fluctuating. Caries of the walls of the meatus is accompanied by similar swellings over the seat of disease, but suppuration follows more rapidly, and the opening of the abscess, either spon- taneously or by incision enables an exploration of the bone to be made with the probe. Caries of the tympanic roof, unfortunately one of the most serious situations where the disease occurs, affords no characteristic symp- toms by which it can be recognized, except occasionally by the bent probe. Extensive caries of the temporal bone, involving several of the situations already spoken of at once, often produces inflammation and abscesses in the neighborhood of the ear, due either to extension of inflam- mation from the bone, to the gravitation of pus, or to ex- tension along the blood and lymphatic vessels. These abscesses usually appear about the mastoid process or be- low the auricle, but occasionally are found in front of the auricle. They sometimes rupture externally, leaving fis- tulae which discharge continuously a thin, offensive, sani- ous pus, and which are surrounded by hard, indurated tissue, or they may rupture into the cartilaginous meatus, or occasionally may penetrate to the naso-pharyngeal cav- ity, forming a petro-pharyngeal abscess (Chimani). The discharge with caries is sometimes abundant and creamy, but often thin, bloody, acridly offensive, and very irritating to the healthy skin with which it comes in contact. The intimate relation of the facial (seventh) nerve and the Fallopian canal, through which it passes, being sepa- rated from the tympanum merely by a thin layer of bone in which there is often a congenital dehiscence from ar- rest of development, exposes this nerve to injury when- ever caries occurs in the posterior and inner wall of the tympanum. Paresis, or paralysis of the facial nerve, is a frequent symptom of caries of the tympanum, and if, with a chronic tympanic suppuration, loss of motion is found in the regions supplied by the seventh nerve, this is con- firmatory evidence of caries if some of the other symp- toms of caries are also present. It must be borne in mind, however, that we may have loss of motion in this nerve from other causes than caries. The simple purulent in- flammation of the mucous membrane may extend to the Fallopian canal, and the slight exudation in the neuri- lemma of the nerve thus produced, being enclosed in un- yielding osseous walls, may so press upon the nerve as to cause paresis or even paralysis, and this affection is prob- ably more common than is generally supposed, the slighter cases often escaping observation. On the other hand, cases have been reported of necrotic destruction of the whole pars petrosa where the facial nerve was surrounded by caries and bathed in pus for a long time and yet no in- terference with its functions was perceptible. From these facts, the existence of paresis, or paralysis of the facial nerve, cannot be accepted in itself as proof for or against the existence of caries, although, as lias been said, it is confirmatory when united with other symptoms. The course and duration of caries is uncertain ; it may go on rapidly to the formation of a sequestrum, or very slowly, and in some cases there seems to be no tendency to a line of demarcation and resulting separation of a sequestrum, but the ulcerative osteitis extends continu- ously. Moreover, a distinct sequestrum by no means al- ways results from a caries which has formed such a line of demarcation ; instead of a sequestrum, the carious bone disintegrates and comes away invisibly in the discharge, and when the disintegration is completed down to the line of demarcation, healthy tissue covers the spot, and the recovery is complete. This recovery by disintegra- tion may occur not only in the smaller spots of caries, but even when a considerable surface is involved ; there- fore, a distinct sequestrum is by no means always to be looked for. In circumscribed superficial caries, as it often appears on the surface of the promontory and on the walls of the meatus, this disintegration of the bone without the for- mation of a sequestrum is very common, and when all of the carious bone has been thrown off healthy gran- ulations spring up over the surface, which gradually change into epidermal membrane, or else the membrane on the edges of the exposed surface extends over the ex- posed spot, and the caries is cured without any percep- tible loss of substance in the bone or change in the cavi- ties of the ear. In other cases, where the disease extends deeper, or where a larger surface is affected, necrosed fragments of the bone separate, sometimes in one, sometimes in sev- eral pieces, and these fragments often show distinctly the anatomical characteristics of the part from which they come. From the meatus are thrown off smooth, curved lamellae, with a part of the sulcus tympanicus, generally from the posterior upper part. In children, especially after scarlet fever, when a necrosed sequestrum often forms very rapidly, the whole annulus tympanicus is often separated. From the promontory the superficial surface may come away as a thin lamella, on which often the sulcus Jacob- sonii is distinct. From the deeper parts of the tympanum irregular masses of cancellated structure separate either from the antrum or from the upper cavities of the tym- panum, while in more extensive caries, large portions of the temporal bone separate, or a part or the whole of the pars petrosa is thrown off, in which the labyrinth is distinctly visible. After all of the diseased bone has been removed, granu- lations may spring up from the walls of the cavity, par- tially or wholly filling it, and these being changed into connective tissue, ossify, and in place of the normal bone we have a solid hyperostosis. In other cases the walls of the cavity are covered with a cicatricial connective tissue covered with epithelium from which not infrequently desquamation takes place, and the cavity becomes filled with a cholesteatomatous mass which may cause further trouble, as has been already shown in speaking of desqua- mative products. The hyperostosis, originally started as ossification of the granulation, arising from a cavity produced by caries, often increases till it fills the natural cavities of the ear, and we may thus have partial or complete ob- literation of the tympanum and of the meatus. Exten- sive and deep-seated caries sometimes attacks different parts of the tympanum at the same time ; and if hyper- ostosis, with obstruction of the tympanum and meatus, occurs from the natural course of one focus of caries, while active ulcerative osteitis and abundant purulent se- cretion is going on from another focus of caries, a most dangerous complication results from the retention of the secretion. The diagnosis of caries and necrosis can only be made with absolute certainty by means of the probe, and the use of this instrument is limited to the parts which can be reached. When the probe fails, a probable diagnosis only can be made from the combination of symptoms. In the use of the probe great care should be taken not to interfere with important parts of the ear, and no force should be applied, for not only may the remnants of the membrana tympani be destroyed, the ossicles be dislo- 608 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. cated, or the secondary membrane around the stapes be punctured, but the labyrinth may be opened by pressing the probe through the carious promontory. When the drum-membrane has been wholly destroyed the end of the probe may be bent so that it can be passed into the tympanum, and thus partially explore the parts which lie out of the field of view ; in this way the tympanic ori- fice of the Eustachian tube, part of the cancellated struct- ure above the tympanum, and the whole posterior por- tion of the tympanum, together with the inner wall, can be examined. Unfortunately, a narrowed condition of the meatus, from swelling or hyperostosis, sometimes very much contracts the field over which the probe can work. A probable diagnosis of caries may be made from per- sistent or frequently recurring pain in the ear, with a constant offensive, often bloody, discharge, which keeps up in spite of thorough cleansing, and when, at the same time, the meatus shows infiltration of its lining mem- brane, or there are recurring abscesses in the neighbor- hood of the ear. Occasionally a gritty feeling in the discharge, due to particles of lime, is confirmatory of caries, but this symptom is by no means common. The prognosis of caries depends on the character of the disease, its seat, and the extent of surface involved. In healthy persons the tendency is to self-limitation of the ulceration, if the disease is not too extensive, and the prognosis is generally favorable in them if there is a free exit for the secretion and the sequestrum. In constitu- tional diseases, especially tuberculosis, scrofula, and syph- ilis, the tendency to self-limitation is often wanting, and successive portions of the bone are destroyed. When the caries of the petrous bone is extensive, the prognosis is doubtful, and with caries, however slight, of the upper (roof) wall of the tympanum or antrum, of the inner wall of the mastoid cells, or in the immediate neighborhood of the labyrinthine fenestrae, threatening penetration of the labyrinthine cavity, the prognosis must be guarded, for in these situations a slight extension of the inflammation may start up fatal disease of the brain-membranes or si- nuses. The influence of caries on the hearing varies according to its position. Slight caries of parts acoustically unim- portant has no influence on the hearing, while involve- ment of the labyrinth, either by extensive caries of the petrous bone, or by a small carious perforation into its cavities, almost of necessity destroys the nervous struct- ures and produces total deafness. Treatment of Caries and Necrosis.-The only cure of caries and necrosis is by removal of the diseased portions of bone. This may take place naturally either by disin- tegration of the bone, or by the formation, separation, and removal of a sequestrum, or artificially by operation. A cure by either method implies the formation of a natu- ral line of demarcation. If the disease is in such a posi- tion that it can be reached, operative interference will very often hasten the removal of the diseased bone, and perhaps, in some cases, check further progress of the disease by removing a constant source of irritation. In the first place, great pains should be taken to keep the parts thoroughly cleansed by carbolic syringing, in order to make sure that no decomposing secretion is keep- ing up an irritation. Special pains in this regard are often necessary on account of a contracted meatus, granula- tions, or exostoses, and the long canula for the meatus, the middle-ear syringe, or syringing per tubam may be advisable as described in speaking of cleansing the tym- panum. All astringents and caustics are to be avoided, as productive of no good, and possibly of harm; caustics especially are contraindicated. If the caries is in a position where it can be reached, such as the walls of the meatus, the edges of the tym- panic ring, or the inner wall of the tympanum, and at the same time is superficial, the removal of the softened bone will very much hasten the cure, and may be the means of checking further extension of the ulcerative process. The operation is performed with the sharp curette, first recommended by Oscar Wolf, of which various shapes are necessary for getting at different portions of the ear. The instrument being passed in to the desired spot, the bone is scraped till all the softened parts are re- moved. The operation is only successful when the caries. Fig. 957.-Sharp Curettes ; various curves. is superficial, a condition which cannot always be deter- mined beforehand, and the depth to which the scraping should be carried depends upon the position of the caries. When on the promontory of the tympanum only the most superficial scraping is justifiable, and then only when the carious spot is very limited in extent; when on Fig. 958.-Sharp Curettes; various curves. the edges of the promontory, or within the niches of the labyrinthine fenestrae, it should not be attempted on ac- count of the risk of injuring the labyrinth. When the caries is on the tympanic ring the scraping can be done with greater freedom, and likewise when it is on the walls of the meatus, although in operating on the upper walls of the meatus the close proximity of the cranial cavity must be borne in mind. The operation of scraping is not justifiable when the caries is on the roof of the tympanum, in the exceptional cases where this spot can Fig. 959.-Sharp Curettes; various curves. 609 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL'SCIENCES. be reached, on account of the great risk of penetrating the cranium and wounding the dura mater. Sometimes it is found that granulations have sprung up from the edges of the caries of such a size that the dis- eased bone is concealed, and when such exist it may be necessary to remove them by a fine snare, by forceps, or by the curette, in order to get at the bone. ' They are the result of the irritation of the diseased bone, and will con- tinue to grow as long as the caries continues ; the appli- cation of caustics increases the rapidity of their growth, and the other methods of getting rid of granulations by applications are useless here so long as the caries remains. On this account their removal by operation is indicated whenever they are so large as to interfere with drainage, or to obstruct the view of operations upon the bone, and this, not for the cure of the granulations, but as a tempo- rary measure till the caries is relieved. After the softened bone has been scraped away, iodo- form in powder should be applied to the osseous surface, either by taking up a small quantity on the moistened tip of a probe, or by insufflation. Of the two methods I pre- fer the former, which places the medicament directly on the diseased bone only where it seems to favor the devel- opment of healthy granulations, and I follow the appli- cation to the bone by treatment of the general tympanic inflammation, using the boric acid as already described. In some cases the iodoform seems to be so stimulating that it produces an exuberant growth of granulations, and if such is the case it should be omitted, and simple boric acid, or alcohol and boric acid, substituted. In any case, as soon as the bone is fairly covered with granula- tions, the iodoform had better be omitted, and the treat- ment of the tympanic inflammation alone used ; under this the granulations become covered with an epithelial membrane. Exfoliations of the bone should be removed as soon as possible. They will often separate, of themselves, and when small, come away in the discharge, or from syring- ing ; if too large for this, they may often be felt and seen in the tympanum or meatus, retained either by irregular spiculae which hold them, or from their size being so great that they cannot pass the perforation of the drum- membrane, or the narrowest part of the meatus. Some- times they are retained in their original position by the granulations which surround them, and will thus remain a source of irritation for months, unless removed arti- ficially. If the sequestrum is lying loose and is not too large for the meatus, it should be seized with forceps and withdrawn ; if so large that it cannot pass the meatus, at- tempts should be made to break it in pieces. This can sometimes, in the case of cancellated structure, be accom- plished with the probe ; but, when this is impossible, the bone can sometimes be crushed and removed piecemeal by the use of a delicate pair of bone-forceps. In the case of very large sequestra, as of large pieces of the pars petrosa, no attempts at crushing or removal can be successful through the meatus. If external abscesses had formed, leaving fistulae down to the diseased bone, it might perhaps be possible, by following such fistulae inward, to chisel away the external cortical substance till a large enough opening was obtained to remove the se- questrum. On theoretical grounds an operation seems possible, by displacing the auricle and cartilaginous meatus forward, and removing with a chisel the posterior wall of the meatus as far as the tympanum. When an exfoliated fragment is retained in position by granulations it can often be loosened by the probe, and when the granulations are large they may require re- moval, as has been already stated. After exfoliation has taken place, the treatment by iodoform should be insti- tuted under the same rules as given in speaking of caries. The general treatment, although of less importance than the local, should not be lost sight of. The local pain, when severe, can only be relieved by opiates in- ternally, but they should be used sparingly, and omitted whenever possible, to avoid any approach to the opium habit, no slight risk in a necessarily long-continued patho- logical process like caries. The irritability of the general nervous system may be relieved by the milder sedatives. The syrup of the phosphates of iron, quinine, and strychnine is a useful general tonic, but with severe pain, the tonics may be contraindicated as tending to increase it. Iron may be indicated by anaemia and iodine, and potassic iodide by a scrofulous taint. Labyrinthine Inflammation may occur from an ex- tension inward of a chronic purulent inflammation of the tympanum along the blood-vessels which connect the cir culation of the labyrinth with that of the tympanum, or by ulcerative destruction of the secondary membranes covering the labyrinthine fenestrae, or by deep caries of the bone opening the labyrinthine cavities. Whichever way it occurs, the extension of the inflammation to the labyrinth is an increased element of danger, on account of the very free communication of the labyrinth with the brain, as will be considered later. But little of accurate pathology of the labyrinth is es- tablished. Two forms of labyrinthine disease are in this connection to be distinguished, rather, however, from their clinical histories than from accurate pathological in- vestigation ; these are swelling, and serous infiltration of the tissues, referable only to the anastomosis of the blood- vessels between the labyrinth and tympanum, or else a distinct purulent inflammation, arising from an extension of the tympanic inflammation in any of the ways above- given. The former may pass away, leaving the nervous structures but slightly injured ; the latter may, and gen- erally does, result in such a disorganization of the delicate nervous structures that the hearing, for the practical pur- poses of life, is lost forever. The subjective symptoms of involvement of the labyrinth are often wanting, often overlooked, and always uncer- tain. An accurate study of the disease as it occurs, for instance, in the acute exanthemata, is very desirable. Al- most the only subjective symptom likely to call attention to it is the character of the subjective noises : when these are described as a distinctly metallic ringing, like small bells, or as a clashing of metallic cymbals, in contradis- tinction to buzzing, roaring, hissing or throbbing, there is strong reason for suspecting the labyrinth, when such noises occur in the course of either acute or chronic tym- panic inflammation. The objective symptoms are more pronounced, although inspection, which is so important in tympanic disease, is here of no value. In testing the hearing, and especially in trying the bone-conduction with the tuning-fork, we have a fairly accurate means of making the diagnosis. With a unilateral purulent inflammation of the tympan- um and an intact labyrinth a vibrating tuning-fork placed on the median-line of the skull, forehead, or teeth, or a watch held between the teeth, will be heard loudest or entirely in the diseased ear. If the labyrinth is seriously inflamed the opposite is found, the sound being then re- ferred to the well ear. In other words, the loss of per- ception of sound through the bones is characteristic of disease of the nerve within either the labyrinth or brain, and if this occur in the course of a purulent inflamma- tion of the tympanum, without any symptoms of brain disease, it is almost certainly indicative of extension of the inflammation to the labyrinthine structures. In the case of bilateral tympanic inflammation, the loss of perception when the vibrating-fork is placed on the mastoid would indicate labyrinthine inflammation of the ear where per- ception was so lost. The only possible exception to this, with our present knowledge, may be a paralysis of function in the nerve, due to compression of the labyrinthine fluid through the secondary membranes, ovalis, and rotunda, produced by collections or growths in the tympanum ; the relief of the tympanic condition by removing the pressure would in this case produce a rapid improvement in the labyrinth, while a true inflammation of the nervous structures would improve much more slowly. We have no means of distinguishing between simple serous infiltration and swelling, on the one hand, and a full, purulent inflamma- tion on the other. The prognosis of labyrinthine inflammation is generally serious for the hearing ; the slighter forms are apt to 610 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Kar. Ear. leave some impairment of function, and from the higher inflammations are left almost any degree of deafness down to the mere perception of individual tones and noises, or absolute and complete deafness. The involvement of the labyrinth in purulent tympanic inflammation explains without doubt a very considerable proportion of the cases of total deafness. The treatment of labyrinthine inflammation can only be accomplished secondarily by treatment of the tympanic inflammation in the way that has been already spoken of. Polypi are a frequent complication of chronic purulent inflammation of the tympanum, and once formed they keep up the inflammation so that the recognition and proper treatment of them is necessary for the relief of the tympanic disease. They are connective-tissue new- growths, more or less pedunculated and covered with epi- thelium ; are essentially inflammation tumors which have been variously classified by different authors, although all agree in giving them the same general characteristics. The broadest, and at the same time, the simplest class- ification seems to be that of Politzer,13 who recognizes two common varieties, round-celled polypi and fibromata; and, on the authority of Steudener, he adds the very rare true myxomata. " The round-celled polypus (mucous ■or cellular polypus) consists of a hyaline, homogeneous, myxomatous stroma, traversed by a more or less well- developed, fibrous framework, in which are enclosed scat- tered or thickly-set round cells, and sometimes also a few spindle-cells. By transformation of the round cells into spindle-shaped cicatrix cells, the soft polypus receives a hard, fibrous character. This transformation usually pro- ceeds irregularly from the root to the body of the poly- pus. The surface of these polypi is seldom smooth, but is commonly glandular, papillary, with deep glandular indentations. These growths are covered with an epithe- lium which shows all the transition stages, from simple ciliated epithelium to the complicated epithelium of the mucous membrane of the mouth. In the interior of the polypus there are often enclosed cavities lined with epi- thelium and cyst-like spaces (Steudener's retention-cysts), which probably originate in the adhesion of secondary or tertiary growths, whereby the original indentations come to occupy the interior of the polypus. Once I found a cyst the size of a hemp-seed, filled with epithelial cells and ■cholesterine crystals." " The true fibromata are distinguished from these polypi by the fine, long-fibred, fibrillar construction of the stroma in which spindle-cells are also often inter- spersed. They are not so rich in vessels as the mucous polypi. Their surface is usually smooth and covered with pavement epithelium in several layers, the upper- most of which is cornified. The epithelium penetrates the tissue in the form of long cones." " Many polypi of the tympanic cavity are traversed by numerous blood-vessels, and receive thereby the charac- ter of cavernous polypi or angiomata. By the strong de- velopment of the interstitial tissue, the blood-vessels be- come so contracted in the progress of the case that they partly atrophy, giving to the polypus in longitudinal sec- tion a striated appearance." Ossification has been found in polypi by Cassells and by Hedinger. The majority of polypi originate from the tympanic cavity, usually from the inner and superior walls, but they may also originate from the drum-membrane, com- monly from the superior posterior portion, or from Schrap- nel's membrane, or from the tissue covering the ossicles, or from the walls of the meatus-most frequently from the posterior superior wall of the osseous meatus. Of sixty- seven removed by Schwartze,14 he was able to determine the exact point of origin in forty-five ; of these twenty- three arose from the tympanum, nineteen from the me- atus, and three from the drum-membrane. Polypi ap- parently originating from the upper wall of the meatus are occasionally found to be in reality from the tym- panum, taking their origin from the small cavities, part of the tympanum, which lie external to the head of the hammer, and project for some little distance over the meatus. They may vary in size from microscopic dimensions '* up to tumors three or four centimetres long, which fill the meatus and project externally. The shape of polypi is dependent on their histological character, and on the shape of the cavity in which they grow ; the surface may be smooth or papillary, or a com- bination of both, that is, smooth on the external portions and papillary toward the base ; their contour, when they project into the meatus, is more or less club-shaped, but when confined in the irregular cavities of the tympanum they sometimes become distinctly lobulated. Their color, when they are confined in the deeper parts, varies from light pink to a deep red, or even crimson ; but when they project externally the epithelium, especially of the fibro- mata, often undergoes a transformation to epidermis, and the color of these external portions is that of the skin. They are all benign growths, although in some instances simple fibromata suggest a semi-malignant character from the rapidity of their growth and rapid recurrence on re- moval. The rapidity of growth in polypi depends upon their histological character ; the round-celled variety may come on very rapidly, sometimes in a few days, while the fibro- mata are always slower in their growth. The subjective symptoms of polypi are none of them ab- solutely characteristic. The growth usually develops insidiously without symptoms, but when it has become large enough to press upon important parts of the ear, or to interfere with the discharge of pus, there may be pain, a sense of weight and fulness in the ear and head, dizziness and vomiting, diminution of memory, and vari- ous cerebral symptoms, or any of the results of retention of secretion, as caseous and desquamative products and caries. The objective symptoms are occasional blood in the otor- rhoea and the appearances on inspection. Through the speculum the growth is seen, and when any doubt exists the use of the probe will make the diagnosis certain. In the case of very small polypi in any situation, inspection is generally sufficient, the growth being seen clearly to project from the surrounding surface; in such a case, there may be uncertainty as to whether the projection is a polypus or a simple granulation, but the distinction is unimportant, either for treatment or prognosis. When the growth fills up the deeper meatus or completely fills a perforation of the drum-membrane, there may be doubt whether there exists polypus or whether the red mass seen is swollen and inflamed tissue merely ; in such a case the probe is necessary, and if, on passing this along the side of the growth, it can be distinctly moved, as if pedunculated, the existence of polypus is confirmed. The natural course of polypi is for them to continue in- definitely, usually increasing in size, but occasionally ceasing to grow after reaching the limit of nutrition which their vessels can supply. As long as they exist they keep up the otorrhcea. Occasionally they are discharged spontaneously by a rupture of the pedicle, but this occurs rarely, and proba- bly only when the pedicle is very small. Spontaneous shrivelling rarely occurs, although I have seen it take place in a polypus the size of a pea, which originated from the tympanic mucous membrane in a case where a nar- rowed meatus absolutely precluded its removal ; in this case, however, the most scrupulous cleanliness by infla- tion and carbolic syringing was kept up for months, and the polypus entirely disappeared, the perforation in the drum-membrane closed, and the hearing returned in a great measure. The diagnosis of polypi is usually easy from the ap- pearances on inspection and by the use of the probe. The probe is also of value in determining the point of ( origin of the pedicle ; it should be passed in to one side of ' the growth and swept around it, gradually passing deeper, till its circular motion is arrested by the pedicle; and the depth at which the pedicle is encountered will often de- termine whether the insertion is in the meatus or in the tympanum. If the pedicle is felt at a less depth than sixteen millimetres, the insertion is probably in the meatus; if deeper than that, it may be in the deepest 611 Kar. Kar. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. meatus, membrana tympani, or tympanum (Politzer).16 If the growth is freely movable the pedicle is small ; if but slightly so it is probably large. The differential diagnosis between polypi and other forms of tumors is not always easy; fortunately, how- ever, all the other tumors of the ear are rare. Enchon- droma of the meatus could scarcely be confounded with polypus, its firmness, immobility, and normal skin would characterize it. Pedunculated warts in the meatus show the papillary formation on their apices peculiar to the warts found in other positions. Milium of the meatus would show the white contents of an obstructed seba- ceous gland. Encysted tumors wmuld be more or less fluctuating. The extension of malignant growths from neighboring parts to the ear, as epithelioma from the au- ricle or naso-pharynx, myxo-sarcoma from the cranial cavity, atheroma from the auricle, would be suspected from the history and from the condition of neighboring organs and the lymphatic glands about the ear. Osteo- sarcoma would be suspected from its hardness. The new-growths which would be most likely to be confounded with polypus are round-celled and spindle- celled sarcomata and epithelioma which originated in the tympanum or meatus. Epithelioma usually begins as a moist eczema followed by ulceration, pain, and, finally, spongy growths ; the pain and jagged ulceration might lead to a suspicion of its character, but the microscopic examination of a portion of the growth would alone set- tle it. The two forms of sarcoma have both been found in the ear ; in their earlier stages, while yet small, they can both be readily mistaken for polypi, and I know of no way of distinguishing them except by removal and microscopic examination of a portion ; their subsequent rapid growth and extension to neighboring parts, with the formation of nodules, will eventually characterize them. It is very possible that inflammation-tissue occa- sionally becomes sarcomatous from some constitutional predisposition not now understood, and, after all, the clinical history of rapid recurrence, growth and extension to neighboring parts is often the only certain diagnosis of these rare sarcomata.17 The treatment of polypi consists in removal either by operation or by destruction, or else by shrivelling. The removal by operation is accomplished by excision, with Blake's modification of Wilde's snare (page 605). The loop of the snare, being opened to a size a little larger than the growth, is passed in and made to embrace the pedicle of the polypus if this can be reached, and the loop is then withdrawn within the cannula, thus cutting off the pedicle. Subsequent syringing, if necessary, will then remove the excised portion. The application of the loop over the polypus is often difficult, and the angle with the cannula at which it should be bent must be decided by the size and situation of the pedicle and by a knowl- edge of the minute anatomy of the parts; it must be de- termined for each individual case. With polypi filling the whole calibre of the meatus, the exact insertion of which cannot be determined beforehand, the loop should be bent so that it will adapt itself to the drum-membrane, which is known to lie at such an angle with the meatus that the anterior and inferior walls of the meatus are longer than the posterior and superior ones; The loop thus bent should be inserted by a slight rotary motion over the polypus, the external portion of the loop gliding along the anterior and lower wall of the meatus, and when the depth of the drum-membrane is reached the growth should be cut off. The bleeding from the operation varies ; from the softer polypi it is usually slight and soon ceases; from the firmer varieties it may be considerable, but is readily checked by syringing and, if necessary, by a tampon of cotton. With the larger polypi a second operation may be necessary on account of the impossibility of passing the snare down to the insertion of the growth at the first at- tempt ; this second operation may be done as soon as the bleeding ceases, so that a good view can be obtained, or it may be delayed for a few days. The more thoroughly the growth is removed by the snare, the shorter the after- treatment is, but it should be understood that the after- treatment is as important as the operation itself. After as much has been removed by the snare as is pos- sible, the ear should be thoroughly cleansed by syringing and inflation, and any remnants of the polypus should be cauterized with pure argentic nitrate fused on the end of a probe; if a considerable portion of tissue remains the caustic should be passed thoroughly into its struc- ture, but if only a slight depth of the polypus tissue is left, the caustic should be rubbed over the surface only. This cauterization should be repeated as soon as the slough from the previous cauterization has come away ; this time varies according to the rapidity of growth of the tissue ; if the tendency is for a rapid recurrence of the growth, the slough may come away within twenty- four hours ; if the growth is sluggish three or four days may be required ; hence a slow separation of the slough is always a favorable indication. The same rules apply for polypus as have already been given for cauterization of granulations ; the caustic treatment must be continued till the whole growth is destroyed. The alcohol treat- ment may be used by the patient daily, between the cau- terizations, and when all the required destruction has been accomplished, alcohol and boric acid can be used as described for granulations. When, from the irregularities of the ear or from any other cause, a large mass of the polypus cannot be reached by the snare, one or two deep cauterizations will often so shrivel it up as to allow of another application of the wire. If this remnant is very firm and fibrous, the caustic should be bored deeply into the mass ; if especially hard, I have occasionally made an incision di- rectly into its centre in order to get the caustic deep in. Other caustics than argentic nitrate are recommended by some, as crystals of ferric chloride or of chromic acid. Not until the point of insertion of the polypus has wholly healed over is the possibility of immediate recurrence of the growth excluded, and this having been accomplished the simple chronic inflammation of the tympanum re- mains to be treated according to the principles already discussed. Very small polypi, with distinct pedicles, may some- times be seized with forceps and crushed or twisted off. Anaesthesia is rarely necessary on account of the pain from the polypus itself, but may be necessary in order that the head may be kept motionless, or on account of the sensitiveness of the meatus and deeper parts, which must necessarily be touched in applying the snare. Destruction of polypi by caustics is a slower, and, on the whole, more painful method, but may be advisable from dread of instrumental interference. The round- celled polypi and the softer varieties of fibromata may undoubtedly be gotten rid of in this way, by the use qf argentic nitrate, ferric chloride, and chromic acid applied frequently for a long time. The galvano-caustic is highly extolled by some authors, but is open to the objections already described. The shrivelling of polypi can in many cases be brought about by the alcohol treatment, and, although very slow, is often successful even with the fibromata. Nothing need be added to what has already been said of this treatment in speaking of granulations ; polypi are treated in the same way. Its effect is only seen after several weeks. This treatment is particularly adapted for intra- tympanic polypi, but is useful for all varieties, and in many cases does away with the necessity of operative in- terference, except where retention of pus from the ob- struction offered by the polypus requires rapid removal of the growth. Its objections are its slow action, and the difficulty experienced by the patient in cleansing and dry- ing the ear, and in getting the application sufficiently thoroughly over the growth. The methods for doing this should always be carefully explained. Occasionally it happens that a polypus develops very rapidly in the ear during an acute inflammation of the mastoid. In these cases the removal of the polypus, ex- cept where it offers serious obstruction to the escape of pus, is useless until the acute inflammation of the mas- toid is relieved. As the mastoid improves these growths. 612 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Ear. Ear. will often disappear spontaneously ; if they do not they should receive attention later. Mastoid inflammation, the last of the complications which arise in the course of purulent inflammation of the tympanum, might almost be considered a distinct disease on account of its great importance, its serious nature, and the many phases it assumes. The anatomy of the mastoid and it* abnormalities are very important, as this part is sometimes the seat of difficult operations. The normal mastoid process is de- scribed as a hollow bone with thin cortex, divided in its interior into many cells by thin osseous partitions ; these cells communicate freely with one another, are filled with air from the tympanum, and all of them lined with a of development, the pneumatic cells being the highest and normal condition. In connection with operations in this region, some of the relations of the bone, and especially abnormalities in these relations, require attention. The inner cortex of the mastoid, next the brain, forms the sigmoid groove of the lateral sinus and the depression of this groove, or in other words, its curvature outward and backward, varies, as will be readily seen from the illustrations ; and this curving outward brings the sinus toward the posterior Fig. 962.-Mastoid Opened ; small-celled diploe throughout. (Politzer.) wall of the meatus, leaving but a small space of osseous structure, and this occurs just at the seat of the opera- tion for opening the mastoid antrum. Politzer 19 found, on examination of four hundred tem- poral bones, that this unfavorable position of the sinus was more common in the diploetic and sclerotized mas- toid processes, and the most favorable position was in the pneumatic and well-developed bones. In one of Politzer's preparations the sinus arches out- ward so much as to actually separate the inferior from the superior portion of the mastoid. The abnormalities of the sigmoid groove and lateral sinus constitute the most serious risks encountered in the operation of opening the mastoid antrum ; they cannot be foretold, although, according to Politzer, the slighter development of the mas- toid process renders their existence more probable than when that process is large and fully developed. The relative frequency of this outward curvature of the groove has not yet been investigated, so far as I know. The upper surface of the petrous bone forms the floor of the middle fossa of the skull, and some external land- mark is necessary to define the level of this floor, in order to avoid opening the cranial cavity in operations. This mark is found in the linea temporalis, or upper edge of Fig. 960.-Mastoid Opened; large pneumatic spaces throughout. (Politzer.) delicate mucous membrane which is a direct continuation of the tympanic mucous membrane. This condition is, however, by no means universal; the investigations of Zuckerkandl18 on two hundred and fifty temporal bones show that in only 36.8 per cent, was the mastoid process entirely pneumatic, while in 43.2 per cent, it was in parts pneumatic, and in parts filled with a fatty diploe-like substance enclosed in fine osseous cells, and in 20.0 per cent, the entire mastoid process was composed of fine cells of diploe, or else of thickened osseous tissue, being wholly destitute of pneumatic spaces. The connection of the mastoid cells with the tympanum proper is through the mastoid antrum, a passage running upward, backward, and outward from the superior pos- terior portion of the tympanum, and this antrum is the most constant cavity connected with the mastoid, although varying somewhat in size at different ages, and also in different individuals. At birth the mastoid process is represented only by a small tubercle of bone destitute of cells ; the antrum, how- Fig. 961.-Same: pneumatic above, diploetic below. (Politzer.) Fig. 963.-Mastoid Opened ; small-celled diplod, except in the extreme upper part, where it is pneumatic. (Politzer.) ever, exists in connection with the tympanum, and is of large size even at this early period. The full develop- ment of the bone has never been thoroughly studied. At three years of age it has become a distinct protuberance, but still without cells, and it finallyreaches its full develop- ment only at puberty. It is more than probable that the imperfect structures found by Zuckerkandl were arrests the posterior root of the zygomatic process, which the in- vestigations of Hartmann20 on one hundred temporal bones show to be usually on the level of this floor of the middle fossa, and never more than one centimetre above it; therefore an opening more than one centimetre below this linea temporalis is certainly below the middle fossa of the skull. The antrum mastoideum is, in many cases, the object- 613 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ive point to be reached in operations, and its develop- ment, size, and position are therefore important. It is the most constant of all the mastoid cavities, exists as a pneumatic cavity even at birth, and is said by Hartmann to be relatively larger up to two years of age than in adults. In adults it varies considerably in size, but is very rarely absent-and then, probably, only when there is enormous hyperostosis of the whole bone. Relatively of the fistula being composed of softened and carious bone. Exactly the same process may occur, during a chronic purulent inflammation of the tympanum, from an acute exacerbation of disease in the mastoid cells'. . More than this, however ; Politzer asserts that in every post-mortem examination of suppuration of the middle ear which he has made, there were simultaneous patho- logical changes in the mastoid cells. When the suppura- tion continued till death the mucous membrane of the Fig. 966.-Horizontal Section through a Compact Mastoid with Scat- tered Diploetic Spaces, t, Tympanum ; n, inferior wall of meatus ; s, sigmoid groove; w, seat of operation. (Politzer.) Fig. 964.-Horizontal Section through a Pneumatic Mastoid, g, Pos- terior wall of the auditory meatus ; t, tympanum; s, sigmoid groove ; a, antrum mastoideum ; w, wz, place for operation on the external plate of the mastoid. (Politzer.) cells showed inflammation, and the cells were filled with a purulent or muco-purulent fluid, or with masses resem- bling tuberculous matter, or with granulation-tissue. When the suppuration had ceased before death the mas- toid mucous membrane was sometimes thickened, some- times covered with dry epidermal layers, or the cells were filled with succulent connective-tissue growths or layers of epidermis ; in some cases the cells were obliterated by sclerosis of the bone, in others circumscribed or extended caries or necrosis of the bone existed. lie asserts, more- over, that these pathological changes in the mastoid may exist for years without producing any subjective symp- toms. The caries may involve either the cortex or the cancel- lated structure, and to any extent. The hyperostosis may likewise affect either the osseous partitions between the cells alone or the cor- tex as well, and in some cases it goes so far as to obliterate all the cancellated struc- ture, changing the mastoid into a solid mass of ivory - like bone. It is rare, how- ever, that the mastoid antrum is thus filled up. In some of these cases of mastoid hy- perostosis the mea- tus is seriously en- croached upon, the passage being nar- rowed by bony pro- jections from its pos- terior wall. Hyper- ostosis and caries occasionally exist together in the same mastoid. From what has been said, it will be seen that mastoid inflammation may exhibit any and all of the phases of in- flammation of the bone-softening, caries and necrosis, and hyperostosis ; on this account the name mastoid os- titis, used by Politzer, is a very expressive one. The accidents, as they may be called, of mastoid ostitis are extension of the inflammation to neighboring parts, occurring in two ways, either through some of the nat- ural foramina along the fibrous tissue or blood-vessels, or to the tympanum it lies upward, backward, and outward, its floor generally about on a line with the upper wall of the osseous meatus. Another important relation of the mastoid is shown in Fig. 964. The posterior wall of the meatus constitutes the anterior wall of the mastoid, and it will be seen espe- cially, that the antrum mastoideum is separated from the meatus by a comparatively thin layer of bone, which ex- plains the swelling and oedema already described as usu- ally accompanying inflammation and caries of the an- trum. Pathology.-The mastoid inflammations here discussed are those occurring as complications of purulent inflam- mation of the tym- panum, although the other forms of mastoid disease will be considered in treating of dif- ferential diagno- sis. In almost every case of acute tym- panic suppura- tion, the mastoid is involved by ex- tension ex continuo along the mucous membrane, as is shown by tender- ness on deep press- ure of the bone. This condition has already been dis- cussed in speaking of acute purulent inflammation ; it often subsides spontaneously as the tympanic inflamma- tion is reduced ; sometimes it extends through the exter- nal cortex along the minute foramina of the bone, setting up an external periostitis; along the course of these foram- ina the inflammation may extend to the bony structure, leading to an absorption of the calcareous particles, thus leaving the bone so soft over a more or less extended area that it may be readily incised with a strong knife. The next higher stage of the pathological process is a distinct fistula through the bone from carious ulceration, the edges Fig. 965.-Horizontal Section through a partly Diploetic, partly Pneumatic Mastoid. g, Au- ditory meatus; a, antrum; s, sigmoid groove; w, w', seat of operation. (Politzer.) Fig. 967.-m, Cavity of abscess in mastoid; p, rupture through the posterior wall of the meatus; v, lining membrane of the meatus swollen out to the anterior inferior wall; i, inner portion of the meatus; t, tympanum. (Politzer.) 614 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. else through a distinct perforation of the bone due to caries, or, in exceptional cases, to natural dehiscence from arrest of development. Outward the inflammation may extend through the ex- ternal cortex, producing a subperiosteal abscess. For- ward, as the result of caries of the anterior wall of the mastoid, we may have a perforation into the meatus with consecutive inflammation of that passage, and granula- tions from the edges of the carious bone. Inward, by ex- tension along the minute foramina or by carious perfora- tion, the lateral sinus may become involved, producing phlebitis, thrombosis, emboli, and their consequences. Upward, the middle fossa of the skull is invaded; this occurs especially through the roof of the mastoid antrum, and as its result may be produced abscess beneath the dura mater, abscess of the brain, or meningitis. Down- ward, a perforation through the floor of the mastoid opens into the digastric groove, allowing a gravitation of pus among the deeper tissues of the neck. The pus thus en- tering the digastric groove is prevented from finding an external outlet by the digastric muscle, the broad tendon of the splenius capitis, the trachelo-mastoid, and the sterno-cleido-mastoid; it also lies in close contact with the occipital artery. The anterior edges of the splenius and trachelo-mastoid are united by connective tissue with the fascia parotidea masseterica, and backward the ten- dons of the sterno-mastoid and splenius spread out like a fan and connect with the tendon of the trapezius. The pus is thus confined between the deep muscles and fasciae of the neck, and burrows along them and along the sheaths of the vessels, especially along the occipital artery, which is a branch of the external carotid. As the result of this an inflammation of these tissues is set up, which may extend forward to the chin, backward to the median line, and downward to the clavicle, producing, unless early relieved, death from exhaustion, pyaemia, or throm- bosis, and emboli. The subjective symptoms of mastoid ostitis are generally pain and tenderness the pain is referred primarily to the mastoid region, but often shoots to the vertex, temple, neck, and occasionally to the occiput. The tenderness is in the bone itself, not in the soft tissues, unless an external abscess has already formed ; it is often developed only by deep pressure, and is usually most marked at the point of greatest inflammation. A variable amount of fever, sometimes moderate, sometimes severe, accompanies acute mastoid inflammation ; in the slower and more chronic processes this fever is usually absent, and its occurrence, when previously absent in a chronic case of mastoid dis- ease, is apt to be indicative of some of the accidents spoken of. Extension of the disease outward is first indicated by oedema of the tissues over the bone so slight as to be easily overlooked ; this is followed by redness and heat, and soon by a hard swelling or increased oedema which presses the auricle forward. As pus forms, indistinct fluctuation can be detected, but only by deep palpation. Sometimes the swelling extends beyond the confines of the mastoid backward and downward, and by involving the sterno-cleido-mastoid muscle causes contraction of that muscle. As a rule, the swelling having once formed externally increases, and, if the pus is not evacuated, it may burrow upward beneath the scalp, even to the vertex of the skull, before it discharges. Occasionally, how- ever, especially in cases in which the extension outward is very slow, the swelling is circumscribed, lasts but a few days, and then recedes, to recur again and again at intervals of a few days, but lasting only for a few hours, or one or two days, each time ; in these cases there is always, in my experience, a carious fistula through the external cortex which eventually requires operation. The cedematous swelling of the posterior and upper wall of the meatus, already spoken of, accompanies al- most all acute and subacute mastoid inflammations, and is often present even in the chronic pathological processes, when these are situated in the antrum or anterior portion of the mastoid cells. Extensive chronic disease, even with caries and necrosis, may, however, exist without producing any symptoms, subjective or objective, and it is very probable that unrecognized chronic disease of the mastoid cells or bones, such as caries of slight depth, caseous deposits, or inflamed diploe, is often the cause of the persistence of a purulent discharge from the tym- panum -which refuses to yield to treatment, or which quickly relapses without apparent cause. The hyperostosis of the mastoid, when small and in the interior of the bone, affords absolutely no symptoms for its recognition ; when extensive it sometimes narrows the meatus by diffuse hypertrophy of the osseous walls, and occasionally a distinct external enlargement of the whole bone is seen. Hyperostosis may be suspected, also, when occasional attacks of acute and subacute inflammation of the mastoid, with pain, tenderness, and perhaps slight external swelling of short duration, and not going on to suppuration, have shown themselves for several years as accompaniments of a chronic tympanic suppuration. The extension of the inflammation forward is charac- terized by an inflammation of the lining of the posterior wall of the meatus, with the formation of an abscess which bursts, and from the edges of this rupture granulations, sometimes of large size, simulating polypi, are formed. In exceptional cases the inflammation may go down with- out progressing further ; but, as a rule, the extension to the meatus means carious perforation of its posterior wall, for the sure diagnosis of which the use of the probe is necessary. The point of the probe should be bent at nearly a right angle for about three millimetres, and the whole posterior wall within the abscess or granulations should be explored ; the carious opening will thus be dis- covered. The symptoms of extension inward to the lateral sinus and posterior fossa of the skull, and those of extension upward into the middle fossa of the skull, will be spoken of later, in connection with the brain complications. The symptoms of extension downward through the floor of the mastoid into the digastric groove are, first, swelling and tenderness just below the point of the mas- toid ; the swelling gradually extends down the sterno- cleido-mastoid muscle, then forward to the fossa retro- maxillaris, and downward along the large vessels of the neck. The character of the swelling is that of a cellu- litis, the tissue dense, hard, usually with sharply defined edges and protruding but little. The swelling may cease at these limits, or may extend backward and downward over the whole side of the neck to beneath the clavicle, and finally show indistinct fluctuation at the edge of the tra- pezius muscle ; or it may extend upward to the superior curved line of the occiput. If rupture has taken place into the meatus, or if the mastoid cells have been opened by operation, an upward pressure on any part of the swelling will evacuate pus from these openings. In- cisions in the swollen tissues only reach pus when they have been carried very deeply. More or less pain in the swelling is complained of throughout the disease, but as the swelling extends backward there is often, in addition, severe pain in the occiput. Death often results from ex- haustion, from caries of the vertebrae, from oedema of the glottis, from pus burrowing into the thorax, or from embolic infarcts due to involvement of the blood-vessels. Bezold21 first gave the anatomical reasons for the ex- tensive area involved in this inflammation, and tested experimentally the course of fluids injected into these parts by boring through the mastoid into the digastric groove, and then forcibly injecting colored gelatine. The swelling which resulted was exactly similar to that which had been described clinically, and subsequent dissection show'ed that the gelatine had passed along the belly of the digastric muscle, under the parotid, and along the sheath of the occipital artery to the carotid, and backward along the same artery; and it was found to lie in three successive strata, between the trapezius and splenius, be- tween the splenius and complexus magnus, and between the complexus and the short deeper muscles of the neck, running down even to the second dorsal vertebra. Differential Diagnosis.-The chief disease with which the secondary inflammation of the mastoid, just considered, is likely to be confounded is the primary inflammation of the external mastoid region, which has been described by 615 Ear. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. authors, but of which I have never seen an example. This appears without known cause, and is characterized by a hard, red swelling over the mastoid region, with ill- defined edges and painful on pressure, which appears over the mastoid region and sometimes extends to the temple ; it is apparently a simple primary periostitis. With it there may be a slight reddening, but no (edematous swell- ing of the posterior wall of the osseous meatus, and there are absolutely no inflammatory appearances on the mem- brana tympani, no history of previous tympanic inflam mation, and no affection of the hearing. It is a very rare disease. It may subside spontaneously, or may go on to suppuration, and even produce superficial caries of the bone, or it may rupture into the meatus. The absence of a history of tympanic inflammation, and of all appearances of inflammation of the drum-membrane, distinguishes it from the inflammations within the mastoid cells. An intense diffuse inflammation of the meatus externus is occasionally accompanied by great oedema and swelling over the mastoid, simulating a true mastoid inflamma- tion. The great swelling of the cartilaginous meatus, the passage being more or less closed by a very sensitive swelling, will distinguish it, together with the fact that deep palpation fails to develop tenderness of the mastoid bone, whereas any palpation which moves the auricle or cartilaginous meatus produces great pain. If such an inflammation goes on to suppuration the pus is in the subcutaneous cellular tissue just behind the auricle, and not beneath the periosteum of the mastoid. The prognosis of secondary mastoid inflammation is always doubtful, on account of the possibility of occur- rence of some of the accidents which have been described and which cannot be foretold. But, aside from these ac- cidents. the prognosis varies according to the intensity of the inflammation, the condition of the general system, and the obstacles to evacuation of the pus. With a free out- let to the pus, in a healthy person the prognosis is good. With caries, especially on the inner ami upper walls, it is doubtful, and the same may be said when the inflamma- tion coexists with tuberculosis. With symptoms point- ing to the brain, as will be considered later, the prognosis is very bad. Treatment.-Before any treatment is used for the mas- toid itself, care should be taken to afford as free an exit for the tympanic secretion as is possible under the exist- ing conditions. In the case of acute tympanic suppura- tion free exit must be established, if necessary by para- centesis tympani, the secretion cleared out, and the cavity kept free by inflation and cleansing in some of the ways already indicated. With chronic tympanic suppuration the cavity should also be thoroughly cleansed, as has been already described, and Politzer says he has allayed very intense inflammation of the mastoid by syringing out the tympanum from the Eustachian tube by means of the catheter, using simple warm water. If, however, the pain and ten- derness of the mastoid continue or increase in spite of this drain- age and cleansing used for two or three days, cold seems best calculated to reduce the congestion and check the inflamma- tion. Formerly it was so difficult to limit the action to the mastoid, and to retain a steady degree of cold, that this method was but little used ; but now, with Leiter's cooling apparatus, the action of the cold is capable of such strict limitation, and the temperature can be so steadily maintained, that this method seems likely to be of great value Leiter's cooling apparatus, which has obtained great favor in Germany, not only for the mastoid, but for many other surgical uses of cold, consists of a small lead tube, coiled as in the illustration, so as to adapt itself to the mastoid. Through this water of the desired temperature, generally with ice, passes continuously from a reservoir above the patient. The coils in front of the ear should be bent up so as not to touch the skin at that point. If, from the continuous use of this for from one to two days, the pain and tenderness are not relieved, and if swelling and redness appear over the bone, two to four leeches should be applied over the most sensitive spot, and free bleeding encouraged according to the age and strength of the patient, and after the bleeding the cooling apparatus should be reapplied. The cleansing of the tympanum should also be continued while these other means are used. If, in spite of antiphlogistics and cleansing, the pain and tenderness is succeeded by marked oedemato.us swell- ing over the mastoid, which increases to the distinct peri- ostitis which was spoken of under Pathology, and this continues for three or four days, a free incision should be made down to the bone through the periosteum. This, which is known as Wilde's incision, consists in making a cut about one inch long through the periosteum down to the bone ; when this is done, not infrequently a few drops of pus will be evacuated as soon as the peri- osteum is cut through ; but even if no pus has as yet formed, the free bleeding and the relaxation of the tis- sues afford great relief, and often check the further prog- ress of the inflammation. Surprise will often be felt at the depth to which the knife must be carried before it reaches the bone, from one and a half to two centimetres of tissue being penetrated even in cases in which the swelling seemed very slight. The folly of waiting for natural evacuation, or even for distinct fluctuation, will be appreciated when it is remembered that the pus in these cases forms first beneath the periosteum, and outside of this, as an obstacle to evacuation, lies the strong fibrous insertion of the sterno-cleido-mastoid muscle. After the periosteum has been incised, it should be slightly raised and the cortex of the mastoid examined by firm pressure with a steel director, to see if it is softened at any point; if such a spot of softening is found it should be exposed, broken through, and the mastoid cells freed from pus and thoroughly douched or syringed with an antiseptic solution, acid carbolic (1 to 80) or a saturated solution of acid boric. The softened edges of the fistula should then be scraped away with a gouge or sharp curette till healthy bone is reached, and the wound and fistula kept open for daily antiseptic cleansing till all suppura- tion has ceased. The thin partition-walls between the mastoid cells, if softened, should be thoroughly broken down at the time of operation. Frequently a free pas- sage is immediately established between the wound* and meatus through the mastoid antrum and tympanum ; in other cases such a passage is only found after several days of cleansing, and exceptionally no such passage can be made. Such a passage is a great advantage, by reason of the more thorough cleansing thus obtained, and cases in which it occurs often heal more rapidly than the simpler cases. The points at which the softening occurs are the upper portion of the mastoid, opposite the antrum, about on a line with the upper edge of the meatus, the lower tip of the mastoid, and least frequently the centre of the mas- toid. If, during the formation of the mastoid swelling, seri- ous symptoms appear-chills, high fever, and, above all, any symptoms pointing to the brain-Wilde's incision and examination of the bone should be performed imme- diately, without the few days' interval spoken of ; and the same rule should be applied in case symptoms of exten- sion of the inflammation in any of the directions spoken of show themselves. Some cases remain unrelieved by any of these methods of treatment; these are purulent collections within the bone, which show no tendency to extend outward, prob- ably on account of a very firm cortex; caseous and cho- lesteatomous collections, resulting from long-continued inflammations, the products of which have had no sufli Fig. 968. 616 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. cient outlet; caries and necrosis within the cavity of the bone without external manifestations, owing either to an unusually firm cortex or to hyperostosis resulting from a slow chronic ostitis ; and, finally, hyperostosis. Evacuation and surgical cleanliness are the distinct in- dications for all of these conditions except hyperostosis, and these indications can only be fulfilled by an artificial opening of the mastoid, followed by antiseptic cleansing. The great value of this operation is now fully established, both by the pathological studies and clinical experience of many observers in Europe and this country, but more especially by the thorough and painstaking observations of Schwartze,22 wdio has recorded the full histories of one hundred cases of the operation. It cannot be denied, however, that it is often difficult, and in some cases im- possible, to diagnosticate the pathological condition within the mastoid, and a large field lies open here for increased clinical investigation in enlarging the indications for the operation. Dissection shows that all of the pathological conditions above stated may exist within the mastoid without producing any symptoms by which they can be recognized ; but, on the other hand, many cases show symptoms of undoubted mischief going on in the mastoid cavities, without one being able to determine accurately whether there is abscess within the bone, caseous collec- tions, inflamed diploe, caries, necrosis, or hyperostosis. Such symptoms are pain and tenderness in the mastoid, continuous, remittent, or intermittent, with or without external swelling. Fortunately all of these pathological conditions are relieved by the same means, even the symp- toms dependent upon hyperostosis, so that a differential diagnosis between them is not as important as it would be if the treatment varied according to the form of dis- ease. The duration and severity of the mastoid symptoms af- ford a means of making a probable diagnosis in many cases ; if of but twTo or three wreeks' duration, abscess or inflamed diploe is probable, especially if the pain has been of the intense character common with acute inflam- mation, and attended by febrile disturbance ; if the symp- toms have extended over a long interval-many weeks, months, or even years-caries, caseous collections, or hy- perostosis are probable. Schwartze, in a paper read at the last International Medical Congress, held at Copenhagen in 1884, concludes that the artificial opening of the mastoid cells is indicated: " 1. In acute inflammation of the cells, with retention of pus, if oedematous swelling, pain, and fever do not sub- side after antiphlogosis and free incision. 2. In chronic inflammation of the mastoid process with subacute (peri- osteal) abscesses or fistulse in the mastoid. 3. With a sound cortex of the mastoid, on account of cholesteatomata or purulent retention in the middle ear, which cannot other- wise escape, and with which symptoms arise showing that the life of the patient is in danger, or when a congestive abscess has formed in the upper posterior wall of the me- atus. 4. When the mastoid appears healthy and there is no pus in the middle ear, but when the mastoid is the seat of long-continued and unendurable pain which other means fail to relieve." ' ' The operation is of doubtful utility in old, incurable, middle-ear secretion, when no symptoms of inflammation of the mastoid nor of purulent retention in the middle ear exist. It is contra-indicated when there are positive symp- toms of already existing metastatic pyaemia, or of second- ary meningitis, or of cerebral abscess." Schwartze's conclusions are: (1) Opening of the mas- toid is a valuable measure for curing the most severe and dangerous diseases of the ear ; (2) the danger of the oper- ation is slight in proportion to the danger of the affection for which it is performed. The following are the indications for the operation, as stated by Politzer : " 1. Purulent inflammation in the mastoid process, ap- pearing in the course of acute suppuration of the middle ear, where the persistent severe pain in the bone is re- lieved neither by the application for several days of cold by means of the ice-bag, or Leiter's cooling apparatus, nor by Wilde's incision." "2. Painful inflammations in the mastoid process, oc- curring in acute and chronic suppurations of the middle ear, frequently preceded by great infiltration and redness of the external integument, when these are caused by stagnation of pus in consequence of contractions of the external meatus, or of numerous growths filling up the tympanic cavity and covering the perforation. The oper ation is necessary wflien several attempts to remove the obstacle to the escape of pus have failed, and especially so in all cases of suppuration of the middle ear when the dis- charge suddenly ceases while the inflammatory symp- toms in the mastoid continue. The indication exists in such cases, even when the soft parts over the mastoid process are not swollen or infiltrated. "3. Persistent pain in the mastoid process when, at the same time, the posterior superior wall of the meatus is bulged out by the inflammation having been trans- mitted to it from the mastoid cells, and when, after incis- ion of the suppurating wall of the meatus, the mastoid abscess is either not emptied at all or only insufficiently, and when the symptoms indicating retention of pus in the mastoid process remain unabated." "4. Obstinate pain in the mastoid, continuing for days or weeks without appreciable stagnation of pus and ex- ternal swelling ; especially if the bone is very sensitive to pressure, as then there is probably a deep-seated abscess within the mastoid which does not communicate with the tympanum." " 5. As a vital indication, in every suppuration of the middle ear combined with inflammation of the mastoid, in which fever, vertigo, and headache are developed dur- ing the course of the affection, symptoms which may foretell the approach of a dangerous complication. In such cases the indication is vital." The indications for the operation as given by these two distinguished authors are practically the same in most particulars, and no better tabulation of the indications seems possible at the present time, although further ex- perience will undoubtedly enlarge the field. Of Schwartze's 100 cases of the operation the results were as follows : Cured, 74 ; not cured, 6 ; died, 20. The duration of after-treatment varied between one month and two years ; the average duration of treatment was about nine months for all cases, but for the acute cases it was about three months. The cause of the failure to cure in three out of the six cases is positively asserted to have been merely an insufficient after-treatment. Of the 20 deaths, 6 were from meningitis purulenta, 3 from meningitis tuberculosa, 2 from abscess of the brain, 1 from phlebitis of the sinuses, 1 from pneumonia catarrhalis, 3 from tuberculosis puhnonum, 2 from py- aemia, 1 from anaemia, and 1 from epithelioma. In one case the operation was undoubtedly the cause of death, the dura mater being perforated by a splinter of bone and death resulting from traumatic meningitis. In the majority of the cases the histories show that the fatal dis- ease had already set in before the operation, surgical in- terference being regarded as an indicatio Vitalis, to give the patient the benefit of the evacuation of pus. Allowing all the cases where there was the possibil- ity of a connection between the operation and the death, and adding the single case of traumatic meningitis, it is found that the mortality is reduced to six per cent. This mortality of six per cent. Schwartze considers as merely relative, since many times one hundred cases are neces- sary to get the absolute coefficient of mortality. It should, however, be remembered that these hundred cases include every case presented, without selection or reservation ; a number of the earlier ones being operated upon imper- fectly before the details of procedure had been fully elab- orated, and a number also were already suffering from advanced consecutive brain-disease at the time of opera- tion, which, in view of his past experience, Schwartze would now consider as beyond surgical interference.23 Two methods of performing the operation of opening the mastoid are in use ; one by boring with drills, the other by chiselling. Various forms of drills are made for the purpose, but a solid triangular borer, resembling the centre point of a common trephine, made of the desired size and 617 Kar. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. adapted to the common cross-handle of a trephine, works, in my opinion, more firmly and smoothly than any other form. The other method of chiselling, first introduced and strongly insisted upon by Schwartze, and now sup- ported by Politzer, is also being adopted in this country, and bids fair to supersede the use of drills, especially in cases of long-standing disease. While the drill works more rapidly and easily, it fails in many cases to make a sufficiently large opening, and its very rapidity of action increases the risk of injury of the sinus, especially if there exists a malposition of that vessel. With the chisel, on the contrary, the opening can be made of any desired size, and the removal of successive small pieces of bone enables the operator to see each step of progress, and to better guard against any malposition of the sinus. The instru- ments necessary for chiselling are chisels and gouges the linea temporalis and the edge of the anterior surface of the mastoid should be sought as landmarks for making the artificial opening. This opening should be started at a spot about two to three millimetres below the line of the superior wall of the meatus, and about five millimetres backward from the edge of the anterior surface of the mastoid, provided always the upper edge of the opening is at least one centimetre below the linea temporalis. The size of the opening is a matter of judgment; if it is probable that it will be necessary to keep the opening patent for a long time it should be made large ; if only for a short time it can be made smaller. Often this ques- tion cannot be answered until the condition of the in- terior of the bone is known, and it is well to begin with an opening from seven to ten millimetres in diameter. If the cortex is of only moderate thickness, and the evacua- tion of pus and antiseptic cleansing are found to be all that are requisite, this moderate-sized opening is all-suf- ficient ; but if the cortex is thickened by inflammation, if there are large sequestra to be removed, or if an exten- sive surface of caries exists, showing that it will be neces- sary to keep the wound open for a long time, the opening should be enlarged downward till its vertical diameter is from one and a half to two centimetres long, while the horizontal diameter is retained at about one centimetre. Until the interior cavities are opened so as to allow the tympanic roof to be defined, the upper edge of the open- ing should be kept at least one centimetre below the linea temporalis to avoid opening the middle fossa of the skull. When the bone is thickened the opening should be funnel- shaped. On reaching any cavities the chisel and gouge had better be replaced by a strong curette or a hand- chisel, and the opening continued inward by these means, remembering that the antrum, which is the objective point of the operation, probably lies somewhat upward and inward from the cavities first exposed. Hyperostosis is sometimes found to exist in an extreme degree, and the question arises to what depth the surgeon is justified in carrying the opening in these cases pro- vided he reaches no cavity ; for, on the one hand, if he abandons the operation too soon he may fail to relieve a serious condition, and perhaps save the life of his patient, and, on the other hand, by going on to too great a depth he not only passes the point sought for, the mastoid an- trum, perhaps obliterated by the hyperostosis, but he runs the risk of injuring the facial nerve or the hori- zontal semicircular canal, and adding new dangers to the case. The answer to this question is that the opening should be continued, if possible, till the situation of the antrum is reached; according to Schwartze, from the posterior edge of the opening in the bone to the antrum is eighteen millimetres, and Bezold gives the distance from the anterior edge of the opening to the antrum as twelve millimetres; Politzer advises not carrying the opening beyond fifteen millimetres, but does not state from what point he measures-probably, however, from the centre of the opening-;and this depth of fifteen milli- metres from the centre of the opening is as safe a one as can be given. The interior of the mastoid having been exposed, the thin partition-walls between the cells, if present, should be broken down and the interior surfaces of the cells ex- amined ; caseous and epithelial collections should be re- moved by loosening them and syringing them out, gran- ulations should be removed, any softened or carious bone scraped away with the curette down to the hard bony structure, and sequestra, if loosened, should be removed. The curette, however, on the inner wall toward the sinus, should be used with great care for fear of perforation. Occasionally caries is discovered so deep in the antrum that the curette cannot be applied with effect. In such cases the dental engine is a most efficient instrument, and the only one which can work effectively at the bottom of a small and deep opening; its finely-honed burrs and rapid revolutions enable it to cut quickly, and it can be applied as delicately or forcibly as is desired. It can well replace the curette for all operations on the bone, and is much more rapid and delicate in its work. During the whole operation the wound and surround- FiG. 969.-Instruments for Opening the Mastoid. (Politzer.) from five to seven millimetres broad, mallet, scalpels, periosteum-scraper, strong curettes, and bone-knife. In the operation the linea temporalis and the posterior wall of the meatus are the two chief landmarks ; the opening in the bone should be kept at least one centi- metre below the linea temporalis, and the direction of the opening should be parallel with the posterior wall of the meatus. Great care is necessary in preserving this direc- tion of the opening, for the tendency is to open directly inward as the patient lies on the table, whereas the pos- terior wall of the meatus runs decidedly forward. The chief risk of the operation is wounding the lateral sinus in the sigmoid groove, an accident which can readily occur from slight carelessness on the part of the operator in failing to retain a direction parallel with the wall of the ear-passage, or which may happen to any one from the malformation of the sigmoid groove already spoken of. Opening of the middle fossa of the skull cannot oc- cur if due attention is paid to the linea temporalis and other landmarks. To expose the field of operation, an incision should be made down to the bone close to the insertion of the auri- cle, and slightly concave anteriorly; this should begin about one centimetre above the auricle, and extend down nearly to the tip of the mastoid. From a point of this first incision, about opposite the middle of the meatus, a second incision should be made backward and slightly upward, about two centimetres long. The periosteum should now be turned back with these two triangular flaps, and the whole mastoid thoroughly exposed. The bone should then be examined. If a carious fistula exists, it should be thoroughly opened by removing all of the soft- ened bone around it with a gouge ; it should then be fol- lowed inward, and all softened, carious, or necrosed bone removed, and the cancellated structure broken down so far as is possible without too great violence. If no fistula exists, and firm pressure with a steel di- rector fails to develop any softened bone-in other words, if nature has furnished no guide for opening the cavity- 618 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. ing skin should be frequently syringed with carbolic solution (1 to 60), and the instruments occasionally dipped in the same. In most cases the establishment of free communication with the tympanum is desirable for thorough cleansing and drainage. After the operation is completed, the wound should be thoroughly syringed with a warm car- bolic solution (1 to 60), and usually the tympanic com- munication is proven immediately by the fluid appearing in the meatus; in some cases, however, the fluid only passes after two or three days, the communication being obstructed by inspissated pus or epithelial collections, which are gradually loosened by repeated syringings. The closure of the opening should be guarded against by the insertion of a drainage-tube of rubber, or a metallic cannula of silver or lead over which an antiseptic dressing should be applied. Warm antiseptic syringing should be continued twice a day, then once a day, as long as suppu- ration continues, and the wound should not be allowed to close till all suppuration has ceased. The interior of the bone should be treated on the same principles as the tym- panum, for which rules have already been given-with acid boric for the suppuration, or that substance with alco- hol for persistent granulations, or iodoform for stimula- tion of granulations on carious surfaces. The duration of treatment varies, according to the con- ditions, from a few weeks to many months, or even two years. A little ingenuity in adapting means to ends will often enable the surgeon to instruct the patient in the methods of making applications, so that the tedium of constant attendance is dispensed with. The opening in the bone is sometimes largely replaced by new osseous tissue, sometimes it is covered by an extension of the skin inward ; in either case the scar is very much less than would be expected. The treatment of the carious perforations from the mas- toid into the external meatus should be conducted on the principles already laid down-removal of the granulations if such exist, and of the softened bone when possible, and antiseptic syringing. This latter can be best effected through a small metallic cannula, bent in such a way that it can be inserted fully into the fistula. In case of extension into the digastric fossa, the indi- cations are to evacuate the pus as soon after the carious perforation of the bone as possible. The accident, as has been said, is a rare one, and my own experience is limited to three cases, all of which showed the characteristic cellu- litis of the neck described by Bezold, Two of them oc- curred years ago, before the disease was fully understood, and, after developing deep abscesses in the neck and below the occiput, died, if I remember rightly, one from pyae- mia, and one from exhaustion. The third case was seen in consultation with Dr. Richard M. Hodges ; the cellu- litis was confined to a square space of about eight centi- metres, just below the mastoid. An incision was made by Dr. Hodges from the centre of the mastoid to just be- low its tip through the periosteum, and on raising the periosteum beneath the tip of the mastoid a small amount of pus was evacuated ; the whole inner and lower surface of the tip of the mastoid was found to be carious, and was removed by the curette. This patient made a tedious but good recovery. Bezold proposes for these cases to bore through the tip of the mastoid, and thus reach and evacuate tie pus in the digastric groove. It is evident, however, that either of these operations, to be effectual, ought to be done early, before new suppuration has been started in the neck. In the later stages of the disease the inflammation must be treated on general surgical principles, and abscesses, when formed, opened and thoroughly drained when possible. In cases of excessive hyperostosis in which no puru- lent collection or caries exists, the boring or chiseMing into the bone, without opening any cavity, has frequently relieved severe and long-continued pain and dizziness. The operation is analogous to trephining other bones for the relief of ostitis, and the relief is apparently as marked in the mastoid as in other bones, as was shown in a paper read by me at the First International Otological Congress in 1876, and since confirmed by others.24 If, while attempting to open the mastoid antrum, the lateral sinus should be wounded, all further operation must be given up and the wound cleansed and carefully dressed antiseptically. Although the injury is a very- serious one, as liable to set up a traumatic meningitis, it is by no means necessarily fatal, as several cases of per- fect recovery from the injury have been reported. The Intracranial Diseases which result from puru- lent inflammation of the tympanum are meningitis of the convexity and of the base of the brain, phlebitis and thrombosis of the sinuses, abscesses of the cerebrum and of the cerebellum. All of these are produced by exten- sion of inflammation from the tympanum and mastoid, either through some of the natural communications be- tween those cavities and the brain, or through one or more carious perforations of the bone. The temporal bone is in direct connection, by means of its blood-vessels, with the dura mater and with the soft tissues of the tympanum, sending blood-vessels in both directions through the minute foramina of the bone.25 The veins of the tympanum proper enter the superior petrosal sinus through the iissura petroso-squamosa ; the posterior temporal veins of the diploe of the temporal bone enters the lateral sinus ; the petroso-mastoid canal furnishes a large passage for the veins from the interior of the mastoid to the superior petrosal sinus.26 In addi- tion to these lesser connections there is the large natural communication from the labyrinthine cavity to the brain throughtthe meatus internus, which serves for the pas- sage of the acoustic nerve, the arteria auditiva which is a branch of the basilar artery, and for veins emptying into the inferior petrosal or lateral sinus. From the same labyrinthine cavity the aquseductus vestibuli furnishes a passage for the veins from the semicircular canals to the meningeal veins, or, in some cases, directly to the superior petrosal sinus.21 Lastly, the mastoid foramen should be mentioned for the passage of the mastoid emissary vein which connects the circulation of the external mastoid region and the adjacent tissues of the neck directly with the lateral sinus. In infants a still more intimate connec- tion exists between the dura mater and the tympanic mucous membrane through the iissura petroso-squamosa, at that age an open fissure, through which a considerable surface of dura mater lies in direct contact with the tym- panic mucous membrane. , Formerly it was thought that caries of the petrous bone was the only affection of the ear which could produce in- tracranial disease, but now it is abundantly proven that any and all of those communications above given afford opportunities for extension of inflammation to the brain, even without caries of any part of the bone. With Meningitis the spot at which the inflammation reached the dura mater is usually indicated by a collec - tion of pus, often only one or two drops, just beneath that membrane next the bone ; over this the dura mater is infiltrated, often shows organized lymph, and is very frequently adherent to the pia mater. From such a spot the inflammation extends, sometimes over the whole con vexity, sometimes over the base of the brain, and rarely over both. The inflammation is only exceptionally con- fined to the dura mater ; it usually involves the pia mater as well. Often meningitis is only produced by the rup- ture of the pus through the dura mater, and it is some- times found that before thus rupturing the pus has bur- rowed for quite a distance, so that the point of rupture in the dura mater by no means corresponds with the original seat of inflammation. Symptoms of Meningitis.-Premonitions of a tendency in the inflammation to extend inward are absolutely wanting in the ear in most cases. Sometimes, however, the extension from the tympanum to the labyrinth, from which, as has been said, there is a direct connection with the brain, can be diagnosticated by means of the tuning fork, and if, in a case of tympanic suppuration, there oc- curs a rapid and total loss of perception of all sound of a vibrating tuning-fork when placed on the mastoid of the affected side, and at the same time there is vertigo, exacerbation of fever, and perhaps vomiting, an exten ■ sion to the labyrinth is probable, and the risks of deeper 619 Kar. Ear. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trouble are increased. With this exception of involve- ment of the labyrinth, the extension of the inflammation inward is insidious, and destitute of any aural symptoms. The most frequent symptom preceding meningitis is headache, often at first intermittent, but soon becoming- continuous and gradually increasing in severity. This usually precedes the symptoms of an active meningitis by from one to ten days, and a frequently-recurring or continuous headache, increasing in severity, with tym- panic inflammation either acute or chronic, is a cause for great anxiety. This headache is referred by the pa- tient to the deeper brain, and is usually over the whole head, although sometimes described in the occipital re- gion and occasionally in the temples ; it must be distin- guished from the pain over the side of the head which often accompanies inflammations of the tympanum and darts from the ear, and which patients generally charac- terize, when their attention is called to it, as superficial. After the headache, restlessness, wakefulness, and oc- casionally vomiting are the more common symptoms of a beginning meningitis, followed by dulness of the intel- lect ; in children frequently coma, and finally fever of greater or less severity, and the other well-known symp- toms when the disease is fully established. In a number of the cases which I have seen in adults the prodromatous stage has been prolonged even to ten days before the dis- ease was fully established. Attempts have been made to diagnosticate the earlier stages of an otitic meningitis by examination of the eyes and the presence of optic neuritis, but the cases are as yet too few for any conclu- sions to be drawn from them as to the constancy of this symptom. A true meningitis due to tympanic inflammation is fatal in the majority of cases ; but, very exceptionally, re- covery takes place in cases where the symptoms admit of no doubt in the diagnosis. This is especially the case in children. The general treatment of an otitic meningitis requires no special mention here ; it does not differ from that of the disease when produced by any other cause, but, as certain pathological conditions of the ear are the cause of the brain disease, so long as these pathological conditions exist the meningitis continues. The local treatment of the ear thus becomes the important feature of the menin- gitis, and if, by such local treatment, the tympanic dis- ease can be relieved, recovery from the meningitis may occasionally take place. This local treatment may be shortly described as consisting in the immediate removal, where possible, of obstructions to the escape of pus and of special sources of irritation, with thorough cleansing. These indications may require free incision of the drum- membrane, removal of polypi and granulations, removal of sequestra, and occasionally opening of the mastoid process when collections of pus, sequestra, or caries are suspected there. Thorough cleansing by antiseptic so- lutions and by inflation should be energetically followed up. These different conditions have already been fully discussed, and need not be repeated here. If any of them exist, the occurrence of any symptoms of menin- gitis calls for immediate action, and every means possible should be taken to remove them. The prognosis, how- ever, remains unfavorable even when retained pus or other marked sources of irritation are capable of being removed. Phlebitis and Thrombosis of the sinuses may occur from extension of the tympanic inflammation inward by any of the routes already mentioned. They are most common in the lateral sinus, from extension of a mastoid inflammation inward either through some of the minute foramina, or through carious perforation of the sigmoid groove which forms the inner wall of the mastoid. They may also occur in the superior petrosal sinus, which re- ceives many small veins from the tympanum proper, and also the quite large petroso-mastoid vein from the interior of the mastoid, and often also the veins from the laby- rinth through the aquaediictus vestibuli; diseases of this sinus may come from any of these parts of the ear. They are sometimes developed in the inferior petrosal sinus, ■which receives veins from the interior of the labyrinth. The anatomical connection of these three sinuses should be borne in mind, for upon this knowledge the diagnosis often depends. A thrombus forming in either is liable to extend to the neighboring sinuses, and by closing them check the venous circulation, producing oedema, and oc- casionally inflammation in the parts drained by the ob- structed sinuses. Anteriorly the superior and inferior petrosal sinuses pass into the cavernous sinus, which lat- ter receives the veins from the supraorbital, ciliary, an- terior and posterior nasal regions ; posteriorly both these petrosal sinuses connect with the lateral sinus in the sig- moid groove. From the inferior portion of the lateral sinus, in this groove, the internal jugular vein is given off, and a little above this the emissary mastoid vein,28 which drains the external tissues of the neck and scalp, enters the lateral sinus. Posteriorly the lateral sinus passes to the torcular Herophili, just before reaching which it receives the condyloid emissary vein, which drains the deeper muscles of the neck and the spinal column ; the torcular Herophili itself receives the occipital emissary vein, which drains the superficial structures of that region. Of these three emissary veins the mastoid is very much the largest, and the most important in con - nection with thrombosis and phlebitis of the sinuses from ear disease. The symptoms of beginning phlebitis of the sinuses are severe chills followed by high temperature (104° F. or more); these chills increase in frequency and duration, and the remissions in temperature become less, till there is a continuous fever with which there is often headache and dizziness. The phlebitis of the walls of the sinus, in most cases, soon produces a thrombus in its interior, and the circulation is checked ; this thrombus is very apt to extend along some of the connections already described, with the result of checking their circulation ; plugging of the cavernous sinus is followed by oedema, suppuration, or erysipelatous inflammation in the supraorbital, orbital, or nasal tissues, and by epistaxis. From the sigmoid curve of the lateral sinus the thrombus may extend down into the internal jugular vein, so as to be distinctly felt as a firm, hard cord along the course of that vein in the neck, and this is often followed by inflammation of the cellular tissue of the neck. From the lateral sinus the thrombus may extend into the emissary mastoid vein, producing oedema and inflammation of the superficial structures on the posterior side of the neck, the swelling starting at the point of emergence of this vein close to the edge of the base of the skull, about one inch backward from the insertion of the auricle ; and as the inflammation extends from this spot the characteristic cellulitis of the neck appears. In extreme cases the thrombus may extend backward to the torcular Herophili, and external manifestations of this may appear in oedema and cellulitis at the point of emer- gence of the condyloid and occipital emissary veins (ride Fig. 970). Symptoms of an affection of the emissary mastoid vein, internal jugular vein, and cavernous sinus, may appear one after the other at short intervals. A closure of the internal jugular vein is followed in a few days by such an increase in the collateral circulation over that side of the neck and face that the superficial veins are dilated to several times their natural size. A thrombus extending to the bulbus venae jugularis internae may, Beck says,29 by its pressure upon the vagus, glosso-pharyngeal, and spinal accessory nerves where they pass through the jug- ular foramen, produce paralysis of those nerves. Epi- leptiform attacks are asserted by Politzer to occasionally occur with phlebitis and thrombosis of the sinuses. The thrombus, in any position, may at any time under- go suppuration, and the pus may rupture through the dura mater, setting up a meningitis ; or a phlebitis of the walls of a sinus may extend to the meninges ; or the pus may be absorbed into the circulation, producing septi- caemia ; or emboli, separating from a thrombus and being carried into the general circulation, may produce metas- tatic abscesses. The course of phlebitis and thrombosis of the sinuses varies very much in duration ; with a slight extent of phlebitis and a non-suppurating thrombus, the disease 620 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ear. Ear. may extend over weeks, and even months, death finally resulting from exhaustion due to inflammation in the neck, face, or occipital region. In very rare instances recovery may take place. 1 have seen one such recovery, the disease being due to mastoid inflammation and caries ; the thrombus was felt distinctly in the internal jugular vein, there was great oedema of the upper facial region and orbit, with erysipelas, and also enormous dilatation of all the superficial veins over the temple, cheek, neck, and chest of the affected side ; this patient, a little girl of about ten years of age, finally recovered, and was living eight years after If suppuration occur in the thrombus septicaemia, emboli, and metastatic abscesses, and menin- gitis from extension to the brain membranes are immi- nent, and once started are rapidly fatal. A possible cause of death from phlebitis is ulceration and perforation of the lateral sinus, with resulting fatal haemorrhage ; such a case has been described by Wreden.30 The differential diagnosis of phlebitis and thrombosis of the sinuses from meningitis depends, aside from the local connected by a fistulous tract with the diseased bone ; or there may be a portion of healthy brain-tissue between it and a carious spot of bone without any fistulous tract ; or, in very rare cases, it may be in the substance of the hemi- sphere on the opposite side from the ear disease. In these two latter positions the connection of the abscess with the ear disease often cannot be directly traced, but is as- sumed by Gull31 to be by metastasis. The abscess may appear in the cerebellum, either upon its lower surface or in its substance, usually on the same side as the ear dis- ease. Instead of a single abscess in any of these posi- tions, there may be multiple abscesses, either connected to- gether by fistulie or isolated. Of 206 cases of abscesses of the brain collected by Meyer,31 53 were due to disease of the ear ; of 89 of the cases originally tabulated by him, 2 only showed multi- ple abscesses, in one of which there was an abscess in the cerebrum and one also in the cerebellum, while in the second case there were three abscesses in the cerebellum. The law as laid down by Toynbee and afterward modi- Fig. 970.-Diagrammatic View of the Brain-sinuses and their Connections. manifestations of venous stasis, upon the severity of the rigors and high temperatures, and the clearness of the intellect and consciousness. Treatment of the intracranial disease can only be a treatment of the symptoms as they appear, and aside from this, supporting and stimulating. In regard to the ear, the patient should, in my opinion, have the benefit, at least in the earlier symptoms of the disease, of the re- moval of any extraordinary sources of irritation, such as have been mentioned already in speaking of meningitis. Abscess of the Brain, the result of a circumscribed encephalitis, varies very much in its position. It may be in the cerebrum, on the lower surface of the hemi- sphere directly over, and communicating with, a caries of the tympanic roof; or in the substance of the hemisphere, fled by Gull, in which it was asserted that the cerebellum and lateral sinus suffer from disease of the mastoid, while the cerebrum is endangered by caries of the tympanic roof, has not been fully confirmed by later observations ; but it can be said that, in most cases, disease of the upper surface of the petrous bone is associated with abscess of the cerebrum, and disease of the posterior surface of the petrous bone with abscess of the cerebellum. The obscurity of the symptoms in abscess of the brain is well known, as is also the marked disproportion be- tween the anatomical changes found after death and the clinical symptoms observed during life. This can be ex- plained, at least in a great measure, by the slow growth of the purulent collection, its softness, and the consequent slight pressure on the healthy portions of the brain, and 621 liar. liartli-Dressiu". REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by the fact that the position of the abscess is usually in the white substance of the hemispheres, which plays a com- paratively unimportant part in the physiology of the brain. In abscess of the brain there is also, frequently, a marked latency in the disease intervening between the initiatory symptoms and the final, fatal ones ; total latency of the disease throughout its whole course is, however, rare, but two cases being reported by Meyer. The primary symptoms seem to mark the early period of congestion and beginning softening, while the final ones are found when the abscess has reached a motor centre, or when it ruptures or sets up another disease of the brain, as men- ingitis or extensive oedema. The beginning of an encephalitis, always difficult to define, is especially so when caused by disease of the ear, for the pain and other symptoms in the ear are apt to obscure the brain symptoms. The more gradual the ex- tension of the ear disease to the brain, the slower is the primary congestion of the encephalitis and the less marked the brain symptoms. Slight headache is often the only brain symptom complained of, but, as this is a not in- frequent accompaniment of the simple ear disease, little reliance can be placed upon it unless it becomes very se- vere and long-continued, without symptoms of menin- gitis. In two-thirds of Meyer's cases of abscess of the brain, headache, variable but gradually increasing with the length of the disease, was the first symptom noticed; this was sometimes accompanied with fever, dizziness, and occasionally with vomiting, but seldom with convul- sions or paralysis. After headache, fever with chills, thirst, and loss of appetite would seem to be the next frequent initiatory symptom. Meyer found this fever in one-eighth of his cases, while convulsions were the first symptom in one-tenth of his cases. The convulsions were usually general, of an epileptic character, and ac- companied with loss of consciousness. Neuralgia, anaes- thesia, and disturbances of the intellect are rare as early symptoms. The less severe the initiatory symptoms of encephalitis, the slower, as a rule, is the development of the abscess. The earlier symptoms often disappear entirely, so that for a time the patient is absolutely free from symptoms of any kind. The course of the disease, after the earlier symptoms, may be either acute or chronic, depending largely on whether the abscess becomes encapsuled or not; in the acute form death results from the increasing suppuration and destruction of the brain-substance; in the chronic form from rupture of the abscess into the ventricles, or onto the surface of the brain, or else from oedema or anaemia. In the acute abscess there is little, if any, latency in the disease; at the most, the patient is free from symptoms for only a few days, and the disease runs its course and ends fatally in from one to five weeks, although occa- sionally the period is somewhat longer. The chronic abscess is characterized by a period of marked latency intervening between the earlier and the later symptoms; this latency is often complete, but is sometimes interrupted by short, intermittent attacks of headache. Sometimes the earlier symptoms are wholly overlooked and the disease runs its course absolutely with- out noticeable symptoms till the final ones set in. The duration of this latency may vary from a few weeks to several months ; and in two cases, narrated by Bruns and Schott, it was thought to have reached twenty years. The period of latency being once disturbed, the final course of the disease is usually rapid. In thirty-four cases given by Meyer, in which the period of latency and that of the final symptoms were well marked, the latter ran their course and ended fatally : within the first week, 13 ; second, 7; third, 4 ; fourth, 4 ; fifth, 4 ; sixth, 1; ninth, 1. Occasionally an abscess without an envelop- ing capsule assumes this chronic course, but this is rare. In the chronic abscess death is usually caused by a rupture into the ventricles or upon the surface of the brain, by an extensive oedema of the brain-substance, by involvement of the medulla oblongata in the disease, or occasionally by anaemia of the brain. Of these different causes the rupture into the ventricles is the most fre- quent, and is followed by symptoms of irritation in the motor centres, febrile disturbance, delirium, limited or general paralysis of motion and sensibility, coma, and death. Rupture onto the base of the brain is generally followed so rapidly by profound coma that other symp- toms are masked, but sometimes headache, dizziness, and vomiting are noticed. Hemiplegia and continuous coma have been noticed from extensive oedema ; but the symptoms of all of the above-enumerated causes of death are so little distinctive that a differential diagnosis is usually impossible. They all lead to a fatal termination in from a few hours to a few days. Differential Diagnosis. - In meningitis the following symptoms are generally observed : violent fever with a very high pulse, especially in the beginning of an attack ; severe headache, general and never distinctly circum- scribed, and continuous ; violent delirium ; contractions of the pupil and vomiting ; convulsions and sopor. In encephalitis the diagnosis must be very uncertain, as there may be absolutely no symptoms, or-only in the beginning of the disease-symptoms which resemble, and often are due to, meningitis. When the abscess is in certain positions there may be affections of the sensory or motor nerves, showing themselves as anaesthesias or paralyses. The early history will often help the diagnosis if it shows the existence of a predisposing cause to encephalitis, such as injury of the head or disease of the ear, and especially if there has been an acute illness with meningitic symp- toms. The history of an acute febrile attack resembling meningitis, with a high pulse and severe general headache, associated with purulent disease of the ear, and these symp- toms followed by a marked falling of the pulse below the normal, and occasional headache distinctly circum- scribed and in one spot, is often characteristic of encepha- litis.33 The result of abscess of the brain is probably invariably death, and of treatment nothing can be said. Dangerous hannorrhages from the ear may occur as the result of caries of the bone in the neighborhood of any of the large vessels in close relationship to the ear. These vessels are the lateral sinus, inferior and superior petrosal sinuses, the internal carotid artery, and the internal jug- ular vein. Dissection has actually shown all of these vessels, except the superior petrosal sinus, to have been the sources of serious bleeding. The relationship of the sinuses to the tympanum has been already described. The carotid canal, through which the carotid artery passes, forms the anterior wall of the tympanic cavity, the osseous partition being very thin. The jugular fossa, in which lies the bulb of the jugular vein, constitutes the floor of the tympanic cavity, and is also very thin. With caries of the bone in either of these localities, the walls of the vessel may be so soft- ened by inflammation as to rupture, or they may be per- forated by ulceration or by spicuhe of necrosed bone. From either of these causes there results a dangerous and often fatal haemorrhage into the tympanum or mastoid, although such complications of a caries are very rare. The most frequent source of profuse haemorrhage is the carotid artery ; the bleeding in these cases varies very much in its rapidity, probably depending upon the size of the arterial opening, and is more apt to be a con- tinuous oozing of bright arterial blood than intermittent arterial jets ; it usually ceases in a few minutes, but re- curs again and again till death results, either directly from the haemorrhage or from exhaustion. Occasionally, however, the bleeding is so profuse as to be rapidly fatal of thirteen cases collected by Hessler,34 three resulted in death within a few minutes from a single enormous haemor- rhage. The diagnostic characteristic of these cases is the arterial quality of the blood, and the fact that the bleeding is checked by compression of the carotid in the neck. Hessler has collected thirteen cases in which autopsy confirmed the fact that the haemorrhage came from the carotid artery, and six other cases where autopsy was wanting but where the diagnosis of haemorrhage from the carotid was probably correct; of these last six cases, five were fatal. The bleeding generally occurred very 622 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Ear. Earth-Dressing. 2 Archiv fur Ohrenheilkunde, vol. i„ p. 200. • 3 Politzer: Diseases of the Ear. Translated by Cassels, p. 405. 4 Deutsche Chirurgie. Billroth and Luecke. 6 Diseases of the Ear, translated by Cassells, 1883; also, The Drum Membrane in Health and in Disease, translated by Mathewson and New- ton. 6 Pathological Anatomy of the Ear, translated by Green. 7 Archiv fur Heilkunde, vol. xiv., p. 428. 8 Diseases of the Ear, translation, p. 452. 9 Ibidem, p. 453. 10 Op. cit. >i El Pabellon Medico, Madrid, 1870. 12 Diseases of the Ear, op. cit. 13 Op. cit., translation, p. 636. 14 Billroth and Luecke : Deutsche Chirurgie, 1884. 16 Lucae : Virchow's Archiv, xxix., p. 7. 16 Loc. cit. 17 For cases of these new-growths see Politzer, loc. cit.; Schwartze, Pathol. Anatomy of the Ear, also Deutsche Chirurgie, loc. cit.; Green, Archives of Otology, vol. xiii. 18 Monatschrift fiir Ohrenheilkunde, 1879. 19 Op. cit. 20 Langenbeck's Archiv, vol. xxi. 21 Deutsche Med. Wochenschrift, No. 28, 1881. 22 Archiv fiir Ohrenheilkunde. 23 Archiv fiir Ohrenheilkunde, xix. 24 Politzer: Diseases of the Ear, p. 576. Schwartze, Zaufal. 25 Troeltsch. 28 Henle: Anatomic. 27 Henle: Anatomie. 28 For the position and variations of this vein, see American Journal of Otology, April, 1881. 29 Deutsche Klinik. 1863, quoted by Politzer. 30 Monatschrift fur Ohrenheilkunde, No. 10, 1869. 31 Guy's Hospital Reports. Third Series. Vol. iii. 32 Zur Pathologic des Hirn-abscesses von Dr. Rudolph Meyer. Zurich, 1867. 33 Disease of the Brain in its Relations to Inflammations of the Ear, Green: Med. and Surg. Reports, Boston City Hospital, second series, 1877. 34 Archiv fiir Ohrenheilkunde, vol. xviii. 35 Archiv fiir Ohrenheilkunde, vol. xx., p. 47. suddenly, without warning and without any predisposing cause, such as violent exertion ; when slight it could be checked by a tampon in the meatus ; when severe, it re- quired long- continued digital compression in the neck ; in most cases it kept recurring daily. Ligation of the carotid was performed in four cases, those of Baizeau, Broca, Pilz, and Syme. In the first case the left com- mon carotid was ligated, but the bleeding recurred at the end of twenty-four hours and was fatal by three repeti- tions in the course of the next three days. In the second case, the right internal carotid was tied and the bleeding checked entirely, the patient dying two months after from tuberculosis of the lung, In the third case, the right common carotid was ligated by Billroth, and there was no bleeding for nine days ; it then began again from the ear, mouth, and nose, and although checked by com- pression kept recurring till, on the fourteenth day, the left common carotid was tied ; three days after this a violent haemorrhage from the ear, mouth and nose ended fatally. In the fourth case the right common carotid was ligated, but the same evening there was a severe haemorrhage from the mouth and ear ; eighteen days after there was another haemorrhage from the pharynx and right nostril, and two days after this still another ; from this time the patient, a boy of nine years, began to improve, ami in less than two months was discharged in good health. It will be seen that two of the four cases in which ligation of the common carotid was performed recovered. Hessler, in his discussion of these cases, concludes that in severe arterial haemorrhages from the ear the common carotid should be ligated, although, even if this is done, a collat- eral circulation through the circulus arteriosus Willisii may renew the bleeding. A fatal haemorrhage from the left bulbus venae jugu- laris, caused by caries of the jugular fossa, is reported by Bbke;35 the first bleeding was checked by injections of cold water in the ear; two weeks after it recurred and was again checked in the same way, but again returned so profusely as to cause death. The source of the bleeding was confirmed by autopsy. A case of fatal haemorrhage from the inferior petrosal sinus is also reported by the same author ; the blood came from the tympanum, and the bleeding was checked by the instillation of liquor ferri sesqui-chloridi. Three days after an enormous haemorrhage took place from the ear, from which the patient died in a few minutes. The autopsy showed that the blood came from the inferior petrosal sinus, which communicated with the tympanum through a carious perforation of the bone. Bbke also calls attention to the fact that there may be haemorrhage from the small arteries of the tympanum itself, especially from the arteria stylo-mastoidea, al- though there is no reason for thinking that the bleeding from these sources is ever alarming. The diagnosis of the source of a haemorrhage from the ear is often uncertain ; if the blood is arterial, profuse in quantity, and checked by compression of the carotid artery in the neck, it is probably from the carotid ; if it is arterial and only small in quantity, it may come from some of the small tympanic arteries ; but this is not certain, as the cases of carotid bleeding show that at first the loss of blood is sometimes small. If the blood is venous the source of the bleeding may be either the sinuses or the jugular vein. In any case a profuse haemorrhage from the ear is a very serious symptom. Treatment.-The common styptics-cold water, alum, iron, with tampons in the meatus-may check the slighter cases. In injury of the carotid ligation of the common carotid seems to offer the only chance of recovery. In case of bleeding from the sinuses or jugular vein no treat- ment is possible except that by styptics and tampons of the meatus ; the latter, carefully applied, might perhaps be successful in a slight injury of the vessels, as from a sequestrum, especially as it is well known that several cases of accidental perforation of the lateral sinus, during the operation of opening the mastoid, have made good recoveries. J. Orne Green. 1 Pathological Anatomy of the Ear, constituting Part vi. of Kleb's Handbuch der Patholog. Anatomie. Translated separately by Green. EARTH-DRESSING. From very early times the deo- dorizing power of earth has been known (Deuteron- omy xxiii. 13), as also its value as a local application in cases of slight wounds, bruises, stings, etc. " Mud- baths " for the relief of obstinate skin- and joint-affections are not among the new things that have been introduced in modern times and among civilized peoples. Prompted by the satisfactory working of the "earth- closet," Dr. Addinell Hewson, of Philadelphia, in 1869 began the systematic employment of earth, dry and moist, in the treatment of wounds and ulcers ; and three years later published a monograph (" The Use of Earth in Sur- gery "), in which were given details of nearly one hundred cases thus dressed, and the author's views upon the modus operandi of the applied clay. A similar dressing was used and reported upon by a few surgeons in this coun- try and in Europe, and sufficient facts were accumulated to prove that in properly selected and prepared earth we can have a wound-dressing preventing or limiting sup- puration, effecting quite thorough deodorization, and favoring the growth of healthy granulations. The purer clays, not readily absorbing fluids, but cak- ing and therefore retaining the discharges, are neither as comfortable nor as serviceable as the ordinary yellow earth (containing slightly more than fifty per cent, of clay), which should be taken from a little depth belowr the surface, thoroughly dried (preferably in the sun), and then sifted to free it from any lumps or fine gravel that may be present. Thus prepared, it should be dusted over the wound, which with the parts around should be covered in to a depth of from one-fourth inch to one or one and a half inch, according to location, size, and character. As soon as the entire thickness of the layer becomes moistened with the discharge, the dressing should be re- newed ; the necessary changes therefore may have to be made every three or four hours, or perhaps not oftener than once or twice a day. If allowed to remain in place after thorough saturation with bloody serum or pus, the dressing quickly becomes foul and irritating. If the earth is wet when applied it acts much like a poultice, raising the temperature of the part, increasing suppura- tion, and favoring putrefaction and the separation of sloughs. Such an earth-poultice long and continuously employed has, in a few cases, been reported to have caused the disappearance of non-malignant tumors, e.g., of the ovary. If the disease or wound is located in a natural cavity, as the rectum or vagina, the space is to be packed with the earth ; and narrow canals, as sinuses or the ure- thra (in cases of gonorrhoea), may be treated by injections of thick muddy water. In the summer of 1872, in the wards of the Good Sa- maritan Hospital (Cincinnati), I used the "earth-dress- ing " to the exclusion of any other in the treatment of fourteen cases, among which were two arm-amput«tions, 623 Earth-Dressing. Eclampsia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. three railroad*compound fractures of the foot and leg, and one removal of a fibro-cystic tumor of the buttock. The results were satisfactory except in three cases of chronic leg-ulcer, in which the treatment, though con- tinued for some time, seemed to be of little or no benefit. Observation of these cases convinced me that Dr. Hewson wTas fully justified in claiming for the "earth-dressing" that it is "cool and pleasant;" is unattended by pain (unless bleeding occurs, when a sensation of burning is likely to be complained of) ; acts well as a deodorizei'; favors the development of healthy granulations ; and has a decided power in preventing inflammation in the parts about. In my own cases, while the wounds cicatrized kindly and in good time, the rapidity of the healing did not seem to be so materially affected as in many of the cases reported on by Dr. Hewson. Leaving out of consideration any natural dislike to hav- ing certain parts, as the face, the rectum, or the vagina, plastered over or filled with earth, two more or less seri- ous objections lie against this dressing : first, the repug- nance that many patients have to being, even in part, buried alive; and, second, the annoyance and trouble caused by the escape of the earth from the retaining box, cloth, or bandage, and its getting upon the bed-clothing, and under the trunk or limbs, which, in patients com- pelled to keep the recumbent posture, may be productive of much discomfort, if not positive injury. With our present improved methods of wound-treat- ment the " earth-dressing" will not often be employed by those who can readily obtain the ordinary antiseptics and the prepared cottons, wools, oakum, or jute; but in the absence of such, dry earth may very advantageously be employed, and will certainly be found much superior to the bran, meal, or sawdust so often used in the treatment of compound fracturesand wounds attended with profuse suppuration. Of the modus operandi of this dressing little or nothing is known beyond the fact that its deodorizing power lies in the breaking up by deoxidation of the gaseous pro- ducts of decomposition that the loose earth so readily absorbs. Dr. Hewson was strongly of the opinion that its prevention of inflammation and furtherance of healing are due to chemical influences; such consisting in the power of earth to oxidize and deoxidize, to decompose certain salts and absorb and retain their bases, and through the action of its double silicate of alumina and potassa to effect the substitution of ammonia for certain other bases (potassa, soda, lime, magnesia), of which po- tassa, when set free, has an influence in promoting the healing process by " increasing or tending to make more Climate of Eastport, Me.-Latitude 44° 54', Longitude 66° 59'.-Period of Observations, April 1, 1873, to December 31, 1883.-Elevation of Place of Observation above the Sea-level, ^feet. Mean temperature of months at the hours of Average mean temperature de- > duced from column A. B Mean temperature for period of ob- servation. Average maximum temperature _ for period. Average minimum temperature 1 » I for period. ) • : L E Absolute maximum temperature for j)eriod. F Absolute minimum temperature for period. Greatest number of days in any single month on which the tern perature was below the mean monthly minimumtemperature. Greatest number of days in any i : : : : : single month on which the tem- m ; ; ; : ; coco<o>-'<o<oe<»o<»-,a> perature was above the mean * monthly maximum temperature. January.... February... March April May 7 A.M. Degrees. 17.2 19.9 26.0 35.9 46.5 54.7 59.8 59.8 54.5 45.9 34.2 23.4 3 p.M. Degrees. 22.6 25.7 31.6 41.3 51.5 59.5 65.3 65.4 59.2 49.9 87.4 27.0 11 P.M. Degrees. 19.4 21.7 28.0 35.9 44.2 51.1 56.5 57.2 53.3 45.7 34.4 24.4 Degrees. 19.7 22.4 28.5 37.7 47.4 55.1 60.5 60.8 । 55.6 47.1 35.3 24.9 37.8 58.8 46.0 22.3 41.2 Highest. Degrees. 27.5 27.5 33.4 41.2 49.4 57.6 61.7 62.2 57.4 50.3 39.0 32.0 40.9 60.0 47.9 24.6 | 43.0 Lowest. Degrees. 13.1 16.7 23.6 33.8 45.3 52.6 58.8 59.1 53.4 44.7 29.0 20.6 36.2 57.2 42.8 17.5 38.6 Degrees. 27.6 30.4 34.8 44.4 54.9 63.9 69.6 68.9 63.0 53.5 42.3 32.7 Degrees. 11.7 15.5 22.4 32.2 40.5 47.0 52.4 53.3 50.1 41.5 30.7 19.1 Highest. Degrees. 51.0 47.0 53.0 63.0 80.0 81.0 86.0 88.0 81.0 80.0 64.0 54.0 1 ' Lowest. Degrees. 36.0 38.0 44.0 49.0 63.0 67.0 76.0 76.0 69.0 59.0 52.0 43.0 Highest. Degrees. Zero 8.0 19.0 31.0 38.0 45.0 50.0 51.0 44.0 36.0 22.0 8.0 Lowest. Degrees. -20.0 -20.0 -4.0 2.0 29.0 30.0 45.0 45.0 85.0 24.0 -13.0 -20.0 21 16 ' 21 18 22 21 19 21 21 21 25 18 June July August September.. October November.. December.. Spring Summer.... Autumn.... Winter Year January.... February .. March April May J 71.0 67.0 57.0 61.0 51.0 51.0 41.0 43.0 46.0 56.0 77.0 74.0 84.0 58.0 94.0 74.0 108.0 K g Q c ~ cS Q S 77.0 76.0 75.3 71.3 73.3 E >> G'O a> o 12.3 11.1 10.5 8.4 11.0 11.5 14.0 11.5 10.5 11.1 10.8 11.6 29.9 37.0 32.4 35.0 134.3 M 1" Eg ■I cS u Q ◄ 7.1 7.0 6.3 6.9 6.1 5.2 5.2 8.0 8.1 7.6 5.4 5.8 19.3 18.4 21.1 19.9 78.7 W a o c cd <D . O'S 19.4 18.1 16.8 15.3 17.1 16.7 19.2 19.5 18.6 18.7 16.2 17.4 49.2 55.4 53.5 54.9 213.0 o 73 e Q o Inches. 3.15 3.73 5.45 3.39 4.31 R h K s - ce.o £ From N.W. N.W. N.W. S. S. S. S. S. S. S. N.W. N.W. S. S. S. N.W. S. ____ Average velocity of wind, in miles, x uwo-n* per hour. perfect the formative action in the part." How much the dressing may act as a filter, separating from the air its contained micro-organisms, or serve by chemical action to destroy such organisms, has not, so far as I know, been in any degree determined. P. S. Conner. EASTPORT. The accompanying chart representing the climate of the town of Eastport, Me., and obtained from the Chief Signal Office in Washington, is here in- troduced for convenience of reference. A detailed ex- planation of this and of other similar charts will be found under the heading Climate ; where also the reader may find suggestions as to the method of using these charts. H. R. EAUX BONNES. The thermal station bearing this name is situated in the valley of the Ossan, in the depart- ment of the Basses-Pyrenees, France, about twenty-six miles from Pau. It lies at an elevation of 2,250 feet above the sea, and, though the mornings and evenings are cool, the climate is favorable to the class of invalids frequent- ing the springs, owing to the absence of high winds. June July August .... September. October.... November. December . Spring Summer... Autumn ... Winter Year 76.9 78.7 78.9 79.4 76.5 75.2 77.1 73.3 78.2 77.0 76.7 76.3 4.28 4.82 3.16 3.80 4.80 4.61 3.41 13.15 12.26 13.21 10.29 48.91 6.8 6.3 5.9 7.6 9.6 11.9 11.9 10.5 6.3 9.7 12.3 9.7 perfect the formative action in the part." How much the dressing may act as a filter, separating from the air its contained micro-organisms, or serve by chemical action to destroy such organisms, has not, so far as I know, been in any degree determined. P. S. Conner. EASTPORT. The accompanying chart representing the climate of the town of Eastport, Me., and obtained from the Chief Signal Office in Washington, is here in- troduced for convenience of reference. A detailed ex- planation of this and of other similar charts will be found under the heading Climate ; where also the reader may find suggestions as to the method of using these charts. H. R. EAUX BONNES. The thermal station bearing this name is situated in the valley of the Ossan, in the depart- ment of the Basses-Pyrenees, France, about twenty-six miles from Pau. It lies at an elevation of 2,250 feet above the sea, and, though the mornings and evenings are cool, the climate is favorable to the class of invalids frequent- ing the springs, owing to the absence of high winds. 624 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Earth-Dressing. Eclampsia. The season embraces the months of July and August. There are five springs, the Vieille Source, Nouvelle Source, Source du Rocher, Source d'Ortech, and Source Froide, the last named of which is cold while the waters of the others are warm. The Vieille is the only one employed internally. The following is its composition according to the analysis of Filhol. In 1,000 parts there are of ; absolute abolition of consciousness as an essential element of eclamptic as well as of epileptic attacks. This loss of consciousness need not persist during the whole attack, but must have occurred at some part of it. It is true that there are attacks of very slight spasms in children in which it is difficult to be positive that consciousness has been lost, by the application of such imperfect tests (irrita- tion of the conjunctivae, etc.) as these little subjects will admit; but analogous attacks in adults prove that loss of consciousness, however brief, is an essential element of an eclamptic convulsion. An important point in the dit ferential diagnosis between an attack of eclampsia and one of epilepsy is, that in the former the convulsions are not repeated in a series. It is true, attacks of eclampsia may be repeated, but unless the repeated attacks can be shown to have depended upon one or other of the condi- tions which ordinarily give rise to eclampsia, every repe- tition of the convulsion renders our suspicion as to its epileptic character more positive. In describing an eclamptic seizure, it is important to remember that the convulsion differs in no way from an attack of epilepsy. Hence a general clinical picture of the disease will be that of an ordinary epileptic spasm. There may be an aura, a cry, then convulsive move- ments in some of the voluntary muscles, proceeding rapidly to more or less general convulsions, at first tonic, then clonic in character. There is loss of consciousness, generally, before the clonic convulsions have set in, the little patient may froth at the mouth, the tongue may be bitten, the respiration is that characteristic of epileptic at- tacks ; finally the spasm is often followed by sleep. It is evident, then, that we must not depend upon the char acter of the convulsion for a differentiation between epi- lepsy and eclampsia, although a careful study of the clin- ical history of the case will generally give us the data necessary to a correct diagnosis. Clinical Occurrence.-Nothnagel1 and Ozanam2 discuss the possibility of the occurrence of eclampsia in- fantum as an idiopathic affection. The latter authority limits the term eclampsia to convulsions of non-epileptic origin, occurring independently of other diseases, or path ological conditions. Nothnagel, however, includes under the term eclampsia convulsions which are the reflex ex- pression of some peripheral irritation, such as dentition, etc. The convulsions occurring at the outset of acute infectious diseases and acute inflammations, he terms sim- ply epileptiform, a term that might be applied to all varie- ties of eclamptic attacks. Eclampsia infantum should be considered not so much a disease as a symptom of other diseases ; in one case the convulsion may only precede or usher in a pneumonia, in another it may appear at the same time with a brilliant scarlatina ; here dentition ap- pears to have been the exciting cause, there the ingestion of indigestible food ; in all of these conditions the attacks resemble each other, although in each case the clinical etiology is different. Looking, then, upon eclampsia from an etiological standpoint, it appears that all the possible conditions under which eclamptic attacks may occur in children will come under one of the following subdivis- ions : 1. Febrile or symptomatic eclampsia. 2. Reflex eclampsia. 3. Toxic eclampsia. The most common form of eclampsia occurring in young children is undoubtedly the first group, the fe- brile or symptomatic eclampsia. By this class is meant that form of eclampsia which occurs, as a rule, at the out- set of febrile diseases ; we say at the outset, to distinguish these initial convulsions from those occurring later on in the course of severe inflammatory conditions, and due not so much to the fever as to cerebral adynamia, or the aggregation of toxic elements in the blood as a result of the disease. So commonly does a convulsion mark the outset of inflammatory disease, and acute infectious fevers of infancy, that it would almost appear that in these little patients the eclamptic seizure corresponds to the chill which ushers in similar diseases in adults and grown chil- dren. This substitution of a convulsion, an eminently nervous phenomenon, for a chill, corresponds to the exalted Grammes. Sodium sulphide 0210 Calcium sulphide 0072 Calcium sulphate 1750 Potassium sulphate 1 Sodium sulphate > traces Magnesium sulphate ) Sodium chloride 2640 Sodium silicate 0310 Silica 0320 Sodium borate, iron, and iodine traces Organic matters 0480 Total solids . . 5782 Temperature of the water, 32.75° C. (90.95° F.). The correctness of this analysis by Filhol has been called in question by Garrigon, who has himself made an examination of the same spring with very different re- sults. It has never been determined with certainty which of the parties in the dispute is right, but it is probable that the analysis as above given is very nearly correct. At the beginning of a course the waters act as an ex- citant of the circulation, being said to sometimes cause haemoptysis in those predisposed to this accident, and on this account they must be given in very small doses, even a tablespoonful at a time, mixed with whey, milk, or syrup of some sort. In addition to their internal admin- istration, the waters are employed in douches, gargles, baths, and pediluvia. The diseases for which they are especially indicated are those of the throat and lungs, pharyngitis, laryngitis, bronchitis, chronic pneumonia, incipient phthisis, and asthma. It is particularly when these throat and lung affections are found in gouty and scrofulous individuals that the waters are most beneficial. T. L. S. EAUX CHAUDES. The little hamlet where these springs are found is situated in the Basses-Pyrenees, a few miles from Eaux Bonnes, at an elevation of nearly two thousand feet above the sea. The climate is change- able and less suited for sufferers from pulmonary troubles than is that of the latter place. The mean summer tem- perature at Eaux Chaudes is 62.5° F. There are six springs, known as the Source Baudot, Source du Clot, Source du Key, Source de l'Esquirette, Source de 1'Ar- ressecq, and Source Minvielle. The following is Filhol's analysis of the Source Baudot. In 1,000 parts there are of: Grammes. Sodium sulphide 0087 Calcium sulphate 1030 Sodium sulphate 0420 Sodium carbonate 0350 Calcium silicate 0050 Magnesium silicate | Aluminium silicate j Sodium chloride 1150 Iodine trace This is the only spring which is employed for internal ad ministration. The waters of the other springs are even less richin mineral constituents and are used in baths,douches, and gargles for the relief of neuralgia, flying muscular pains, rheumatic skin diseases, pharyngitis, laryngitis, scrofulous inflammations, chlorosis, and amenorrhcea, and other functional uterine disorders. Internally the source Baudot is employed for throat and lung affections, and as a diuretic. T. L. 8. Total solids 3087 ECLAMPSIA INFANTUM. Synonyms : Convulsions in children ; acute infantile epilepsy ; spasms. By eclampsia in children is meant a variety of convulsions, more or less general, occurring with or without prodromal mani festations, and not dependent upon any material organic lesion of the nervous centres. Most authorities consider 625 Eclampsia. Eclampsia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. irritability of the nervous system characteristic of in- fants. This excess of irritability is especially marked in the medulla oblongata; and since the studies of most observers, among others Shroeder van der Kolk,3 point to the medulla as the starting-point of the changes resulting in an epileptiform convulsion, the increased lia- bility to convulsions at this early age is readily explic- able. How shall we explain the occurrence of this fe- brile form of eclampsia ? Is the convulsion due to the fever, or to some mysterious infection of the blood by the poison of the disease of which the fever is a symp- tom ? Authorities differ as to this point, the tendency being to individualize and explain the occurrence of the eclampsia in distinct ways for different diseases. In the first place, in inflammation of the brain and meninges the convulsions are not eclamptic, being dependent upon a material lesion of the nervous centres. But the eclampsia introducing an attack of pneumonia pleurisy, measles, or scarlet fever, how is this produced ? Steiner4 considers the convulsions which precede an attack of pneumonia as the reflex result of the irritation of the peripheral filaments of the pneumogastric distributed to the congested lung. The weakness of this explanation does not lie in the fact to which Soltmann5 calls atten- tion, that eclamptic convulsions do not occur in all cases of pneumonia in children, but rather in this, that the con- vulsions are not so frequently repeated as we should ex- pect were this theory true, for the lung remains con- gested during many hours, while the convulsion lasts but a few minutes, and in many cases is not repeated. We do not think that any further explanation of the eclampsia of the early stage of pneumonia need be given, than the high temperature which ushers in the disease. The rapid and bounding pulse, characteristic of the' fe- brile process, produces cerebral hyperjemia, the already over-excitable medulla is rendered more excitable, and a convulsive discharge of nerve force takes place; the cause here is evidently simply increased temperature, and its recognition serves as an important indication for treat- ment. In the acute infectious diseases, one might readily be excused for supposing that the initial convulsion is most probably due to the altered condition of the blood. The bacteria of scarlet fever, as well as those of measles and diphtheria and other infectious diseases, may well have so changed the blood, even in the opening stages of the disease, as no longer to enable it to properly nourish the nerve-centres ; accordingly such writers as Soltmann6 and Hevnoch6 consider that the eclampsia, even in the onset of these diseases, is mainly due to the toxaemia ; and yet these convulsions frequently do not occur in the most severe cases, and do occur in the mild ones. The toxaemia must be considered as varying in direct proportion to the severity of the affection, and the same should be true of the convulsions to enable us to accept the view of Hevnoch. We do find, however, that in most of these cases in which convulsion has occurred, the temperature was very high, irrespective of the severity of the disease. I recall a case in my own experience, similar to one reported by Hunter,' in which, with the onset of a varicella, the temperature rose to 105° F., and the child had two eclamptic convul- sions ; on the succeeding day the temperature had fallen and the little patient was able to run about in the room. One can cause the cessation of repeated eclamptic attacks in a case of commencing infectious disease by the applica- tion of a cold bath. For these reasons it would appear that, in these cases also, the active cause of the convulsion is the increased heat of the body. It must be acknowl- edged, however, that there are cases in which the specific toxaemia of the disease is so great that the nervous centres are completely overwhelmed. In these cases the con- vulsions are really toxic in character, and are far more fatal than those depending upon the fever ; here, too, we shall often find upon post-mortem examination inflam- matory disturbances of the brain and spinal cord. In the vast majority of cases of eclampsia occurring early in the course of infectious diseases, reduction of temperature will result in cessation of the convulsions. The diseases in which this febrile form of eclampsia may occur include almost all of the febrile affections of childhood, that is, all of the acute infectious diseases, among which must not be forgotten erysipelas and typhoid fever ; also all of the inflammatory affections of the respiratory organs, such as laryngitis, bronchitis, pleurisy, and pneumonia ; also the acute catarrhal, croupous, and diphtheritic affec- tions of the throat and pharynx. Febrile eclampsia, al- though more frequent at the outset of febrile diseases, may occur later on in the course of these diseases. As already stated, the eclampsia thus occurring is, as a rule, depen- dent upon blood changes; but not necessarily, for al- though the nervous system of the child seems to become habituated to mere elevated temperature, yet a great and sudden rise of the fever at any stage of the disease may produce a convulsion; thus, I have seen a convulsion occur in a child suffering from a pneumonia on the even- ing before the critical day, the convulsion being simulta- neous with the highest rise of the temperature curve. Malarial fever, according to many authorities, fre- quently has the chill which ushers in the paroxysm in adults replaced, in children, by a convulsion. Here again the thermometer points to the elevated temperature of the post-algid stage as the cause of the eclamptic seizure. Malarial eclampsia, so-called, is most frequent in infants under three years of age suffering from intermittent fever. In older children the convulsion is absent while the chill is present. When the convulsion takes the place of the chill it is said to be exceedingly severe and may last for hours ; sometimes each recurrence of the malarial par- oxysm is accompanied by a convulsion. Dubrisay8 reports a case in which the convulsion recurred with eleven dis- tinct malarial paroxysms. Parotitis, when accompanied by high fever, may be an etiological factor in the production of an attack of eclamp- sia. Dysentery, gastritis, cholera infantum, all of these when accompanied by high fever may produce a con- vulsion. Here again, however, we must distinguish the febrile convulsions from those which occur in the later stages of these diseases and are dependent upon the cerebral vascular changes, of which the depressed font- anelle is so characteristic a symptom. In conclusion, it may be said that any affection accompanied by high fever may result in an eclamptic attack in infants. By the term reflex eclampsia, which is the second sub- division under which we shall discuss the subject, we mean that form of eclampsia which is the reflex motor expression of some peripheral irritation of sensitive nerves. Such motor manifestations as a reflex result of peripheral irritation are not unfamiliar, even in adult life; as an instance we have the hysterical, and even epileptic manifestations in females as a result of uterine disease. In infants the inhibitory action of the brain over the spinal cord is still in abeyance, and reflex action is more uncontrolled ; there is an exalted irritability of the spinal cord, and hence these little patients are excel- lent subjects for the full manifestation of the evil effects of a constant peripheral irritant. Among the most con- stant of these peripheral irritants during infant life is dentition, and this is, accordingly, the most frequent cause of reflex eclampsia. There are those who believe that dentition, being a physiological process, cannot be connected with the production of so serious a patholog- ical condition as convulsions, but they are of right in the minority. When it shall have been proved that other physiological processes are never productive of serious morbid states, then we shall give some credence to such a view; for the present, it is emphatically the opinion of the vast majority of authorities that difficult dentition is frequently the only assignable cause for a series of eclamptic attacks. The convulsion is often followed in a short time by the appearance of one or two teeth ; some children have a convulsion preceding the breaking through of almost every tooth. We deprecate the assigning of dentition as a cause for almost all the diseases to which infant life is liable ; but, on the other hand, we place this physiological process as the chief among the peripheral excitants which sometimes result in reflex eclampsia in infants. To account for the occurrence of these con- vulsions during the period of first dentition, and their 626 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eclampsia. Eclampsia, almost uniform absence during that of the second, it is only necessary to remember that the condition of exalted irritability of the nervous centres, which is present in in- fants, is not present in the older children ; hence a similar, or even greater irritation will fail to produce a con- vulsion in the older child, which in the infant might have produced a serious eclampsia. For an excellent dis- cussion of the subject of dentition eclampsia I would refer the reader to Fleischmann9 and Politzer.10 Hel- minthiasis is another condition which is supposed by many authorities to give rise in some cases to eclampsia infantum. Such convulsions occur more frequently with the larger worms (round worms, taenia). I recall a severe ■epileptiform attack in an adult, who had never suffered from epilepsy, which preceded the expulsion of a tape- worm. Other authorities give undoubted cases in which the convulsions were the precursors of the discharge of large quantities of worms. It must not be forgotten, however, that the convulsions may depend upon the in- testinal catarrh which is the result of the helminthiasis. The irritation of indigestible food, or food in too large quantities, may be the cause of a convulsion. In these cases, again, the convulsions maybe reflex in character as a result of the irritation of the indigestible matter in the stomach, or they may be produced by an acute rise of temperature ; finally, the spasm may be the result of a toxaemic condition of* the blood. If the attack be the re- sult of the irritation of indigestible food, it generally oc- curs soon after the ingestion of the offending nutriment. Children vomit so readily that emesis will generally free the stomach from this irritant, and thus prevent a repeti- tion of the attack. This cause of eclampsia has been ac- knowledged and well recognized as far back as the time of Hippocrates. I am disposed to class under this head the occasional attacks of eclampsia resulting from prae- putial irritation and masturbation11 in children. Where these attacks are frequently repeated, they would with more propriety be classed as epileptic. Other peripheral irritants have been observed, by good authorities, to pro- duce convulsions in children. Soltmann mentions a case in which ascent of the testicles into the inguinal canal re- sulted in a convulsion. Foreign bodies in the ears have been repeatedly shown to be active in the production of a convulsion. Scalding of the surface of even a small por- tion of the body, or any other extremely painful, sudden injury, even if of short duration and of slight character, has been sufficient to produce an eclamptic attack. The group of toxic eclampsiae, although least under- stood, is by far the most interesting. In this class I include all eclamptic attacks which seem to depend upon some blood change which renders it unfit to nourish the nerve-centres. We do not know enough of the changes produced by different diseases in the composition and constitution of the blood to enable us to state, with even an approach to positiveness, the exact alteration upon which this toxic action of the blood depends. In some cases it may be that there is a change in the quantity or quality of the constituents of normal blood; in others some of these may be entirely absent, or other foreign substances may have appeared in addition to the normal ingredients. Whatever the changes may be, it is positive that in certain diseases blood changes produce eclamptic convulsions both in children and in adults. One fact seems to be characteristic of this form of eclampsia, and that is, that the attacks do not occur at the outset, but always in the course of a disease. To this group belong the convul sions occurring in the course of a pneumonia as a result of the insufficient aeration of the blood ;12 and here also belong the convulsions (Stickungskrampf) accompanying the dyspnoea of severe croupous and diphtheritic laryn- gitis ; also that of prolonged attacks of laryngismus stridulus and whooping-cough. As will be seen later on, in every complete epileptiform attack the clonic con- vulsions are the result of the strangulation produced by the early tonic spasm of the respiratory muscles, and it is therefore not surprising that similar clonic convulsions occur in diseases whose chief clinical manifestation is spasm of the respiratory muscles.13 An important class of cases belonging to this group is the eclampsia of scar let fever, which is the result of a concomitant kidney af- fection with albuminuria. As to the connection of these convulsions with the albuminuria we are still in the dark.14 Is it the loss of the albumen, and consequent hydraemia (Franke and Rilliet and Barthez), or is Frerichs right when he points to the retention of the urea in the blood as a cause of the convulsion ? It is scarcely our province to decide, but the fact of the occurrence of eclamptic at- tacks in primary or secondary parenchymatous nephritis is positive and well acknowdedged. The convulsions oc- curring in the course of acute diseases which are non- febrile, but which seem to be dependent upon the action of the poison of the disease process, are well recognized, although we cannot define the nature of the toxaemia in each individual case. We must not forget to mention, under this head, convulsions occurring as a result of per- mitting infants to nurse at the breast of a mother who has undergone some severe fright or mental shock. At the risk of being accused of belief in what is vague and unproven, I must express my conviction that nervous shock certainly does impair and alter the character of the milk secreted by the mother. The experience of years teaches that a frightened mother should not nurse her child. Although, theoretically, all cases of eclampsia ought to fall under one or more of the three groups into which I have divided the subject, yet clinically there may be cases which will not seem to depend upon any one of the as- signed causes, and will have to be classified as a sepa- rate and distinct group, which I have termed idiopathic eclampsia-in other words, cases that cannot be classified etiologically. This group will probably diminish with knowledge and improved methods of examination. Etiology.-It has already been stated that infantshave a marked predisposition to the occurrence of attacks of eclampsia. Why this should be so has occupied the at- tention of many excellent observers, among whom may be mentioned Nothnagel and Soltmann, the latter of whom has written a monograph on the peculiarities of function in the brain and spinal cord of infants. Clini- cally, we recognize that children under two years of age are more frequently seized with eclampsia than children beyond that age. So frequent is this disease in infancy that it may be counted as the most fatal pathological con- dition to which infancy is liable. By this is not meant that the prognosis of all attacks of eclampsia is necessarily bad. On the contrary, the prognosis is very good, but so frequent is the condition itself, that notwithstanding its comparatively favorable prognosis it still causes the death of more infants than any other affection. The fact that it occurs most frequently during the period of dentition led many of the older writers to ascribe eclampsia to the dentition process ; but the exalted reflex irritability of the spinal cord in infants, as already set forth, is the only element necessary to account for the predisposition to convulsions shown at this time of life. Heredity is an ad- ditional factor which helps to augment this natural pre- disposition. Most physicians in active practice will re- call families in which all of the children have " spasms," while in other households such a thing is entirely un- known. A careful examination will generally reveal the fact that in the former class of patients the parents are of a nervous temperament; there may be a history of in- sanity, paralysis, or convulsions in other members of the family ; in other words, these patients give a neurotic family history. It does not appear that either sex shows any predisposition for the disease. Male and female chil- dren seem to be equally liable to have convulsions; if in- dividual experience is of any value in this connection, I think I have observed more children with convulsions among the male sex than among females. As to the ex- citing causes, they have been thoroughly discussed in a previous paragraph. Symptomatology.-Atypical attack of eclampsia may be divided into two stages : First, the prodromal stage; second, the convulsive stage. It is necessary to state that in many cases the first stage is entirely absent, and the second is so brief as to be scarcely noticeable. Many authorities have considered 627 Eclampsia. Eclampsia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that the symptoms described under the head of premoni- tory symptoms are simply the marks of the general dis- turbance, of which the eclampsia is the result. Thus restlessness, a premonitory symptom to which all writers draw attention, may simply be a sign that there is some- thing wrong with the little patient, without really fore- shadowing a convulsion. There can be no doubt, how- ever, that many children who are about to have a convulsion show this by a certain aggregation of phe- nomena which, to the anxious mother who has already experienced a convulsion in her infant, are the mutterings preceding the coming storm. In one variety of cases the child, which has been in good health, is observed to be feverish. There is a flush in the face, or the countenance may be exceedingly pale. The sleep is restless, the child starts, it grinds its teeth. As it lies dozing it may smile occasionally, or there may be a conviflsive twitching of the lips and muscles of the face. The eyes are half closed, the nostrils move irregularly. It throws its arms and legs about, occasionally it sighs deeply, the breathing is irregular, although not stertorous ; now and then the whole body starts violently, sometimes waking the patient and causing it to cry fretfully, to be followed again by drowsiness. These cases may be termed the somnolent cases. There are others in which the picture is an entirely different one. The little one is abnormally wakeful, it appears to be more than usually bright, the cheeks are flushed as though with hectic ; the eyes sparkle, the pupils are enlarged ; the muscles of different portions of the body twitch-now a finger, or arm, or leg, sometimes the eyelids, again the face-the child laughs more than usual, will not rest in the lap of its nurse, seems to prefer activity to rest, and asks to be taken from one attendant to another. The abnormal brightness and restlessness in- crease, until suddenly the little patient is thrown into violent convulsions. In these cases the parents will re- late how bright the child had been before its spasm. There are other symptoms which may well be termed premonitory, although not as frequently observed as the two varieties just described. Thus I recall a little one who, in four out of six attacks of eclampsia (dentition), vomited a few minutes previous to its attack. There are other children who have many of the above-described symptoms without having an attack of eclampsia. In these cases the absence of the complete convulsion is due to a more than usually well-balanced nervous system, which, while yielding to the irritant to a certain extent, does not lose control of the "organ of mind" to a suffi- cient extent to place the body under the influence of the purely reflex nervous centres. Many cases have a con- vulsion without any of the above-described premonitory symptoms, or rather without any having been observed. There may not even be a cry, but suddenly the child falls into a more or less general and violent epileptiform spasm. The convulsive stage follows the prodromal symptoms after a shorter or longer period. But the prodromal stage, as has already been stated, may be en- tirely absent, or so little marked as to escape notice ; then the convulsion proper would set in suddenly, often run a rapid course, and the child recover without sequelae, so that before the physician has arrived the child appears bright, and as though nothing had happened. This con- vulsive stage of eclampsia exactly resembles the convul- sive stage of epilepsy. Indeed, most writers have agreed that the attack as such is indistinguishable from an epilep- tic seizure (Reynolds, Hughlings-Jackson, Niemeyer, Brown-Sequard). While this is true for a typical attack of eclampsia, as compared with a typical attack of epi- lepsy, we shall call attention to several points peculiar to some attacks of eclampsia when we come to consider the subject of differential diagnosis. The little patient, who may or may not have presented the premonitory symp- toms above described, is suddenly heard to cry out ; the cry is immediately followed by a tonic spasm of the vol- untary muscles ; the body is in the position of opisthoto- nus, the head is drawn back, the veins of the neck stand out prominently ; the arms are rigid, abducted, and par- tially pronated ; the hands are tightly clinched; there is a gurgling sound heard from the throat, as though the patient were choking ; the teeth are firmly closed, the face' is at first pale, hut gradually grows congested and dark; the pupils are dilated, the eyes being open. This tonic spasm affects muscles of respiration as well as the volun- tary muscles, and it is owing to this fact (Shroeder van der Kolk) and the interference with the venous return from the brain that the other clonic stage of the convul- sion is due-that is to say, the clonic spasm is the asphyx- ial convulsion. Fortunately the severe tonic spasm is but a few seconds or a minute in duration ; were this not so, death from as- phyxia during the tonic spasm would be more frequent. Even as it is, death sometimes occurs at this stage of the spasm. In the largest number of cases the brief tonic spasm is followed by clonic general convulsions. The extremities are alternately flexed and extended, the arms are pronated, the body is often shaken, and sometimes even raised from the bed in the violence of the convulsion. The eyeballs roll, and the head is turned to one or the other side convulsively. The lower jaw is moved for- ward and downward, and laterally ; the tongue is some- times caught between the teeth and bitten ; there are swal- lowing movements performed by the larynx and pharynx ; even the diaphragm may take part in these clonic convul- sions, giving rise to hiccough which Soltmann considers a very dangerous symptom. Consciousness is entirely abolished, the conjunctivae can be touched without the patient wincing. During this stag^ the sphincters may become relaxed, so that there is involuntary passage of faeces and urine. The respiration is stertorous, the pulse frequent and intermittent. The temperature is elevated during the convulsion, even when the spasm is of non- febrile origin ; in that case, however, it subsides very rapidly, which is not the case in febrile eclampsia. The clonic convulsions may last from a minute to half an hour. In this respect attacks of eclampsia differ from those of epilepsy, which, as a rule, are not of long duration. The convulsions gradually diminish in severity until they cease, although convulsive movements may still remain localized in some muscles of the face or upper extrem- ities long after they have ceased in other portions of the body. The patients return to consciousness gradually ; they are at first irritable, soon they become drowsy, and frequently fall asleep. Such is a general description of an ordinary eclamptic seizure. This single attack is fol- lowed in many cases by a repetition, either shortly after the first convulsion, or at a longer interval depending upon the etiology. If the convulsion is of the febrile variety, the reduction of temperature will generally cause a cessation of the spasm ; should it belong, on the other hand, to the toxic or reflex group of convulsions, the fre- quency will depend upon our success in combating the etiological factor. When the patient falls from one con- vulsion into another, giving rise to a series of convul- sions, he may be said to be in a condition analogous to the status epilepticus. Such a status may continue for days. Eclampsia, as well as epilepsy, may be very slight, consisting chiefly of a brief period of rigidity followed by little or no clonic spasm. There may even be nothing but slight paleness, accompanied by momentary loss of consciousness, and almost immediate recovery. These slight attacks, however, are not as frequent in eclampsia as in epilepsy (petit mal). Localized spasm, well defined in character and unaccompanied by loss of conscious- ness, cannot be considered as eclamptic ; thus a spasm of one arm or one leg, or of one side of the face alone, even with loss of consciousness, especially if repeated, would point to a local cerebral disease, and therefore cannot be classed in the group of eclampsia, but belongs rather ta the class of localized epilepsies. Sequelae.-Although in the large majority of eclamp- tic attacks, of which the patients do not die, recovery is complete, leaving absolutely no sequelae, the text-books relate a large number of possible injurious effects from eclampsia infantum. A fatal result is far more frequent in these seizures than is generally supposed. Dr. West, in his work on "Diseases of Children," showed that in Lon- don the proportion of deaths from convulsions in children under one year, as compared with deaths from other 628 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eclampsia. Eclampsia. •causes, was twenty-one and nine-tenths per cent. ; from one to three years, about four per cent. ; and from three to five years, about three per cent. Other authorities also agree that eclampsia is the most fatal condition to which children under one year are subject. It is almost impos- sible, however, to estimate what proportion of infants thus attacked die, since only fatal cases are reported in official statistics, while private statistics are neither suf- ficiently numerous nor sufficiently trustworthy to be re- liable. Of cases which recover, many are subject to re- peated attacks, even under slight or no provocation, and it becomes a question as to whether the eclampsia so-called has not turned into chronic epilepsy. Among the authori- ties who favor the view that chronic epilepsy is often the result of repeated attacks of eclampsia are R. Demme 15 and E. C. Seguin.16 It does not seem at all improbable that a frequently repeated convulsion may so disturb the equi- librium of the nervous centres as to render these liable to initiate a convulsion, even under slight provocation, finally terminating in confirmed epilepsy. It is more probable, however, that the cases in which a so-called tendency to eclampsia finally terminates in epilepsy are really at the start epileptic. Some conditions frequently known to give rise to eclampsia may have been present at the time of the first attack, and a diagnosis of eclampsia may have been hastily made ; such cases will be cleared up, later on, by the more or less frequent recurrence of the attacks without any cause. Some of the more immediate sequelae of an eclamptic seizure are ecchymoses under the skin and conjunctiva. These haemorrhages appear to be the result of the venous congestion which accompanied the tonic spasm at the onset. The violence of the clonic spasm may be so great as to tear muscular fibres or tendons, or even produce dis- locations. Indeed, a case has been reported in which a fracture of the sternum was caused by the violent con- tractions of the rectus abdominis. Temporary paralysis of individual muscles or muscle-groups often results from an attack of eclampsia ; this seems to be only functional, however, for in a few hours or days power returns, and no trace of the paralysis is left. Temporary contractures may remain in the muscles that have been the seat of the greatest convulsions; thus wry-neck and various con- tractures have been observed to follow an attack of eclampsia. I recall a case in which the fingers of both hands remained contracted into the palm of the hand for two days after an eclamptic convulsion; but in a short time the patient recovered full use of his hands. I can- not agree, however, with those who claim that a simple attack of eclampsia, not connected with any lesion of the nervous centres, is capable of producing permanent pa- ralysis or contracture. Where a monoplegia or hemi- plegia seems to result from an attack of eclampsia, I feel convinced that a careful clinical examination will point to the suspicion that the convulsion was the result of a lesion of the nerve-centres resulting in convulsions, rather than that the eclampsia had resulted in the paralysis. It is claimed by those who hold the latter view that these paralyses are the result of meningeal haemorrhages over the motor area of the cortex of the brain as a result of the convulsion. It is possible that a monoplegia could occur in this manner, for even a very slight haemorrhage would be sufficient to affect the functions of a limited area of the cortex. A hemiplegia, however, produced in this manner would necessitate the presence of a clot suf- ficiently large to interfere with the whole of the motor area of one hemisphere ; that such a haemorrhage should occur as a result of an attack of eclampsia is scarcely conceivable. Some common congenital deformities, such as club-foot, for instance, have been ascribed to attacks of eclampsia occurring in foetal life, and resulting in con- tractures of the muscles, and thus in club-foot, contractured knees, etc. A careful study of these deformities will generally reveal their true etiology.11 I am disposed to consider all cases of permanent paralysis or contracture (primary or secondary) in children as the result of a lesion of the nervous centres, of which the convulsion was only a symptom ; in such cases there will generally be found some more rational method of accounting for the production of the convulsion than that which refers it to meningeal haemorrhage as a result of eclampsia. Diagnosis.-Eclampsia may be confounded with epi- lepsy, and with convulsions due to disease of the nervous centres. From epilepsy it can be distinguished by a careful examination into the previous history. The older the child, the more often the convulsions have occurred without any recognizable cause, the more probable be- comes the diagnosis of epilepsy. In this connection it must not be forgotten that attacks that were originally eclamptic may, after a time, when the convulsive habit has been acquired, become epileptic. Such children must be carefully watched, and should any suspicion of the presence of chronic epilepsy arise, the patient must be treated accordingly. As far as the attack of eclampsia itself is concerned, there is no way of distinguishing it from an ordinary attack of epilepsy. Convulsions due to disease of the nervous centres have certain peculiarities which dis- tinguish them from ordinary attacks of eclampsia. One important characteristic is that these convulsions are apt to be localized, especially if due to chronic brain disease ; lesions of the various motor centres will give rise to con- vulsions limited to portions of the body supplied with nerve force from these centres. In acute diseases of the brain and spinal cord, and the meninges, there will be other symptoms which will lead to a diagnosis of the dis- ease, of which the convulsion is only one of other mani- festations. A differential diagnosis of the different vari- eties of eclampsia infantum will depend upon a careful physical examination of the patient. If there be fever or toxa?mia, they should be recognized together with the diseases which have produced them. If the convulsion appears to be due to neither of these causes, we should carefully search for some possible peripheral irritant, and, if possible, remove it. Accuracy of diagnosis is apt to depend in these cases upon the broadness of our knowl- edge of diseases and conditions of infancy. To attempt to treat a case of eclampsia infantum without at least an attempt at an etiological diagnosis, is to submit the patient to the most injurious form of empiricism. The convulsion is a symptom of a disease which the physician must detect. We must search for the pneumonia, the diphtheria, the scarlet fever, the cause, and treat that at the same time that we treat the symptom. Pathology. - Eclampsia infantum being rather a symptom than a disease, has no pathology. It is true that morbid changes have been found in the nerve-centres of children who have died of an attack of so-called eclampsia, but the mere fact that these changes were found precludes the diagnosis of eclampsia, which is es- sentially a convulsion that does not result from any grave lesion of the nervous centres. It is possible that repeated attacks of eclampsia result in subtle changes in the nerve- centres, but if this be the case the changes are not dis- coverable by any method of examination practised in the present stage of pathological investigation. Concerning the physiological mechanism by which an attack of eclampsia is produced, it will be proper to say a few words. The subject belongs, of right, under the head of epilepsy, as it is in connection with epileptic convul- sions that it has been more thoroughly studied. Clin- ically, we have already stated, the eclamptic paroxysm in no way differs from an epileptic attack. The mechanism by which the latter is produced is stated by Reynolds,18 in his " System of Medicine," as follows : " The derangement consists in an increased and per- verted readiness of action of these organs (medulla and vaso-motor system of nerves), the result of such action being the induction of spasm in the contractile fibres of the vessels supplying the brain, and in those of the muscles of the face, pharynx, larynx, respiratory apparatus, and limbs generally. By contraction of the vessels the brain is deprived of blood, and consciousness is arrested ; the face is or may be deprived of blood, and there is pallor ; by contraction of the muscles which have been mentioned there is arrest of respiration, the chest-walls are fixed, and the other phenomena of the first stage of the attack are brought about. 629 Eclampsia. Ecthyma, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. " The arrest of breathing leads to the special convul- sions of asphyxia, and the amount of these is in direct proportion to the perfection and continuance of the as- phyxia. "The subsequent phenomena are those of poisoned blood, i.e., of blood poisoned by the retention of carbonic acid, and altered by the absence of a due amount of oxy- gen." These are practically the views held by Kussmaul and Shroeder van der Kolk,19 as to the manner in which a paroxysm is produced; the causes of the primary de- rangement of the nervous centres will vary with the cause of the convulsions: in one case it is elevated temperature, in another toxaemia, in a third a peripheral nervous irri- tation. Prognosis.-The prognosis of an attack of eclampsia resolves itself into two elements : first, as to the fatal or non-fatal termination of any attack, and secondly, as to the recurrence of the convulsion. Although many infants die in an attack of eclampsia, yet, when we consider the great frequency of such attacks, those that die are com- paratively few in number. The prognosis in this respect does not depend upon the severity of the seizure ; very severe convulsions will often last but a short time, and terminate in complete recovery. The duration of an at- tack of eclampsia is a more important factor in the prog- nosis. A series of convulsions of long duration, with short intervals between the individual attacks, renders the prognosis grave; and yet children sometimes recover after lying in "status convulsivus" for one or two days. Convulsions in which one side appears to be far more af- fected than the other are much more apt to be fatal than those in which the difference between the two sides is not so marked. A fatal termination, as well as a repetition, of attacks of eclampsia, will often depend upon our inability to remove the cause which lies at the root of the derange- ment of the nervous centres. An attack of eclampsia may be repeated either within a short time after the orig- inal attack, and is then probably due to the same cause as the original convulsion; or after the lapse of weeks and months, and must then be studied with reference to its etiology as an entirely new seizure. If after an eclamptic seizure a child recovers completely and returns to its nor- mal condition, and especially if the cause of the convul- sion has been surmised and removed, the prognosis is good, the convulsion will probably not recur ; it is best, however, even in these cases, to be guarded and prepare the patient and friends for a recurrence, rather than the contrary. In the large majority of cases, however, and above all in those cases in which the cause of the convul- sion cannot be removed or is unknown, the convulsion is apt to be repeated ; the more frequently the convulsion is repeated during a limited period of time, the more unfa- vorable the prognosis as to recovery. The convulsions are more apt to be multiple in the peripheral and toxic vari- ety of eclampsia than in the febrile. The reason of this is obvious, inasmuch as fever is a condition which, tem- porarily at least, may be removed, while the former two do not so readily admit of treatment. A child that has already had attacks of eclampsia is far more liable to re- peated returns of convulsions, under the influence of proper exciting causes, than one that has never had a convulsion. In the former case the nervous system has already shown its instability, and hence our distrust. In conclusion I would repeat, the prognosis depends to a great extent upon our ability to recognize and treat the cause. Treatment.-In discussing the treatment of eclampsia infantum, we would repeat what has been urged, concern- ing the necessity of a careful differential diagnosis as to the etiology of the convulsion. We should distinguish whether the convulsion belongs to the febrile, the toxic, or the peripheral group of convulsions. If it belongs to the former, the abnormally elevated temperature, should be reduced as speedily as possible. For this purpose rapid and certain means should be employed. Cold sheets, sponging with equal parts of cold water and alcohol dilu- tus, cold baths, Ziemssen's baths-all of these are ex cellent methods of reducing the temperature by external means, and our choice should be governed by general principles. Among antipyretic drugs, the best, most trustworthy, and most rapid antipyretic is antipyrine, in proper doses and at proper intervals. I am accustomed to give to children, a year old, live grains every hour until two doses have been taken, and repeat the dose in six hours if the temperature shows a tendency to rise again. The object being to reduce temperature, the drug must be used in sufficient quantity to effect our purpose. If the convulsion be of the toxic variety, the indication is as far as possible to get rid of, or diminish, the toxaemia of the blood ; the kidneys, the bowels, and the skin, all the excretory channels, should be brought into play. An enema, together with a cathartic, should be administered; a mustard bath should be given to produce sweating and to make the skin act vicariously, for the kidneys; should these organs be at fault; diuretics should be administered if not contra-indicated by the general dis- ease. Should the convulsion depend upon a peripheral irritant, it must, if possible, be removed. If the stomach be overloaded an emetic should be administered ; if con- stipation appears to be the cause, the bowels must be emptied. If dentition is the cause, and the gums are swollen, lancing is indicated ; the swelling will thus be diminished, the teeth will be more easily cut through, and the irritation removed ; if helminthiasis is at the root of the evil it must be treated. Whatever the peripheral irritant may be, it should be removed. There will be many cases that cannot be classified, which must be treated on general principles. In addition to treating the etiological element in any attack of eclampsia, it has been the custom of physicians to administer a class of drugs known as- antispasmodics. The most important of these are the bromides and chloral hydrate, and during the convul- sions amyl nitrite and chloroform. The bromides should be given in comparatively large doses to produce a bene- ficial effect. Thus, I am accustomed to give six to eight grains every three hours to children one or two years old ; even larger doses should be given if necessary, un ■ til the convulsions cease and sleep is produced. Chloral hydrate may be used in small doses, either alone or in combination with the bromides. I have used the amyl nitrite, a few drops inhaled from a handkerchief during the convulsions, with but little success ; I have been un- able to convince myself of its utility when thus presented to infants. Should the convulsions be very severe, and continue for a long time, chloroforming the little patient may be tried, although in cases severe enough to require this measure the convulsions are apt to return as soon as the effect of the chloroform passes away. In cases in which the bromides must be administered during a convulsion, it is best either to inject the drug per rectum, or subcutaneously, in solution. When given by the rec- tum the dose should be at least twice as large. 1 have always considered the application of cold cloths or ice- bags to the scalp as superfluous in ordinary eclampsia ; if they accomplish any good at all it is only in cases in which reduction of temperature is an element in the treatment, and in these cases we have more effective means to accomplish this result. In conclusion, it must not be forgotten that, whatever may be the disease of which the convulsion is a symptom, our attention must be mainly directed to the treatment of it, and not to the treatment of the convulsion alone. Henry IK Berg. 1 Handb. v. Ziemssen, xii-ii., 2, p. 285-295. 2 Recherches Cliniques snr 1'Eelampsie des Enfants. Arch. Gen. de Med.. 1850, March, May, June. 3 On the Minute Structure and Functions of the Medulla Oblongata, and on the Causes and Rational Treatment of Epilepsy. New Sydenham Soc. Translation. London, 1859. 4 Die Ursachen der Cerebralen Symptome bei der Sogenannten Gehirn Pneumonic. Jahrb. fur Kinder Heilkunde, 1869. 6 Soltrnann, in Gerhard's Handb. fur Kinder Krankheiten. * Beitraege zur Kinder Krank., 1868. 7 Hunter: Lancet, 1875, vol. i., No. 2. 8 Dubrisay : L'Univers Medical, 1876 (98-100). 9 Zur Lehre von der Zahnfraisen. Wien Med. Presse, v., 1876, No. 13-16. 10 Ueber die Dentition zugeschriebenen Krankheiten, etc. Wien Med. Wochenschrift, 1874 (47-51). 11 Jacobi: Masturbation and Hysteria in Children. New York, 1876. 12 Steiner: Die Ursachen der Cerebralen Symptome bei Gehirn Pneu- monic. Jahrb. fur Kinder Heilkunde. 630 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eclampsia. Ecthyma. 13 Henoch : Charite Anal., 1874, 1 ; Cerebral Symptoms of Whooping- cough. 14 Bouchut : Encephalopathie Albuminurique avec 1'Eclampsie. Gaz. des Hop., 1871, No. 53-54, also 1875, No. 78. 16 R. Demme: Zur Kentniss und Behandlung der Chronischen Eclamp- sie und Epilepsie. Jahrb. fur Kinder, viii., 113, 1875. 18 E. C. Seguin : The Early Diagnosis of Epilepsy. 17 H. W. Berg : Etiology of Congenital Talipes Equino-varus, Archives of Medicine. December, 1882. ls Reynolds : System of Medicine, American edition, p. 777. 19 On the Minute Structure and Functions of the Spinal Cord. Syd. Soc. Translations. Ordinarily, during the attacks no very striking changes in organic functions occur. The pupils dilate, and the pulse and respiration generally quicken. All kinds of hysterical symptoms may appear also in connection with the phenomenon of ecstasy. It will be seen that ecstasy is only a symptom of a mor- bid nervous state, and is generally one that is fastened upon a hysterical person of unusual sensitiveness and peculiar training and environment. The phenomenon in its more marked forms is growing more rare in civilized countries, and it will continue to do so as long as those agencies which tend to dispel ignorance and to educate the young by rational methods continue to act. Charles L. Dana. ECSTASY. Ecstasy, medically speaking, is a form of mental disorder in which the mind is intensely and morbidly concentrated upon some rapturous idea, while all voluntary motion and conscious sensation apart from the single object are in abeyance. Owing to this powerful concentration, conscious feeling is exaggerated to the highest point (see Consciousness, Disorders of). The body may remain motionless in some attitude of rapt attention, or it may go through certain movements corresponding with, or ex- pressive of, that which the patient feels. The condition of ecstasy is evidently, therefore, only another of the protean manifestations of the hypnotic state (see Automatic Actions). It differs from catalepsy and from ordinary forms of somnambulism and hypnotism in that the sen- sations and ideas experienced are more or less distinctly remembered when the paroxysm is ended. Etiology.-Ecstasy occurs only in young persons and adults, almost never in children or the aged. It occurs oftener in men than in ■women. Persons of neurotic temperament, of narrow intelligence, of emotional dis- position, and over-trained religiously, are most subject to it. The Celtic and Latin races have shown it most con- spicuously in the past, and the negro race often shows it in a crude form at the present day in their religious re- vivals. In the middle ages, and up even to the present century, paroxysms were brought on by imitation, and great epidemics of ecstatic seizures were not rarely ob- served. In women, and sometimes in men, who have been forced by environment to a morbid degree of re- ligious introspection, while all opportunities for the grati- fication of sexual desire or the expansion of social feelings were denied, states of ecstasy have been superinduced. Examples of the higher order of ecstatics are St. Theresa and St. Francis; of a lower order, Louise Lateau and Berguille. States of ecstasy occur in the clairvoyants or self- mesmerized, also in hysteria, and especially in the form of it known as hystero-epilepsy. They also occur in cer- tain forms of insanity. Clinical History. - The ecstatic state sometimes comes on periodically without apparent exciting cause, as in the case of Louise Lateau. Sometimes it is volun- tarily induced, as by the followers of St. Francis. Arti- ficial ecstasy may be produced at will in those sensitive to hypnotic attacks. The ecstatic phases of hystero- epilepsy, which are not always well-developed illustra- tions of the state, generally follow a convulsive seizure. The ecstatic assumes a position and expression indicative of the idea and emotion that absorb him. The pleasur- able feelings at the time are described afterward as being very keen and intense. They are, as we have said, usually of a religious character, and the subject believes that he sees Christ, or the Virgin, or is in communion with God. There is sometimes an underlying current of erotic feeling. In pagan times ecstasy was with some only an imaginative apotheosis of the sexual feeling, if we may trust to the poetic description given by Sappho, as an example. Very often the ecstatic feeling finds vent in rhythmical movements. Spectators then may become affected by a kind of psychical contagion, and hence developed the epidemics of the dancing mania and tarant- ism in the fourteenth century, the convulsionnaires of the eighteenth, and the revival performances in the nine- teenth century. In some instances persons subject to periodical paroxysms of religious ecstasy are able to pro- duce remarkable disturbances of the inorganic system, such as the production of stigmata. These persons have at times also apparently lived on very small amounts of food, and have acquired notoriety by this means. ECTHYMA. Ecthyma is an affection of the skin char- acterized by the formation of one or more discrete flat pustules, the size of a finger-nail, situated upon a firm, inflammatory base, followed by an excoriated surface and a brownish crust. The existence of the disease as an affec- tion sui generis has been denied by German authorities following Hebra, who considered the ecthymatous pus- tules as part of an eczema, a symptom and not a disease. It is therefore described meagrely or not at all in German works on skin diseases. In America and other countries, however, observation has shown that ecthyma possesses certain peculiarities which distinguish it from other skin affections, and it is described as a separate disease. The pustules of ecthyma are generally well developed, and may be single or numerous. They are notably flat, broad, and seldom fully distended. At first yellowish, they are later of a reddish color ; in size they vary from a small to a large finger-nail. There is usually a hard, red, tender areola, the tint of which, especially when the lesions occur upon the legs, is peculiarly livid or "lurid." The lesions dry into flat crusts of a dark brownish color, which when raised show an excoriation covered with a sanious secretion. An acute and a chronic form of ecthyma are described by authors. The acute form, which is very rare, com- mences, according to Tilbury Fox, with slight feverish- ness, and occasionally sore throat; locally there is first a sense of heat and burning, followed by the appearance of reddish raised points, with hard indurated bases, and dis- tinct vivid areolae ; these points, which vary in size from that of a pea to that of a quarter dollar, quickly pustu- late and are often accompanied by acute, sharp pain. In two or three days the pustules give exit to discharge, which dries into the crusts above described, and these fall off in a week or so, leaving behind dark stains. The lesions may be few or many in number. In the latter case a good deal of irritation is set up ; the patient may be unable to sleep for pain, and the glands and lym- phatic vessels may become inflamed, small abscesses form- ing subsequently. The disease is generally protracted by successive crops of pustules, or it may relapse into a chronic state. The limbs, shoulders, and trunk are the chief seats of the disease. Although the writer cannot recall a case of the typical acute form just described as having come under his no- tice, yet it is not uncommon for some of the above symp- toms to be observed in connection with the more chronic variety usually met with. The latter most commonly occurs in the form of a single lesion, or several lesions, upon the legs or thighs, less frequently upon the but- tocks, arms, face, or shoulders. The lesions show the local appearances described, but are not usually accom- panied by any general disturbance. The patient com- monly presents himself with one or more flat, dark, crusted lesions, with a lurid red areola and some scratch-marks. When the legs are affected slight oedema is often ob- served, and the lesions sometimes eventuate in chronic ulcers. The general condition of the patient is one of low nutrition, and the affection is rarely met with in peo- ple of the better class. Ecthyma is in fact the outcome of want, misery, and chronic alcoholism ; it occurs in persons who live in the slums, in prisons, and in alms- houses, and who have been subjected to privation. Im- proper and insufficient diet, abstinence from food, as in 631 Ecthyma. Eczema. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. prolonged alcoholic debauch; want of ventilation, ex- cessive work, and uncleanliness are among the causes of the disease. Ecthyma consists anatomically in an acute inflamma- tion of the upper layers of the derma, more intense than that of impetigo, but not so deep as that of furuncle. The affected part heals by cicatrization, and a temporary dark pigmentation often results. Ecthyma may be confounded with eczema pustulosum, impetigo, dermatitis herpetiformis, furuncle, and the large flat papular syphiloderm. From eczema it is distinguished by the size, form, and discrete arrangement of its pus- tules, by the indurated base and the areola, the large flat pustule, the excoriation, and the blackish or brownish crust. The character of the developed pustule distin- guishes it from impetigo or impetigo contagiosa. From the latter its non-contagious character and different dis- tribution distinguish it. The history will prevent us from confounding it with dermatitis herpetiformis, the latter displaying various quite diverse lesions at different periods of its course (see Dermatitis Herpetiformis). From fur- uncle the deep hard infiltration of the latter, with the pre- ponderance of solid tissue as compared with pus, and its tendency to a conical shape, together with the quite differ- ent appearance of the furuncular lesion as it approaches its climax, and the absence of a marked crust, will distin- guish ecthyma. From the large flat pustular syphiloderm, which ecthyma resembles closely in some respects, it is chiefly distinguished by its base, which is merely excori- ated, whereas the removal of the crust in the syphilitic lesion shows an ulcer beneath with pus. The internal treatment of ecthyma should be tonic and supporting. Good hygiene and diet are requisite. Ec- thyma is a cachectic disease, and it often occurs in those in whom the eliminating organs are sluggish, and in whom effete material has been largely produced in the system. In addition it is often secondary to other dis- eases, as scabies and pediculosis, or it follows the use of external irritants, as lime, sugar, etc. Of course in these cases the irritating cause must first be removed. This having been accomplished, soothing local remedies, as lead water or black wash, may be applied to the general surface, while rags spread with oxide of zinc ointment may be applied to the crusts and lesions with the view of softening them. When the excoriations are exposed by the removal of the crusts, a mild stimulating ointment as the following may be employed : Hydrarg. chlor, mitis, Gm. 1.5 (gr. xx.); ung. zinci oxidi, Gm. 32 ( 5 j.); or this : Bismuthi subnitrat. Gm. 4 ( 3 j.) ; ung. zinci oxidi, ung. petrolii. aa Gm. 16 ( 3 iv.). The internal treatment should include rest, fresh air, bathing, cleanliness, with such nourishing food as milk, eggs, strong soups, etc. In a few cases the administra- tion of alcoholic and malt liquors is desirable, but in the majority of cases these should not be prescribed. In old persons tonics and remedies which will stimulate the ac- tion of the kidneys may be employed. The following formula, analogous to the well-known Basham's mixture, is useful : Liq. ammonias acetat., Gm. 75 (f § ijss.); acid acetic, dil., Gm. 5(3iv.); tinct. ferri chlor., Gm. 7.50 (f 3 ij.) ; Cura^oa, Gm. 90 (f § iij.) ; aquae, ad Gm. 240 (Oss.) M. Sig.: A table-spoonful in water three times a day between meals. In younger persons we may prescribe a brisk purge with blue pill and colocynth, followed by an aperient tonic, as the mist, ferri acid, of Startin : Magnesii sulphat., Gm. 32 (§j.); ferri sulphat., Gm. 2 (3ss.); sodii chloridi, Gm. 1.5 (9j.); acid, sulphuric, dil., Gm. 3.75 (f 3 j.); infus. quassias, ad Gm. 120 (f§iv.). M. Sig. : Table- spoonful in a goblet of water before breakfast. In broken-down cases pure tonics, as quinine, iron, etc., may follow these or be used in connection with them. The prognosis of ecthyma is favorable; a few weeks generally suffice to effect a cure if the patient can follow out the treatment carefully. Arthur Van Harlingen. thelial tissue, and in the course of the development of the embryo gives rise to the epidermis, the nervous system, the sensory portions of the organs of special sense, cutane- ous glands, etc. See Germ-layers. C. S. M. ECZEMA. Eczema is an inflammatory, acute, or chronic, non-contagious disease of the skin, characterized at its commencement by erythema, papules, vesicles, or pustules, or a combination of these lesions, accompanied by more or less infiltration and itching, terminating either in discharge, with the formation of crusts, or in desqua- mation. Eczema is eminently a protean disease. At one time it begins as an erythema; later this may become moist and secreting, and finally terminate in a thickened, dry, and desquamative surface. At another time the affection may begin in the form of vesicles or pustules, with swel- ling and heat. These soon burst, and a red, weeping surface results, which is soon coated with bulky crusts from the drying of the liquid, gummy discharge. The character of the patch may then suddenly change, and instead of a weeping surface there may exist a dry, scaly, infiltrated, fissured area of skin, which continues until the disease is healed. Or, again, papules may first ap- pear ; these may remain as such throughout their course, or may pass into other lesions, or they may be associated, sooner or later, with vesicles. There is no other disease of the skin in which the le- sions undergo such sudden and manifold changes, and every variety may manifest itself in turn. More or less itching is almost always present in eczema. It may vary in degree from the merest titillation to unendurable tor- ture. Sometimes burning takes the place of itching ; at other times these two symptoms occur together. But eczema is the itching disease par excellence. Eczema may be acute, running its course in a few weeks, and then disappearing, or it may be chronic and continuous, or recurring through years. It may occur in small patches, single or multiple, or more rarely covering ex- tensive surfaces. Unless quite extensive it is not usually ushered in by constitutional symptoms, but a severe gen- eral attack may begin by chill, nausea, feverishness, etc. The varieties of eczema are named according to the lesions which the disease assumes at its beginning. They are as follows : Eczema Erythematosum.-This form shows itself in typical cases, first, as an undefined erythematous state of the skin, occurring in small or large patches, without discharge or moisture. There is a slight infiltration and thickening of the skin, the surface of which is dry and slightly rough, with some slight scaliness, and occasion- ally excoriations. The skin may be bright or dusky red, or even violaceous in color. It often has a yellowish tinge, and is occasionally mottled. The process may affect a small or large surface ; it is often better one day and worse the next, or it may even go away entirely only to return a little later. It is apt to be chronic, and the relapses are annoying and discouraging, especially in winter time. Exposure to heat and cold, a heavy meal, or indulgence in alcoholic liquors, is apt to be followed by an exacerbation of the attack. Mental over-exertion or worry may at times be a factor in the causation of the disease or its aggravation. Burning and itching, alone or together, are prominent symptoms. Erythematous ec- zema may run its course as such, or may develop into eczema squamosum. Vesicles or pustules are rarely seen. The usual seat of this form of eczema is the face or geni- tals, although it occurs elsewhere. Eczema Vesiculosum.-Vesicular eczema commonly begins by a feeling of heat and irritation in the part, which shows a diffuse or punctate redness, with itching and burning, and small vesicles soon show themselves, either alone or grouped, or sometimes running together. They are soon filled with a yellowish gummy fluid, and then they ordinarily break and form a crust. Sometimes, however, the vesicles simply dry up without breaking. In more marked cases new crops of vesicles continue to come out, and when a considerable surface is involved the quantity of fluid is at times quite large, and the under- ECTODERM. The ectoderm, also called ectoblast by some German, and epiblast by some English, writers, is the outermost layer of cells in the embryo. It is an epi 632 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ecthyma. Eczema. clothing or dressings may be saturated. When the se- cretion dries it is very sticky and tenacious, and this is characteristic of this form of eczema. Typical eczema, as thus described, is not as common as the more complex varieties where the lesions are multiform, papules, pa- pulo-vesicles, vesicles, pustules, and other lesions being found in conjunction. The two chief characteristics of this form of eczema, wherever found, are the itching and the gummy secretion, leaving a yellow stain upon the linen. Vesicular eczema may occur in very small patches or in quite extensive areas, and has no particular locality of predilection. As it shows itself in children over the face and scalp, it forms the eruption popularly known as milk crust, scalled head, tooth rash, or moist tetter. Eczema Pubtulosum (Eczema impetiginosum).-This form begins very much in the same way as vesicular eczema, only the lesions are pustules. There is usually less heat and itching. The two forms not infrequently coincide. The scalp and face are the favorite seats of pustular eczema, and it is particularly apt to occur in ill- nourished infants and young children, and in ill-fed and scrofulous adults. Eczema Papulosum.-Papular eczema occurs in the form of small, round, or acuminated papules, varying in size from a small to a large pin's-head. The lesions may be pale, or they may be bright- or dusky-red, or even violaceous. They may be discrete and scattered, or they may coalesce in patches of greater or less size, these latter often becoming much thickened and infiltrated. Now and then these patches become abraded and moist, constitut- ing a variety of eczema rubrum described farther on. Papular eczema is apt to occur on the arms, trunk, and thighs, particularly the flexor surfaces. It may involve a small surface, showing itself in a few isolated papules or a small patch, or it may invade large areas ; and it is apt to be the most stubborn, troublesome, and annoying of all the forms of eczema, the chief feature being the excessive, and at times agonizing, itching. Eczema Rubrum.-This is rather a secondary condi- tion of the skin, resulting from some other form of eczema, than a distinct variety of the disease. It may follow any of the other forms, the surface of the diseased skin becoming denuded of epidermis, red, moist, weep- ing, inflamed, and infiltrated. Occasionally the diseased surface is covered with crusts, disguising the character- istic appearances beneath. Eczema rubrum may occur upon any part of the body, although it is most commonly found upon the legs or the flexures of the joints. It is particularly common as an accompaniment of varicose veins and ulcers of the leg. Eczema Squamosum.-Scaly eczema is, commonly, rather a sequel to other varieties of the disease than a distinct form, following and resulting from the other forms of the disease, particularly the erythematous. When typical, it shows itself in the form of variously sized and shaped reddish patches, which are dry and more or less scaly. The skin is always more or less thickened and infiltrated. Other lesions occur in eczema which are worthy of mention. These are rhagades or fissures, occurring where the diseased and infiltrated skin becomes cracked by flex- ure, as about the joints, or at the margins of the lips or anus. Chapped hands, for example, are instances of fissured eczema. Sometimes eczema may assume a warty condition, and at other times hard sclerosed patches may form. In addition to the above varieties of eczema, as just de- scribed, the disease may be regarded as divided into two forms, acute and chronic, this division referring not so much to the actual duration of the disease as to the pathological changes wfliich occur during its course. When the general inflammatory symptoms are high and the secondary changes insignificant, the disease may be said to be acute. When, however, the process has set- tled into a definite course, the same lesions continually repeating themselves, accompanied by secondary changes, the disease is to be considered chronic. Eczema is the commonest of all skin diseases. It oc- curs in this country in the proportion of one-third of all skin diseases encountered. It attacks persons in all grades of society, and occurs at all ages and in both sexes. In some cases the tendency to eczema appears to be heredi- tary, especially in the children of persons of light com- plexion with fair to reddish hair and a liability to scrofu- lous affections. Some persons are so prone to eczema that the slightest provocation will bring on the eruption ; and an attack of dyspepsia, which in another person would have no effect upon the skin, or contact with an irritant, which in most persons would only cause a transient dermatitis, is, in such individuals, a sufficient cause to bring out an eczematous eruption. Dyspepsia, especially when accompanied by constipation, is one of the commonest constitutional causes of eczema. In cer- tain individuals the presence of an excess of uric acid and urates in the system is sufficient to produce and keep up eczema. The occurrence of gout and rheuma- tism also may be mentioned among the etiological factors of eczema. Improper or insufficient food acts as an ex- citing cause of eczema, and this is especially the case in infantile eczema, many cases of which, commonly attrib- uted to the influence of teething, are in reality due to improper or inadequate diet. Pregnancy and lactation, debility, nervous exhaustion, excessive mental or bodily work, dentition, vaccination, internal irritation, as of ascarides or taenia in the bowels, may also determine the eruption of eczema. Eczema is not contagious. It cannot be acquired from being in contact with or handling the discharge. The external causes of eczema are such irritants as in ordinary cases produce simple dermatitis (see Dermatitis), but which, when applied to the skin of a person prone to eczematous inflammation, may light up a true eczema. Among the chief of these may be mentioned water, alka- lies and acids, flour, sugar, clay, etc. Likewise heat and cold, maceration of the epidermis by excessive perspira- tion, particularly about the genitalia and elsewhere, may give rise to eczema. Eczema intertrigo is the result of chafing between two contiguous surfaces, and is often seen on the inside of the thighs or about the scrotum. Eczema is of much commoner occurrence in the win- ter than in the summer. Many cases get well in summer only to recur in winter. Water, as in water-dressings or fomentations, and especially as not infrequently em- ployed in the " water cure," is a cause of eczema. Too frequent ablutions, and especially the too free use of soap, often leads to the outbreak of eczema in persons prone to this disease, or to the aggravation of the eruption when it is present. Finally, among the local causes of eczema may be mentioned the irritation caused by the presence of lice and itch-mites, together with the scratch- ing to which they give rise. The diagnosis of eczema is of great importance, and is especially difficult at times because the disease shows it- self in such protean forms, and is often initiated or ac- companied by other affections. Certain features of ec- zema are, however, one or another, present in almost every case of the disease, at one stage or another of its history. Such, for instance, is the inflammatory thickening of the skin, which may usually be seen by the eye or perceived by pinching up a portion of skin between thumb and fin- ger. Swelling and oedema exist in all acute eczemas, and often in chronic cases. The patch is red and congested. In most cases of eczema there has been more or less fluid exudation or moisture at one stage or another in the his- tory of the disease. The fluid may be clear, limpid and yellowish, or turbid and puriform, or it may contain blood. This discharge is a most characteristic feature of eczema, and is not present in any other disease. The crusts formed by the drying up of the discharges are characteristic. When this has been copious the crusts form rapidly and in such quantity as sometimes to cover and mask the skin. They are yellowish, brownish, or greenish in color, and when removed show a moist sur- face beneath. Among the most important diagnostic symptoms of eczema is the subjective one of itching. This is rarely altogether absent, although it may vary much in degree. It is often intense, being more severe 633 Eczema. Eczema. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. than in any other disease, an important diagnostic mark. Burning is a not infrequent subjective symptom, being more apt to be present in erythematous eczema, and often giving way to itching as the disease progresses. Having mentioned the chief characteristics of the vari- ous forms of eczema which may serve to identify the af- fection, the specific points of diagnosis between this dis- ease and other particular affections may be mentioned. Erysipelas sometimes resembles erythematous eczema, particularly as the latter show's itself upon the face. It is, however, an acute disease beginning at a given point, and creeping slowdy from place to place. The inflamma- tion is a deep one ; the surface is smooth, shining, tense, and more or less dusky red, while deep infiltration, oede- ma, heat, and swelling exist underneath. Erysipelas is also accompanied by considerable fever and constitutional disturbance. There is no scaling or roughness of the sur- face in erysipelas, and no discharge save in the bullous form, when large blebs may occur. Urticaria, particularly that variety which is accom- panied by the formation of small papular lesions, is occa- sionally confounded with eczema papulosum. The irri- table condition of the skin, the history of itching and burning occurring before the appearance of the lesions, all characterize urticaria in contradistinction from eczema. Herpes zoster sometimes resembles eczema vesiculosum, but is distinguished from it by the arrangement of the vesicles, the more regular grouping of the lesions of zos- ter along the lines of some well-known nerve-trunk, and the ordinary occurrence of neuralgia in connection with the zoster eruption. Pityriasis, as it occurs upon the scalp, closely resembles squamous eczema, and they are the more difficult to dis- tinguish because both sometimes occur together. In ec- zema, however, the scales are larger, less abundant, and drier than in pityriasis. Eczema is more apt to occur in a patch on the scalp, while pityriasis is more generally diffused. The skin in eczema is usually red and inflamed, and is always itchy; in pityriasis it may be even paler than normal, and may have a dull leaden hue. It is com- monly less itchy also. Psoriasis is often confounded with eczema, the disease, when occurring in limited patches or upon the scalp, being sometimes almost indistinguishable from it. Old, infiltrated, inflammatory patches are especially difficult to make out, but in psoriasis the edges usually terminate abruptly, while in eczema they are more apt to fade into the surrounding skin. The scales on eczematous patches are thin and scanty ; on the patches of psoriasis they are comparatively more abundant, larger, silvery, and imbri- cated. In eczema there is usually some history of moist- ure or weeping in one stage of the disease or another; in psoriasis the process is always dry. The distribution of the disease, and the occurrence of patches on other parts of the body, may aid in the diagnosis. In doubtful cases all lesions should be examined, as a single character- istic one will settle the question. Lichen ruber may be confounded with eczema, but the peculiar quadrate shape of the lesions in lichen ruber planus (q. v.), together with their dusky hue, and the fact that they usually run a quiet, chronic course without changes, and leave a deep stain behind, all seem to distin- guish this affection from eczema. Pityriasis rubra is a very rare disease in this country, and in any suspected case the chances are certainly five thousand to one against it and in favor of eczema. It presents symptoms, however, which closely resemble those of generalized erythematous and squamous eczema. It may be distinguished, however, by its universal red- ness ; by the presence of large, thin, papery, whitish epi- dermic scales in great abundance ; by slight itching, and burning heat; and lastly, by the absence of marked infil- tration and thickening of the skin, a symptom common in eczema. It undergoes but slight changes throughout its course. Tinea circinata occasionally resembles eczema and, oc- curring in certain localities, as about the inside of the thighs, groins, and genitalia, is very apt to be confounded with it. The name "eczema marginatum," given by Hebra to ringworm in this locality, has helped to confuse the distinction between the diseases. Both here and in other parts of the body the progressive character of the ringworm, usually forming in rings and segments of cir- cles, will aid the diagnosis, although the microscope is the only sure guide, the discovery of mycelium in the epi- dermis being conclusive. Tinea tonsurans in its milder and more chronic stages may readily be confounded with squamous eczema of the scalp. The especial diagnostic points will be found under the head of tinea tonsurans (?• ®-). Tinea sycosis resembles eczema of the beard when the parasitic disease is superficial. When at all well devel oped, however, the looseness of the hairs, which may be withdrawn with ease and without any purulent matter adherent to the root, together with the lumpy red ap- pearance of the skin, will suffice to distinguish between the two affections, although a microscopic examination of the hair-roots may be needed to make sure. In tinea sycosis the hair-roots are loaded with a roe-like mass of spores. Sycosis non parasitica is essentially an inflammation of the hair-follicles ; each hair involved is seen growing out of the centre of a pustule, and the inflammation is seen to be deep-seated, while eczema of the beard is superficial and does not involve the hair-follicles. Favus, a disease of rather rare occurrence in this coun- try, sometimes resembles eczema ; but the peculiar canary- yellow color of the favus crust, its favorite seat upon the scalp with a hair running through each cup, and the very peculiar mousey odor, is usually quite enough to dis- tinguish it from the disease under consideration. In doubtful cases microscopic examination will invariably disclose the characteristic and abundant fungus of favus- where this affection is present. Scabies is very likely to be confounded with eczema, more especially because the irritation of the itch-mite itself arouses a sort of eczema which is the most obvious symptom of the disease. Eczema, however, does not show the marked preference for certain localities, as the hands and fingers, buttocks, axillae, abdomen, mammae, nipples, and penis, which scabies displays. But chiefly the presence or absence of the peculiar burrow of the itch insect will decide almost infallibly between the two affec- tions. Syphilis.-Eczema of the scalp is at times liable to be mistaken for syphilis. There is a form of pustular ec- zema, characterized by the presence of a few scattered lesions of the scalp, without a sign of the disease else- where, which it is sometimes difficult to differentiate from the pustular syphiloderm of the scalp. The occur- rence or absence of a history of syphilis or of concomitant syphilitic lesions in other parts of the body, and the suc- cess or failure of a treatment other than antisyphilitic, will demonstrate whether one or the other affection is present. Occasionally, fissures with abundant purulent secretion occur on the scalp in the course of syphilis, and this form of the eruption may closely resemble confluent pustular eczema. The disgusting odor which ordinarily accompanies the discharge from this form of syphilitic disease, will usually, however, serve to distinguish it. It is hardly possible to confound syphilitic eruptions of other parts of the body with eczema ; the fact that syphi- litic lesions are always accompanied by new cell infiltra- tion of the lower layers of the skin, and the absence of inflammatory symptoms, being usually sufficient to dis- tinguish the affections. The symptom of itching or its absence, though one to be borne in mind, must not be suffered to mislead. Syphilitic eruptions, though usually nonpruriginous, do occasionally itch quite severely, and this is especially the case with the earlier generalized eruptions. The Treatment of Eczema.-Eczema is a perfectly curable disease, but for its relief both internal and external remedies must at times be employed. Constitutional rem- edies judiciously employed are almost always needful, and prove of decided benefit in the majority of instances. In some cases, as when the eruption is local and due to some external irritant, or when it is exceedingly limited in ex- 634 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eczema. Eczema. tent, no internal measures are called for. The subject of diet must be carefully attended to ; all articles which are difficult of digestion must be avoided, and especially salt or pickled meats, pastry, cabbage, beer, or wine. The bowels should be carefully regulated ; dyspepsia is often the sole exciting cause of eczema. The condition of the kidneys should be looked into. Diuretics are often of value. Saline laxatives are frequently called for in the treatment of eczema, and among these the following tonic aperient, to which the name " mistura ferri acida" has been given, is one of the best; B- Magnesii sulphat., 32 Gm. (I j.); ferri sulphat., 2 Gm. ( 3 ss.); sodii chloridi, 67 centigr. (gr. x.); acid, sulphuric, dil., 3.75 Gm. (f 3 j.); infus. quassise, ad 150 Gm. (f 3 iv.). M. Dose, a table- spoonful in a goblet of water before breakfast. It is im- portant that a full goblet of water should be taken. In acute eczema, when the bowels are loaded and there is a tendency to dyspepsia, six grains of blue pill at night, fol- lowed the next and succeeding mornings by this mixture, forms the best treatment in a majority of cases. The laxative mineral waters are also useful, The Hathorn and Geyser Saratoga springs of this country, and the Friedrichshall, Hunyadi Janos, and Ofener Racoczy among German waters, are the best. The Hunyadi water, which is the most generally useful, should be given in the dose of a wineglassful, more or less, in a goblet of hot water once, twice, or thrice daily, the object being to re- lax the bowels, not to produce purgation. It can be con- tinued indefinitely without injury. In infantile eczema, when constipation exists, the simple unspiced syrup of rhubarb alone, or with magnesia, is often found desir- able (see Eczema in Infants). The continued use of lax- atives and cathartics is of course to be deprecated, but they make a good beginning for a course of treatment which may afterward take a purely tonic form, or give way to local treatment alone, as the case may require. In old persons, particularly when the patient has been a high- liver or is rheumatic, or in those cases in which a gouty element may exist, diuretics and alkalies are indicated. Colchicum, magnesium carbonate and sulphate, the ace- tate and carbonate of potassium in full doses, and also the alkaline mineral waters, may be employed. In per- sons of debilitated constitution or in scrofulous persons, particularly in the badly-nourished children of tubercu- lous parents, cod-liver oil is indicated, and is frequently very useful. Iron'in various forms is to be recommended in some cases, particularly when anaemia is evidently present. It is well, however, to remember that the anae- mia which exists in connection with eczema is not infre- quently the result of dyspepsia and malassimilation, and that, therefore, acids, bitter tonics, etc., should precede the administration of purely ferruginous compounds. Quinine and strychnia are sometimes called for by the general condition of the patient. Arsenic is useful in a limited class of cases, more especially in the chronic papular form, and in the squamous stage of the affection. Arsenic was formerly used in all cases of eczema indis- criminately, and with some vague notion of its function being that of a specific. It is less abused at the present day, but is still too often prescribed as if it had some potent magic virtue. The fact is that arsenic has a very limited value in this disease. The Local Treatment of Eczema.-With regard to the local treatment of eczema, the use of water must, for the most part, be avoided, especially when the skin is abraded. When its employment is necessary for the pur- pose of removing epithelial, serous, or purulent debris, it may be made much less irritating by the addition of a small quantity of boiled starch or bran. White Castile soap is ordinarily the only soap necessary to cleanse the skin of crusts and scales, but occasionally the stronger potash soaps, the ordinary household soft soap, or the sapo viridis of Hebra must be brought into use. Some- times the " spiritus saponis kalinus," a solution of two parts of sapo viridis in one of alcohol, may be used in- stead of the solid soaps. Whatever soap is used, it should afterward be washed off the skin, unless a distinctly macerating or caustic effect is sought to be produced upon the epidermis. The local treatment of eczema is of great importance. Many cases can be cured by outward applications alone, and there are very few in which these can be dispensed with entirely. Before instituting local treatment, the part affected should be examined, with the view of determin- ing whether the disease is acute or chronic, what the characteristic lesions are, etc. For, as will be seen, the local treatment of an acute vesicular eczema is quite dif- ferent from that of chronic papular eczema. Crusts and scales, with other debris, must first be removed before curative applications are made. Soap and water, oils alone or in poultices, compresses wrung out of hot water and covered with oiled silk, are among the means to be employed for this purpose. Sometimes a strong solution of carbonate of sodium applied on compresses will soften crusts more rapidly than anything else. Two general principles may be laid down with regard to the local treatment of eczema. These are, first, that in the acute form the treatment can scarcely be too sooth- ing ; secondly, that in the chronic form the treatment can hardly be too stimulating. Of course these general prin- ciples must be modified somewhat according to individual circumstances, especially with regard to the latter. Acute Eczema.-In most cases of acute eczema, particu- larly of the vesicular variety, washing, and especially the use of soap, are to be sedulously avoided. In some cases drying and astringent powders serve the best pur- pose at first, and powdered starch, lycopodium, carbonate of magnesium, subnitrate of bismuth, and oxide of zinc, alone, or two or more in combination, may be employed. Powdered camphor may occasionally be added with ad- vantage, as in the following formula: B • Pulv. cam- phorse, Gm. 2 ( 3 ss.) ; pulv. amyli, Gm. 6(3 jss.) ; pulv. zinci oxidi, Gm. 24 ( 3 vj.). M. Camphor should not be employed when there are fis- sures, nor should powders usually be employed on mu- cous or muco-cutaueous surfaces. Among washes, lead water alone or in combination with laudanum, black wash, or the fluid extract of grindelia robusta diluted with eight parts of water, may be used in most cases. The following combination is also sooth- ing and applicable to many cases. B. Pulv. zinci carb, precip., Gm. 32 ( ^ j.) ; pulv. zinci oxidi, Gm. 16 (3 iv.); glycerinae, Gm. 8 (f 3 ij.); aquae, Gm. 180 (f|vj.). M. It should be applied by means of a bit of rag or a rag mop, the sediment being allowed to remain on the sur- face. A lotion of sulphate of zinc, fifteen to thirty grains to the pint of water, acts admirably in some cases, es- pecially in eczema about the hands. When itching is a severe and prominent symptom, applications of hot water, or of cloths wrung out of the same and applied in quick succession, as hot as may be borne, to the affected skin, often allay this exasperating symptom when all else has failed. Carbolic acid, which is such an efficient anti- pruritic in the more chronic forms and stages of eczema, is frequently not borne in the acute condition. It is most apt to do good in erythematous eczema where the skin is still unbroken. Ointments are frequently irritating in acute eczema, but in some cases, properly made and applied, they may be of great service. A few formulae may be mentioned, and first the unguentum diachyli of Hebra (not that of the last revision of the U. S. Pharmacopoeia). This, when well made, is a remarkably soothing ointment. It is composed as follows: B- Olei olivae opt., Gm. 405 (f^xv.); pulv. lithargyri, Gm. 120 (3 xxx.); aquae, q.s. Coque ; fiat unguent. It should be soft, smooth, and free from toughness or stringiness. Diachylon ointment should be spread upon cloths and laid upon the affected parts. It gives a better result when thus applied than when rubbed in. Among other sooth- ing ointments may be mentioned a modification of the officinal oxide of zinc ointment, made with sixty grains of the powdered oxide of zinc rubbed up with an ounce of cold cream. Also simple cold cream, cucumber oint- ment, glycerole of starch, almond and olive oils, and dilute glycerine. As regards the latter it should be re- marked, that while glycerine in full strength disagrees with many skins, yet, when diluted with two or more 635 Eczema. Eczema, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. parts of water, it will more commonly be found to agree. In papular eczema, the eruption being more discrete and scattered, lotions are preferable to powders or oint- ments. The papular eruptions being usually more chronic, stimulant applications are called for. Tar, carbolic acid, thymol, etc., are the preparations most likely to be found useful. An excellent lotion in diffuse papular eczema is the following: IJ. Acid, carbolic., Gm. 11.25 (f 3 iij.); glycerin®, Gm. 40 (fjj.); aquae, Gm. 480 (Oj.). M. Chronic Eczema.-Whatever the form of chronic ec- zema, the local treatment should be stimulating. Carbolic acid may be employed either in the form of a lotion as above, or as an ointment of the strength of from five to twenty grains to the ounce. Among the other ointments may be mentioned: oxide of zinc ointment, benzoated lard, and cosmoline. Tarry preparations are of great use, but must be handled with care, since if used injudiciously, or in too great strength, they are apt to inflame the skin and retard the process of cure. They are most apt to be useful when the disease has completely reached the chronic stage, and when there is more or less infiltration. In using tar in the form of ointment, which is ordinarily the most convenient way of using this remedy, its strength should at first rarely exceed one or two drachms to the ounce. It can be increased later, if the skin re- quires, and will bear, increased stimulation. The two forms of tar commonly employed are the pix liquida of the Pharmacopoeia and the oleum cadini. Their effect on the skin is apparently identical. A very convenient formula for the latter is this: IJ. Olei cadini, Gm. 2 ( 3 ss.); ung. aquae rosae, Gm. 32 ( § j.). M. On the scalp, where fluid preparations are more suit- able, the oil of cade can be used, mixed with four of alco- hol or oil of almonds. The following is a convenient formula for the treatment of chronic eczema of the scalp : IJ. Picis liquid®, Gm. 4 ( 3 j.) ; glycerinae, Gm. 5 (f 3 j.) ; alcoholis, Gm. 20.25 (f 3 vj.) ; ol. amygdalae amar., Gm. .80 (Ft xv.). M. None of these fluid preparations are to be applied on cloths, but they are all to be worked well into the skin. In thick old patches of chronic eczema, when the disease is limited in area, the following preparation, known as " tinetura saponis cum pice," can be rubbed in firmly with a mop often with excellent results : IJ. Picis liquid®, saponis viridis, alcoholis, aa Gm. 8(3 ij.). M. To produce a stronger impression caustic potash may be used instead of the soap, as in the " liquor picis alkalinus" of Bulkley : IJ. Picis liquid®, Gm. 8 ( 3 ij.); potass® caustic.. Gm. 4 ( 3 j.); aqu®. Gm. 18.75 (f 3 v.). M. The potash is to be dissolved in the water and gradually added to the tar while rubbing in a mortar. Of course this preparation is much too strong to be used undiluted, excepting in the rarest cases. As a lotion it may be di- luted with from eight or more parts of water at first, later with less dilution even, down to two parts after a little trial; care should be taken not to make the lotion too strong at first. Commonly, it is better to anoint the part, which should be rubbed afterward with some oint- ment to mitigate the effect of the excess of potash. Oc- casionally the liquor picis alkalinus may itself be made up with an ointment in the strength of one drachm or two drachms to the ounce. Sapo viridis, the " green soap " of Hebra, made in Ger- many of herring fat and potash, possesses valuable prop- erties as a discutient in tough infiltrated patches of chronic eczema, and in extensive infiltrated eczema ru- brum of the leg. It should be well rubbed into the af- fected part by means of a flannel rag, and either allowed to remain on or washed off, and followed by soothing ointments. It reduces infiltration and quiets itching in chronic cases to a remarkable degree. Mercurial ointments, especially those of the mild chlo- ride, the red oxide, and the acid nitrate, are useful in limited patches of infiltrated chronic eczema, but cannot be used over large surfaces without danger of mercurial absorption. In mild cases of eczema of an intermediate character, between the acute and chronic, ointments of ammoniated mercury or of sulphur are sometimes em- ployed to advantage. For extremely obstinate circumscribed patches of ec- zema, blistering with cantharidal collodion will some- times be found beneficial. With the same object, strong solutions of carbolic acid in alcohol, tincture of iodine, and solutions of nitrate of silver, or even the solid stick, may be employed. Vulcanized india-rubber dressings, and in eczema of the leg the well-known Martin's rubber bandage, may be used with advantage. The latter should be worn during the day only. On retiring at night the bandage is to be removed, and the limb plunged quickly into water as hot as can be borne. Removed from this in a few moments, it is wiped gently dry and the surface dressed with starch powder, and loosely covered with linen cloth for the night. If itching is very severe, a carbolic acid lotion may be substituted for the powder. Under this treatment rapid improvement is usually ob- served, and sometimes no further treatment is required. Now and then, however, the rubber bandage disagrees seriously, and in any case patients using it should be kept under close surveillance. Having now spoken of acute and chronic eczema in general terms, it will be of advantage to consider the dis- ease as it is met with in different localities. Universal Eczema.-This form of the disease is very rare. When it does occur it is usually of the erythematous or the squamous type. It is liable to be mistaken for universal psoriasis, and for pityriasis rubra, but the history will serve to aid the diagnosis, as in the earlier stages all the characteristics of circumscribed eczema manifest them- selves-weeping, crusting, etc. The treatment of universal eczema must be based largely on general principles. The surface should be kept mollified by ointments or oils, care being taken not to employ any application liable to be absorbed {e.g., mercurials) and to give rise to toxic ef- fects. Internally, a supporting treatment and tonics, and good diet are called for. Rest in bed, usually unavoidable in any case, should be encouraged. This form of eczema is usually very intractable, and the prognosis, although in most cases ultimately favorable, involves a long and tedious course. Intercurrent disorders, as bed-sores, anky- losis of the knee and other joints from immobility, must be guarded against. Eczema of the scalp is usually erythematous, squamous, vesicular, or pustular. The first variety rapidly runs into the second, the scalp becoming more or less covered with red scaly patches, which are very itchy. The pus- tular variety is common among children. The pustules commonly come out in great numbers about the hair-fol- licles. They soon rupture, and the liquid, oozing over the skin, forms yellowish-green crusts, sometimes amounting to thick masses. The hair becomes matted and caked ; the scalp, if not cleansed, gives out a very offensive odor, and the disease, unless checked by proper treatment, may last from weeks to even years. Itching is not usu- ally so prominent a symptom in this as in some of the other forms of eczema. Sympathetic enlargement of the superficial lymphatic glands behind the ears, and about the back of the neck, is common in this form of eczema, and in the case of children often gives rise to great anxi- ety on the part of parents. The glands never suppurate, and the patient's friends may be assured with confidence that, as the irritation and inflammation about the scalp subside, the glandular engorgement will spontaneously disappear. Small abscesses often complicate eczema of the scalp in unhealthy children. Pediculi are also very frequently present, and the scalp should be examined for the insects or their nits in all cases of pustular eczema. A patch of pustular eczema occurring in the occipital re- gion, especially in neglected, ill-nourished children, al- most invariably points to the presence of pediculi as a cause. When present these should be removed at once by the means described under Pediculosis Capitis (q. v.), and the eczema can then be treated secundum artem. Vesicular and pustular eczema of the scalp are not liable to be mistaken for any other disease, excepting in rare cases the pustular syphiloderm, in which the history 636 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eczema. Eczema. and concomitant lesions will usually suffice to make the diagnosis plain. Squamous eczema of the scalp, how- ever, may at times be readily mistaken for psoriasis, se- borrhoea, favus, and tinea tonsurans. Psoriasis may generally be known by its characteristic appearance as presented on the edge of the scalp, to which it usually ex- tends. The patches here are usually red, infiltrated, sharply defined, scaly, and fissured, while eczema fades imperceptibly into the surrounding skin, and shows slight infiltration and scanty fine scales (see Psoriasis). Squam- ous eczema of the scalp may also be distinguished by the general symptoms of its development, as redness, itching, and occasional weeping, as described above. Pityriasis capitis sometimes resembles squamous eczema of the scalp, but the scales are usually of a more pearly white, and not infrequently connected with a certain amount of seborrhoea and greasiness of the scalp. Favus almost in- variably shows the peculiar cup-shaped, canary-yellow crusts, with redness and pseudo-ulceration underneath, together with a certain mousey odor which is quite un- mistakable. From tinea tonsurans, squamous eczema of the scalp is distinguished by the fact that the hairs, though some- what diminished in number, are not absent, nor are they broken off short, giving that "nibbled " appearance such as is seen in the ringworm of the scalp. The patches in ringworm are apt to be roundish in outline, while those of eczema are irregular. The color of the diseased scalp is of a leaden hue, with, often, a "goose-flesh" appear- ance, while the eczematous patches are reddish and more inflamed looking. In tinea tonsurans there is often a his- tory of contagion, while, finally, a microscopic examina- tion of the short hairs will show in tinea tonsurans the characteristic fungus (see Tinea Tonsurans). The treatment of eczema of the scalp will vary accord- ing to the character of the eruption, its stage-whether acute or chronic-and the general condition and age of the patient. In vesicular and pustular eczema, when the lesions are acute and discrete, and when there is considerable inflam- mation, the hair should be cut short (which can almost always be done in either sex, because this form of the dis- ease is commonly met with in childhood), and simple ap- plications of oil employed until the lesions have matured and crusts have begun to form. Then poultices, wet dressings, hot water and soap, may be employed to re- move effete matter, and some soothing and slightly astrin- gent ointment, such as that of the subnitrate of bismuth given above, can be applied. When there is extreme sen- sitiveness some soothing lotion, as black wash or lead water, must be used at first, but such applications are rarely necessary. When the eruption is less acute, the follow- ing slightly stimulating ointment may be employed after the crusts are removed. I). Hydrarg. chlor, mit., Gm. 1 to 2 (gr. xv. to xxx.) ; ung. zinci oxidi, cosmolin®, aa Gm. 16 ( 3 iv.). M. A small portion only should be used at a time, and this should be rubbed in thoroughly. If the diseased surface is large the possibility of salivation from the absorption of the mercurial should be borne in mind, and the weaker proportion should be employed with circumspection. When the exudation has ceased and the scalp is red and scaly, the treatment for squam- ous eczema is proper. Squamous eczema of the scalp is usually best treated by stimulating and astringent ointments, more rarely by lotions. The following is a very good astringent oint- ment : Acidi tannici, Gm. 4 (3 j.); ung. petrolii, grm. 32-( 5 j.). M. And this is an excellent stimulant: J?. Ung. hydrarg. nitrat., Gm. 4-16 (3j.-iv.); ung. petrolii, Gm. 32 (| j.). M. Tarry preparations are also useful in some cases. Eczema of the face is usually either of the erythematous or of the vesicular and pustular type. Erythematous eczema is an affection of adult and advanced age. The circumorbital region with the eyelids, is a frequent seat of this affection, and next to this come the forehead, cheeks, angle of the nose and chin, sometimes extending back to and around the ears, and on the neck. The skin becomes bright or dusky red, with some thickening, a slight amount of scaliness, and, at the commissure of the eyelids and the alae of the nose, a tendency to cracking and the formation of fissures. Burning is the characteristic sub- jective symptom of this disease, and is often very severe. Itching is a much less prominent symptom. This form of eczema is more apt to occur in winter, and among per- sons exposed to cold and wind. In addition to such means of treatment as are called for by the patient's gen- eral condition, active local measures should be used. Lead-water lotions and black wash are useful in the acute stage, and these should be followed by an ointment of equal parts of cosmoline and oxide of zinc ointment, or some similar preparation. To protect the skin from the outer air, which is strongly irritating, the following paste may be painted on a little while before the patient leaves the house: 3. Pulv. tragacanth., glycerin®, aa Gm. 16 (3iv.) ; pulv. boracis, Gm. 2 (3 ss.); aqua? des- tillat., q.s. M. With these materials a thick, mucilag- inous paste should be made, which, laid on in a thin layer by means of a camel's hair brush, will protect the skin effectually without causing disfigurement. So soon as the acute symptoms have passed-and, in fact, most cases are chronic from -the beginning-lo- tions and ointments containing carbolic acid and tar should be brought into use. The following pigment is a useful one : 3. 01. cadini, Gm. 4(3 j.) ; collodii, Gm. 32 (5 j-). M. Put a brush in the cork, and paint on the diseased surface one or several times a day. Hot water should not be forgotten as an adjuvant to this treatment. Sponging or sopping the parts with very hot water be- fore applying the ointments or other preparations is of advantage. Eczema of the lips is a chronic and troublesome form of the disease. The muco-cutaneous surface becomes dusky, slightly swollen, and puffy, covered with large brownish scales, detached at the edge, and adherent to the centre, and often the lip becomes cracked. Solutions of potash of ten or even twenty grains to the ounce, carefully brushed upon the previously dried surface, by the phy sician, and quickly washed off when pain begins, should be followed by a mild demulcent ointment. The condi- tion of the digestive organs must be looked after. Eczema of the eyelids commonly occurs in scrofulous and badly nourished children, and less frequently among adults also. The follicles of the eyelashes are involved, small pustules forming which dry into crusts, gluing the edges of the lids together. Mild cases of eczema of the eyelid require no more than the application of a weak nitrate of mercury ointment, made of the officinal oint- ment diluted with three to six parts of cold cream. In severe cases the eyelashes should be extracted, the edges of the lids carefully dried, and then touched with a camel's-hair pencil moistened with a drop of a ten-grain- to-the-ounce solution of caustic potassa. This application is to be wiped away immediately, and the effect neutral- ized by the application of cold water. The operation may be repeated every day until the infiltration, exudation, and itching subside, after which the stimulating oint- ment just mentioned may be relied upon to complete the cure. Eczema of the beard is sometimes excessively stubborn and annoying. Pustules seated about the hairs form with great rapidity and persistence, and are followed by yellow- ish or greenish crusts, often matting the hairs together. The affection is usually confined , to a limited locality, as the corner of the upper lip or about the opening of the nostrils, but it may be more extensive. Eczema of the beard differs from sycosis, which in some respects it much resembles, in that it is more super- ficial, crusts being seen instead of deeply-placed pustules, and also in the fact that it is not necessarily confined to the beard as sycosis is, but may spread from that to other parts. In the treatment of eczema of the beard, the crusts should first be removed with oil or poultices, followed by hot water and soap, and then the beard must be shaved or clipped very closely, so as to admit of the application of ointments, etc. Afterall crusts and debris are removed, the unguentum diachyli (Hebra)is to be applied, spread upon 637 Eczema. Eczema. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. small strips of muslin, and bound on. The dressing is to be changed daily, with careful cleansing by hot water and soap. This treatment may be continued until the acute stage is over, when a weak sulphur ointment may be used to complete the cure. Should the unguentum diachyli be for any reason unavailable or prove unsuitable, one of the other ointments mentioned in speaking of the local treatment of eczema in general, may be employed. Eczema of the ears may occur in any form, and may in- volve either the outside or the meatus. In the acute form and stages the ears are red and swollen, and they burn and itch severely. The disease, when it involves the me- atus, may cause temporary deafness from occlusion by large and abundant epidermic flakes and scales. Oint- ments, as a rule, are most useful in eczema of the ears, though, in the acute vesicular form, black wash or the other washes mentioned above may be employed. When there is a deep crack behind the ear, of long standing, sapo viridis may be briskly rubbed in, followed by an ointment containing tar or calomel, a drachm to the ounce. This is a good combination : 3. Picis liquidae, Gm. 4 < 3 j.); ung. zinci oxidi, Gm. 32 (§ j.). M. Calomel may be added to this formula in the proportion of twenty grains to the ounce. When the meatus is involved, a solu- tion of glycerine and water, containing from ten to twenty grains of bicarbonate of sodium to the ounce, may be employed to soften the masses of cerumen and epithelial debris, and after cleansing with a syringe and hot water, dry powders, as of boric acid, may be insuffiated. Further directions for the treatment of eczema of the meatus will be found under Auditory Canal. Eczema of the genitals is one of the most painful and distressing forms of the disease. In the male the penis or the scrotum may be involved, or both together. The latter is more commonly the seat of the disease, and the tissues of the skin here become greatly thickened, swol- len, and infiltated. Moisture, crusts, and painful fissures along the folds of the skin, are often present. Itching is a severe and prominent symptom, and the disease is apt to be very chronic. In the female the labia and even the vagina may be invaded. The affection here is even more distressing than in the male. Itching is violent aud causes extreme misery. The diagnosis is not difficult. Pruritus and tinea circinata may sometimes be mistaken for eczema of the genitals. In pruritus the absence of visible pri- mary lesions will decide the question. In tinea circinata there will almost invariably be other lesions of a charac- teristic sort in the groins or in the neighboring parts of the thigh, and the microscopic examination of epidermic scales will show the fungus. When eczema of the genitals is recent and acute, it sometimes yields quickly to treatment, and it is especially desirable to obtain speedy relief, because, if the affection becomes chronic, it is very much more difficult to cure. Rest is almost indispensable. The chafing of the parts, and the heat and perspiration excited by exercise, exert a bad influence on the disease. In the acute and super- ficial form lotions of lead water, black wash, or sulphate of zinc twelve grains to the pint, are useful. Powders, as simple starch, starch and oxide of zinc, starch, oxide of zinc, and camphor (when the skin is not broken), are all of use. Warm baths (92° to 98° F.) alone, or con- taining alkalies, are frequently grateful. The following formula is a good one: R. Potasii carbonat., Gm. 128 (|iv.), sodii carbonat., pulv. boracis, aa Gm. 64 (§ij.) M. Dissolve in a quart or so of water ; add four to six ounces of dry starch, placed beneath the water in the hand, which is then opened and beaten through. Six to eight ounces of glycerine may then be added, if thought desirable, and the whole mixed in with about thirty gal- lons of hot water in a long bath-tub. The patient re- mains in the bath fifteen to twenty minutes. On coming out, the parts are to be carefully dried without rubbing, and then at once thickly dusted with powdered sub- nitrate of bismuth, or one of the other powders men- tioned above. Sometimes ointments agree better with the patient than powders. In that case the parts can be wrapped up or covered with an ointment composed of equal parts of cod-liver oil and suet. In eczema of the scrotum a bag should be made of fine, thin cambric, to support the parts and to protect from contact with the thighs. The scrotum should then be thickly dressed with a powder, some of which should also be placed in the bag. With this arrangement the patient can often continue to go about his business with comfort. When powders are found too drying and astringent, the least possible quan- tity of vaseline may be smeared on the skin as a first coat- ing, and the powder applied afterward. In women leucorrhoea or some similar disorder is often the starting-point for acute eczema of the genitals ; of course, any such cause of irritation must first of all be looked into and obviated. As in the case of men, the ad- jacent parts must be kept separated, a thing difficult of accomplishment, unless perfect rest is maintained. Pow- ders can rarely be employed in eczema of the genitalia in women. Lotions and, less frequently, ointments must be relied upon. When eczema of the genitals assumes a more chronic form with infiltration, the treatment is to be quite dif- ferent from that just described. Whatever applications are subsequently made, the best preliminary application is almost always hot water applied as hot as can be borne to the parts. " Carbolic acid wash, three drachms of the acid with an ounce of glycerine to the pint of water, forms a very useful anti-pruritic lotion in this form of eczema in both sexes. Stimulating ointments, tarry, mercurial, etc., may likewise be employed to advantage in the treatment of chronic eczema of the genitals; and it must be remem- bered that the affection is annoying, and sometimes tor- menting to a high degree, and that every effort should be made to give the patient relief. One remedy should be tried after another, those mentioned above under the treatment of chronic eczema in general being most apt to be useful. The only internal measures ordinarily of use are aperients. The aim should be to secure soft stools. Eczema of the anus usually assumes the erythematous form to begin with, and later changes to eczema rubrum with fissuring and weeping. Itching and burning sensa- tions at night on going to bed, and in severe cases pain on defecation, are the chief symptoms of eczema ani. The treatment in the acuter stages should be the same in principle as that of acute eczema generally, only that ointments are usually well borne in this part. In the ehronic stages tarry preparations are useful. Almond-oil containing twenty per cent, of carbolic acid forms a cleanly and not disagreeable application. It may be rubbed in with the finger every night on retiring, and at other times should an attack of itching come on. Hot water applications are here an almost indispensable ad- juvant to treatment. The stools should be kept soft. Eczema of the breasts, and especially eczema of the nip- ple, resembles very closely the affection known as Paget's Disease (see Dermatitis, Malignant Papillary). Occur- ing on the breasts, eczema usually shows itself in patches either of the erythematous or of the red moist form. The treatment, unless the case is acute, should be that of infiltrated chronic eczema, and should be vigorous. When eczema occurs about the lower edge of the breast, it generally takes on the form of eczema rubrum or ec- zema intertrigo, and is in part due to a pendulous con- dition of the mammae. The application of black wash, astringent powders, and the interposition of lint or absor- bent cotton, will work a cure. Eczema of the legs is a very common form of the dis- ease, especially among old people. The erythematous and vesicular varieties are commonest at the beginning, but these soon change to eczema rubrum, or weeping eczema. The affection occurs in one or more patches of various size, the whole leg being not unfrequently in- volved. When it comes under notice it has generally lasted some time ; the skin of the leg is smooth, shiny, dusky red or violaceous, and unbroken, or it may be moist and weeping, or covered in part or w'holly with scales and crusts. There is always a good deal of thick- ening and infiltration, with burning and itching to an extreme degree. Varicose veins often accompany this form of eczema, and varicose ulcers are not uncommon. 638 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eczema, Eczema. In moist, weeping eczema the treatment by sapo viridis and unguentum diachyli is the best when it can be carried out. Another excellent application is the follow- ing paste: R. Pulv. zinci oxidi, Gm. 500 ; acid, salicylic., acid, carbolic., aa Gm. 20 ; mucilaginis acaciae, glycerinae, aa Gm. 200. M. This is to be applied daily by means of a large soft camel's-hair brush. The rubber bandage described above is often an excellent treatment for ec- zema of the leg, though it must be used with caution. Bandages of one sort or another are almost a necessity in the treatment of eczema of the leg, especially when there are varicose veins ; and after the disease is cured an elastic stocking must frequently be worn to prevent a relapse. Eczema of the hands may attack either the back or the palm. The appearance and course of the disease is so different, however, in the two localities that they must be considered separately. Eczema vesiculosum is the variety most common on the backs of the hands, some- times running into eczema rubrum. Sometimes the pustular variety is found. Vesicular eczema of the backs of the hands and between the fingers is apt to occur as a result of exposure to acids, alkalies, brick-dust, etc. The diagnosis between eczema and scabies of the backs and sides of the hands and fingers is sometimes very dif- ficult. In scabies the peculiar burrow of the itch insect, a short, irregularly curved, beaded, black line, one-fourth of an inch in length, is often present, and the vesicles are few in number and scattered. In eczema, on the other hand, the vesicles are numerous and closely grouped. The occurrence of scabies elsewhere over the body will also assist in the diagnosis. Eczema of the backs of the hands, and particularly eczema of the fingers, is apt to be very intractable, sometimes returning every year, or oftener. The treatment is that described above as the general treatment for acute and chronic eczema. In addition, the rupture of the vesicles, espe- cially those occurring upon the fingers, by rubbing in a twenty-grain solution of caustic potassa, to be quickly washed off so soon as burning begins, is an excellent treatment preliminary to the application of ointments. India-rubber finger-stalls are sometimes employed with success. Eczema of the backs of the feet and toes is very apt to take on the form of eczema rubrum. Here the treat- ment given above for eczema of the leg will prove useful. Eczema of the palms and soles possesses some peculiar- ities due to the great thickness of the epidermic layer on these parts. There is no form or variety of eczema more difficult to treat successfully than this. Induration, thick- ening, and callosity mark the disease. Occasionally deep and painful fissures occur. The diagnosis is sometimes difficult. From psoriasis of the palm eczema differs in showing at times moist and bloody fissures, while those of psoriasis are usually dry and show little disposition to bleed. The patches of eczema are usually larger than those of psoriasis, and their edges pass gradually into the healthy skin. The patches of psoriasis are smaller, darker, and covered with more abundant and paler or white scales. The best means of diagnosis is to examine the eruption on some other part of the body where it is more characteristic. It must be remembered also that eczema of the palm is a very common disease, and ec- zema of the sole moderately so; while psoriasis of the sole is rare, and psoriasis of the palm excessively rare. Syphilis and eczema are distinguished without much difficulty when the eruption runs up on the face of the wrist, as it not infrequently does in the case of syphilis, or when there are lesions elsewhere on the body. When the diagnosis must be made from the appearances on the palm alone, it must be remembered that the infiltration is of a firmer nature in syphilis than in eczema ; it also extends more deeply into the skin. The patches are smaller, and more circumscribed, and sharply defined upon the edge, and they have a tendency to spread upon the periphery, and to assume the circinate form. Eczema is usually much more uniformly diffused ; it is apt to be of a light color, while syphilis is darker and sometimes ham-colored. It is also apt at times to itch, while syphilis does not itch. The history will often aid the diagnosis. The treatment of eczema upon the palms and soles must be most vigorous and energetic if any result what- ever is to be expected. The first point is to get rid of the thickened and horny epidermis, so far as this can be done. This may be accomplished by covering the surface with rags spread with sapo viridis, or wet with a five- to ten-grain solution of caustic potassa, and covered with rubber cloth. These are to be kept on day and night until the epidermis is softened, macerated, and reduced to something like its normal thickness. Then stimulat- ing ointments containing mercury and tar may be em- ployed. Sometimes the application of stronger solutions of caustic potassa, to be made by the physician himself, are advisable. These should be washed off as soon as burning is experienced, and some mild emollient oint- ment should then be applied. The prognosis of eczema of the palms and soles should be very guarded. When it is dependent upon exposure to some irritant, little hope of entire recovery can fairly be given until the source of the irritation shall have been removed. Eczema in Infants.-Infants are liable to eczema from the first few weeks of extra-uterine life onward ; the chief differences between the disease as shown in these cases, and as it manifests itself in later life, being, on the one hand, the restricted causes which may give rise to the dis- ease, and on the other hand, the different appearance of the eruption, dependent upon the peculiar structure of the skin in early life. Eczema in infants and in young children, is due either to digestive disturbances, to teeth- ing, or to that inherited weakness of constitution and poor nutrition generally attributed to the scrofulous habit. Bottle-fed infants are most apt to suffer from indigestion, and these are also most liable to the eruption of eczema. While too much stress must not be laid upon the irrita- tion of teething as giving rise to eczematous eruptions, yet, when the tendency to eczema exists, each tooth, as it comes out, will often be accompanied by an eczematous rash, which fades away as the tooth develops. It will be found on observation, that the children of parents who suffer from a tendency to phthisis, or who present the symptoms commonly associated with the idea of scrofula, are most apt to be attacked with eczema, even when fed upon the breast and presenting no sign of indigestion. When, as among the lower classes, improper nourish- ment and bad hygienic surroundings are added, the dis- ease sometimes takes on a quite severe form. Eczema in infants and young children, is occasionally connected with the peculiar dry and unhealthy condition of the epi- dermis found in icthyosis; and in the more inveterate forms of eczema in young children asthma plays a part which is not yet understood. The diagnosis of infantile eczema is usually not diffi- cult. About the buttocks, genitalia, and folds of the neck it commonly occurs in the form of eczema erythe- matosum or eczema intertrigo. In the former locality it may be mistaken for syphilis, but the absence of deep infiltration, and above all the absence of characteristic syphilitic lesions, whether of the palms and soles or of the body generally, will usually assist the diagnosis. The vesicular and pustular forms of eczema are those most frequently met with upon the cheeks, behind the ears, and about the head generally. It sometimes runs on to eczema rubrum with very abundant discharge of serum. Occasionally shallow ulcers with abundant crusts form, and in this variety it is at times difficult to say whether we have eczema or syphilis. Especially is this the case when the child is poorly nourished and ema- ciated. But in syphilis we areapt to have "snuffles," cracks in the commissures of the lips, and lesions about the anus ; also some of the lesions are apt to be infiltrated and to show deeper ulceration. Eczema, moreover, tends to itch to a marked degree, and this alone will commonly distinguish it. Papular eczema is more apt to occur in older children ; it may very readily be mistaken for scab- ies ; the diagnostic points will be found under Scabies. The treatment of infantile eczema must depend to a considerable extent upon the cause. When indigestion seems to be at the bottom of it, the food must be changed and regulated. Constipation in infants is a frequent cause of eczema and must be combated. If it be habitual the 639 Eczema. Egypt. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. food should be changed, with the view of improving this condition, while for occasional use the following powder may be administered : R. Hydrarg. chlor, mit., Gm. 0.8 (gr. xij.); pulv. rhei., Gm. 1.20 (gr. xviij.) ; magnesias calcinat., Gm. 2 (gr. xxx.). M. ; div. in chart No. vj. Sig.; One every morning. This is the dose for an infant of eight or twelve months ; the quantity should, of course, be regulated according to the general condition of the child as well as its age. Purging should be avoided. When general debility exists, particularly when there is a scrofulous taint, syrup of the iodide of iron in doses of from five to ten drops, even in infants a year old, may be administered. Sometimes also cod-liver oil, in- ternally or by inunction, may be employed. The external treatment of eczema in infants will de- pend upon the form of the disease present. When this is erythematous and situated about the buttocks, genitalia, and folds of the neck, astringent dusting powders, as kaolin, oxide of zinc, and subnitrate of bismuth, may be employed ; while parts that are in apposition should be separated by a thin wisp of absorbent cotton, or a piece of scorchedlinen. Black wash and dilute lead-water may be used in some cases. Ointments are generally not so convenient in this form of eczema. In vesicular and vesiculo-pustular eczema, and especially in eczema ru- brum about the head and face, ointments are more useful. Scales and crusts should first be cleared away as far as pos- sible, and then the milder and astringent ointments may be used first, and later, those of a more stimulating quality. In the more chronic forms of eczema rubrum of the face and scalp more stimulating ointments are well borne, as this : R. Picis liquid®, Gm. 2(3 ss.); pulv. zinci oxidi, Gm. 2(3 ss.); ung. aquae ros®, Gm. 32 (SD- M. Instead of anointing with ointments, the cheeks and scalp and other affected parts may be painted with the following pigment, which is very effectual, and cannot be rubbed off like the ointments : R. 01. cadini, Gm. 4 ( 3 j.); collodii. Gm. 32 (§ j.). M. The prognosis of infantile eczema is always favorable, and every effort should be made to mitigate the disease during dentition, and, by removing the cause in dyspepsia, debility, etc., to bring about an entire cure. Arthur Van Harlingen. Allied Substances.-The eggs of most birds have about the same composition. Albumen is also prepared for the sugar refiners, etc., from blood. Dried albumen from both sources is to be had ; it keeps perfectly in a dry atmosphere. IK. P. Bolles. EGYPT. The cloudless skies, mild temperature, and dry atmosphere characteristic of the winter climate of Egypt, combine to render this country particularly well suited as a place of residence for invalids during the four or five coldest months of the year. Lower Egypt, or that portion of the country comprising the Delta of the Nile, is far less suited to the residence of invalids than are the middle and upper portions lying further up the river, that is, further to the southward ; inasmuch as its imme- diate proximity to the Mediterranean Sea renders the at- mosphere more humid, and the rainfall far greater than is the case in both Middle and Upper Egypt. Middle Egypt extends from about lat. 30° N. to lat. 27° N. ; Upper Egypt from this latter point to 24° N. lat. The limits of Egyptian rule, however, extend very consider ably to the southward of this point-in fact as far south as lat. 10°-and comprise the regions of Nubia, Sennaar, Kordofan, and Shilluk; but, in the strictest sense of the word, Egypt proper, when considered as a health-resort, may be said to be comprised within that portion of the Nile basin extending from the Mediterranean coast to 24° N. Lat. Alexandria, the chief sea-port of Egypt (lat. 31° 12' N.), is the principal town of Lower Egypt, and its climate is fairly representative of that of the whole sea-coast and Nile Delta region. Cairo (lat. 30° 2' N.) is the capi tai of the whole country and its largest city (population about 350,000); its climate is fairly representative of that of Middle Egypt. The mean annual temperature at Alex- andria is about 70.5° F. ; at Cairo it is about 2° F. higher. According to Dr. H. C. Lombard, from whose " Traite de Climatologie Medicale" the foregoing figures are also taken, the mean temperature of each of the twelve months of the year at Alexandria, during a period of observations extending over four years (1858-1861), was as follows ; January, 57.2° F. ; February, 59.4° F. ; March, 62° F. ; April, 68.2° F. ; May, 73.8° F. ; June, 78.3° F. ; July, 77.9° F. ; August, 82° F. ; September, 79.5° F. ; Octo- ber, 77° F. ; November, 70.7° F. ; December, 61.4° F. The mean temperature of the three winter months is 59.4° F. At Cairo, Dr. Lombard tells us, the mehn winter tem- perature is precisely the same as at Alexandria, but the variations of temperature at Cairo are greater than at Alex andria, so that lower degrees of temperature are experi - enced at the former than at the latter place. At Keneh, in the northern portion of Upper Egypt, the mean winter tem • perature is 63.7° F. For the months of October, January, and April, the mean temperature at Alexandria is stated Dy Dr. Julius Hann (" Handbuch der Klimatologie ") to be as follows: October, 75° F. ; January, 58.8° F. ; April. 66.6° F. For Cairo Dr. Hann's figures for these same months are : October, 73° F. ; January, 53.8° F. ; April. 69.8° F. The December and February mean tempera- tures at Cairo are stated by the same author to be respec- tively as follows : December, 56.7° F. ; February, 54.9° F. The mean winter temperature of Cairo would be, according to Dr. Hann's figures, 55.1° F. ; or, if the Jan- uary mean be taken from the table on page 447 of his work instead of from the table on page 419, the mean winter temperature would be 54.7° F. Dr. J. Burney Yeo (in "Climate and Health-Resorts") gives 58" F. as the mean winter temperature of Cairo. The temperature at Cairo "rarely falls below the freezing-point" (Dr. Yeo, op. cit.), and snow is never seen there. As might be expected from the dryness of its atmosphere, caused by the close proximity of the deserts to the Nile Valley, variability of temperature is a marked characteristic of the Egyptian climate. For the most part, however, the variations in temperature are of the periodical variety, and consist in a marked contrast between the day and night temperatures ; that is, they are what have already been alluded to in the article on "Climate" as nycthe meral variations. EGG, YOLK OF (Vitellus, U. S. Ph.; Ovi vitellus, Br. Ph. ; (Euf de Poule, Codex Med. ; also Albumen Ovi, Br. Ph.). The egg of the common fowl, Gallus Bankiva domesticus Tern., can hardly be said to be a medicine, although admitted to most pharmacopoeias for one pur- pose or another. Its shell was formerly used as a form of lime-salts like oyster-shells, coral, etc., but is now ob- solete. The white of the egg, Ovi Albumen, is a source of albumen for pharmaceutical and chemical purposes (estimation of pepsine, clarification of solutions, etc.), and a useful antidote to poisoning by corrosive sublimate. It is composed of twelve or fourteen per cent, of pure albu- men, and eighty-eight or eighty-six of water, with traces of salts, etc, The yolk, which alone is officinal here, is a bright yellow mixture of about sixteen per cent, of vi- tellin, a substance resembling albumen ; forty-three hun- dredths of a per cent, of cholesterin ; three-tenths of one of cerebrin ; eight and a half of lecithin, a fat-like nitro- genous substance containing also phosphorus ; one of glycerin acids ; twenty-one of palmitin and olein ; a num- ber of saline substances ; coloring matter ; and, finally, fifty-one of water (Gabley, quoted by Hager). Yolk of egg has considerable emulsifying power for oils and resins, and is officinal simply on that account. A mixture with glycerine {Glyceritum Vitelli, U. S. Ph.), "glyconon; " consisting of yolk of egg forty-five and glycerine fifty- five parts, is permanent and very useful in this way. Cod-liver, castor, and other oils, besides some resins and other insoluble substances, are well suspended by it. The standard chloroform mixture (Mistura Chloroformi, U. S. Ph.) contains ten per cent, of yolk of egg. An egg beaten up alone or with milk, or digested artificially, makes an excellent nutrient enema where such method of feeding is necessary. In respect to the more irregular variations, occurring be- 640 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eczema. Egypt- tween the temperature of two successive days, a greater degree of equability prevails in Egypt than is to be found in any part of Europe (Dr.Kisch, in Eulenburg's " Real- Encyclopadie "). The low temperature of the nights as compared with the days in the Nile Valley depends rather upon rapid radiation of heat after sundown, from the sands of the surrounding deserts, than upon a low degree of atmospheric humidity in the Nile Valley itself. The mean relative humidity at Cairo for the live months from November to March, inclusive, is not less than 70 per cent., varying from 76 per cent, in November, to 62 in March: in the warmer months of early summer (April, May, and June) the dryness of the atmosphere is much more marked, the relative humidity varying from 49 to 45 per cent. (Dr. Julius Hann, op. cit., pp. 445, 446). The absolute humidity of the Nile Valley is, of course, far more considerable than at such health-stations as Colorado Springs, Denver, or Davos, where the temperature is much lower; but when even Dr. Weber, who lays especial stress upon absolute as compared with relative humidity, tells us that during the winter months at Cairo the relative hu- midity " sometimes rises to eighty per cent." (Ziemssen's " Handbuch der allgem. Therapie," vol. ii., p. 184), it is evident that the reputation of Egypt for dryness of cli- mate is abundantly well deserved. Concerning the mag- nitude of the nycthemeral variations of temperature in the Nile Valley, we learn much from the following figures, taken from the pages of several standard works. At Cairo, in January, the mean temperature at 8 a.m. is 41° F., at noon it is 57.2 ° F., and at 6 p.m., 40.1° F. (Dr. A. Rotureau in ' ' Dictionnaire Encyclopedique des Sciences Medicales."). The average difference between the tem- peratures at 5 a.m. and at noon is 12.6° F. in winter, 13.6° F. in spring, 13.5° F. in summer, and 11.5° F. in autumn (Dr. H. C. Lombard, op. cit., vol. iv., p. 626). "The temperature by night is sometimes 40° below the highest point reached during the day, more especially in March and April, when the south and southwest winds prevail, and the thermometer frequently rises to upward of 100° in the shade" (" Encyclopaedia Britannica," art. " Cairo"). In Upper Egypt a nycthemeral variation of 30.9° F. (17.2° C.) is not uncommon (Lombard, op. cit., vol. iii., p. 550). Unlike the more irregular falls of temperature, which occur with greater frequency and are apt to be of greater severity in European countries and in a large part of the United States (the land of "blizzards" and "cold waves "), these nightly falls of temperature in Egypt may in great measure be guarded against by the invalid, especially if he have taken up his residence at Cairo. Greater precautions are of course necessary to the invalid who is making the Nile journey on board of a dahabeeah, or who has determined to pass the winter living, like the Arabs, in a tent upon the desert. Flannel under-clothing should be worn by all visitors to Egypt, and a supply of warm outer-clothing and of wraps is necessary as well, es- pecially for those intending to make the river trip, or to convert themselves temporarily, for the benefit of their health, into amateur Bedouins. Not only is it the decided fall of temperature after sunset against which the invalid must be on his guard, but in addition to this (and depend- ing partly upon it and partly upon the moderate humidity of the Nile Valley), the precipitation of dew is very abundant, at least in all portions of Egypt lying in close proximity to the river and its bordering tract of arable land. Rainlessness is undoubtedly that feature of the Egyp- tian climate for which it is most notorious. Along the coast, however, the climate, at least during the winter months, is by no means an absolutely rainless one. Thus at Alexandria the total annual rainfall (according to Dr. Hann) is 8.22 inches, of which quantity no less than ninety-four per cent, is precipitated during the five months from November to Mapsh, inclusive. At Cairo, on the other hand, the annual rainfall is but 1.3 inch, while the number of days on which a fall of rain occurs does not exceed twelve. The greatest annual rainfall re- corded at Cairo was 2.3 inches (Lombard, op. cit.). " In 1871 the number of rainy days was only nine, and the total duration of the fall was nine hours eight minutes " (Art. "Cairo," in "Encyclopaedia Britannica"). The percentage of cloudiness throughout the year is small in all parts of Egypt: it is greatest on the coast, less at Cairo, and least in Upper Egypt and in Nubia. For Alex- andria the total annual percentage is but 24, December being the most cloudy (40 per cent.), and June the least cloudy month (10 per cent.). At Cairo June has but 8 per cent, of cloudiness, January and February (the most cloudy months) but 30 per cent.; while for the year the percentage is but 19 (Hann, op. cit.). In a total of 1,083 observations, made during the course of three years, the sky at Cairo was found to be cloudless 709 times, clouds were observed 254 times, an overcast sky was seen 95 times, and a truly cloud-covered sky was recorded on only 25 occasions (Lombard, op. cit., vol. iv., p. 626). Unless it be in southern and south- western Arizona, no portion of the United States can be compared with Egypt in this matter of cloudlessness of sky ; and it is hardly necessary to add that no such freedom from clouds exists in any part of Europe. This circumstance, taken in connection with the mildness of its day temperature, even in mid-winter, and the com- paratively long duration of the hours of possible sunlight (depending upon its southern latitude), marks the whole country of Egypt, and particularly its more southern portion, as that region of the world affording per- haps the best facilities to the invalid desiring to pass as much time as possible in the open air during the cold season of the year. The hours of possible sunshine are much longer in Egypt than in Davos or the Engadine, longer than in Colorado, and even longer than in South- ern Arizona; the intensity of the sunlight, especially in Upper Egypt, is probably as great as at any of these places (although we have no data at hand to prove that such is the case) ; the purity of the atmosphere in respect to the presence of germs, outside of the towns, is prob- ably not far inferior, even in the Nile Valley, to that of Colorado, Davos, or Arizona; while in the desert proper it is quite as great; the temperature during the day is higher without being, as a rule, excessive; while by night it is also higher, and, although abundantly cool to be in- vigorating, is, nevertheless, not more contrasted with the day temperature than is the case in Arizona, Colorado, or Davos. Rain is less frequent than at Davos or in Colo- rado, and is as infrequent as in Southern Arizona, even at Cairo; and, owing to the absence of clouds, the actual number of hours of sunshine coincides more nearly with the possible number of such hours than is the case in Colorado, Davos, or Arizona. Winds in Egypt are of more frequent occurrence than at Davos during the win- ter, but probably no more so than in Colorado or in Ari- zona ; while in point of velocity they are probably not higher than in Colorado, although higher than at Davos, and perhaps higher than in Arizona. Absence of statistics prevents an accurate comparison of these resorts in this re- spect. Violent hot winds, laden with sand from the desert, and exerting a very debilitating influence not only upon men, but also upon animals, occasionally blow in Egypt during the latter part of the winter season. These winds come from the south, and seldom begin to blow before the middle of February ; indeed, their time of most fre- quent occurrence is during a period of fifty days after the vernal equinox, to which circumstance they owe their name, Kamsin. The Kamsin blows, on the average, at Cairo only upon eleven days out of the whole year. The rapid and extreme rise of temperature produced by one of these winds, occurring on May 31, 1857, is instanced by Dr. Hann on page 443 of his " Handbuch der Klimatolo- gie." The drying effect of the wind is also shown in the figures quoted by Dr. Hann, which figures are given below. 7 a.m. 10.30 a.m. Noon. 1 2 p.m. 9 p.m. 11 p.m. Temperature 78.08 j 100.76 | 103.64 105.62 95.18 [ 91.4 Relative humidity.. 54 19 12 15 13 1 19 Wind Calm. S.S.W.2 | S.S. W.2, S.S.W.3] Calm. Calm. Kamsin of May 31, 1857, at Cairo. The small figures appended to the letters S.S.W. show- ing the direction of the wind, probably indicate the ve- 641 Egypt. Elaterin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. locity in metres per second, a velocity which would be equivalent to 4.47 miles per hour at the hours of 10.30 A.M. and noon, and to 6.71 miles per hour at 2 p.m. Even if these figures are intended to mark the velocity of the wind according to the scale in which 0 represents a calm and 10 a violent hurricane, it is evident that the force of this particular Kamsin wind was not particularly great. At Cairo, the prevailing direction of the wind during the months of January, February, March, and April is stated by Dr. Kisch (Eulenburg's " Real Encyclopadie ") to be as follows : January, northeast; February, northwest; March, west; April, north. Of the winds at Cairo, Dr. Rotureau (" Dictionnaire Encyclopedique des Sciences Medicales") speaks as follows : " The east wind is almost the only one which blows at Cairo during the months of January and February; it lasts from ten o'clock in the forenoon until sunset, and it is against its freshness, often very considerable, that invalids walking out of doors should especially protect themselves. When the east wind is violent, it is almost impossible to go out of doors on account of the clouds of dust which it raises, and which it causes to penetrate even into the most tightly closed apartments. Such a violent easterly wind, how- ever, seldom occurs at Cairo on more than six or eight days out of the whole year. Winds from the northeast, north, and northwest sometimes blow, but never last long enough to be dangerous (n'existent jamais assez longteinps pour etre dangereux). The Kamsin, or south wind, does not occur at Cairo until after the middle of February; . . . occasionally (however) it appears earlier," etc. The following quotation respecting the winds of Egypt, is taken from the article on "Egypt" in the "Encyclopaedia Britannica." " The wind most frequently blows from the N.W., N., or N.E., but particularly from the first direction. The proportionate prevalence of these winds to those from all the other quarters, in the year, is about 8 to 3; but to those from the S., S.E., and S.W., about 6 to 1 (Clot-bey, Aperqu General sur I'Egypte, i., p. 30). The northerly winds are the famous Etesian winds of Herodotus (ii., 20), which enable boats constantly to ascend the Nile against its strong and rapid current, whereas in descending the river they depend on the force of the stream, the main-yard being lowered. These winds also cool the temperature during the summer months. The southerly winds are often very violent, and in the spring and summer, especially in April and May, hot sand-winds sometimes blow from the south, greatly raising the temperature and causing especial suf- fering to Europeans." Several other special winds are also mentioned in this article in the "Encyclopaedia Bri- tannica," but none of them require mention in this place. Finally, it should be remarked that a morning fog is a not infrequent occurrence along the banks of the Nile ; but such a fog never lasts more than a few hours, being quickly dissipated by the heat of the Egyptian sun. On account of the rapidly increasing heat of the spring season, and the especial frequency of occurrence of the Kamsin at that season, it is not desirable that invalids should linger in Egypt later than the month of March, and preferably not later than the middle of this month : owing also to the great heat during the early autumn, and to the prevalence of malarial fevers at that season, it is not well for the invalid to go to Egypt before the middle of November, and for such as intend to make the Nile journey, the middle of December is abundantly early to start. Consequently we see that the season for invalids in Egypt is a comparatively short one, quite as short as at Davos, and considerably shorter than in Colorado. For residence all the year round Egypt is not at all well suited, the summer and autumn heat being far too op- pressive. As a sample of the degree of heat which may be experienced in the autumn, it may be of interest to re- mark that a temperature of 103.5° F. was observed at Alexandria on October 11, 1877, being the maximum temperature for that whole year, and that the month of October is generally warmer than May at that place, while September is nearly as warm as June (Hann, op. cit., pp. 422, 423). Several methods may be adopted by an invalid desirous of obtaining the benefit of a winter's residence in Egypt. He may either pass the whole season at Cairo, where the hotel accommodations are good, and the large number of foreign residents, together with the existence of an Italian opera-house and a French theatre, offer abundant facili- ties for social intercourse and for amusement; or he may take up his residence at the neighboring station of Heluan les Bains, a place situated closer to the borders of the desert, and which is said to have latterly become quite a fashionable resort (Dr. Yeo, op. cit., p. 324); or he may make the extremely interesting Nile journey on board of a dahabeeah; or, finally, he may camp out in the desert region of Middle or Upper Egypt, or of Nubia. The latter plan is, no doubt, the best for those who are able to put up with the inconveniences which always at- tend camp life. This mode of life is particularly well suited to cases of pulmonary phthisis when the disease is not too far advanced, and Dr. Hermann Weber (op. cit., p. 184) reports excellent results from it on a number of such cases. Asthmatic patients are said by the writer in the "En- cyclopaedia Britannica," to do better on the Nile than in the desert. " The climate of the desert does not in all cases suit them, the small particles of sand which are inhaled increasing the irritation." The occurrence of early morn- ing fogs on the river, and the risk of exposure to the night air, together with the greater changeableness of the valley climate, and the absence on board a dahabeeah of means for producing artificial heat, render the Nile voy- age unsuitable and not unattended with risk for certain classes of consumptives. The climate of Egypt would appear to be well suited to the same class of consumptives as are also likely to de- rive benefit from passing a winter season at Davos or in Colorado, and it is also beneficial to cases of rheuma- tism and gout, to some cases of diabetes, and of Bright's disease, to neuralgic patients, and to sufferers from the effects of overwork and nervous exhaustion. Dr. Weber recommends the Egyptian climate also in cases of cardiac disease complicated with catarrh of the bronchi and with gastric disturbance. Dr. Lombard characterizes the climate of Cairo as tonic and stimulating in its effects, and as occasionally tending to produce a condition of over-irritability from the height of the temperature, the great power of the sun's rays, and the clearness and dry- ness of the atmosphere. As quarters of the city especially to be recommended for the residence of invalids, he speci- fies the southern side of the great square called the Ezbekeeyah, and the quarter known as that of Bab-6- Charye. A very excellent summary of the therapeutic effects of the Egyptian climate is to be found on page 326 of Dr. J. Burney Yeo's work (" Climate and Health Re- sorts "), and we shall take the liberty of quoting it in this place. " The climate of Egypt, then, is tonic and stimulating, and it is useful in a great variety of chronic ailments, the chief of which are the following : It is said to be especially useful in cases of phthisis in scrofulous persons, those cases of phthisis which have a tendency, even in this country, to run a very protracted course; it is helpful, too, in most other forms of scrofulous disease; it is of value in gout and rheumatism, and especially in certain important visceral changes which gout induces ; catarrhal conditions find their relief and cure here as well as in the cold dry air of high altitudes, so that cases of chronic bronchial, laryngeal, and pharyngeal catarrh get well in Egypt, as do also some cases of catarrhal asthma. Persons suffering from exhaustion of the nervous system from too great excitement, worry, or undue application to business or study, are precisely the cases for the Nile voyage. The same may be said of those numerous cases of intractable dyspepsia associated with hypochondriasis or hysteria. The climate of Egypt is not limited simply to the relief of early phthisis, but advanced cases often do well there, though it is considered inexpedient that they should venture on the Nile voyage or go beyond Cairo. Cases of phthisis with a tendency to rapid pro- gress in irritable or highly nervous constitutions must not, however, be sent to so tonic and exciting a climate. 642 Egypt. Elaterin. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The same remarks apply to cases with a tendency to haemorrhage." In one respect it is self-evident, that a winter residence in Egypt is incomparably superior to residence at such places as Davos or any of the Colorado resorts, and that is, that it supplies food for the mind over and above the food for the body contained in the pure, dry, and mild air. Unquestionably, some share, and probably not a small share, of the benefit accruing to the educated invalid from a winter residence in Egypt, is directly due to the interest excited by the numerous historic remains of this most in- teresting country, as well as by the novel sights and sounds of the oriental life of the Egypt of to-day ; such interest serving to take the invalid's thoughts away from dwelling upon himself, his ailments, and his business cares and worries. Nearly all the health-resorts, even of Europe, are comparatively destitute of this important ele- ment of mental distraction and relaxation, while the utter and wearisome lack of such means of distraction in al- most every one of the health-resorts of the United States is but too well known to many an invalid. The necessity of making a short sea-voyage (three days from Brindisi or five days from Marseilles) is to certain European in- valids a serious obstacle in the way of resorting to the desirable winter climate of Egypt. Invalids from the United States, who are able to support the far longer voyage across the Atlantic, will not of course hesitate to go to Egypt on this account. In conclusion, it may be suggested, that, to some of the latter class, the line of steamers plying directly between New York and Genoa may be found a convenience, as by taking these steamers they may avoid the cheerless and damp autumn climate of northern Europe. Huntington Richards. petioled, triangular-heart-shaped. The flowers monoeci- ous, solitary or nearly so, yellow. All the green parts of the plant are bristly or hispid. The staminate flowers have three stamens (two double ones and a simple one); the pistillate ones an oblong inferior, hairy, one- but appa- rently three-celled ovary, and three styles. Each sort of flowers has a five -parted calyx, and a five-lobed spread- ing corolla. The peduncle becomes recurved as the fruit develops, so that, at maturity, the latter is nodding or pendulous (see Fig. 971). The fruit is from three to six centi- metres long, by one or two in diameter (1 to inches by i to J inch), oblong, ovoid, covered with fleshy, tapering, soft bristles, and of a yellowish-green color. Texture firm externally, but soft and very watery in the middle. At maturity the tension produced by the accumulation of liquid within the pericarp becomes so great as to burst the fruit at the base, forcing off the peduncle, and following it by a squirt of the soft contents, seeds and all, to a con- siderable distance (see Fig. 971); from this peculiar mode of distributing its seeds the plant has received its name (fK0dKXu). The seeds arc numerous, compressed, ovoid, smooth, brown ; they were also formerly employed. This plant is indigenous to Persia, India, and the warmer Mediterranean countries. It has been also nat- uralized and cultivated in various parts of Europe. It is raised in England and elsewhere for medicinal use. It is a very old medicine, having been mentioned before the Christian era. The fruit, for medicinal purposes {Ecballii Fructus, Br. Ph; Concombre sauvage, Codex Med.), should be gathered just before it is wholly ripe, and, of course, be- fore it has expelled its contents. It is used to prepare the crude and impure Elaterin, which has been long known as Elaterium (Br. Ph., also U. S. Ph. of 1870), and is still the more common article in the markets. This Fig. 972.-Pistillate Flower of Ela- terium. (Baillon.) ELATERIN (Elaterinum, U. S. Ph., Br. Ph.), the active principle of Ecballium Elaterium A. Richard (Momor- dica Elaterium Linn.), Order, Gucurbitacea,-the Wild or Fig. 973.-Staminate Flower of Elaterium. (Baillon.) Fig. 971.-Elaterium Plant, about one-fourth natural size. (Bailion.) is a precipitate which forms spontaneously in the liquid juice of the Ecballium fruits, and is collected as a sedi- ment from it. The purer and clearer this juice, there- fore, the better the precipitate ; there are several ways of collecting it, two of the best being as follows : The British Pharmacopoeia directs to " Take of the Squirting Cu- cumber Fruit, very nearly ripe, one pound. Cut the fruit lengthwise, and lightly press out the juice. Strain it through a hair-sieve, and set it aside to deposit. Care- fully pour off the supernatant liquid ; pour the sediment on a linen filter, and dry it on porous tiles in a warm place. The decanted fluid may deposit a second portion of sediment, which can be dried in the same way." Dr. Squirting Cucumber. The fruit is also official in coun- tries where it grows or is cultivated, and is the original source of the above active principle. Its juice, upon standing, deposits a sediment which contains the Elaterin, known as Elaterium (Br. Ph.; formerly also U. S. Ph.). Ecballium Elaterium A. Richard, is a small perennial or, in temperate climates, sometimes annual herb, with a fleshy, tapering root, and succulent, prostrate, cucumber- like stems, from twenty-five to seventy-five centimetres long (10 to 30 inches). The leaves are alternate, long- 643 Elaterin. Elbow - joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Clutterbuck saved the juice of the sliced fruit, and then scooped the soft pulp out with the thumb, threw it upon a sieve to drain, and washed it with water without pressure. These liquids were set aside, and the precipi- tate collected and dried as above. This method pro- duced a very fine quality of Elaterium, which has been famous for more than half a century. Elaterium ap- pears to be good in proportion to the near approach to ripeness of the fruit used, and to the absence of pressure in manipulating it. The Continental grades of this article are generally inferior to the English, whose prop- erties are thus given in the British Pharmacopoeia. " In light, friable, flat or slightly-curved opaque cakes about one-tenth of an inch thick ; pale-green, grayish-green, or yellowish-gray, according to age ; fracture finely gran- ular ; odor faint, tea-like; taste bitter and acrid. Does not effervesce with acids; boiled with water and the cooled mixture treated with iodine, affords little or no blue color ; yields half its weight to boiling rectified spirit." It should contain from twenty to twenty-five or thirty per cent, of pure Elaterin. The yield of the fruit pression of the brain, etc. For all these there is no bet- ter hydragogue than this. To be efficient, it should be given by mouth, as it is very much less active in in- jections either into rectum or the cellular tissue ; and in inunction it scarcely produces any but local effects. It is said further, that the presence of bile in the intestines is essential to its full effect; but the proposition can scarcely be considered as finally settled. It is, no doubt, neces- sary that the intestinal contents should be alkaline. Upon dogs, rabbits, and some other animals, it is an un- certain cathartic, and may even kill by nervous depres- sion, without moving the bowels at all. After death in man signs of gastro-intestinal inflammation have been present. Administration.-Elaterium is very variable in its strength, and while of Clutterbuck's or the best English the dose is about a centigram (| to | gr.), that of the ordi- nary Malta or German varieties may be five or six times as large. In an untried sample the smaller dose should always be started with and increased until suffi- cient. Elaterin is uniform, and should supersede the impure substance just mentioned. Dose from three to five milligrams (Ad to A? gr.). The officinal Trituration {Trituratio elaterini, U. S. Ph.), strength Ao, is a convenient form. Dose, from three to five centigrams (J to 1 gr.). Allied Plants.-See Colocynth. Allied Drugs.-Gamboge, Croton Oil, Podophyl- lum, Jalap, Scammony, etc. IF. P. Bolles. ELBOW-JOINT.-The functions of this joint have a very important influence over those of the hand, the va- riety of movements which it allows determining in a great degree the distinction between the upper and the lower extremity. This variety is produced by the union of three articulations within a single capsule : one between the humerus and the ulna, one between the humerus and the radius, and one between the ulna and the radius. By this means there is produced an angular motion of great steadiness by which the forearm is flexed and extended, and also a motion by which the radius and ulna are al- tered in their relations, being made to turn over each other across their long axes, and thus rotate the attached hand. Movement of this kind toward the median line, turning the palm downward, is termed pronation; in the opposite direc- tion, turning the palm upward, supination. The humero- ulnar is the ar- ticulation which gives the whole system solidity, its strength being due to the con- figuration of the articulating surfaces, and the peculiar arrangement of the ligaments. The humerus presents at its lower end a surface curved like an Ionic volute, and grooved like a pulley, which gives it its name of trochlea (see Fig. 975). The surface is obliquely directed, and the groove is not quite symmetrical, but has a slight lateral twist. On this surface the ulna glides, embracing it by the gape be- tween the olecranon and the coronoid processes known as the greater sigmoid cavity (see Fig. 976), not quite a semicircumference, the olecranon passing up behind into the fossa of that name in the humerus when the arm is extended, and the coronoid process similarly fitting into its appropriate fossa in front during flexion (see Fig. 977). The coronoid and olecranon portions of the ulnar sur- face are separated by a transverse line devoid of cartilage (see Fig. 976), corresponding to the place where the epi- physis unites with the shaft. The whole olecranon pro- cess is a secondary growth, as in fcetal life the joint be- Fig. 974.-Elaterium Seeds magnified and in section. is about 0.123 per cent, of Elaterium. Besides the active principle, coloring matter, cellular tissue, starch, ash, and water make up the rest. Elaterin.-Discovered by Morries and Hennell, 1831. This crystalline substance has been adopted by our last Pharmacopoeia, to the exclusion of Elaterium, in conse- quence of the very uncertain quality of the latter drug. It is also official in Great Britain, and prepared there from Elaterium " by exhausting it with chloroform, add- ing ether to the chloroform solution, collecting the pre- cipitate, washing the latter with ether, and purifying by recrystallization from chloroform." Elaterin is a definite chemical combination of the formula C2oH2806, and is thus described in our Pharma- copoeia : " Small, colorless, shining, hexagonal scales or prisms, permanent in the air, odorless, having a bitter, somewhat acrid taste, and a neutral reaction. Insoluble in water ; soluble in 125 parts of alcohol at 15° C. (59° F.) ; in 2 parts of boiling alcohol, in- 290 parts of ether, and also in solutions of the alkalies, from which it is precipi- tated by supersaturating with an acid. When heated to 200° C. (392° F.), the crystals turn yellow and melt; on ignition they are wholly dissipated. A solution of Ela- terin in cold, concentrated sulphuric acid assumes a yel- low color, gradually changing to red." Action and Use.-Elaterin is the most active and certain of known hydragogue cathartics, purging re- peatedly and comparatively painlessly in exceedingly minute doses. In larger ones, colic, nausea, vomiting, and prostration may follow. It is especially indicated when there is no inflammatory trouble in the digestive tract, and it is desirable both to empty it of its contents and to secure a copious transudation of water from the blood to its canal. Such conditions are frequently pres- ent in cardiac and renal diseases, accompanied by general dropsy ; occasionally also in ascites from various causes, and in cerebral congestion, plethora, concussion, or com- Inner con- dyle. Axis of joint. Capitellum. Trochlea. Fig. 975.-The Lower End of the Humerus, showing the Articular Surface. 644 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. E1ateri n. Elbow-joint. gins its development as a simple slit between two ends of bone which are apposed very much as the ends of the finger-bones are in the adult. At birth the process is not completely developed, and the olecranon and coronoid fossae of the humerus are not as deep as they are in the adult.1 It is interesting to note that in renewal after resection the foetal conditions reappear, the ulna not usually acquiring an olecra- non, but resembling more the upper end of the tibia. The trans- verse line above men- tioned is crossed at nearly right angles by a guide ridge which fits into the deepest part of the trochlear groove. The directionof this is not quite the same in the two portions, and a piece cut from the ole- cranon or coronoid process will not exactly fit all parts of the trochlea.2 There is usually, therefore, a slight devia- tion or lateral wabbling of the joint in flexion and exten- sion, which is not, however, sufficient to be noticeable without instrumental measurements. By sticking a nee- dle into the joint near the point of the coronoid process, and noting the scratch made on the trochlea, Meissner3 obtained a curve which he believed to be a portion of such a spiral path as is made by the thread of a screw. He therefore called the articulation a screw-joint, and believed that the ulna moved laterally in flexion and extension,4 Braune and Kyrklund6 found the needle unsatisfactory, and substituted a point carrying ink. Their results are shown in Figs. 978 and 979, the two lines there drawn on the trochlea being tracings of points attached to the coro- noid and olecranon processes, re- spectively. They found the curves to bend and return into each other, so that, though there is a slight lateral working, it is readjusted be- fore the end of the course. That this lateral working is real may be easily demonstrated by observing, during flexion and extension, a spot of ink placed on the most promi- nent point of the olecranon. By carefully sighting this with a ver- tical thread, it will be seen to move laterally. It may also be demon- strated by making a vertical section through the extended joint, and then flexing, when the cut surfaces of the bones will be seen to ride past each other.5 It appears, then, that there is a slight interval be- tween the articular surfaces at the sides, only the guide ridge remain- ing constantly in contact. The joint cannot, therefore, be said to be a perfect hinge, although it may be so regarded for all practical purposes. External to the trochlear surface of the humerus, and separated from it by a shallow groove, is a rounded por- tion about as large as an ordinary marble, called the cap- itellum or radial head (see Fig. 975). It does not extend far back, and the button-like head of the radius which articulates with it can be felt behind, moving from side to side when the extended arm is supinated. This is an important assistance in diagnosticating dislocations and other injuries here. The shallowness of the depression by which the radius fits would make the joint very insecure, were it not that that bone is bound sidewise to the ulna by a strong band called the orbicular ligament (see Fig. 976), articulating in a shallow depression called the lesser sigmoid cavity. The broadest part of the radial rim fits this, in the position of the arm which is most usual, viz., that of semi-pronation. The rim passes a little beyond the sigmoid cavity and just touches the side of the troch- lear portion of the humerus, rolling upon it in pronation and supination.® The combination of flexion with prona- tion, and of extension with supination, are therefore in Olecranon. Greater Sigmoid Cavity. Guide ridge. Trans- verse line. Radius. Ulna. Fig. 978.-The Trochlear Surface of the Humerus, showing Tracings of the Paths of the Olecranon and Coronoid Processes of the Ulna during Flexion and Extension. (After Braune and Kyrklund.) Fig. 976.-The Upper End of the Radius and the Ulna, showing the Articular Surfaces. accordance with the nature of the articular surfaces. The line of the articulation is oblique, and in amputating it is useful to remember that it lies about three-eighths of an inch below the external condyle, and one-fourth inch lower on the inner side. The head of the radius, which can be felt as mentioned above, is the best guide to it. From the configuration of the surfaces here described, it will be noticed that lateral luxations must be rare, the dislocation outward being easier than inward; that an- tero-posterior luxations are easier and can be effected in any position of the joint, the posterior one being neces- sarily the most common. When a single bone is dislo- cated it must be the radius. A fibrous capsular ligament lined with synovial mem brane invests the joint. Above and below it is attached beyond the articular surfaces of the corresponding bones, the head of the radius being, as it were, stuck through a slit in it. Being quite loose, to admit of extensive move- ments (see Fig. 977), it would be nipped in front and be- hind during flexion and extension, were it not held out of the way by the flexor and extensor muscles which blend intimately with it. It is further protected by a pad of fat in each fossa, and over this the muscles pull. The Capsule Syn. cavity Fig. 977.-A Sagittal Sec- tion through the Elbow- joint, showing the Adap- tation of the Articular Surfaces, and the Folds of the Capsular Liga- ment. Fig. 979.-The Same Detached from the Shaft, so as to show how the Paths meet if continued. capsule is thinner behind than in front, and an effusion into the joint cavity first shows there, on either side of the olecranon and the tendon of the triceps. In certain situations the capsule is strengthened by ac- cessory bands, which have received special names. The strongest of these are the lateral ligaments, which radiate from points on the humerus which are approximately in a line with the axis of rotation, and some of their fibres are therefore tense in every position of the joint. They are important sustainers of the articulation-indeed, if they are intact the anterior and posterior portions of the capsule may be removed without affecting the security of the joint. They also prevent the coronoid and olecra- non processes from quite reaching the bottom of their re- 645 Elbow-joint. Elbow-joint. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. spective fossae in the humerus, which might cause chip- ping of the bone.1 The internal lateral ligament (Fig. 980) presents sev- eral small bundles, which radiate to the coronoid process and the internal border of the olecranon. In front it is intimately blended with the origin of the flexor sublimis The synovial membrane is large, and contains numerous deposits of fat, which are especially abundant in front and behind. The movements of the joint are imparted by muscles which are arranged somewhat like the links of a chain, the flexors and extensors lying on the anterior and pos- terior surfaces of the limb, while the pronators and supin- ators lie mainly at the sides. It should be remembered, however, that the biceps, while a strong flexor, is at the same time a supinator, and the supinator longus is also a flexor, and in some positions a pronator. Flexion and extension may, as stated above, be consid- ered for practical purposes as occurring in a single plane. This plane is not parallel with the median plane of the body, but is directed obliquely, so as to carry the hand toward the mouth. This results from the fact that the axis of rotation of the joint is not at right angles to the long axis of the humerus, but makes with it an angle of some twenty degrees (see Figs. 981 and 983). This obliquity does not occur in the foetal joint, and is not nearly as marked in the lower races of men or in the an- thropoid apes.13 In them ease of bringing the arm across the body is effected by an obliquity of the trochlear axis to the frontal plane. This can be measured by noting the inclination of the trochlear axis to a line drawn through the axis of motion in the head of the humerus. Careful measurements made by Weicker,13 Lucae, Gegenbaur,14 and Schmid15 show that this angle averages about sixteen degrees in Europeans and thirty-two degrees in negroes and Malays (see Fig. 982). In the foetus the angle is about forty-three degrees, and in a child of one year about thirty-eight degrees. It would appear from this that the humerus has undergone a twisting about its long axis to bring the palmar surface of the hand forward, and thus make it more useful as a prehensile and tool-using organ, and that this is more complete in the higher races.16,17 When this torsion be- comes nearly complete it would make it difficult to carry the hand across the body, were it not compensated for by the inclination of the trochlear axis which proceeds pari passu with it. It results from this inclination that in extreme exten- sion the arm and forearm make an outwardly directed Fig. 980.-View of the Ligaments of the Elbow joint from the Inner Side. 1. Hand extending from the condyle to the tuberosity of the coronoid process. 2. Radiating bundles from the condyle to the bor- der of the greater sigmoid cavity. 3. Arciform fibres which pass for- ward from behind and protect the ulnar nerve. 4. Oblique band which passes to the head of the radius, blending with 5, the orbicular liga- ment of the radius. digitorum ; behind it forms, together with some arching fibres and the tendon of origin of the flexor carpi ulnaris, a smooth groove for the ulnar nerve, which lies so closely on the ligament that it cannot be divided here without risk of opening the joint, Sutton8 has pointed out that certain fibres which bridge over the nerve are the ves- tiges of the epitrochleo-anconeus muscle, rarely found in man, but common in some apes. It is probable that these are necessary to keep the nerve from slipping out of the groove, a lesion which often occurs in dislocations, and occasionally takes place with- out any traumatic cause, whenever the elbow is bent.9 It is mainly because of this nerve that in resections the joint is opened on the outer side. In forced extension, caused by violence, the in- ternal lateral ligament is always ruptured or in- jured, and the bones fractured in some manner.10 The anterior band of the ligament appears to check pronation, as it is ruptured when this movement is violently performed. In forced flexion the posterior band is frequently torn. In fracture of the olecranon this ligament often prevents separation of the fragments. The external lateral ligament (Fig. 981) blends in front with the supinator brevis, the tendon of origin of that muscle being, in fact, a part of it. Below it unites with the orbicular ligament, sends a strong band to a tubercle below the lower sigmoid cavity of the ulna, and adheres to the internal edge of the olecranon. In forced move- ments (except adduction) this ligament does not usually give way until others are ruptured.10 The middle band is especially strong, and may tear a piece olf the bone before parting. If the orbicular ligament is broken, the supinator brevis and the biceps pull the radius out of its socket. As this bone is more loosely attached than the ulna, the accident is not infre- quent, being usually caused by falls on the pronated hand, or, in young children, by a strong jerk on the arm. The orbicular ligament is considerably more elastic in children.11 A band, sometimes described as the quadrate ligament, usually passes from the lower border of the sig- moid cavity to unite with the orbicular ligament (Fig. 981). Ordinarily relaxed, it limits pronation and supination.12 Quadrate ligament. Capsu- lar liga- ment. RADIUS ■ULNA Oblique ligament. Fig. 981.-View of the Ligaments of the Elbow-joint from the Outer Side. angle of about one hundred and sixty-five degrees. This •is most marked in supination, and almost entirely disap- pears on pronating the hand. It is therefore best, when applying extension to the humerus by pulling the hand, to first effect pronation. When the muscles are relaxed the force of gravity necessarily carries the hand into a semi-prone position with the thumb to the front. The attitude of " attention " prescribed by tactics for a soldier, i.e., with the palm forward, is therefore a forced one. When a body like a ball is grasped by the hand and thrown by suddenly extending the arm, the inclination of 646 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Bl bow-joint. Bl bow-joint. the axis of the forearm causes it to be sent obliquely un- less this is counteracted by strongly pronating the fore- which represents the usual method of articulating the bones for class demonstration.19 A fixed axis passes through the head of the radius above and the head of the ulna below, so that the radius flaps back and forth around this in a way that may be rudely expressed by two boards obliquely hinged together (Fig. 985). It is rather strange that the ab- surdity of this view has not been more generally seen, especially as a movement of the ulna was recognized by Winslow, Monro, and Vicq d'Azyr,20 the latter anatomist demonstrating it by the impression which the rotating hand left in a bed of clay. Cruveilhier21 (following Bertin) declared this movement to be only apparent, and that by stripping off the muscles from the shoulder down and fixing the humerus, the immo- bility of the ulna could be demon- strated. The general treatises on anatomy have copied this state- ment with great docility, only a few investigators insisting, not- withstanding the weight of author- ity, that the ulna actually does move. Among these is Duchenne,22 who, by observing the movements of the end of a style fixed trans- versely upon the ulnar prominence of his own wrist, declared that the lower extremities of the radius and the ulna describe semicircles equal in extent and opposite in direction. Lecomte23 showed that by fitting an inextensible ring around the wrist above the styloid processes the movements of pronation and supination could still take place, which would not be the case were the radius alone active. He be- lieved the ulna to be capable of circumduction, and pointed to the multiple facets in the sigmoid cavity as being proof that there is a riding from side to side. He compared the bones of the forearm to two revolving axles (arbres) parallel, supporting and pivoting upon each other with their ex- tremities united by very movable articula- tions. The ulna has a pronator, the anco- neus, and a supinator, the pronator quad- ratus. This latter muscle shows, by its attachment wrapping around the shaft of the ulna, that it is intended to roll that bone toward the radius. Later observers 24, 25, 26 have pointed out, that as Lecomte discarded all experiments on the cadaver, he could not have been sure that he fixed the humerus, and that consequently many of his results arise from the slight rotation of the humerus which usually accompanies pronation and supina- tion. The ring causes forced and unnat- ural movements. A mathematical calcu- lation shows that the action of the prona- tor quadratus must vary according to the situation of the axis around which the bones turn, and may be in one direction or the other, as that axis varies. In 1883 Heiberg97 published the results of some investigations made by him on the cadaver, which seemed to completely con- firm Lecomte's views. Disarticulating at the wrist, he inserted into the radius and the ulna stiff rods, at the end of which were brushes charged with ink. It was necessary to use brushes, as the motions described were not in a single European. African'. Fig. 982.-Inclination of Axis of Elbow-joint to the Frontal Plane of the Body. A, B, Line drawn through the condyles of the humerus; C, D, line drawn through the long axis of the articular surface of the head of the humerus; E, F, axis of elbow joint. (After Weicker and Lucae.) Fig. 984.-Usual Method of Illustrating the Move- ments of Pronation and Supination. The radius and ulna joined together by means of a rod passing through the head of the radius and the head of the ulna. arm. This pronation is the so-called "twist" of base- ball pitchers. In performing it the limb is slightly lengthened. This may be demonstrated by standing so as to just touch a horizontal table with the end of the index-linger in pronation and then supinating the hand, when the linger will be found to rise about three-eighths of an inch. The mechanism of this will be apparent on in- specting Fig. 983, which shows that the plane f, in which the lower end of the radius moves, is ob- lique to the plane of the table.18 Pronation and supination in- volve not only the movements of the bones in the superior radio-ulnar articulation, but also the movements of the radius and ulna at the wrist. Anato- mists have been divided in opinion as to exactly what part is taken by each bone in this mo- tion. By far the greater number have held, wuth Galen, Vesalius, and Albinus, that the ulna can take no part in the movement, being incapable of late- ral motion at the elbow. The prevailing view is illustrated in Fig. 984, Fig. 985. - The Same Mechan- ism Illustrated by Pieces of Board Hinged Together. (Af- ter Weicker.) Fig. 983.-The Bones of the Rieht Arm in Ex- tension and Supination, a, b, axis of humerus ; c, d, axis of motion of elbow-joint; /, the plane in which the styloid process of the radius moves in pronation and supination. 647 Elbow-joint. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plane. On effecting movements of pronation and supina- tion, these brushes described on paper curves which are approximately shown in Fig. 986. That for the radius is rather flat and appears to be a portion of a cycloid, while that for the ulna is smaller and is nearly an arc of a circle. In order to ascertain if similar results could be obtained in the living subject, he strapped a metal rod firmly to the arm along the edge of the ulna, carrying it out beyond the olecranon process so far that the distance between the lower edge of the greater sigmoid cavity and the end of the rod should be approxi- mately equal to the distance between the same point and the styloid process of the ulna. This upper end he found to describe curves which were similar to those described by the lower end in the cada- ver, and he therefore concluded that the ulna describes movements of circumduction during pronation and su- pination, the lower portion generating a conical surface and the upper portion another, the vertices of the cones meeting at the lower edge of the greater sigmoid cavity. He presented his views to the International Medical Con- gress in 1884, and a lively discussion ensued. It was pointed out that his apparatus must necessarily produce very inexact results. Since that Cathcart28 has stated that in patients who have ankylosis of the humerus at the shoulder-joint he finds pronation and supination to be difficult, and Flesch29 found that in an apparatus rigged to imitate the elbow-joint the movements of the fore, be used as a guide to disarticulation, as is the case with the folds near some other joints. Underneath the skin are seen the superficial veins, the radial, ulnar, and median, with their branches, the median basilic and the median cephalic. Still deeper lie on either side the mus- cles arising from the condyles, which in their course to the lower arm leave a triangular depression into which sink the tendons of the great flexors, the biceps, and the brachialis anticus. The brachial artery and the median nerve pass through the middle of this space underneath the veins, the nerve lying internally. In the days when phlebotomy was in vogue, aneurisms or varices were not infrequent here, caused by a puncture of the artery when bleeding from the median basilic vein. Consider- able retardation of blood-current is occasioned by flexion, and aneurisms have been cured thus. As the median nerve here passes between the two heads of the pronator radii teres, it is possible that strong and repeated pronation, such as is used in swimming, may cause cramp in the muscles which it supplies. Behind is the olecranon, over which is a subcutaneous bursa liable to inflammation. A number of other bursae exist about the joint, for which see the article Bursae in vol. i. The joint and contiguous bones are well supplied with arteries, which probably accounts for the success usually attending resections. A free anastomosis takes place be- tween the superior and inferior profunda above .and the recurrent branches of the radial and ulnar below. Too tight bandaging interferes with this important supply, and may retard recovery from an injury to the joint. Frank Baker. 1 Henke & Reyher: Uber die Entwickehing der Gelenke. Sitzungsb. der Wiener Acad, der Wissensch., naturmath. Classe, vol. Ixx. 2 Braune, W., & Kyrklund, K.: Ein Beitrag zur Mechanik des Ellen- bogengelenks. Archiv f. Anat, und Entwickgsch. Leipzig, 1879, p. 321. 3 Meissner, G.: Henle & Pfeuffer's Zeitsch. Ill Reihe, vol. i., 1857, p. 514. 4 See also the quite recent work of Langer, C., Lehrbnch der system, und topographischen Anatomie, 3d edn. Wien, 1885, p. 77. 6 Henle, J. : Banderlehre, 2d ed., p. 77. 6 Henke, J. W.: Handbuch der Anatomie und Mechanik der Gelenke, 1863, p. 146. 7 Humphry, G. M.: The Human Skeleton, including the Joints. Lon- don, 1858. 8 Sutton, J. B.: On the Nature of Ligaments. Jour. Anat, and Phys., London, xviii., 225; xix., 27. 245. 9 Zuckerkandl, E. : Uber das Gleiten des Uinarnerven auf die volare Seite des Epicondylus internuswahrend der Flexion im Ellbogengelenke. Strieker's Mediz. jahrbucher, 1880, pp. 135-140. 10 Honigschmied, J. : Leichen-Experimente fiber die Zerrissungen der Bander ini Ellbogengelenk. Deutsche Zeitsch. f. Chir. Leipzig, 1879, xii„ 317-332. 11 Pingaud, E.: Diet. Encycl. des Sciences Medicales, article Coude, vol. xxi., Ire ser. Paris. 1878. 12 Denuce: Nouveau Dictionnaire de M6d. et Chir. Pratiques, article Coude. Paris, 1877. 13 Lucre, G. : Die Stellung des HumeruskOpfes zuin Ellbogengelenk beim Europaer und Neg$r. Arch. f. Anthrop. Brnschwg., 1866, i., 273- 276. 14 Gegenbaur, C. : Jen. Zeitsch., iv., 50. 15 Schmid, F. : Uber die gegenseitige Stellung der Gelenk- und Knoch- enaxen der Vorderarm und hinteren Extremitat bei Wirbelthiere. Arch, f. Anthrop., vi., 181. • 16 Martins, Ch.: Mem. de 1'Acad. des Sciences de Montpellier, iii., 482. 17 Albrecht, r.: Beitrag zur Torsionsthcorie. Schriften der Univ, zu Kiel, 1875. 18 Langer, C.: Anatomie der iiusseren Formen des menschl. Korpers. Wien, 1884. 19 Weicker, H.: Arch. f. Anat, und Phys., 1875. pp. 1-46. 20 Vicqd'Azyr: CEuvres, Paris, 1805, vol. v., 347. 21 Cruveilhier, J. : Anatomie Descriptive. Paris. 1871, vol. i., 368. 22 Duchenne, G. B.: Physiologie des Mouvements. Paris, 1867, p. 130. 23 Lecomte, O. : Du Mouvement de la Rotation de la Main, Arch. Gen. de Medecine. Paris, 1874. xxiv., 129-149. Ibid.: Le Coude et la Rota- tion de la Main., do., 1877, xxix., 533 and 663. 24 Koster, W.: Bijdrage tot der Kenniss van het Mechanisme der Be- wegingen in het Elbogoogsgewicht. Nederl. Tijdsch. voor Geneesk, 1880, p. 213. 25 Braune, W., & Flugel, A. : Uber Pronation und Supination des mensch. Vorderarms und der Hand. Arch. f. Anat, und Entwickgsch., 1882, pp. 169-196. 28 Einthoven, W.: Quelques Remarques sur le Mecanisme de PArticu- lation du Coude. Arch. Neerland. d. sc. cxactes, etc. Haarlem, 1882 xvii., 289-298. 27 Heiberg, J.: Uber die Drehung des Vorderarms. Christiana Viden- skabs. Forhandlinger, 1883, No. 8. Ibid.: Zur Geschichte der Lehre von der Drehung der Hand, do., No. 11. 28 Cathcart, C. W.: On the Movements of the Ulna in Pronation and Supination, Jour, Anat, and Phys. London, xix., 1884-85, p. 355. Bibliography. Radius. Ulna. Fig. 986.-The Lower Ends of the Radius and Ulna in showing the Movements of Prdnation and Supination. (According to Heiberg.) ulna appeared to be mainly those of flexion and exten- sion. In the living subject the anconeus strongly con- tracts during pronation, and the brachialis anticus and flexor carpi ulnaris during supination. My own experiments completely confirm this. The most important paper that has recently appeared has been one by Braune and Fischer,30 who made, during the past few months (1885), a series of most careful experi- ments on the cadaver, in order to establish the character of Heiberg's curves of movement. The cadaver used was that of a suicide, and quite recent. The motions were in- duced by weights and pulleys acting as nearly as pos- sible in the line in which the muscles pull during life, and pains were taken not to force them by making the weights too heavy. Styles were inserted firmly into the ulna and radius, and the path described by their ends carefully observed and traced upon glass in at least two planes, or marked by reflecting mirrors on a wall. From the tracings, a system of co-ordinates was obtained by which the path of each style was calculated. It was found that the paths described by the ulna belonged to no regular curve, but were a series of motions of flexion and extension, with a slight degree of lateral motion. These results agree with experiments which I have myself made on this subject, but it should be added, that the amount of ulnar movement undoubtedly varies con- siderably according to circumstances, and tlmt the axis of motion, instead of being fixed, as usually stated, changes according to the act performed. Certain anatomical relations of the elbow-joint should be remembered. The fold of skin which is made in front when the joint is flexed passes transversely in the direction of a line joining the condyles. It cannot, there- 648 Elbow-joint. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 29 Flesch, Max: Zur Pronation nnd Supination <ler Hand. Arch. f. Anat, und Entwickgsch, 1885, p. 216. 30 Braune, W., & Fischer, O. : Die bei der Untersuchung von Gelenk- bewegungen anzuwendende Methode, erlautert am Gelenkmechanismus des Vorderarms beim Menschen. Abhandl. der mat. physisch. Classe der Konigl. Sachs. Gesellschaft der Wissenschaften, vol iii., 315-336. short fracture ; internally grayish, fleshy, slightly radiate, and dotted with numerous shining, yellowish-brown resin- cells ; odor peculiar, aromatic ; taste bitter and pungent." Composition.-Inulin, alant camphor, essential oil, alantoic acid, waxy, resinous, and bitter substances, be- sides ordinary vegetable principles and ash. The first of these, although of no medicinal properties, is the most in- teresting, and has received its name from this plant. It was discovered in it in 1804 by Valentine Rose, who also pointed out its intermediate position between starch and sugar. Since then it has been observed in the roots of nearly a hundred Compositce, but in the plants of no other family.1 It has likewise not been found in the aerial ELDER {Sambucus, U. S. Ph.). The American Elder, Sambucus canadensis Linn. ; order, Caprifoliacece, is a medium-sized or small shrub with smooth, upright, rather simple stems, which are soft and herbaceous in the up- per part. Their woody ring is very narrow, and their pith very large. Leaves opposite, petiolate, pinnate, large ; leaflets ovate-acuminate, sometimes pinnate. Flow- ers small, in large, compound, five-branched, flat-topped cymes, regular, pentamerous. Calyx minute. Corolla cream-colored, urn-shaped, with spreading lobes. Stig- mas three. Ovary inferior, ripening to a purple-black, shining, spherical, juicy, berry-like drupe, containing three minute nutlets. The elder is a common plant in moist places over a large portion of this continent, and is represented by nearly related species in other parts of the world. The flowers alone are officinal ; they should be gath- ered in full blossom, and dried without heat. They have a peculiar, rather agreeable, odor, and a sweetish and slightly bitter taste. Their constituents are probably the same as those of the European elder mentioned below {Allied Plants). The use of our Elder was unquestionably derived from that of the black elder of Europe, which is almost ex- actly like it in sensible properties. Elder is slightly aro- matic, and when given in hot infusion also diaphoretic. Its employment is confined almost entirely to household medication. Dose, the infusion, -/□, may be taken ad lib- itum. Allied Plants.-The genus comprises ten or twelve species of shrubs or herbs, all natives of temperate cli- mates. S. nigra Linn. , of Europe, attains to the size of a small tree, and has a rough, gray bark, but otherwise resembles our species ; its flowers, which are officinal in most European countries {Sambuci Flores, Br. Ph.; Flores Sambuci, Ph. G.; Sureau, Codex Med., etc.), are smaller than those of S. canadensis, but otherwise similar. Their constituents are an essential oil or stearopten, which crystallizes upon standing (0.03 to 0.04 per cent.), tannin, resin, bitter extractive, etc. Black Haw, and the pretty honeysuckle of lawns and trellises, are in the same order. Allied Drugs.-The diaphoretic "herbs" in general, whose name is legion. Chamomile, Spear-mint, Rose- petals, etc. Elder berries, from both species, which have a mawkish, sweet, slightly acidulous taste, are made into a sort of wine by country folk, who attribute some medi- cinal virtue to it. It probably has no more than those made from other sweetish fruits. The bark of the elders is bitter and purgative ; both this and the berries are of- ficial in the Codex, as are those of S. Ebulis (Hieble). W. P. Bolles. portions. For a description of Inulin and its properties, see Starch. The alant camphor, or helenin, is obtained by boiling the roots with alcohol, filtering, and adding cold water to the filtrate, when the helenin separates, upon standing, in fine needles ; or it may be separated by distillation. It is a faintly odorous and nearly tasteless, volatile substance, insoluble in water, but soluble in ether, oils, and hot alcohol. The Oil is a yellow liquid of mint- like odor. Alantic acid is a crystalline substance asso- ciated with the oil. Action and Use.-Although an old remedy, it can hardly be said that Elecampane has any place in modern therapeutics. It is slightly stimulant, very gently, if at all, tonic, and enjoys a slight reputation in the treatment of amenorrhoea and bronchitis. Dose from two to four grams (gr. xxx. ad 3 j.) in decoction or infusion. Allied Plants.-See Chamomile. Allied Drugs.-Inula has no properties sufficiently marked for comparison. W. P. Bolles. 1 For a list of these inuliniferous plants, see Husemann's Pflanzen- stoffe, 138. Fig. 987.-Elecampane, Flower and Anther. (Bailion.) ELECAMPANE {Inula, U. S. Ph. ; Radix Ilelenii, Ph. G. ; Aunee officinale on Grande Aunee, Codex Med.). The root of Inula Helenium Linn. ; Order, Composites. This is a large, rank, perennial herb, with a thick fleshy rootstock and root, and an upright, branched, hairy or rough stem-, from one to two metres high (three to six feet). Leaves large and stout, oblong or oval, up to half a metre long, or those of the stem smaller, narrower, pointed and sessile. Flower-heads large, the outer in- volucre scales broad and leaf-like ; receptacle flat, naked, pitted ; flowers yellow, those of the ray in a single row, with long, very narrow corollas. Anthers tailed at the base. Inula grows, either indigenous or naturalized, in the temperate parts of Europe, Asia, and North America, and is also cultivated in Europe. The root should be collected either in spring or autumn, suitably sliced, and dried with gentle heat. It is then "in transverse, concave slices or longitudinal sections, with overlapping bark, externally wrinkled and brown ; flexible in damp weather; when dry, breaking with a ELECTRICITY IN MEDICINE. The limited space alloted to this subject precludes the possibility of indulg- ing in more than a bare allusion to electro-physics and physiology, a cursory description of the methods of electrization, and a brief consideration of the special dis- eases in which this agent has been found to be of es- sential service. Electricity is a generic term, under which is included its three manifestations-magnetism, static or franklinic electricity, and dynamic electricity. The magnet has little, if any, therapeutic influence, and need not detain us. Static electricity, signifying elec- tricity at rest, in contradistinction to dynamic (electricity in motion), has a wide range of usefulness. The best apparatus for the generation of franklinic electricity for medical purposes is the Holtz machine. This contrivance, although a great advance upon the old- fashioned cylinder machine, still proves inoperative dur- ing most of the summer months at least, and frequently fails even during the cold of winter. 649 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It has been found, however, that if the ordinary Holtz apparatus is covered with a glass case, in which is placed a quantity of chloride of calcium, by which all the moisture is absorbed, electricity can be generated in all kinds of weather. The double Holtz, consisting of four plates, two stationary and two revolving, of about twenty inches in diameter, fulfils every practical purpose. The methods of treatment by static electricity are : 1st, insulation ; 2d, electrization by spray or sparks ; 3d, gen eral franklinization ; 4th, electrization by shocks. In the treatment by insulation the patient is placed upon an in- sulating stool, and connected with the conductors of either side, according as a positive or negative charge is de- sired. The silent reception of the electricity and its silent and more gradual discharge from the body to the sur- rounding atmosphere produces in most persons very pleas- ant and soothing effects. In the treatment termed electrization by sparks or spray, the patient is placed in the condition of insulation just described, and sparks are drawn from any portion of the body by the near approach of a conducting substance. Brass balls of various sizes (mounted on glass handles, held by the operator), connected by a brass chain with the ground, or, better still, with the nearest gas- or water-pipe, are usually employed. The electric wind, so called, fol- lowing the use of a pointed electrode, is due to the agita- tion of the air as the silent discharge takes place. The term general franklinization is employed when a roller is substituted for the ball electrode, and moved up and down the back, and over the body generally. It acts reflexly, and excites the cutaneous nerves most decidedly. When the roller is used upon the bare skin, the conduc- tion is so perfect that no sensation is appreciated. It is only when the clothing intervenes, acting, possibly, as a sort of Leyden jar, that the peculiar pricking sensation is observed. The last method, the treatment by shock, is a violent one, and not usually called for. It is produced by bringing the body, or that portion of it on which we wish to operate, in the circuit between the outer and inner coating of the Leyden jar attachment. The third form of electricity, viz., current or dynamic electricity, occupies the chief place in electro-medicine and surgery. Under this head we have : 1st, that form called galvan- ism or voltaic electricity, the result of chemical action; and 2d, induced electricity (electro-magnetism or magneto- electricity), the result of current or magnetic induction. Much confusion has arisen, and still exists, in regard to the different manifestations of current, because of the loose nomenclature that prevails. There is an indiscrimi- nate use of the terms induced, galvanic, direct, second- ary, etc., that serves to mystify and mislead. The sub- ject becomes much simplified if we bear in mind that the third or dynamical kind of electricity, with which we have principally to deal, manifests itself in two forms of cur- rents, viz., the galvanic, so called after Galvani, the dis- coverer of chemical action ; and the faradic, after Fara- day, the discoverer of the principle of induction. The synonyms of the term galvanic are: constant, primary, voltaic, and direct; the synonyms of the word faradic are: induced, secondary, interrupted, electro-magnetic, and magneto-electric, the latter referring to the current when induced through a permanent magnet instead of through chemical action. By the term tension we mean that quality of electricity by which it overcomes resistance. The tension of a galvanic battery depends upon the number of its cells, while quantity signifies that amount of electricity which passes through a circuit in a given time, and depends upon the size of the elements in the cells and not upon their number. The term quantity is retained for convenience. By it, more than by the term tension, is understood the strength or working power of the current. The current from a single galvanic cell or circle pass- ing through a coil of wire, induces, simply by proximity, a secondary current in a second coil of wire, differing al- together in its physiological effects from the galvanic current. In this way is derived faradic electricity, or the current of induction. These induced or secondary currents, again, have the power to induce currents, in other coils of wire, called tertiary currents, and so on for a long series. The strength of the current decreases, however, the higher one ascends in the series ; hence, batteries made for thera- peutical purposes have no more than the two coils. The wire of a primary coil is made quite large, because it is a law of electro-physics that the thicker the wire the better is electricity conducted, and the more readily is magnet- ism excited in the iron core which it encircles. The secondary coil is, however, made of very thin wire and of great length, so that as many turns as pos- sible may be brought within the influence of the primary coil. As with the galvanic or inducing current, the electro-motive force of the battery is proportionate to the number of cells, so with the induced or secondary cur- rent, the electro-motive force is proportionate to the num- ber of turns or coils in it. There are two forms of faradic batteries varying materially in construction and in phy- siological action. These are termed respectively, the single or continuous, and the double or separate coil machine. In the first-named there is a continuous wire, varying in thickness in different parts of its course This wire is tapped at different points, and the quality of the current generated depends upon the length and thick- ness of the coils included in the circuit. In the separate coil machine, the helix is composed of two entirely separate and distinct wires, the inner or inducing coil of wire being thicker than the outer coil. It is not a matter of indifference in what way a helix is constructed. Every modification of a conductor in length, thickness, or constitution more or less modifies the quality as well as strength of the current, and therefore the currents pro- ceeding from these different forms of helices, as well as from the different portions of the continuous coil helix, vary considerably in their action. As regards the rela- tive therapeutic effects of the continuous and separate coil machines, as well as the differential indications for the use of the currents proceeding from the various com- binations of the continuous induction coil, the reader is referred to the more exhaustive treatises upon the sub- ject. . It is only through the use of galvanism that we obtain that peculiar modification of irritability of nerves and muscles termed electrotonus. When applied along the course of a nerve, that portion between, as well as a limited portion outside, the poles, is said to be in an electrotonic state, and that part of the nerve not included between the poles will deflect the needle of a delicate galvanometer, a result due to a modification of the natural nerve-current. The two modifications of the electrotonic condition are termed, respectively, anelectrotonus and catelectrotonus. Anelectrotonus is a condition of diminished irritability taking place at or near the positive pole or anode ; while catelectrotonus is a condition of increased irritability at or near the negative pole or cathode. In addition to these phenomena, caused simply by the current passing in a single direction, we have other phys- iological effects, caused by changes in the current when it is closed, broken, or reversed. When the electrodes are applied to a nerve, and the current is closed, we observe a momentary. contraction proportionate in vigor to the tension of the current. While the current is flowing continuously no contrac- tions take place, but immediately on breaking the circuit, if the current be not too weak, muscular contraction again occurs. In regard to external applications of the galvanic current to the head, physiological experiment has taught us, and clinical experience has confirmed the teaching, that it affects the brain directly as well as reflexly. On the contrary, just to what extent it is possible to affect the spinal cord in the living man by external applications it is difficult to say. That it can be influenced reflexly, however, and in all probability directly as well, has been sufficiently attested by many well authenticated thera- peutic results. The great sympathetic is readily influ- enced, and the action of the galvanic current upon the ganglia of this nerve is productive of more remarkable 650 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Electricity. therapeutic results, perhaps, than when applied to any other portion of the nervous system. Upon all the nerves of special sense, the action of galvanism is seen in call- ing into activity the vital function of each nerve. Before the eyes flashes of light appear and perception of color; the ear responds by humming or rumbling sounds, the nerve reacting according to certain fixed laws; the gustatory nerve appreciates a metallic taste; while through the olfactory nerve an odor somewhat resembling sulphuretted hydrogen may be detected. On voluntary muscleselectricity acts by causing immediate contractions, while in involuntary muscles movements are not induced so quickly, but, unlike voluntary muscles, the movements that are excited continue for a time after the cessation of the current. Nutrition is very decidedly affected by elec- tricity, and results powerfully tonic in character are readily produced by this means. Physiological effects are produced by either current, although the galvanic is the more important in this re- spect. By it the secretions may either be increased, di- minished, or arrested, or their quality modified. The usual effect is to increase both the secretory and excretory pro- cesses, but when very mild currents are used, their ac- tivity is not always increased, and experience teaches that in the healthy organism very strong currents may produce a partial arrest of these functions. Diagnostic Uses of Electricity.-Electricity is often an important aid in diagnosis, and in some forms of paralysis is the only means by which we can arrive at correct conclusions. The fundamental principles of the subject depend upon the character of the polar reaction, by which is meant the measure of muscular contraction that follows the application of the positive (anode) or negative (cathode) pole to a nerve or muscle. Although contractions occur only on closing or open- ing the current, yet we distinguish four kinds, designated by the following abbreviations: first, C.C.C ; second, A.C.C.; third, A.O.C.; fourth, C.O.C. The first is the cathodal closure contraction, and occurs when the cathode is applied to the nerve or muscle, and the current is closed. The second, anodal closure contraction, occurs when the anode is applied to the nerve or muscle, and the circuit is closed. The third, anodal opening contraction, occurs when the anode is applied, and the current is opened. The fourth, cathodal opening contraction, occurs when the ca- thode is applied, and the current is opened. When nerve and muscle are in their normal condition, electro-muscular contractions occur in the order just given, the cathodal closure contraction being more readily induced than the anodal closure contraction, and so throughout. In diseased conditions, however, this for- mula is subject to great variations. The readiness with which a muscle contracts in response to electrical in- fluences may be increased. This occurs in certain cases of hemiplegia associated with an irritative lesion, and in the early stages of facial paralysis due to the action of cold, associated with a rheumatic diathesis. In these cases the intramuscular nerves are attacked from the be- ginning, while there is but little, if any, alteration of the muscular fibres. The faradic current causes contractions through the intramuscular nerves ; therefore, in such cases, farado-muscular contractility is necessarily lost. The galvanic current, acting more especially on the mus- cular fibres, retains its power, and, as experience shows, a current insufficient in strength to contract a healthy muscle, will readily induce contractions in these cases. As the patient improves, it takes an increased tension of galvanism to produce the same effects, until finally farado- muscular contractility becomes manifest. Again,the readi- ness with which contraction takes place may be decreased, and finally abolished, as in the last stages of bulbar paraly- sis, occasionally in paralysis following acute diseases, in myelitis, and in progressive muscular atrophy. These are termed quantitative reactions, consisting, as already stated, in a simple increase or diminution in the quickness of re- sponse to a current of given strength. Qualitative, which includes quantitative, changes (reaction of degeneration) consist in an alteration in the order of occurrence of the contractions. These changes are observed in any form of traumatic paralysis in which the continuity of the nerve has been completely interrupted ; in rheumatic paralysis associated with compression at some point of the nerve ; in lead palsy ; in many forms of infantile paralysis ; in spinal paralysis, where the gray matter is much involved; in progressive muscular atrophy ; in some cases of neuritis ; in cases of pressure on the nerve, and in some paralyses, the result of acute diseases. In these cases the normal formula becomes subject to marked changes. The cathode at its closure (C.C.C.) may act even less readily than the anode (A.C.C.); and the anode at its opening (A.O.C.) maybe less effective than the cathode at its open- ing (C.O.C.). At the same time the contractions become weaker and less rapid than in health. When the circuit is closed the contractions are also liable to become tetanic, while rapid interruptions of the galvanic current utterly fail to call forth any response. By the foregoing princi- ples we may also utilize the currents for the detection of malingerers, and for deciding between real and apparent death. By recollecting, again, that all parts and organs of the body are more or less sensitive to the electric current, and that this sensitiveness is modified by disease, we are often enabled to point out the seat of derangement, although the special nature of the disorder must be deter- mined by the ordinary means of differential diagnosis at our command. The success with which special applica- tions of the principles of electro-diagnosis are made must depend upon the thoroughness of individual observation and experience. Methods oe Application.-The principal methods of employing dynamic electrization are four in number, viz.: first, localized faradization ; second, localized galvaniza- tion; third, general faradization; fourth, central galvaniza- tion ;-all of which are subject to many variations in the practical details of their application. The art of limiting the excitation of the electric current to certain organs and tissues is in the main due to Duchenne, and is called localized electrization. When the faradic current is used, it is termed localized faradization, and when the galvanic, localized galvanization. He called attention to the fact that electricity could be localized tinder the skin if moist electrodes were firmly pressed upon the skin. He was led to this observation by the very familiar phenom- ena that follow the application of the dry electrode, or hand, to the surface of the body, viz., a crackling sound, but no sensation and no muscular contractions. This was due to the very slight conductivity of the skin. Through moisture, however, its conductivity is increased, and he observed that when wet electrodes were applied the same strength of current excited contractions im- mediately. This system, simple in its origin and detail as it may seem, has been refined and developed until it has grown into a permanent department of science. To be proficient in its uses demands a certain degree of anatomical and physiological knowledge and manual facility ; but its successful employment requires neither the dexterity nor the care that is exacted by localized gal- vanization, general faradization, and central galvanization. For these reasons, localized faradization has been gen- erally adopted by the mass of the profession, to the ex- clusion of the more advanced processes, by which alone we can fully utilize the therapeutic powers of elec- tricity. In carrying out the details of localized faradization, the situation of the motor points should be carefully stud- ied. Ignorance of these points will involve waste of time in searching for them with electrode in hand, and at the same time add to the annoyance of the nervous pa- tient. By placing the negative pole over the motor point, and the positive over the belly of the muscle, we obtain immediately the best possible contraction, whether for therapeutic or diagnostic purposes, with the minimum strength of current. Localized galvanization, especially when applied for the relief of pain, is a procedure of much greater delicacy than localized faradization. The term stabile application is employed when both electrodes are kept in a fixed position. The term labile application is employed when 651 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. one or both electrodes are glided over the surface with- out, however, causing any interruption of current suffi- cient to produce appreciable muscular contractions. When it is desired to induce a purely sedative influence, it is often of the greatest importance that the galvanic current should not only be free from any distinct inter- ruption, but that every variation of current influence, such as follows moving the pole along the skin, should be carefully avoided. At other times, however, it is desira- ble that our application should be " increasing," by which is meant that the current strength is gradually augmented without removing the electrodes. If the current is thus gradually increased, a much greater power can be borne than if it is suddenly let on in full force, with the closure of the circuit. A current which may produce unbearable pain, or, when applied near the nerve-centres, dizziness and faint- ness, may be borne without discomfort and with positive advantage if brought up to this point of strength gradu- ally and without interruption. Applications to the brain, eye, and ear especially, and to the sympathetic, spinal cord, urethra, and to all con- ditions of great irritation wherever seated, should always be thus gradually increased, and in the same way de- creased. With the faradic current, the management of these increasing and decreasing currents is very simple ; but to gradually increase the galvanic current, especially if no rheostat is at hand, requires very great care. Most galvanic batteries that are now made have an arrange- ment that gradually adds to the number of working ele- ments without interrupting the current, but, even with the greatest precision of manipulation, breaks are apt to occur when least expected or desireci, and it is therefore far safer to be always provided with some form of rheostat. Labile, or stabile, interrupted currents are generally preferred for the galvanization of muscles, while for the galvanization of the head, sympathetic nerve tracts, and plexuses, stabile continuous currents, either uniform or increasing, are, as a rule, indicated. In addition to their power'to produce muscular contractions, labile, or stabile, interrupted currents cause more marked physical and mechanical effects, while stabile continuous currents, whether uniform or increasing, produce the stronger, electrolytic, and catalytic action. In applying the galvanic current to the brain, it is well to remember that there is less tendency to dizziness if the negative pole is applied first, and the circuit closed and opened with the positive. There are many special effects of localized electriza- tion, as of general faradization and central galvanization, but the leading and general result of all the methods is improvement in nutrition. Localized electrization of poorly-nourished and atro- phied muscles develops size and increases strength ; local- ized electrization of any organ, such as the uterus, the nutrition of which has become impaired, and its size di- minished, tends to develop it and increase its functional activity. In localized electrization these results, of course, are mostly of a local nature ; yet, owing to the fact that absolute localization is impossible, we not infre- quently observe effects extending far beyond the parts actually enclosed in the circuit. The galvanic current, unless it be quite strong, or directed over a motor point, at first causes little if any sensation. In a short time, how- ever, a slight burning sensation is experienced, rather more keenly felt at the negative pole. This sensation rapidly increases in acuteness, until it may become unen- durable ; for, unlike the faradic current, the galvanic has not the same tendency to anaesthetic effects. In the administration of general faradization we em- ploy, as the name implies, the faradic current. Its object is to bring the external portions of the body, from the head to the feet, and as far as possible the internal tissues and organs also, under the influence of the current. In order to influence the whole body in this way, the feet of the patient should be placed upon a copper plate to which the negative pole is attached. The soles of the feet are not at all sensitive to the current, but if the patient is especially nervous or susceptible, the feeling of constric- tion that is experienced in the ankles as tlie current passes, and the occasional contractions of the flexors and extensors, may become disagreeable and even hurtful. In such a case it will be better for the patient to sit upon the plate, or to apply the negative pole near the coccyx by means of a broad, soft sponge. The positive pole may be either natural or artificial. The hand is the natural electrode, and those who are able to bear the requisite strength of current through their own persons will find it unrivalled by any other form. It is not absolutely neces- sary that the hand be used, but it can be readily under- stood that no artificial electrode that human skill can devise can equal the hand in its flexibility, and the readi- ness and completeness of its adaptation to every inequality of surface. In all applications to the head, eyes, and face, and in the more general treatment of acutely sus- ceptible patients, and especially hysterical women, far better results will follow the use of this natural than of any artificial electrode. In submitting a patient to general faradization, the operation should be made with some re- gard to order. The hair being thoroughly wet, the hand is passed with firm pressure over the entire surface of the head. In treating the forehead, which is far more sensi- tive to the current than any other portion of the body, the operator should first press his moistened hand firmly over the part, and then make the connection with his other hand on the sponge of the positive pole. The strength of the current, when applied to sensitive parts of the body, can be sufficiently regulated by increasing or decreasing the grasp of the positive pole' held by the right hand. An application of the faradic current to the head in many forms of neuralgia, nervous headache, and insomnia, if properly given, is capable of affording most grateful relief. Especial care must, however, be exer- cised. The slightest concentration of current in such sit- uations as the forehead is capable of exciting pain, while a proper diffusion, with equal and gentle pressure, affords a sensation as agreeable as it is curative. The back part of the head and upper portion of the spine will usually bear powerful applications ; and it is an interesting and important fact that applications to the back of the neck (cilio-spinal centre) will produce far greater tonic effects than when the pole is applied to any one other portion of the body. Care should be taken to avoid all bony prom- inences, since slight currents in these regions give pain. Hence, over the scapula, clavicle, sternum, crest of the ilium, tibia, etc., care should be exercised in the modera- tion of the current. Let the first applications be tenta- tive. Experience will soon teach that there is no remedy to the effects of which there is such a varying degree of susceptibility as to this. Careful examination will some- times fail to give information as to the proper strength and the thoroughness of treatment that should be first at- tempted. Not until the patient is submitted to a careful electrical test can we be sure that what we might con- sider very gentle treatment will not be too severe for the case in hand. To make the applications successfully, not only in the ultimate good that comes, but also in that the patient experiences no subsequent weariness, soreness of muscles, or vague but distressing nervous feelings, re- quires far more care and experience than is generally supposed. On the part of the operator is demanded a certain degree of mechanical dexterity, entire familiarity with the instruments required, a complete knowledge of electro-therapeutical anatomy, a personal acquaintance with the sensations and behavior of all portions of the body under the different qualities of the induced cur- rent, and a close and patient study of the diseases and morbid conditions in which they are indicated.1 By central galvanization we understand that method of treatment by which the whole central nervous system is brought under the influence of the galvanic current. To accomplish this, one pole, usually the negative, is placed over the solar plexus, while the other is firmly pressed on the top of the head and gradually passed over the oc- ciput, along the inner border of the sterno-cleido-mas- toid muscle, and from the cilio-spinal centre down the whole length of the spine. For this method, which we first introduced and described a number of years since, is 652 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Electricity. claimed a distinct and important position. The different applications to the head and neck, which have been vari- ously used since the time of Remak, are simply forms of localized electrization ; but in central galvanization, as it is observed, the poles are so placed that the whole central nervous system is brought under the influence of one pole. In central galvanization, if the current be gradually in- creased, and as gradually decreased, without interrup- tion, few, if any, unpleasant sensations are experienced, even if currents of considerable strength are used. Be- cause of the symmetrical influence which in this way is exerted on the brain, little, if any, dizziness is experienced by even the most sensitive patients ; if, however, the current be passed transversely through the head, the so- called falsification of the muscular sense that results through an unsymmetrical stimulation (one pole affecting the right, and the other the left, hemisphere) is the occa- sion of immediate and intense vertigo. Polar effect and current direction exercise a more important influence than is conceded by many, and the question, which is the more important factor in the production of therapeutical effects, the position of the poles, or the direction of the current, is one of exceeding interest. Those who deny the efficacy of polar influence in excit- ing physiological phenomena ascribe them chiefly to cur- rent direction. The contraction laws of Pfliiger, however, render it probable that in the electrical stimulation of a given nerve-piece, the polar influence has more to do with the resultant physiological effects than the direction of the current. In central galvanization few facts are better established in my own mind than that certain con- ditions, such as cerebral congestion and forms of hys- teria, may be aggravated by what are termed ascending currents ; but whether the ill effects are due to current direction or polar action, is more difficult to determine. Effects of Electrization.-The effects of electriza- tion may be divided into general and special. The gen- eral effect is that of a tonic, with a tendency either stim- ulating or sedative, according to the strength, duration, and method of application, and the character of the morbid condition under treatment. One of the greatest obstacles that for many years impeded the advance of electro- therapeutics was the incorrect estimate of its action as a remedial agent. It was regarded as more especially a stimulant, and indicated in those conditions calling for an excitant; hence, paralysis was the disease par excel- lence for which it was used. Valuable as this effect is, it is far less important than the sedative and nutritive ef- fects, which are general or local according as the applica- tions are general or local. General faradization and cen- tral galvanization are the methods by which we most successfully elicit constitutional effects. The special effects of electrization necessarily differ with the vary- ing degrees of susceptibility among patients. The usual primary effect of the general method is a refreshed and moderately exhilarated feeling, which may last some hours. If there be vague pains, with nervous excitement, the tendency of the treatment is to relieve and soothe. Unpleasant secondary or reactive effects are not generally experienced. In a certain proportion of cases, however, the patient may experience some soreness in the muscles of the up- per and lower extremities, and an indefinable nervousness which soon gives place to a feeling of increased strength and steadiness of nerve. The effect of general faradiza- tion is to temporarily lower the temperature when it is abnormally high. It acts also as an equalizer of the cir- culation, and patients who suffer from cold feet and creep- ing chills over the body become sensible of a feeling of warmth even in the midst of a seance. General faradiza- tion has very little influence on the normal pulse, but its power to reduce the frequency of the beats when it is ab- normally high in conditions of nervous exhaustion is dis- tinctly marked. In the treatment of such cases I have, in a seance of five minutes, frequently noted a fall in the pulse-beat ranging from ten to thirty to the minute. At the same time the heart's action becomes stronger and more regular. An almost invariable accompaniment of general fara- dization and central galvanization is an improvement in sleep ; and as insomnia, more or less marked, is frequently associated with those neurasthenic conditions for which electricity is indicated, this improvement is indicative of the further benefit that will follow. A better appetite and increased power of digestion, although not observed so early in the treatment, are pretty constant effects, while through the direct mechanical effects of the cur- rent on the intestines, and its influence over the secretory processes, more or less relief is afforded in constipation. The influence of general faradization over nutrition is, perhaps, in no way more marked than in an occasional in- crease in the size and weight of the body. Treatment of Special Diseases.-Neuralgia.-In the treatment of neuralgia electricity is most valuable. While failures follow the most skilful manipulations, and exacerbations of pain not infrequently result from ill-directed applications, it is safe to say that, more than any one remedy, it relieves this distressing affection, and in many instances the acute pains dependent upon cen- tral structural changes are very decidedly alleviated also. In a given case of neuralgia the question at once arises, which current is indicated ? True neuralgia, as defined by Anstie, is without doubt most successfully treated by galvanism; while hysterical neuralgia and the so-called pseudo-neuralgias, which are simply forms of pain, oc- cupying certain areas and running, seemingly, in the di- rection of certain nerves, yield most readily to faradism. More specifically, the effects of pressure in the various forms of neuralgia are exceedingly useful as guiding symptoms indicating the proper current to be employed. It cannot be laid down as an invariable law, but it will be found that in the great majority of cases of neuralgia, where firm pressure over the affected nerve aggravates the pain, the galvanic current is indicated, while the faradic current has the greater power to relieve when such pres- sure does not cause an increase of pain. There is no special law as to the strength of current to be used, but it is a very important general law that it should not be carried to the point of pain. In neuralgia especially the milli- ampheremeter is an essential part of the armamentarium of the electro-therapeutist, and very accurately gauges the strength of the current used, whatever be the form of gal- vanic battery employed. A marked exception to the law of mild currents occurs in sciatica, in which disease ex- ceedingly strong currents are frequently most efficacious. Stabile are to be preferred to labile applications. Chorea.-The two methods of treatment that have in my hands been most efficacious are, general faradization and central galvanization, associated at times with local galvanization. While the ascending galvanic current is to be preferred in the treatment of chorea, located in a single limb or group of muscles, general faradization is far more efficacious when the disturbance is general. It acts here both as a sedative and as a tonic, allaying irrita- bility and inducing sleep. Hysteria.-The various conditions associated with hys- teria, as paralysis, contractures, anaesthesia, hyperaes- thesia, hiccough, aphonia, and incontinence of urine, are often more or less amenable to electrical treatment, either general or local. The general disease itself calls for this form of treatment quite uniformly, and in many cases is speedily and permanently benefited. Spinal Irritation.-Of the many affections allied to hysteria, spinal irritation is one of the most prominent, and is often associated with it. When it is simply a lesser symptom of hysteria, it cannot claim a distinct nomen- clature, and does not call for special consideration in treatment. When, however, the spinal tenderness and the symptoms that directly flow from it overshadow other accompanying conditions, it claims a place as a distinct disease. Treated as such, spinal galvanization, with la- bile descending currents, rarely fails to effect a cure. There is hardly a disease in which there is so little doubt as to the treatment indicated and the benefit to be de- rived. Epilepsy.-Electrization cannot be said to be a recog- nized method of treatment in epilepsy, although it has 653 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. been used successfully to oppose certain symptoms which occasionally accompany it, such as tremors, paresis, and contractures ; and in slight epileptoid seizures good re- sults come from stimulation of the peripheral nerves by means of the faradic current. That it has, however, by the method of central galvanization, some influence over the frequency with which the paroxysms occur, experi- ence fully proves ; it is worthy of further trial.2 Exophthalmic Goitre.-Graves' disease, supposed to be due to enervation of the sympathetic, is almost invariably benefited by galvanization. My method of treatment is to place one pole (the positive) just above the sixth cer- vical vertebra, and the other in the auriculo-maxillary fossa, gradually drawing it along the inner border of the sterno-cleido-mastoid muscle to its lower end. A mild current should here be used, and for two or three min- utes only. The negative pole being now removed to the region of the solar plexus, the strength of the current is increased, and allowed to pass for a much longer time. Nervous Dyspepsia.-In this and in most of the ordi- nary difficulties of the digestive tract, the faradic current is more especially indicated, on account of its mechanical effects, producing vigorous muscular contraction. It may be said also that both the constipation and nausea that are so frequently associated with, and constitute a part of, nervous dyspepsia, are often disposed to yield with more or less permanency to electrization. Sequela of Acute Diseases.-Electricity is often directly and rapidly efficacious in dissipating the effects that fol- low certain acute diseases, of which are to be especially noted cerebrospinal meningitis, diphtheria, and intermit- tent fever. In the paralysis of diphtheria the faradic current is of well-recognized value, and its application should in ob- stinate cases never be neglected. In chronic cases of intermittent fever also, when quinine and other tonics have failed to entirely arrest the symptoms and to build up the system, undoubted benefit has often followed the use of general faradization. Paralysis.-In hemiplegia, due to brain lesion, little if any benefit is to be derived from applications made directly to the head for the purpose of causing absorption of the effusion, and a careless use of the current might induce serious results. Much good may, however, be accom- plished when there is impaired electro-muscular contrac- tility, by persistent galvanization or faradization of the paralyzed muscles. In the electrical treatment of infan- tile paralysis, whether essential in character and associ- ated with organic changes, or simply peripheral and reflex, we must be guided in the selection of the proper current by the phenomena of muscular contractility. If the muscle responds with considerable readiness to the faradic current it is seldom necessary to resort to galvanism. If the far- adic current induces but feeble contractions; its use may be alternated with the galvanic, but if there be no response to faradism, the galvanic current should be alone relied upon till there is some indication of returning farado- muscular contractility, when the faradic current should be gradually substituted. These rules must, of course, be considered as only approximate and not absolute. Of the many forms of peripheral paralysis, facial is, perhaps, the most frequent and important. The diag- nosis is made easy, not only because in paralysis of the seventh pair of central origin the eye can be closed, wffiile if the cause is peripheral the orbicularis palpebra- rum muscle is paralyzed, preventing complete closure of the lids, but also because the muscles readily respond when the origin is central, while in purely peripheral cases the muscles either respond but slightly or not at all to fara- dism. In these cases, however, the galvano-contractility is, as a rule, either normal or increased. The prognosis of facial paralysis is, in general, exceedingly favorable, the differential indications for the use of the currents being much the same as in cases of infantile paralysis. In lead palsy, farado-muscular contractility is lost. The affected muscles are most successfully treated by mild, interrupted galvanic currents. The associated colic may sometimes be subdued by galvanization of the coeliac. In paralysis agitans, progressive locomotor ataxia, pro- gressive muscular atrophy, writers' cramp, and angina pec- toris, electricity, more especially in the form of galvanism, often greatly alleviates the symptoms, but rarely effects a cure. Dilatation of the stomach, due, not to organic lesion, but to atony or paralysis of its muscular fibres, is greatly benefited by electricity. In incontinence of urine in chil- dren, galvanization of the lower part of the spine some- times proves of service, and in spermatorrhoea and impo- tence electricity is of much value. Not only has galvanism been used successfully in opacities of the vitreous body and occlusion of the pupillar aperture, but it is claimed also that in white atrophy of the optic nerve, consecutive to neuro-retinitis, the disease may be arrested by the action of galvanism on the encephalic circulation, through the cervical ganglia. In subacute articular rheumatism elec- tricity is of unquestioned value, but in the chronic variety it is of doubtful efficacy. In chronic and deep-seated mus- cular rheumatism franklinic electricity acts well, and fre- quently relieves after other efforts have failed. Diseases of Women.-The diseases of women for which electricity has been used with greater or less success are, the disorders of menstruation, uterine displacements and engorgements, sub- and superinvolution of the uterus, fibroid and ovarian tumors, ovarian neuralgia, ovaritis, salpin- gitis, chronic pelvic cellulitis, and extra-uterine pregnancy. The methods by which most of these conditions are treated are well known, and will be found described in most works on electro-therapeutics. The relation of electricity to chronic pelvic cellulitis and extra-uterine pregnancy, however, are not so well understood. In the former condition the galvanic current acts by causing ab- sorption of the exudations. It must be applied internally and locally, care being taken to use currents neither too strong nor too prolonged. Persistent efforts will result not only in a reduction of the enlargement, but in dissipation of various painful symptoms, as sciatica and incomplete paraplegia, resulting from pressure of the exudation on the pelvic floor. Extra-uterine Pregnancy.-It is now thoroughly estab- lished that for this dreaded complication, if detected by the third or fourth month, we have in electricity a safe and sure antidote. Both currents have been used suc- cessfully, but my own preference is very decidedly for galvanism. It is more certain in its effects than faradism, and equally safe, and in the many cases that I have treated, and all successfully, the galvanic current alone has been used. After the destruction of the foetus it becomes en- cysted and gradually absorbed. There has existed, and still exists, even among those who should be better in- formed, a gross misconception of the method to be em- ployed in this condition. The great merit of the operation is its simplicity. Needles are not used. One electrode (the negative) is in- troduced to the foetal nest, either through the vagina or rectum, while the other (the positive) is applied over the lower part of the abdomen, and the foetal life is destroyed by rapidly interrupted shocks. If properly employed, this treatment results in but little if any pain to the mother. A. D. Rockwell. 1 For a more exhaustive exposition of this subject, and also of central galvanization, see Beard and Rockwell's Medical and Surgical Electricity, fourth edition. Wm. Wood & Co. 2 See N. Y. Medical Record, April 6, 1878. ELECTRICITY IN SURGERY. It is not the writer's intention to treat here of the applications of electricity in the diagnosis or treatment of paralytic affections which lead to deformity, or in many other cases which might properly be called surgical. The detection of a paretic condition of muscles as figuring in the etiology of club- foot, for instance, is in no wise different from the similar examination of a purely medical case, and the treatment of the condition is based on exactly the same general principles. And so, while atony of the bladder, func- tional disability of the sphincter ani, ptosis, strabismus, etc., are troubles which most often fall into the surgeon's hands, their treatment by electricity may be just as effec- tively carried out by the practitioner who disclaims all 654 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Electricity. pretensions to being a surgeon. Excluding, then, for present purposes, all cases of such a nature, we may say that the surgeon, as such, uses only the continuous cur- rent, and for the following purposes : I. For its chemical effects : Electrolysis. II. For its physical effects in causing heat: Galvano- cautery. III. For this same effect in sufficient intensity to pro- duce light, for diagnostic purposes. IV. For its correlation into motion in actuating various surgical engines or other instruments. I. Electrolysis.-By this term is meant a chemical decomposition whose exciting cause is the galvanic cur- rent. The reader will remember that it was by the de- composition, by this means, of ordinary potassa that the metal potassium was discovered. Two simple experi- ments will serve to illustrate the surgical uses to which this current may be put. Let the two terminal wires of any battery be immersed in the white of an egg which has been poured into a teacup. Immediately the albu- men coagulates about the negative (zinc) pole, while a froth of bubbles of gas will collect about the other. By a similar process the blood is coagulated in vascular tumors. Again, let a piece of lean beef be placed between two small metallic plates con- nected respectively with the poles of a galvanic current, say of fifteen cells. The more or less rapid change which takes place in the flesh when the current passes through it will illus- trate what takes place when electrolysis is practised in a tumor- in modified form, how- ever, since conditions within the living body can never be the same as those obtaining in a piece of lifeless flesh. Respecting the pro- cess itself, it must be remembered that suc- cess depends in no small degree upon methodical skill, care, and thoroughness, combined with an exact knowledge of the laws of electro- physics and electro-physiology. Until at least the rudi- ments of the latter are obtained, one had best not attempt even the simplest electrolytic operation. It must be borne in mind that coagulation of albumin- oids occurs by preference around the negative pole. If one were trying to secure a coagulum in the effort to cure an aneurism, for instance, while the negative needle would be apparently the best one to introduce into the tumor, the clot which would form around its point with- in the sac would be not only loosened when the needle was withdrawn, but would render such withdrawal diffi- cult, and might even endanger the integrity of the sac. The electrolytic procedure, therefore, must always be tempered by reason and judgment. For electrolysis there are needed battery, conductors, needles, and electrodes. The battery may be of almost any pattern, either of gravity cells, or of some form of small zinc-carbon cell using the potassium bichromate solu- tion, the latter being more portable. More than twenty cells are rarely needed. A. rheostat, though advanta- geous, is not essential, provided there be some provi- sion for bringing any desired number of cells into use without breaking the current. The conductors and elec- trodes are of the ordinary patterns. Various sorts of needles are made by various dealers; moreover, with a little ingenuity any one may contrive for himself such a device as shall answer the needs of individual cases. For work on superficial surfaces of the body the needles need not be insulated, but for deep work they should in most cases be insulated nearly to their points, else the electrolytic action would be exerted where it was not wanted. For full and detailed information the reader should consult some of the numerous works devoted especially to surgical electricity. Zinc needles have been recommended by some operators, with the idea that the zinc chloride, which would be formed by the chemical action of the current, would exert a cauterizing effect on the tissues to be attacked. Let us now suppose that we have a simple naevus of the cheek to treat. A single needle will answer the purpose, or two held in some form of clamp ; these are connected with the negative pole. To the positive (carbon or cop- per) pole is attached an ordinary sponge electrode, the sponge having been moistened with salt water, which makes it a better conductor. This may be applied to the face in the neighbor- hood, or held in the patient'shand-itmat- ters little, so long as it touches his body somewhere. The pa- tient being held firm- ly, if an infant (anaes- thesia may be fre- quently dispensed with), the needle is plunged into the growth to a depth suffi- cient to insure that the point is near the centre of the mass. The cur- rent is then turned on, cell by cell, until, in such a case as this, from five to eight cells are in the circuit. In a few seconds the skin at the site of each needle puncture may be seen to turn white, and perhaps minute bubbles of gas will es- cape. The position of the point should be changed every few seconds without en- tirely withdrawing it -in other words, without multiplying external punctures. If the growth be very vascular, a little blood may ooze from the puncture as the needle is withdrawn ; otherwise the little operation will be quite bloodless. The current is to be passed for from three to ten minutes in the aver- age of such cases, when the cells are shut off one by one and the needle withdrawn. There is usually some local reaction after this procedure, but it will probably subside within thirty-six hours. After from two to four or six weeks the operation may be repeated, if desirable, several sittings being preferable to the risk of overdoing the mat- ter in a single sitting. The following comprise the most common surgical af- fections which yield with more or less readiness to elec- trolysis. Aneurism.-In the treatment of aneurism the Italian surgeons have been, perhaps, more successful than those of any other nationality. Two methods have been em- ployed : in the first, a single needle is inserted into the tu- mor, while a rheophore or electrode is applied somewhere on the surface of the body; in the other, and better, meth- od, especially for aneurisms of considerable size, fine, sharp needles, insulated almost to their points, and con- nected with each pole of the battery, are employed. By this means a double clot is formed, while resistance is Fig. 988.-Galvano-faradic Co.'s Cautery Battery. 655 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. much reduced, and, the blood being the best electrical conductor, when the poles are nearer together a milder current will suffice. The current should be very gradually increased in strength, and no sudden changes nor discon- tinuance should be permitted. In case of large tumors an anaesthetic will probably be required. Angeiomata, Noevi, Erectile Tumors, Mother's Marks.- Inasmuch as these vascular tumors appear in great vari- ety, only the general principles of treatment can be given here. First of all, it must be understood that electrolysis does not necessarily cure them without leaving a cicatrix. In many cases a certain amount of tissue must necessarily be destroyed in order to destroy the integrity of the growth, and this can hardly be accomplished without leav- ing a trace. With a small naevus in a young, growing child, the slight resulting scar will probably be outgrown. In the next place, electrolysis is by no means painless, and local or general anaesthesia may be required. For this purpose we may expect some good from cocaine. Details must differ with individual cases. If the tumor be small, one needle may be used, the sponge or carbon electrode (usually connected with the positive pole) being applied, and by introducing needles connected with the positive pole, there is no reason why the electrolytic method should not give a large measure of success in the treatment of varicose veins, especially of the lower extremities. Hemorrhoids.-The same is true of haemorrhoids ; the operative procedure is practically the same, though a greater number of needles may be advisable and an an- aesthetic may be required. Goitres.-Beard advises that these be treated with sharp, bayonet-shaped needles, either insulated or not, the former being but little more difficult of introduction than the latter. The advantage of the latter is, that by the action which takes place around the needle connected with the negative pole, it becomes so far loosened that it may be easily pushed farther. For all goitres the nega- tive pole is much preferable to the positive. The circuit is best completed by a sponge (posi- tive) electrode ap- plied over the sur- face of the tumor. Local anaesthesia is usually all that is required. Some- times reflex distur- bances, such as nausea, faintness, etc., may be ob- served. Treatment may be repeated twice a week. This may be alternated with external gal- vanization and faradization with pretty strong cur- rents, which o f themselves a r e often sufficient to cause considerable reduction in the size of goitres. The prognosis must depend large- ly on the exact na- ture of the mass. Small, soft goitres may entirely disap- pear ; so may even large ones, p r o - vided they are not too hard. The cys- tic varieties usu- ally yield satisfac- torily. Improve- ment is always most rapid at first ; the last quarter of the growth will be longer in disap- pearing than were the first three- quarters. What has been said above has no reference to exoph- thalmic goitre, which is in no proper sense a surgical dis- ease, although treatment by electricity is an important adjunct in the management of such cases. Cystic Tumors.-The effect of the galvanic current on the contents of a cyst is complex. The fluid is decom- posed, the gaseous products either escaping through the needle punctures, or finding their way, after distending the cyst, by osmosis into the blood-current. The cyst walls are excited to absorb the contained fluid, and thus the size of the tumor is diminished. When non-insulated needles are used the cyst wall is itself acted on. By way of the puncture more or less of the fluid may leak into the tissues and be there absorbed-this occurring espe- cially when the negative pole has been introduced. Fig. 989.-DawEon's Cautery Battery. applied to any other convenient or accessible point. The needle may be connected with either pole; when with the positive, the clot 'will be small but firm ; when with the negative, the action will be more violent and diffused, but the clot will not be so firm. If the tumor be large, needles connected with both poles may be used. It is also some- times an advantage to reverse the current. Insulated needles are less necessary here than in other cases. The duration of the operation may be from five to thirty min- utes, according to the size of the tumor and strength of the current. It will be best, after inserting the needles, to begin with, say three cells, and gradually increase till the desired effect is gained. The feature calling for the greatest display of judgment is in the matter of doing neither too little nor too much ; timidity is as bad as fool- hardiness. When dealing with large subcutaneous naevi it is necessary to attack not only the growth itself, but the surrounding tissues and their enlarging and tortuous vessels. Varicose Veins.-If care be taken to prevent disturb- ance of the clot, by the use of a tourniquet not too tightly Fig. 990.-Bruns' Cautery Battery, as made by the McIntosh Co. (For office use.) 656 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electrlcity. Electricity. Both poles should be introduced, the positive one being kept quiet while the negative is moved in various direc- tions, so as to set up action at numerous points. Ovarian cysts have been electrolyzed as well as others. This, of course, means puncture of the peritoneum, with various unpleasant possibilities in the way of more or less inflammation, adhesions, etc., which might complicate subsequent extirpation should radical operation be neces- sary later. It is not, therefore, recommended. Hydatids are practically cysts, and are amenable to ex- five to ten days, and last for twenty minutes, the positive and negative electrodes being both introduced to a depth of 8 ctm., with a current of forty to fifty miliamperes. He reports excellent results, much better, in fact, than those generally obtained. Nasal and naso-pharyngeal polypi have been attacked on the same plan, and not without a measure of success. They are usually so accessible that in cases of fibroid polypi springing from the base of the skull, which have a certain degree of malignancy, it would be only proper to give the method a fair trial. Malignant Tumors.-Success with tumors of this na- ture is usually very meagre. It may be possible to effect some reduction of size, and not infrequently pain may be alleviated. It is claimed that epithelio- mata of limited size, and not too greatly disseminated through the surrounding tis- sues, may be positively cured by thorough and persistent treatment; but it will be found that this claim is made by only a few, and is not substantiated by the gen eral verdict of surgeons of large clinical experience. Removal of Superfluous Hairs from Moles, etc.-It is well known that simple epilation does not permanently remove hairs, since the hair-bulbs are not thereby destroyed. Remedies which reach deeply enough to do this are too powerful to be applied to the skin. The only sure method of reaching the bulb without damaging the other cuticular structures is to resort to electrolysis of the hair-follicle. For this purpose not more than five cells are needed. While elaborate needle-holders are made for this or similar purposes, nothing answers the purpose any better than a fine domestic needle held in the or- dinary needle-holding forceps of the pock- et-case, and connected with the negative pole of the bat- tery by means of a wire twisted around the body of the needle. The patient holds the moistened sponge electrode (positive) in the hand. The surgeon then passes the point of the needle right alongside each hair to be removed, and to such a depth that its point must be in the follicle. Within from five to ten seconds, according to the strength of the current, a minute bubble of white foam will be seen to issue alongside of the needle. The latter is kept in situ for from ten to twenty seconds and then removed. If the little operation has been properly per- formed the hair may now be removed with tweezers, and removed with surprising ease, and, the follicle being destroyed, it will never reappear. In cases of trichiasis the method is equally applicable, but may be facilitated by a lid clamp and the use of a lens, since some of the most troublesome ciliae are very fine. A slight local sore- ness of short duration is caused by the treat- ment, but it soon passes off. While this method is very effective with the hairs attacked, I have some- times seen the growth of fine hairs in the immediate vicinity stimulated to an annoying degree. Urethral Strictures.-In these cases electrolysis has been practised and recommended by Tripier, Mallez, Brenner, Clymer, Newman, and others. The electrode used resembles an ordinary catheter, consisting of an in- sulated metal sound, of small size, with a number of Fig. 991.-Cautery Points. actly the same treatment, which, if thorough, should also destroy any contained parasites. Hydrocele is also an encysted collection of fluid, and is treated electrically in the same way. Mere evacuation, however, is not enough ; it is necessary that the inner or secreting surfaces of the sac should be thoroughly acted upon. Benign Tumors.-Fatty tumors are hardly of a nature to be affected by the galvanic current, and are probably always best treated by the knife. Cartilaginous and bony tumors are too firm and resistant, and for the same reason should be submitted to more strictly surgical pro- cedures. Tumors composed of fibrous and muscular tissue will occasionally behave satisfactorily under the influ- ence of the electrolytic current, though decomposition, shrinkage, and atrophy will be slow in proportion to their hardness. They are to be treated by needles connected with both poles, insulated or not, according to circum- stances. With the patient anaesthetized and a current of sufficient strength, so much decomposition may be ef- fected as to cause subsequent suppuration. Uterine fibroids, when still small, may be diminished in size, their growth checked, and the pain and attending evils re- lieved ; but it is not likely that, in non expert hands,, a large uterine myo-fibroma will be dispersed, or largely benefited, by this line of treatment. If it be desired to make the effort, however, such a one may be attacked either by the vagina or by thrusting the needles directly through the abdominal wall. If the peritoneum is to be punctured, smaller and well-insulated needles must be used, in which case there is little risk. The best results are achieved with mural growths. At the Eighth In- ternational Medical Congress (Copenhagen), 1884, Dr. Meniere, of Paris, strongly advocated the destruction of uterine tumors by electrolytic punctures through the ab- dominal walls. He uses a Gaiffe battery of twenty-four pairs, a galvanometer, gold needles 10 ctm. long, 1| mm. thick, with lance points insulated for a distance of 7 ctm., with a stop arrangement by which they can be inserted only to a given depth. The sittings are repeated every Fig. 992.-Cautery Knives. 657 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. egg-shaped metal points, of various sizes, which may be screwed upon its distal end. This is introduced into the urethra until it comes in contact with the adventitious cicatricial tissue ; the circuit being completed by a moist- ened electrode (positive) applied to the perineum or on the thigh. It is hardly necessary to say here that this treatment is only intended for organic strictures ; spas- modic strictures would be greatly aggravated by it. The number of cells to be used must depend partly on the nature of the case, partly on the sensations and suscepti- bility of the patient. Weak currents causing electrolysis are all that are necessary ; strong, destructive currents are to be avoided. First of all, exact topographical knowledge of the par- ticular urethra to be dealt with must be gained, and the location and size of each stricture be mapped out. An- aesthetics are not needed, since painfully strong currents are not to be used. The point to be screwed on the elec- trode should be about three sizes (French) larger than the stricture. After the introduction of the instrument up to the site of narrowing, the current should be turned on, one cell at a time, till a warm pricking sensation is experi- enced by the patient. The operator must then keep the bougie applied against the thickened tissue, guiding, not pushing, it in the correct line ; he will feel it advance, sometimes slowly, sometimes rapidly, until the obstruction is passed. It must then be passed to the next, and so on till the blad- der be gained. It should then be with- drawn carefully, each stricture being reamed out, as it were, on its way out, the current being now slowly reduced to zero. The sitting may last from five to thirty minutes. In three or four weeks it may be repeated. No force should be used ; the appear- ance of a single drop of blood shows that the method is being overdone. The in- troduction of a point of a given size down to and be- yond the stricture, a single time, is enough for one sit- ting, and no sound should be passed at the time. The bougie should not be run up and down the urethra as if it were a plaything; it must be passed once with care, and only once. These are, in brief, Newman'S directions. He has been able to prove, post mortem, that if they are exactly carried out, there may be such perfect absorption and dis- appearance of all adventitious tissue that no trace of stricture is left. Rectal Strictures, etc.-It has been pro- posed by different observers to work on this same principle in treating strictures of the rectum, the oesophagus, the nasal duct, etc., and some excellent results have been reported ; still, with insuf- ficient testimony, the writer does not feel like committing himself further than suggesting the advisability of test- ing the merits of the electrolytic method in these affec- tions. Even if ineffective, it will prove harmless, pro- vided it be practised according to the general principles above suggested. Ulcers and Bedsores.-For intractable ulcers a method of stimulation by a very mild galvanic current has been devised, which may at times prove of value ; it may, moreover, prove of service in certain pressure sores. A piece of very thin silver foil is cut to such a shape as to fit the ulcer surface. (Such foil may be easily made by hammering out a silver coin.) A piece of thin sheet zinc, of any convenient size, is then bent and warped so as to adapt itself to some contiguous sur- face of the patient's body. It must have a prolonga- tion in such direction that it may reach out toward and touch the silver foil when both are in situ. The ulcer surface, which should have been made as clean and healthy as possible by previous treatment, is now covered by the foil. To the surface, to which the zinc is fitted is first applied a layer or two of lint or canton flan- nel moistened with vinegar, or some very dilute mineral acid. Over this the zinc is applied, with its projection so bent and directed as to press with some firmness on the silver, and the whole is then bandaged in place. By the action of the weak acid on the zinc a very mild current is generated which, acting for a few moments, ■would have no perceptible effect, but, kept up for days, will fre- quently furnish the desired stimulus to granulation. The lint is to be moistened occasionally, say every six hours, and the location of the zinc altered from time to time, in order that the skin may not be too irritated by the acid. It is hardly worth while to continue this for more than a week at one time, a better plan being to alternate with some such dressing as a saturated solution of potas- sium chlorate. II. Galvano-Cautery.-The galvano-cautery is based upon the well-known principle that, when a powerful current is passed through a small conductor, one prefer- ably of high resistance, a high degree of heat is generated. For this particular purpose the metal platinum is used, not merely because its resistance is considerable, but be- cause its melting point is so high. Furthermore, while for electrolysis a quantity current is not preferable, but rather a current of considerable tension (such as is gen- erated by elements of small size in greater number), for the cautery we need a battery of large cells, few in num- ber, generating what is known as a quantity current. Various models, devised among others by Byrne, Dawson, Fig. 994.-Small Galvano-caustic Operating Set. and Seiler, are made by the various manufacturing firms at home and abroad, and leave but little to be desired. Fig. 988 represents the Galvano-Faradic Company's; Fig. 989, Dawson's ; in Fig. 990 is shown the arrangement suggested by Professor Bruns, as made by the McIntosh Company, of Chicago. They are usually constructed of two large cells containing zinc-carbon, or, better still, zinc-platinum elements of large surface. The fluid used is a strongly-acidulated solution of potassium bichromate, and the current which they generate is one, compara- tively speaking, of great quantity. Small, portable hand-dynamo machines have been sug- gested for the same purpose, but have hardly yet been made marketable. For surgical purposes the cautery is used in forms like the old cautery irons, in rude knife-shapes, and in ecraseur loops. The former are represented in Fig. 991 in several forms, while in Fig. 992 are shown various shapes of the galvano-caustic knife. One form of the galvano- caustic ecraseur is shown in Fig. 993, and numerous other models are made by foreign and domestic makers. In all of them the loop of heated wire may be tightened up and diminished in size just as in the ordinary ecra- seur. Fig. 994 shows a small set of galvano-caustic instru- ments which include all that are necessary in ordinary practice. For work in the throat and larynx special instruments Fig. 993. - Gal- vano - caustic Ecraseur. 658 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Electricity. are needed, and admirable models have been given us by Schroter, Seiler, and others. In Fig. 995 is shown Schrdter's complete set, which can, of course, be used with any battery. The galvano-cautery has these advantages over the actual or thermo-cautery : it is under complete control of the operator's will, both as to duration and as to intensity of effect ; it diffuses less heat to parts and tissues which it is not desired to affect ; and it can be used in cavities and in ways not permitted by the others. Its use is attended by the disadvantages that, although portable, it is cumbersome; that fresh fluids have usually to be prepared for it; that the fluids themselves are more or less caustic, and need to be handled with care ; and that a skilled assis- tant should always b e employed to man- age it. The advantages of the galvano- caustic over other methods of operat- ing are : It saves much loss of blood. The particularly desirable effects of a cautery are secured. Fairly accurate localization of ac- tion. Little pain results, as also little danger. It is serviceable in deep cavities- nasal, pharyngeal, laryngeal, rectal, vaginal. As compared with other operative methods, it has these disadvantages : Liability to secondary haemorrhage is not diminished. Healing by first intention is, of course, out of the question. Considerable pecuniary outlay for apparatus of limited serviceability. The special purposes for which this cautery is commended may be summed up as follows, after Beard and Rockwell: Cauterization of ulcers, chancres, etc. Cauterization in such affections as follicular pharyngitis, trachoma, etc. Cauterization of malignant or fun- goid tumors to check bleeding. Cauterization of the bases of ma- lignant tumors and of the surround- ing tissue after removal by the knife. Cauterization of erectile tumors, varicosities, etc., to cause coagula- tion. Removal of haemorrhoids. Use as a moxa, in spinal difficulties, neuralgias, etc. Cauterization with a view to subsequent tissue con- traction, as for cure of enlarged tonsils, or of prolapsus uteri, cystocele, rectocele, etc. Treatment of various fistulae and sinuses. Removal of benign and malignant tumors, especially when pedunculated, in any of the cavities of the body, in order to avoid haemorrhage. Amputation of diseased organs or parts of organs, as of tongue, cervix uteri, penis. For purposes of ignipuncture. Among practical hints in using the galvano-cautery are the following: Solutions should be renewed before using; not merely strengthened by a little more acid. When zinc plates become too greatly corroded, their distance from the carbon or platinum plates becomes increased, the in- ternal resistance augmented, and the battery power cor- respondingly decreased. Just before an operation the apparatus should be carefully tested, to make sure that everything is in good working order. Battery connec- tions should be kept bright and clean. The battery itself, during the actual operation, should be in the hands of a skilled assistant, who shall devote his entire time to its proper working, and who should use a bellows or air-bulb, if necessary, to prevent, by this agitation of the fluid, the bubbles of hydrogen from clinging to the plates and thereby impairing the power of the battery. The strength of the current must be carefully adapted to the size of knife or length of wire used; and if the latter be em- ployed, the current must be diminished as the loop is shortened up. If knife or wire be made too hot, it will cut through the tissues too readily, and there will be fail- ure in the desired prevention of haemorrhage. In the case of the loop, the temptation is strong to shorten it up too rapidly; in other words, to hurry the operation too much. Fig. 996.-Combined Battery and Hydrostatic Apparatus. Fig. 995.-Schrbter'B La- ryngeal Cautery Instru- ments. Fig. 997.-The Urethroscope in Position. When shape and position interfere with the proper appli- cation of a wire-loop, a preliminary groove may be first burned around the object with the hot knife. In an oper- ation in which the battery is only to be used at intervals, the plates should be lifted out of the fluid when not needed, in order that battery power may be economized. 659 Electricity. Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. III. The Electric Light for Diagnostic Purposes. -With the development of the application of electricity to surgery, and to general illuminating purposes, came crude efforts to employ the hot wire as a source of light for di- this laryngoscope very beautiful photographs of the larynx have been obtained. An excellent illumination is obtained, while heat is prevented by a current of cool water constantly circulating through the instrument, the Fig. 998.-The Cystoscope. agnostic purposes. The white-hot loop may be readily used to shed forth light, but it also gives out heat in pro- portion ; hence its disadvantages. But for purposes of pure diagnosis we desire illumination without heat. La- zarewicz, Schramm, and Bruck all worked at the problem of trying to make parts translucent or diaphanous by a powerful light, either reflected or electric. Bruck, in- deed, devised a diaphanoscope which was a step in ad- vance, though it now seems to us very clumsy. The suc- cessful application of the principle involved in Bruck's original diaphanoscope to the examination of visceral cavities required not only great ingenuity in device, but also workmanship of very high order. This was ac- complished by Josef Leiter, the well-known instrument- maker of Vienna. Before Leiter entered on the construc- tion of his apparatus, Nitze, of Dresden, and his instru- ment-maker, Deicke, had constructed instruments for the water current being main- tained by the hydrostatic power of the leaden weight shown in the sectional cut. The urethroscope is shown in use In Fig. 997, and the cystoscope in use in Fig. 999, while the construction of the latter is shown in Fig. 998. Other instruments constructed on the same general principles were adapted for examining the ear, nose, pharynx, mouth (for dentist's work), oesophagus, rectum, and vagina, for none of which can space be spared here. Thegastroscope, however, deserves here a brief description. In the construction of this instru- ment the most difficult problem ever yet offered the surgical instrument- maker has been solved. How thoroughly satisfying the solution is may be a question open for discus- sion, but the above statement will hardly meet with a denial from any person familiar with the problem. The earlier instrument figured in Lei- ter's brochure is probably the most complicated ever invented for the surgeon's use; in fact, its complex- ity almost prevented its use even on the cadaver. Professor Gussenbauer has told me how he was once trying to use it on a patient, and, in the ef- fort to withdraw it, drew up a thin strip of mucous membrane nearly as long as the instrument. The patient, however, recovered without any trouble. The problem was in this stage of development when Leiter enlisted the aid of Mikulicz, then a Privat Docent of surgery in Vienna. They attacked it together regardless of out- lay, and with the result figured in Fig. 1000. By the curve at F not only is the introduction of the instrument facil- itated-it having been found impos- sible to pass a perfectly straight tube so far as is necessary for this purpose-but it will be seen that, with partial rotation of the tube about the long axis of the straight portion, the ex- tremity carrying the win- dow and the light makes quite an excursion, and permits the view of a much more extensive sur- face than would be pos- sible were no such excur- sion made. This fact will be still better appreciated by a glance at Fig. 1001, which represents the instru- examination of the urethra, bladder, larynx, and stomach. Of these only the first named proved serviceable on the living patient; the next two could be used on the cadaver, and the last named was useless. His experiments showed correctness of principle, but faulty device and make. Conversant with these facts, Leiter undertook the recon- struction of Nitze's urethroscope, and the construction (Ze now of the instruments for the bladder, larynx, and stom- ach, as well as those of entirely original plan for other parts of the body. The problem in construction to be overcome was a complex one: to secure a neat' and easily manipulated model ; to combine in this the insulated conductors for the electric current, the two tubes for the free passage of cool water about the heated wire without touching it, and in most of the instruments a free and unobstructed tubu- lar passage for light to pass to the observer's eye; and, finally, to make the instrument thoroughly practicable, and not too expensive. To accomplish all this was to over- come no small mechanical difficulties. This is hardly the place in which to describe these in- struments in extenso. The writer has already done this in the Annals of Anat, and Burg., March, 1883, to which he would refer the interested reader. From this article the figures accompanying this brief description are taken. Fig. 996 represents the combined battery and hydro- static apparatus, attached to the laryngoscope, L. With Fig. 999.-The Cystoscope in Position. 660 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Electricity. ment in situ, the dotted lines showing its possible posi- tions. Moreover, as it is provided with an optical system, rota With this instrument I have seen the pylorus, for in- stance, much as one views the optic disk with the ophthal - moscope, and of a bright blood-red hue like the retina ; and whenever I have seen it, it has been in constant, almost peristaltic motion, as of opening and shutting. Whether this motion was induced by the presence of the tube, or not, I cannot say. Besides these large and expensive instruments, we may call attention to a small one made by Trouve, of Paris, and called by him a polyscope. It consists of a variety of small reflecting cups, containing fine platinum strips which, when heated, give out quite a bright light. Ac- cording as these cups are arranged the light is thrown in different directions. With one arrangement of the cup and the addition of a mirror, we have an admirable laryngoscope and rhinoscope. A n - other reflector per- mits thorough ex- amination of the mouth and teeth, andeven diaphano- scopy of the latter. All these parts, with a number of small g a 1 v a n o - caustic knives and points, fit in a small handle. Fig. 1002 shows an otoscope de- vised by the writer, but constructed much on the same general principle. It may be used either in the dark room or in broad daylight. All the instru- ments so far de- scribed depend for light upon a coil of platinum wire heated to white heat. They were all devised before the incan- descent vacuum lamps of very small size had come into general use. Since then numerous experi- menters and mak- ers have construct- ed very small ones, and have made them practically useful - among others Trouve, Raid, St. Clair, and others. We figure here (Fig. 1003) a small instrument made by the White Manufacturing Company especially for dentists' use, but which can be used in the rectum, va- gina, etc. It is of convenient size, good model, requires small battery power, and will be found useful. Fig. 1004 represents a very similar apparatus made by Meyer. The small and very portable battery which is sold with it is an excellent one. The St. Clair lamp and battery are shown in Fig. 1005. They are the device of Dr. St. Clair, of Brooklyn, N. Y., and are the most perfect of their kind that the writer knows of. The light is, considering its size, a most brilliant one, and in the writer's hands has been of the greatest service both in making various examinations Fig. 1001.-The Gastroscope in Position. tion of the instrument to- ward a given point of the mucous membrane causes its image to be enlarged, while as it is further re- moved the image is dimin- ished, the field, however, being at the same time en- larged. At a distance of two centimetres the image is of natural size. The " definition " of this system is excellent, and, granted a tolerance of the instrument on the patient's part, and the requisite skill on that of the ob- server, a very satisfactory examination can be made. By means of two instruments, intro- duced at different times, nearly the whole inner surface of the stomach may be seen. There must necessarily remain some portions inaccessible to the observ- er's eye; but, fortunately, these are the portions of least interest, being least often the site of pathological changes. Fig. 1003.-T$e White Stomatoscope. Fig. 1002.-Park's Electro-otoscope. 661 Electricity. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Elephantiasis. and in operations of various kinds. A small cautery- loop accompanies the battery. Any of these lamps here fig- ured may be worked by any of the various storage batteries now on the market. This is not the place to dis- cuss the matter of secondary batteries and the so-called " storage of electricity." For information on this point the writer would refer to his paper on the subject read before the Chicago Electrical Society, January 15, 1883.1 The sub- ject is of prime importance to every surgeon who employs electricity in his work. Besides these, Helot, of Rome, devised the arrange- ment of a small incandescent lamp, to be fastened in front of the ordinary head mirror of the laryngoscopic set. By means of the mirror behind it, and a convex lens in front of it, a quite brilliant light may be directed into the pharynx of the patient. IV. Electro ■ motors of Surgical Engines, etc. - Concerning the use of elec- tricity as a motive power for driving surgical engines, there is very little to be said. In hospitals, where a complete armamentarium is desired, or for the use of surgical special- ists, a device of this kind is extremely convenient; but first cost, liability to get out of repair, and limited range of applicability must, for the present at least, preclude their coming into anything like general use. by Dr. M. J. Roberts, of New York. Such an instru- ment, when working well, is a great advantage during Fig. 1006.-Roberts' Electric Osteotome. Fig. 1004.-The Meyer Light and Laryngoscope. the performance of many such operations as osteotomy, sequestrotomy, and the like. Roswell Park. 1 Published in the Chicago Medical Journal and Examiner, February, 1883. Also consult a paper by Morton, in Harper's Magazine, December, 1882, and the standard works on electricity. ELEMI, Br. Ph. (Elemi, Codex Med.). Of the several resins which at one time or another have been sold under this name, that in use at present is the one known as Manilla Elemi, and comes from India and neighboring parts of the Orient. The trees which produce it are sup- posed, without much doubt, to be species of Canarium, a rather numerous genus of tropical and very terebinthi- nous Asiatic and Polynesic trees. Of these, C. commune Linn, has been nearly identified as one source. It is a large, fine tree, with good-sized pinnate leaves, and open terminal panicles of small, bell-shaped, rather leathery white or green trimerous flowers. It is a native of Am- boyna, Luzon, Sunda, the Moluccas, and Penang ; prob- ably also of parts of India. Of the method of collection not much is known, but the Canariums are full of tur- pentine, which exudes in abundance when the bark is cut, and hardens upon exposure. Elemi is a soft, trans- lucent, grayish-white or yellowish substance, of pleasant aromatic odor, and rather terebinthinous taste. It comes in large cakes or masses, often very much contaminated with dirt, chips, and leaves. The British officinal de- scription is as follows: "When fresh, soft, granular, resinous, and colorless, but by keeping it becomes harder, and of a pale yellow tint. Odor, strong and fragrant, somewhat resembling fennel and lemon. Moistened with rectified spirit, it breaks up into small particles, which, when examined by the microscope, are seen partly to con- sist of acicular crystals." Composition.-According to Fliickiger it contains ten per cent, of essential oil, which may be separated upon fractional distillation into six portions, all of the turpen- tine series, CioILb, or CJL. The remaining resin is a com- plex mixture, from which several crystalline, resinous substances-amyrin, bryoidin, breidin, etc.-and amor- Fig. 1005.-The St. Clair Lamp aud Battery. Fig. 1006 gives an idea of an electric osteotome, devised 662 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Electricity. Elephantiasis. phous resins have been separated. Elemic acid is finally another ingredient. Action and Use.-Elemi is a local stimulant, like turpentine and resin, and put to the same uses. Its only employment here, and that is seldom, is as an ingredient of plasters and ointments. The British Unguentum Elemi is made of Elemi one part and simple ointment four parts. Allied Plants.-The genus Canarium comprises about fifty species of resiniferous trees, mostly Asiatic. For the order Burseraceoe, see Myrrh. Allied Drugs.-Of the other sorts of Elemi, the fol- lowing are described in the Pharmacographia : Mexican Elemi, which was common thirty or more years ago, is from Amyris elemifera Royle ; it is a light, brittle resin, in scraped, semicylindrical or irregular pieces. Brazilian Elemi, from several species of Idea, is a translucent, tere- binthinous resin. Mauritius Elemi, from Colophonia mauritiana D. C., resembles the Manila or (now) com- mon variety. African Elemi (the original classic variety), from Boswellia Frereana, Birdwood, is in transparent, amber yellowr, brittle tears and masses. None of the above have any present importance. For other resins, etc., see Turpentine. W. P. Bolles. The upper extremities are less frequently attacked than the lower, as are also, in diminishing ratio of frequency, the ears, the cheeks (Fig. 1007), the skin around the arms, and the female breast. It is doubtful whether isolated parts of the skin in other situations can be said ever to be the seat of this disease. In the lower extremity, it usually begins with the ap- pearance of an erysipelatous inflammation. There is more or less pain, fever, and swelling, preceded frequently by a chill. The vessels of the skin are often marked by red lines running for some distance above the affected portion. The skin is swollen, smooth, shining, painful, and hot to the touch. All these symptoms gradually disappear, leaving behind a slight hard oedema and thick- ening of the skin. The first attack is followed at long or short intervals by others, the oedema and thickening increasing after every one until the part affected is en- tirely changed in appearance and size. It was these changes in the contour of the lower extremity which first suggested the name elephantiasis. When the disease has progressed sufficiently, the epi- dermis becomes fissured and cracked ; papillomatous ex- ELEPHANTIASIS ARABUM. Syn. : Pachydermia, Dal til, Barbadoes leg, Elephantenfuss, Mal de Cayenne. Elephantiasis Arabum is a localized hypertrophic dis- ease of the skin and subcutaneous tissue, appearing after chronic or frequently repeated acute inflammation of the blood and lymph vessels, characterized by oedema, red- ness, and swelling. There is a gradual, sometimes an enormous, increase in size of the part affected, which may be accompanied by warty excrescences and ulcerations. Such a definition as the one just given is only useful after the consideration of many cases. In a given case any or many of the enumerated characteristics may be absent. The oedema in E. Arabum, for example, differs from the oedema produced by other diseases and other causes. There is less pitting upon pressure, and the press- ure must of itself be greater to make an impression. In some cases, far advanced, it is difficult to make any im- pression at all. The inflammation of the vessels, which is the starting point of E. Arabum, may be acute enough to resemble erysipelas, or chronic enough to be hardly perceptible. It is not proper, therefore, on the one hand, to state that erysipelas invariably precedes the disease ; nor, on the other hand, to fail in the diagnosis of it be- cause there has been no visible acute inflammation. It may be considered an exception, however, when the dis- ease attacks the lower extremity without acute inflam- mation. There has been in the past a great deal of confusion in the nomenclature of the two diseases, E. Arabum and E. Graecorum. They have been confounded, and each taken for the other, owing to the confusion produced by trans- lators of the Arabic and Greek languages. It has, how- ever, become the custom among authors of the present day to speak of E. Graecorum as lepra, and of E. Arabum as simply elephantiasis or pachydermia. Lepra is not E. Arabum, and should not be confounded with it, nor should the term Lepra Arabum be used to denote E. Arabum, as some authors have done. The two diseases have been known to occur upon the same person', but they are, never- theless, distinct. E. Arabum, although a pandemic disease, is most often found in hot climates near the tropics, particularly in Egypt, on the coast of the Mediterranean, the west coast of Africa, the Antilles (Barbadoes), Brazil, Malabar, parts of India, etc. The lower extremity is most frequently the seat of the disease, which is for the most part confined to the foot and lower leg below the knee. The whole leg (see ac- companying plate) as far as the hip-joint may become affected. It is usually confined to one extremity, but sometimes attacks both, as is seen in the same plate, where the lower part of the left leg is diseased. Next, in point of frequency, it attacks the scrotum and penis of men, the labia majora and minora and clitoris of women. crescences of enormous size, made up of conglomerations of many smaller ones, are seen ; and indolent, unhealthy, ever increasing ulcers follow, which secrete disagreeable- smelling serum and pus, while the lymphatics exude lymph in large quantities. After the disease has reached this point there is little or no pain, unless the fissures and ulcerations be so deep as to reach the deep-seated nerves. The principal dis- comfiture lies in the enormous size and weight of the leg and foot. Cases are on record in which the feet or scrotum have become so heavy that no motion of the body forward was possible without the assistance of a wheelbarrow, or raised platform on wheels, which might uphold the mass. Unless the afflicted one be forced to walk or stand, there is not much pain complained of. Next in frequency to the lower extremity, E. Arabum attacks the male (Fig. 1008) or female genital organs. They may be affected in part or as a whole. The scro- tum is sometimes diseased, the penis remaining normal, or vice versa. In the female the labia majora are most frequently attacked, the clitoris and labia minora being involved at the same time. The latter two parts may, however, be diseased alone. Usually one side of the vulva is diseased without the other. It appears upon the genitals most frequently without preceding erysipelatous Fig. 1C07.-Elephantiasis of the Cheek. (After Pruner.) 663 Elephantiasis. Elm. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. inflammation, though there may be systemic fever and localized pain. In this respect the disease attacking the' genitals differs from an attack in the lower extremities, where acute inflammation usually does precede or accom- pany it. The prepuce in the male becomes thickened and lengthened, and the skin of the whole penis gradually enlarges without necessarily involving the glans. When the disease affects the scrotum its folds and raphe become more prominent, until fissures, excoriations, and ulcers are formed, from which disagreeable-smelling exuda- tions flow. The urine dribbling from the penis, which, if not diseased itself, is imbedded deep within the ponder- ous mass, runs over the excoriations and keeps them irri- tated, so that sloughs may occur of sufficient seriousness to cause blood-poison and death. The same may be said of the female genitals. When the vulva enlarges, the mucous membrane is turned outward, and is so increased in area that it is exposed to all manner of traumata, which cause fissures, excoriations, and ulcers. The urine and menstrual flow irritate them until so great a surface is appear, hypertrophied. There is often a noticeable in- crease in the quantity of pigment in the Malpighian layer, and the capillaries are partially dilated. In some cases the lymph-vessels are intact, while the veins are promi- nently dilated, and accompanied with distinct hyperplasia of the adventitia (Schimmer). If the skin be cut with a knife, it is hard, resisting, and fibrous, the tissues, such as muscle and fat, being hardly distinguishable. The nervous tissue in cases of long standing is mostly destroyed, and the fluid which flow's over the cut surface is lymph exuding from the lymph-vessels. This escape of lymph explains the dif- ference between the oedema of E. Arabum and that of other diseases. In E. Arabum we have what might be called a lymph-oedema, which is followed by cell-prolifer- ation and consequent increase in the surrounding tissues. The general causes which produce this oedema are erysipelas, ulcus cruris, long-standing chronic eczema, varicose veins, thrombosis, obliteration of distant vessels, lupus, and syphilis-the latter two being the most fre- quent cause of the disease when it involves the upper ex- tremities. In hot climates the disease is endemic, and some other cause for it than those already enumerated has been sought for. Thanks to the labors of Wucherer, Salisbury, Lewis, Bancroft, Manson, et al., we are enabled to arrive at a definite conclusion regarding it, and to explain ex- plicitly its prevalence in the tropics. They have found that the embryo of a long, thin, thread-like worm, which has been named filaria sanguinis hominis, from its dis- covery in the human blood (Fig. 1009), is taken into the Fig. 1009.-Filaria Sanguinis. (After Lewis). circulation with the stagnant drinking-water so often used by the natives. In order best and most concisely to explain the habits of this singular destroyer of the human race, the con- clusions derived from Manson's valuable investigations are given in his own words. From a series of systematic examinations, made every four hours, he found that, " unless there is some disturb- ance, as fever, interfering with the regular physiological rhythm of the body, filaria embryos invariably begin to appear in the circulation at sunset; their numbers grad- ually increase till midnight ; during the early morning they become fewer by degrees, and by 9 or 10 a.m. it is a very rare thing to find one in the blood; " and, moreover, he was able to state accurately : 1. "The parent filariae live in the lymphatics ; this is proved by their young and ova being found there, even when absent from the blood. 2. "They do not live in the glands, but in the lym- phatic trunks on the distal side of the gland. Lewis and Bancroft found them in tissues some distance from any gland. 3. " They are oviparous. 4. " Their eggs are carried by the current to the glands, Fig. 1008.-Elephantiasis of the Male Genital Organs. (After Delpech.) unhealthy that sloughing takes place with perhaps fatal result. All these grave symptoms may not present them- selves if the mucous membrane changes its character and turns,as it sometimes does, into a pseudo-epidermis which is thick and resisting enough to protect the underlying tissues. The causes which produce the disease are numerous. As a general rule, it may be said that anything which hinders the flow and favors the escape of the lymph in the lymphatics, whether it be produced by an inflamma- tion of the blood-vessels, or of the lymphatics themselves, or from external pressure, tends to 'an increase of the cutaneous and subcutaneous tissue. Under the microscope we see the epidermis sometimes very thin, and sometimes very thick, depending upon the changes in the papillary layer. Where the papillae are atrophied the epidermis is thin above it, while it may be very much thickened if the papilla; are, as they frequently 664 Reference Handbook of THE Medical Sciences. PLATE 9. Elephantiasis Arabum I after Hans von Hebra. I H. BEKCKK, LI TH. N.Y. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Elephantiasis. Elrn. and being too large to pass, they are arrested till they are hatched. 5. " After hatching, the free embryo passes along the lymph-vessels and enters the general circulation. 6. " Resting in some organ during the day, it circulates with the blood during the night. 7. " Whence the mosquito abstracts it, and acts as its intermediary host. 8. "In certain cases the ova or embryos produce ob- struction of the lymph-circulation through the glands, either directly, by their size, or indirectly, by causing in- flammation. 9. "If the obstruction be partial, varicosity of glands and afferent lymphatics results, but by means of the an- astomoses the lymph-circulation is continuous, carrying the embryos with it into the blood. Lymph-scrotum, or chyluria, or varicose glands with haematozoa, are there- fore the symptoms of partial obstruction of the lym- phatics. 10. " If the obstruction be complete, one or other of two things happens : (a) The accumulating lymph so distends the vessels that they rupture, and a lymphorrhagia re- sults, which is more or less permanent. In this case the lymph does not quite stagnate, but, being able to circulate, though in a retrograde manner, it remains fluid. The symptoms of this form of obstruction are, therefore, lymphorrhagia from scrotum or leg, varicose glands, and filaria embryos in glands, and, perhaps, in discharged lymph, but none in the blood, (b) If the lymphatics fail to rupture, there is complete stasis of lymph and exces- sive accumulation in the tissues on the distal side of the glands; solidification of the glands and tissues, and ele- phantiasis, result. No embryos are found in the blood, as none can pass the glands, and the parent worms prob- ably die, choked, so to speak, by the stagnant and organ- izing lymph and their own young. Consequently, in pure elephantiasis, as a rule, no embryos can possibly be found in the blood- or gland-lymph." London Lancet, vol. ii., 1880, p. 792. Later investigations have shown that the embryos cir- culate during sleep without regard to the night-time. If those suffering from the disease change their habit and sleep during the day, remaining awake at night, the habit of the filaria is changed at the same time, for they then can be found only during the day, and not at night. The author, when he speaks of the mosquito as an "in- termediary host," means that it is the mosquito which carries the embryo of the filaria indirectly from man to man. This is accomplished in the following manner ; The filaria embryo circulates in the blood of the sleeper ; the mosquito fills himself with his infected blood ; he then flies to some damp, stagnant pool of water, which is his nat- ural haunt, and upon the surface of which he drops to die. The embryos of the filaria contained within the blood which he has previously sucked are set free, and are ready to enter the circulation of the next thirsty mortal who hap- pens to take them in with his draught of water. Once in the blood, they develop, and if in sufficient quantity, produce stagnation in the lymph-vessels, which eventu- ally becomes E. Arabum. The prognosis of E. Arabum is an uncertain one, de- pending much upon the stage it has reached, or the pos- sibility of surgical interference. Treatment in the first stages should be undertaken with a view to overcoming as much as possible the stasis or oedema remaining after an acute attack. Bandages, whether of rubber or some other substance which will produce constant, firm, and even pressure, are to be ap- plied continually. The avoidance of anything tending to cause inflammation, such as undue exposure to cold, ex- ternal injuries, gluttony in eating or drinking, too pro- longed standing or walking, is to be advised. The treatment of any constitutional disease, such as syphilis, must be recommended. The use of the constant current, persisted in for a long time and carried to its ut- most limit of strength, has been found useful. The ulcers which appear upon the lower extremities, due to in- jury or want of proper circulation, we should try to cure in order to prevent them from becoming chronic ; an ec- zema running on indefinitely should be promptly treated ; varicose veins and enlarged glands, even when at a dis- tance from the scat of disease, must be simultaneously taken in hand. If the part affected, more especially the genitals, has become so enormous as to be cumbersome, the whole mass should be removed. The operation of tying the ex- ternal iliac artery when the leg was affected, so as to cut off the supply of blood, was first performed in New York by Carnochan in 1851. Since then others have tied the femoral and ischiatic arteries with equal success. In a number of cases electrolysis has been found of ser- vice. Large needles are run deep into the skin, and a strong constant current passed through them from some other portion of the body. Anyone desiring to make a deeper study of E. Arabum than is contained in so short an article, may find suffi- cient reference to the literature of the subject in the books of Hebra, Kaposi, Neumann, Ziemssen's " Encyclopaedia," the volume on Skin Diseases ; the London Lancet, since 1878, under the heading Filaria Sanguinis, or Hans v. Hebra, "Wiener Klinik," Vortrage aus der gesammten praktischen Heilkunde, August, 1885. Robert B. Morison. ELGIN SPRING. Location, Addison County, Vt. Post-office, Vergennes, Addison County, Vt. Access.-By Central Vermont Railroad to Vergennes, thence by stage to springs, three miles south. Analysis.-A qualitative analysis by C. L. Allen, M.D., given in the " Geology of Vermont," is as follows : In one pint there, are about thirty grains of solids, of which the principal element is sulphate of magnesia. There are also carbonate of soda, carbonate of lime, sulphate of soda, sulphate of iron, and carbonic-acid gas, five cubic inches to the pint. The water is a good cathartic. These springs are situated in the western part of Ver- mont, twenty-one miles south of Burlington, and forty- six miles north of Rutland. George B. Fowler. ELM, SLIPPERY {Vlmus, U. S. Ph.; Orme fauve, Co- dex Med.). The Red, or Slippery Elm tree, Ulmus fulva Michx.; Order, Urticacea {Ulmacea), is a smaller and less graceful plant than the common " American," or white elm, U. Americana, which it in general resem- bles. It is a moderate-sized tree, with a brown, rough bark, and soft, but tough, red wood. The leaves are larger and thicker than those of the common elm, and rough or pubescent beneath. The expanding buds and smallest twigs are velvety. The flowers are nearly ses- sile, clustered, small, generally perfect, and apetalous. They consist of a seven- to nine-lobed calyx, as many stamens, and a flat, two-styled, two-celled pistil. Fruit a flat, one-celled, one-seeded, round Samara. The inner bark of most elms, as well as of many other species in the order (nettles, hemp, etc.), is very pliable and tough ; that of the present species is also very mucilaginous, and is valued on this account. This is a common tree in the United States, especially in the central portions ; but the demand for its bark has exterminated it from many regions, and suggests the ques- tion whether it could not be collected in such a way as not to destroy the tree, as the barks of cinchonas in India, and of the cork oaks are. The bark should be collected in the spring. It is " in flat pieces, varying in length and width, about one-eighth of an inch (three millimetres) thick, tough, pale, brown- ish-white, the inner surface finely ridged ; fracture fibrous and mealy ; the transverse section delicately checkered ; odor slight, peculiar ; taste mucilaginous, insipid " (U. S. Ph.). Slippery elm bark is remarkable for the abundance of mucilage which it imparts to either cold or hot water, making a nearly transparent, thin, jelly-like, but not fil- terable solution. It is precipitated by neutral acetate of lead. The addition of strong alcohol to the concentrated mucilage abstracts a portion of its water without coagu- lating it. The employment of slippery elm is said to have been 665 Elm. Embolism. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. learned from the aborigines. In medicine it is used as a pleasant demulcent, like other gums and mucilages ; in sore throats, diarrhoeas, dysentery, inflammation of the bladder, etc. ; also as a poultice. It is a very mild agent, and has hardly any value, excepting that of an unirritating protection to the parts it reaches. The crude bark, chewed and swallowed in large quantity, has been the mechanical cause of serious consequences in one or two cases. Administration.-The powdered bark, stirred into hot water, is sometimes used as a demulcent drink. It, of course, includes the woody dust, and is an unsightly mixt- ure. The officinal mucilage (Mucilago Ulmi, U. S. Ph.), made from the sliced bark and strained (six per cent.), is much better. Dose indefinite. The powder can be used for poultices. It is generally mixed with flaxseed for this purpose. Allied Plants.-Several other elm barks are muci- laginous, but none so much so as this. The European Elm (Ulmus campestris Linn.) is officinal in several coun- tries (Orme champitre, Orme pyramidal, Codex Med.). It is less mucilaginous than ours, and slightly astringent. The order Urticacece is a very large and heterogeneous one. See Hemp, Indian. Allied Drugs.-See Gum Arabic. W. P. Bolles. brown color of the bones suggest some method of em- balming, but one very inferior to that of later date. Herodotus and Diodorus agree in the statement that there were three grades of embalming. The first grade cost one talent (about twelve hundred and twenty-five dollars), the second cost twenty minen (about three hun- dred and seventy-five dollars), the third was very cheap. According to the best authorities, the process of embalm- ing a mummy of the first class was as follows : The brain was first removed, partly by a hook inserted through the nose causing destruction of the ethmoid bone, and partly by subsequent injections of water. The removal in this manner of the entire brain and the spinal cord would be very difficult, and it is probable that some al- kaline fluid was injected, and after a time pumped out. The organs of the abdomen and breast were removed through an opening about seventy-two millimetres (about two and three-fourth inches) long, in the left hypogastri- um, made by a stone-knife of some religious significance. The organs, after being thoroughly cleaned, were washed with palm wine, and treated with some aromatic sub- stances, after which they were put in four vases. The thoracic and abdominal cavities were filled with the purest bruised myrrh, cassia, and every other variety of spicery except frankincense. The body was then put in natrum, which is not, as at first thought, our nitre, but subcarbonate of soda, and left from thirty to seventy days. The body after removal from the natrum was carefully washed, and enveloped in bandages of fine linen cloth held together by gum. The face was protected by a mask made from linen cloth ; over this mask the bandages were placed as over the body. The body thus prepared was returned to the family. The process of embalming bodies belonging to the second class was much simpler. A substance obtained by dis- tilling cedar wood, containing, among other things, car- bolic acid (perhaps the first time it was used as an anti- septic), was injected through the anus into the body, and allowed to remain there while the body lay the usual time in natrum. According to Herodotus, the organs at the end of seventy days became liquefied, and escaped through the anus when the injected fluid was allowed to run out of the body. Very little is known concerning the third class of embalming, except that it was very simple. The foregoing three modes of preserving the dead do not exhaust the list of methods, for mummies have been found that were preserved beyond a doubt by resin and bitumen. Czermak made an histological examination of a female mummy, and found the different structures in an excel- lent state of preservation. The epidermis was partly wanting ; but the rete Malpighii, the ducts of the sweat- glands, the structure of the corium, and the fat cells were well preserved. The muscles, too, after being treated with oil of turpentine, showed the transverse marking very plainly. During the Dark Ages the art of embalming suffered, with other arts, a partial eclipse. At the beginning of the present century, Chaussier first employed chemicals for embalming. He painted corrosive sublimate on the body, the muscles of which were previously cut in many places. The cavities were painted inside with this corrosive subli- mate solution, and then filled with aromatic, resinous, and astringent substances. In 1834 Gannal announced to the Academy of Medicine at Paris, a solution composed of saltpetre, common salt, and alum, for the preservation of anatomical specimens. The most important part of Gannal's communication was, that putrefaction was prevented by injecting this fluid into the arteries. This was a great and permanent step toward perfecting the process of embalming, as it did away with the disagreeable act of removing the contents of the thoracic and abdominal cavities. All subsequent improvements in the art of embalming have aimed to improve the injecting fluid, or to modify the details of employing it. The substances most used for embalming were sulphate of aluminium, and other salts of aluminium, salts of zinc, and arsenic. The use of the latter was restricted in many ELSTER is a watering-place in Saxony, lying in a valley at an elevation of about fourteen hundred feet above the level of the sea. The climate is cool, but not severe. There are several medicinal springs at Elster, the waters of five of which are taken internally. The following is the composition of three of the most popular springs, reckoned in grammes to the litre. Moritzquelle. Marienquelle. Salzquelle. Ferrous carbonate.... ... 0.085 0.062 0.062 Manganese carbonate 0.015 0.008 Sodium carbonate.... ... 0.261 0.726 1.684 Calcium carbonate... ... 0.152 0.205 0.181 Magnesium carbonate ... 0.109 0.241 0.168 Sodium chloride ... 0.697 1.872 0.827 Sodium sulphate ... 0.954 2.947 5.262 Organic matters ... 0.024 0.063 0.133 Total solids .... 2.282 6.131 8.325 There is also free carbonic-acid gas, of which the Salz- quelle contains the smallest amount. Besides being taken internally, the waters of Elster are employed in baths. The station is frequented by sufferers from chronic catarrhal gastritis and enteritis, dyspepsia, anaemia, debility during convalescence from acute diseases or from excesses of any kind, and diseases of the female genito-urinary or- gans. T. L. S. EMBALMING. Embalming is a procedure that pre- vents those processes of decomposition to which the body of the dead is subject. It was practised by many ancient nations ; but the Egyptians alone adopted it as a necessary part of the duty due the dead. Nations as widely sepa- rated geographically as the Assyrians and Persians in the Old World, and the Mexicans and Peruvians in the New World, attempted to preserve the bodies of the dead. The appearance of the royal mummies found in Peru makes it probable that no resinous or other substance was employed by the Incas to preserve the body from decom- position. These mummies were simply exposed to the action of the cold, exceedingly dry, and highly rarefied air of the mountains. The Egyptians carried the art of embalming to the highest point of perfection known. Concerning the method practised by the Egyptians, there are discrepan- cies between the accounts of Herodotus and Diodorus, and these two writers do not agree in all respects with the statements made by the modern mummy pathologists. The examination of mummies belonging to different periods of the Egyptian dynasties shows that it was not until the latter part of her existence that Egypt practised the elaborate manner of embalming her dead. According to Mariette, the sarcophagi belonging to the earliest pe- riods contain no mummies; but skeletons are still to be found in some of them. A bituminous odor and the 666 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Elm. Embolism. countries, and entirely forbidden in France. At the pres- ent time chloride of zinc and corrosive sublimate are the two most in use. The method of injecting the fluid is very simple. The body is first thoroughly cleansed and wet with the embalming fluid. The injecting tube is then inserted into an artery, generally the left carotid, or the crural, and through this tube, which is directed toward the heart, the injecting fluid is injected by means of a large hard-rubber syringe. The fluid should be injected slowly, so that the rupture of the vessels may be prevented ; such an accident is at once detected by the practised hand. It is well to precede the injection of the embalming fluid with a litre of a concentrated solution of common salt, which prevents the coagulation of the blood. The amount of the injecting fluid necessary for a medium-sized adult is five to six litres. The surface of the body must be treated several times with the injecting fluid as a pro- tection against insects. A successful injection of corrosive sublimate or chlo- ride of zinc is followed by a complete preservation of the body; but both substances cause the skin to change in color from white to gray. To prevent this change Leu- quet injected into the face a solution of sulphate of ammonium. Dr. Laskowski, of Geneva, in answer to a letter of in- quiry, has kindly sent me the following formula for mak- ing his very effective embalming fluid : Pour seven litres of pure officinal glycerine into a glass vessel with a capac- ity of twelve to thirteen litres ; next dissolve over a water- bath two hundred and fifty grammes of crystallized car- bolic acid, and pour this, a little at a time, into the glycer- ine, which should be heated to 50° C. (122° F.)and continu- ually stirred. Boil over a water-bath two kilogrammes of absolute alcohol, and dissolve in it five hundred grammes of finely-powdered, pure chloride of zinc ; filter this solu- tion through a piece of fine linen and then pour it into the vessel containing the carbolic acid and glycerine. Next, heat over a water-bath one kilogramme of absolute alcohol, and dissolve in it two hundred and fifty grammes of finely-powdered bichloride of mercury ; filter through fine linen and pour into the vessel containing the preceding liquid. The undissolved salts fall to the bottom and leave the solution clear. Any perfume can be added to this solution. Julian A. Mead. with extensive inflammation of any organ of the body, and with high temperature. This causes these corpuscles to aggregate into masses still retaining amoeboid move- ments, and of sufficient size to embolize any organ. When this takes place in the brain he thinks that these masses are the cause, in some cases, of chorea, in others of high fever, delirium, stupor, and the typhoid state. In other organs they are the cause of softening. Atheromatous and calcareous changes in the walls of any artery may so disorganize and roughen its inner sur- face as to cause the formation of a coagulum which is subsequently washed off. In some cases portions of the degenerated lining-membrane, or calcareous particles, have become detached and have formed the emboli. While nature is endeavoring to effect the spontaneous cure of an aneurism, a portion of the deposited fibrin may be washed off and occlude some vessel beyond. Independent of any organic disease of the heart there is sometimes such a feebleness of its contractions, and con- sequently such slowing-up in the circulation, as to per- mit coagulation to occur in one or more of the cavities of the heart. Sometimes, also, there probably exists, with this weak and sluggish circulation, a condition of the blood itself which favors coagulation. Embolism has fre- quently occurred in this way in marasmus, scarlet fever, typhus, and typhoid, and in all prolonged illnesses of an adynamic type. A case of this kind occurred in the writer's service in the Albany Hospital, in November, 1885, in t^ie person of an Irish servant-girl, with no or- ganic disease of the heart, at the close of the third week of a typhoid fever which presented no other peculiarity. At about four o'clock one morning she was waked from a sound sleep by great pain in her left lower extrem- ity, and on examination the left femoral artery was found to be obstructed near Poupart's ligament. Collateral circulation was soon established, and entire recovery fol- lowed. In rarer instances tumors, especially those of a malig- nant character, involve the walls of vessels, and por- tions are torn off by the blood-current. A number of cases have been reported in which the capillaries of the lungs, kidney, brain, and other organs have been oc- cluded by innumerable small globules of fat, mostly in connection with fractures of the long bones. Bubbles of air, granules of pigment, and various animal and vegetable parasites, have occasionally been the offending bodies. Pathology.-The lodgment of an embolus is invari- ably followed by the partial or complete suspension of the function of the part which is thus suddenly deprived of its nutrition. Cohnheim was the first to clearly set forth the subsequent results, and especially in what he calls " terminal arteries," that is, those which end in capillaries and give exclusive supply to certain small re- gions without any communication with collateral arterial branches. He taught that the lodgment of an embolus was first followed by a temporary ischaemia due to the natural, tonic contraction of the vessels beyond the affected point. Very soon the blood was seen to flow back through the venous radicles and capillaries and to thoroughly di- late the now paralyzed vessels, arteries included. Lastly, all the constituents of the blood, corpuscles as well as fluid parts, passed through the walls of the vessels, invading all the district originally supplied by the obstructed vessel. This is known as haemorrhagic infarction, and is com- monly called "wedge-shaped," such being its appearance on section ; but it is in reality " cone-shaped," the apex of the cone being situated somewhat beyond the point of obstruction. The more recent researches of Litten seem to show that haemorrhagic infarction may occur, not only as Cohnheim states, but also by extravasation from ves- sels in the immediate neighborhood of the occluded one, the veins having little or nothing to do with the process. That haemorrhagic infarction occurs is admitted on all hands, though the exact manner of its production may re- quire further study. Just as after the ligation of an artery a thrombus forms in the vessel both ways from the ligature, so from the point where an artery is cmbolized secondary arterial EMBOLISM-from the Greek, iv, in, and I throw -is the sudden occlusion, partial or complete, of the lumen of a blood-vessel by some substance carried into it in the circulation, the substance being usually a small piece of coagulum. Embolism can only occur in the ar- teries, or capillaries, or branches of the vena portae. Etiology.-Frequently the embolus is a detached por- tion of a venous thrombus, which has been washed off from the main coagulum by the current from an open collateral branch coming into the plugged vein. This embolus will be carried along into and through the right side of the heart, unless, in very rare cases, it be so large as to be arrested at the tricuspid or pulmonary orifice. In the large majority of instances it will lodge in some branch of the pulmonary artery, unless small enough to pass through its capillary network, in which latter event it may pass onward into the left side of the heart, and through it, lodging in some branch of the aorta. In many cases the emboli consist of the so-called " vege- tations" bn diseased valves of the heart, which, very small at first, grow by continued accretions on their sur- face, until the blood-current tears them from their moor- ings. Detached portions of diseased valves have also been found acting as emboli. Valvular disease being so much more common on the left side than on the right, there is probably not an artery in the systemic circulation which has not been embolized in this way. The fibrinous concretions which form on the lining membrane of the heart in endocarditis, acute or chronic, and the masses which are detached in ulcerative endo- carditis, act in the same way. In the British Medical Journal for 1869, at page 66, et seq., Charlton Bastian has expressed the opinion that an undue excitability of the white corpuscles may occur 667 .Embolism. Embolism. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. thrombosis soon starts. In the internal organs this is not generally a very important part of the process ; but in the arteries of the extremities it frequently becomes the most ihiportant -of all. The further history of an infarction depends largely on the character of the embolus. If this be a simple mass of fibrine it is possible that it may be redissolved in the blood and the whole haemorrhagic infarction end in resolution ; or fatty, and subsequently calcareous, degen- eration may occur to the extent of the previous infarction ; or abscess may occur, with all its usual results, from what- ever cause arising-external discharge of the pus and sub- sequent cicatrization of the walls, rupture into a neigh- boring serous cavity, and the like ; and, lastly, gangrene may result. If, however, the embolus contain pus or septic material of any kind, as in the course of hospital gangrene, septi- caemia, or pyaemia, then the neighboring tissues are so poisoned that resolution never occurs, but we have al- ways either gangrene or abscess. If the poisoned mass has started from a thrombosis in one of the extremities it will probably be arrested in the lungs, and, primarily, ab- scess will form there. But part of the process going on in the lungs will be coagulation in the neighboring veins, the clot there formed being also poisoned. If, now, por- tions of these clots be washed off, they may be carried through the left side of the heart into any of the tissues or organs of the body supplied by branches of the aorta, and produce like results wherever they happen to be arrested. The results in embolism of the arteries of the extrem- ities are striking. Here, as soon as the accident has oc- curred, thrombosis of the artery begins at the point of obstruction and extends in both directions much further than in the internal organs. Infarction frequently in- volves the entire extremity, and total gangrene necessarily follows unless the obstruction is removed. The writer has made one autopsy in which, after embolism of the popliteal artery, secondary arterial thrombosis extended up the femoral, external iliac, common iliac, and abdom- inal aorta to a point just below the origin of the renals, and several similar cases are on record. An interesting point in this case was that with such serious interference with the arterial circulation the gangrene was limited to a point below the knee on the right side, and to only two toes on the left. If collateral circulation is perchance established, then the clot in the artery will extend only a moderate dis- tance above and below the point of obstruction, very likely only to the nearest collateral branches. Acute secondary endarteritis will be set up in so much of the artery as is filled with coagulum, the latter will become organized, and eventually it, with the wall of the vessel, will be converted into a fibrous cord. If gangrene ensue, and the thrombosis do not extend too far up toward the heart, a line of demarcation may form and the dead portion of the limb be removed, either with or without surgical interference, the life of the pa- tient being saved. The result of embolism of an artery in a limb, when the plug is not poisoned, seems to depend more upon the condition of the heart-the strength of its contractions- than upon anything else. Surgeons expect to save a limb after ligation of the femoral artery, yet embolism of the popliteal is more frequently than not followed by gangrene. The main difference lies in the fact that the subject of ligation is in possession of a heart in at least fairly good condition, while in the case of embolism the previously diseased and weakened heart propels the blood with so much less velocity, and under so much less ten- sion, that the collateral arteries are not well dilated, and thrombosis extends rapidly and to a great distance. It is quickly observed, in looking over the histories of any con- siderable number of cases of embolism, that the large ma- jority of recoveries occur among those who are not the subjects of chronic heart disease. Embolism occurs more frequently in males than in fe- males ; is most common between the ages of twenty and forty, but by no means restricted to that period ; is more frequent in the lower extremity than in the upper, and somewhat more so on the left side than on the right. In the lower extremity the bifurcation of the femoral is fre- quently the site of the obstruction, and that gangrene should then result is not so surprising when we consider how unfavorably this point is located for the establish- ment of collateral circulation. Symptoms.-The symptoms of thrombosis and em- bolism of any given artery are necessarily very similar, since in each many of the signs depend solely on the loss of function of the part of the body supplied by the oc- cluded vessel. In general terms, thrombosis may be sus- pected if the attack has come on slowly, if the patient be advanced in years, if there be evidence of atheroma- tous degeneration of the arteries, and if there be a rather rapid succession of slight attacks of the same kind. Em- bolism may be suspected if the attack has come on sud- denly, if the patient be under forty years of age, if atheroma be absent, if there be a history of rheumatism in the case, if the patient be the subject of disease of the heart. In the lungs, embolism, with the infarction which fol- lows, will be suspected when, under the circumstances already stated as favoring this occurrence, a localized spot of dulness is discovered with the usual signs of a localized pleurisy, if the infarction be at the periphery. If the embolus be large and central, so that the infarct involves one lobe or more, as has happened in a few cases, all the usual signs of consolidation will be present. This may be accompanied by a rigor and transient faintness or giddiness, and will be followed a day or two afterward by spitting of bloody mucus, dark-red or black in color, small in amount, and continuing a long time, maybe eight or ten days. If the embolus be large, or there be a a number of them, dyspnoea may be present, with hurried respiration, a marked feeling of suffocation, anxiety, tightness of the chest, cold sweats, and a manifestly critical condition of the patient. These urgent symptoms are, however, more likely to attend thrombosis of the pulmonary artery. If abscess or gangrene subsequently develop, the symptoms will be just tlie same as if these depended upon any other cause. In the brain, the attack is sudden, without premonitory signs of any kind, and is usually accompanied by shock, a fall, and loss of consciousness. These signs may be explained partly by sudden, localized anaemia of a por- tion of the brain, and partly by the doctrine of " etonne- ment cerebrale" upheld by Trousseau, Jaccoud, and others. The function of each of the cranial nerves has, at one time or another, been suspended. The loss of con- sciousness is usually recovered from in a few hours, or a few days at most, but may pass into a fatal coma. Pa- ralysis of sensation or motion, either or both, may be present, amounting in some cases to complete hemiplegia, while in exceptional instances motor paralysis of every kind has been wanting. As the middle cerebral artery is frequently the one involved, aphasia is a common accom- paniment ; sometimes the attack is painless, or severe pain in the head may be present ; nausea and vomiting are not infrequent; the temperature often ranges rapidly from high to low, instead of being at first constantly de- pressed, as it is in cerebral haemorrhage. Vertigo, ting- ling, or numbness in various parts of the body, mental confusion, and general bodily weakness may be men- tioned as occasionally present. Chorea has been attributed to minute multiple embolisms, followed by rupture in the corpus striatum. If recovery does not occur, softening of the brain is the ultimate result of its embolism, with the production of permanent morbid symptoms. In other internal organs the symptoms are often ob- scure, and the diagnosis difficult, if not impossible. The function of the organ which is the seat of the infarction is interfered with, the constitutional symptoms may be slight or may be severe, and the diagnosis must, in many cases, be inferred from the general condition of the pa- tient, and from the known probability of the occurrence under consideration, rather than from any manifestations which may be considered as furnishing absolute proof. 668 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Embolism. Eni holism. In the tena porta, embolism and its resulting abscesses have been frequently found post mortem in various dis- eased conditions of the organs the veins of which go to make up the portal vein, and which have been previously the seat of thrombosis ; but no train of symptoms can be said to be diagnostic, during life, of this occurrence. In the arteries of the extremities the symptoms are usu- ally well marked. First, there is an unusual sensation in the limb, suddenly developed, and generally amounting to pain so acute as to be the prominent symptom ; occa- sionally it is described as simply an itching, pricking, formication or numbness, or like the receipt of a severe blow. Frequently this comes on in the midst of apparent good health. In some cases the disappearance of a heart- murmur has been observed to coincide with the occurrence of an embolism. Second, paralysis of motion occurs in the limb, more or less complete, and to this the patient usually calls attention. Third, there is decrease or abolition of sensation. These three symptoms might occur with some lesion or injury of the nervous centres. But when one adds to these the three symptoms dependent on me- chanical obstruction of the vessel-first, paleness; second, coldness ; third, absence of arterial pulsation below the affected point-we have a group of phenomena which be- long to embolism and to nothing else. As occasional symptoms we may also add nausea, vomiting, and muscu- lar twitchings. The physiognomy of the patient is usu- ally indicative of a serious lesion. Diagnosis.-The symptoms already detailed will nearly always make the diagnosis easy when the arteries of the extremities are involved, and very probable in the case of the lungs. In the brain it will frequently be doubtful whether embolism be present, or a slight haemorrhage. The suddenness of the attack is much the same in both, and in point of fact there is not a symptom, or set of symptoms, which may not be present in one as well as in the other. In embolism, however, the symptoms are, as a rule, worst at the very first, and recovery commences sooner than after haemorrhage. In the latter the loss of consciousness is usually more prolonged, and the symp- toms increase in severity for a certain variable period. Attention has been called to the difference between the two affections as to the temperature developed during the first few hours of each. Lividity of the face and stertorous respiration are rather indicative of haemor- rhage ; pallor and shallow respiration, if there be any change at all in these respects, of embolism. The age of the patient, and the presence or absence of the conditions likely to accompany embolism on the one hand, or hae- morrhage on the other, will afford the most valuable in- dications. Prognosis.-The three controlling elements in form- ing a prognosis in cases of embolism are, the character of the embolus as to its septic or benign condition; the strength of the heart's action ; and the importance, as to the continuance of life, of the portion of the body the function of which is arrested. If the embolic mass is impregnated with septic mate- rial, the prognosis is always very bad. Death is the rule ; recovery the rare exception. If the patient is the subject of chronic heart disease the prognosis is always bad ; but in these cases the extent of the valvular lesion will have no more to do with the re- sult than the condition of the heart's walls. If the latter be in a state of fatty degeneration, or if, from any cause, the contractions be weak, the prognosis is bad even though the embolus be benign. The arrest of the discharge of the function of certain portions of the brain means almost instantaneous death. In other portions, the integrity of which is not essential to life, if the embolus be benign in character and the heart in fairly good condition, the patient is often spared, and in many cases functions temporarily suspended are restored to a wonderful degree. In the organs contained in the chest and abdomen re- covery is probably the rule, if the embolus be benign and the circulation good. In the arteries of the extremities the prognosis is bad ; for though the patient may survive the immediate effects of the accident, he is almost certain to be carried off by the extensive gangrene which so frequently follows. If, however, the patient be not the subject of chronic heart disease, secondary arterial thrombosis may occur to only a slight extent, collateral circulation be rapidly established, and gangrene not supervene at all, in which event the prognosis is about the same as if the artery had been li- gated at the embolized point. Even should gangrene oc- cur, if the heart be strong and healthy there is still a fair chance of recovery, with or without amputation. If the occurrence of embolism is due to a condition of the patient which cannot be remedied, the possibility- nay, the probability-of its repetition is to be borne in mind. Several cases are on record in which this accident has happened three, four, or more times to the same in- dividual, at varying intervals. Treatment.-When embolism of the main artery of an extremity has taken place, it has been proposed to make an effort to break up the clot by kneading the part affected, and thus allow the fragments to pass into vessels of less importance and facilitate their solution. The writer finds no record that success has ever attended such efforts. The warmth of the limb should be maintained in order to assist the formation of collateral circulation, except in those cases in which, as Otto Weber points out, there is danger from venous hypersemia and thrombosis ; then cold and astringent lotions should be employed, first among which he classes lead-water. If gangrene of an extremity has set in, the question of amputation comes up. The danger of septic poisoning- stares us in the face so long as the dead parts are in con- tact with the living ; and, if the patient is so fortunate as to escape this, there follows the exhaustive process of ul- ceration and suppuration by which nature removes the gangrenous limb, and cicatrizes the stump. For these reasons it has been advised to amputate the extremity as soon as gangrene declares itself by the appearance of vio- let marbling on the previously pale limb. We are unable to find any case recorded in which amputation has been done before the formation of the line of demarcation, but would venture to predict the uselessness of the procedure. The statement of Otto Weber, in Pitha and Billroth's "Handbuch der Chirurgie," that "the amputation of gangrenous parts should, as a rule, never be undertaken until the line of demarcation of the gangrene is plainly marked out by nature," accords with the experience of the vast majority of American surgeons. Charles II. Moore, in Holmes' " System of Surgery," in an article on " Gan- grene from Occlusion of Arteries," asks: "Should the gangrenous limb be amputated ?" and answers : "Surgi- cal experience and reasoning both prompt a general reply in the negative." It has been claimed by the advocates of very early am- putation that the great danger in waiting lies in the ex- treme probability of secondary arterial thrombosis occur- ring with the embolus as a starting-point, and that by removing the limb early, and at a point sufficiently high up to include the embolus, this may be averted. The reply to this argument is, that a thrombus would im- mediately form at the point of ligation of the vessel in the amputation, and would be just as likely to extend up to a fatal distance as that which would start from the original embolus, under the given conditions of a diseased and weakened heart. If the embolism has occurred in a patient whose heart is at the time functionally weak, but not in a condition of organic disease, there is a manifest advantage in waiting for the line of demarcation to form, since the interval can be well employed in stimulating and strengthening the central organ of the circulation ; and Bryant, of Guy's Hospital, has twice successfully amputated the leg, in consequence of gangrene from em- bolism occurring in the course of scarlet fever, after the line had formed. In the case of the internal organs surgical interference is entirely out of the question, unless it consist in the oc- casional opening of an abscess which may be approaching the surface. We must never forget the great importance of the 669 Embolism. Emetics. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. heart complication which usually exists, and must impart to the contractions of that organ additional strength and tone by whatever means each may consider most expedi- ent. Digitalis and alcohol will probably occupy the first rank among these in the estimation of all. It is generally admitted that the ammonium carbonate, besides being one of the best diffusible stimulants, has the power of increasing the fluidity of the blood-of diminishing its tendency to coagulate ; and Dr. Richard- son claims that he has met with considerable success in effecting, by its use, the solution of coagula in the pul- monary artery. Although clots are undoubtedly found in the hearts and pulmonary vessels of patients who have taken large doses of this drug up to a short time before death, yet there is no reasonable doubt of its usefulness in a certain number of cases, and its administration in full doses, frequently repeated, can be recommended with confidence. Samuel B. Ward. the course of a few years it was definitely proved that the germinal layers exist in all multicellular animals. Since 1870 a multitude of researches have been carried out, a wealth of new discoveries made, largely in conse- quence of the vast improvements in the methods of in- vestigation. These improvements have been-first, in re- gard to the means of preserving ova and embryos; second, in the manners of making sections and staining them. Of recent writers the student of human embryology must place His and Kolliker first; the former has worked out the anatomy of very young human embryos with surprising skill, and the latter has contributed a vast series of observations on the development of nearly every organ and tissue. In the history of embryology, then, the following points mark the chief epochs : 1759.-The doctrine of gradual development, or epi- genesis, definitely established by Caspar Fr. Wolff. 1829.-The existence of the germ-layers demonstrated, and their most important metamorphoses in vertebrates traced out by Carl Ernst von Baer. 1839.-The cell doctrine applied to animals by Schwann, and embryology turned into the study of histogenesis. 1860-70.-The presence of germ-layers in invertebrates proven by Kowalewsky, Metschnikoff, and others. 1870-85.-Constantly increasing number of special re- searches, and steady perfecting of methods. 2. Embryological Methods.-The student of human embryology cannot obtain his material at will, but can only take advantage of opportunity. A considerable number of abortions and miscarriages, natural and pro- cured, occur in every community, and the ova and em- bryos thus discharged are, in a minority of cases, normal and fresh ; the older the embryo the more likely it is to be in good condition. Embryos less than two inches long are best preserved intact; larger embryos are much better opened, and the parts separated and hardened separately. If the specimen is intended only for the study of gross anatomy, it will suffice to preserve it in seventy per cent, alcohol, which must, however, be re- newed once or twice at first, and the larger the specimen the more necessary is the caution of changing the alcohol. If the specimen is good enough to be used for section cutting, it must be preserved with more care, (a) The best method is, on the whole, with Kleinenberg's picro- sulphuric acid (100 c.c. water, 0.1 grm. picric acid, and 0.6 c.c. sulphuric acid), in which the embryo or organ is placed for one to three hours, according to its size ; wash for three to five minutes in thirty per cent, alcohol ; leave for one hour in fifty per cent. ; place then perman- ently in seventy per cent, alcohol, which, however, must be changed until it is no longer stained yellow by picric acid from the specimen, (b) Another good method is to harden the specimen for twelve to twenty-four days in Miiller's fluid (100 c.c. water, 2.5 grms. potassium bi- chromate, and 1 grm. sodium sulphate); wash for one day or more in a stream of running water, and transfer for permanent keeping to alcohol of seventy-five to eighty per cent. This method is especially available for the central nervous system, (c) Of all good methods the most expeditious is to place the embryo or organ for five minutes or less in a mixture of 10 parts strong nitric acid and 90 parts water ; transfer to sixty per cent, for an hour or two, and then to seventy per cent, (d) The simplest method of all is to put the specimen into sixty per cent, alcohol for twenty-four hours, then permanently in seventy to eighty per cent. In preserving embryological material observe the fol- lowing rules : Handle the specimen as little as possible; do not on any account put it in water or wash it; if it is necessary to keep it moist, wrap a soft damp cloth gently round it; never put a fresh specimen in strong alcohol ; never keep a specimen in strong alcohol, i.e., over eighty per cent. The only time when strong alcohol can be safely used is after a specimen has been hardened ; and then only to act for twenty-four hours immediately be- fore imbedding. To cut sections : For very small objects, paraffine is EMBRYOLOGY. The general history of the embryo up to about the end of the second month is given under Foetus, Formation of. The development of special organs is treated under those organs; e.g., for the development of the brain see under Brain. There are also included in the Handbook the following special embryological arti- cles : Allantois, Amnion, Area Embryonalis, Blastoderm, Blastopore, Chorion, Coelom, Gastrula, Germ-layers, Im- pregnation, Neurenteric Canal, Notochord, Placenta, Proamnion, Segmentation of the Body, Segmentation of the Yolk, Umbilical Cord, and Yolk-sac. In this article is given, 1, a brief sketch of the history of embryology ; 2, practical directions for the study of em- bryos. 1. History of Embryology.-Although embryology is the department of morphological science now most in vogue among investigators, it has held this high rank but a very short time. Embryology may date its birth, after gestating for many centuries in the womb of science, from the year 1600, when Fabricius ab Aquapendente published his work, " De Formate Foetu," followed four years later by his " De Formatione Foetus." After Fa- bricius came a series of anatomists, who during the seventeenth and eighteenth centuries slowly added to the knowledge of the development of man and other verte- brates ; but it was a time of vague general notions, a period when principles which seem to us elementary were still under debate. It was not until Caspar Friede- rich Wolff published his dissertation, " Theoria Genera- tionis" (1759), that the mere idea of development by gradual differentiation of unformed material could make its way. Wolff is justly regarded as the initiator of mod- ern embryology, for until his views of gradual differ- entiation (epigenesis) were established correct embryologi- cal conceptions were impossible. The next great advance was due to the influence of Dollinger, of Wurzburg, a man who inspired many of the best researches. Under him were trained Pander and Von Baer, who first defi- nitely ascertained the existence and traced much of the history of the germ-layers. Von Baer was a magnificent intellect-among the great morphologists of Germany easily first. His book (1829) on the development of ani- mals has never been equalled for keen insight and origi- nal profound thoughts in the domain of morphology. The author is no less remarkable for his observational powers. Kolliker says, with perfect truth, that Von Baer's researches " are to be described as unconditionally the best which the embryological literature of all time and all peoples has to show." The third epoch may be said to have begun with the establishment of the cell doctrine by Schleiden and Schwann (1839), after which began the labor of ascertaining the origin and metamorphoses of the cells in the embryo. Schwann's discovery led to the recognition of the real signification of the segmenta- tion of the yolk, which had been previously discovered. The next great change occurred during 1860-1870, after Darwin had given a mighty impulse to biology by the publication of his " Origin of Species ; " in this period the germ-layers were discovered and described in inverte- brates by Kowalewsky, Metschnikoff, and others, and in 670 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Embolism. Emetics. satisfactory, but for most of the work of the human em- bryologist celloidine is the best imbedding material. A specimen to be imbedded in this material is put (1) for one day in ninety-five per cent, alcohol; (2) for one day in a mixture of equal parts ether and ninety-five per cent, alcohol ; (3) for one day in a thin celloidine solu- tion ; (4) imbedded in celloidine. To imbed, wrap a piece of glazed paper round a cylindrical cork, so as to make a paper cup of which the end of the cork forms the bottom ; the paper may be fastened to the cork with a couple of pins ; the cup must be considerably deeper than the object to be imbedded, because bubbles form in the celloidine, and it is desirable to have the celloidine so deep that the bubbles will rise above the specimen ; the specimen is placed in the cup, which is then filled with thick celloidine solution. The object may then be pushed into the right position for cutting. The cup is allowed to stand until a film is formed over the celloidine, and is then (5) transferred to a jar of eighty per cent, alcohol, where it remains until the celloidine is thoroughly hardened, a process requiring several days. To keep the cork down and the cup right side up, put into the bottom of the cork a sinker made of a heavy bullet and a stout pin or sharp-pointed wire nail. Celloidine is made by Schering, at Berlin, and sold in ounce boxes ; it may be dissolved in equal parts ether and alcohol ; two solutions are required, one about the consistency of maple syrup, the other like thick molasses. Celloidine sections must be made under alcohol. The sections are stained and the celloidine left on ; to mount them, place the sections in alcohol on a glass slide, drain off the extra alcohol, and drop on top of the sections a thin filtered solution (fifteen per cent, is good) of white shellac, enough to completely cover the sections ; dry the slide at a gentle warmth, say 30° C., until the shellac is hard ; clear up with oil of cloves, and mount in balsam {this method is new, and has not been published before). Staining : Small pieces, not exceeding one-fourth of an inch in diameter, may be stained in toto before imbedding. The best method, on the whole, because the safest, for in toto coloration, is to soak the object for one to two days in alum-cochineal, made by boiling seven parts pow- dered cochineal and seven parts burnt alum with four hundred parts water for at least one-half hour ; the solu- tion must be filtered before using. For sections it is best to employ a variety of stains; my own experience has led me to consider the following five dyes the most valu- able : alum-cochineal, Beale's carmine, Minot's picric acid carmine, alum-haematoxyline (Boehmer's), and Weigert's acetate of copper and haematoxyline. Osmic acid, ni- trate of silver, chloride of gold, etc., must, of course, be used for special purposes, and their employment will naturally suggest itself to the experienced histologist at the proper moment. Both for the sake of comparison and on account of the rarity of young human embryos, and of the impossibility of obtaining the earlier stages of man's development, it is important to study the embryology of mammals and other vertebrates. An admirable guide for such studies is Sedgwick's edition of Foster and Balfour's " Embry- ology." The best resume ot the methods used in histology and embryology known to me is the first part of Fol's " Handbuch der vergleichenden Histologie." An excel- lent work by Dr. C. O. Whitman, on embryological methods, appeared recently. Charles Sedgwick Minot. may profitably study the common effect of emetics, the act of vomiting. In order that vomiting may take place, certain muscles, whose action is consecutive in the normal state, must con- tract simultaneously. The efferent impulses co-ordinating, their movements come from the medulla oblongata, and are held to start in the emetic centre, which is closely re- lated to the respiratory centre, but is doubtless more ex- tensive. When this centre becomes excited in consequence of the action of a medicine, or of a morbid state of other organs, such as the stomach, uterus, peritoneum, menin- ges, cerebrum, etc., or of the blood, as in uraemia, effer- ent impulses pass from it to the various muscles whose simultaneous contraction is necessary in order that vomit- ing may take place. However induced, by medicines or pathological states, the process of vomiting usually begins with nausea and a flow of saliva, which is partly swallowed, often with much air. Soon retching takes place, an ineffectual effort to vomit, in which a strong inspiratory effort is made while the glottis is closed, so that no air can enter the lungs. The air being drawn into the pharynx, some of it is swallowed and helps to distend the stomach, thus facilitating the act of vomiting. Immediately after the inspiratory effort; and while the diaphragm is powerfully contracted and forced down ioward the stomach, a strong contraction of the abdominal muscles occurs. Since the diaphragm remains contracted and the glottis closed, the whole force of this expiratory effort is spent in pressure upon the abdominal organs, and especially upon the dis- tended stomach. Sometimes several successive retchings take place before the contraction of the abdominal walls becomes so powerful as to cause the ejectment of the contents of the stomach. When this latter happens the cardiac orifice of the stomach is widely dilated, which is supposed to be effected by contraction of the longitudinal muscular fibres of the oesophagus, especially those which pass from the end of the oesophagus over the stomach, but which more probably results from the diminution of the intra-thoracic pressure necessarily following the pow- erful inspiratory effort while the glottis is closed. The intense action of the abdominal muscles, which causes the expulsion of the contents of the stomach, is quickly suc- ceeded by a sudden and powerful expiration, which pre- vents the vomit from entering the glottis, and ejects mucus or other pathological products which may be present in the air-passages. During the contraction of the abdominal muscles the circulation of blood in the abdominal vessels is inter- rupted, and hence the vessels of the face, neck, conjunc- tiva, and probably of the brain, become distended. The mode of action of most emetics is doubtful. Of one only, apomorphine, is it clearly proved that it acts on the emetic centre. Of ipecacuanha and tartar emetic it is not yet fully established how they act, whether on the emetic centre or on the gastric nerves, or both. It is generally held that sulphate of zinc, sulphate of cop- per, mustard, and alum act on the gastric nerves, though some authors hold that sulphate of zinc and sulphate of copper may also act on the emetic centre. According to the supposed action of emetics, they have been divided into two groups : direct and indirect. Those supposed to act on the gastric nerves have been called direct emetics,' and sometimes local, mechanical, or irri- tant emetics. The indirect emetics, which are supposed to act on the emetic centre, have also been called systemic emetics. Apomorphince HydroMoras.-The emetic action of this salt was observed by its discoverers, Wright and Mat- thiessen, in experiments, but Gee first investigated its op- eration on man. Numerous careful experiments on man and animals have been made since the discovery of its emetic power (1869), so that its mode of action and the incidental phenomena preceding and following its opera- tion have been clearly elucidated. It produces vomiting by acting on the emetic centre. This is evident from the fact that when injected into the subcutaneous tissue it acts more speedily, certainly, and in smaller doses than when given internally. That its EMETICS are medicines used to produce vomiting. They are few in number. Some of the medicines for- merly employed have become obsolete, and others are rarely resorted to, because their emetic operation is harsh and disagreeable, and often followed by injurious conse- quences. The principal effect of emetics, the process of vomiting, is essentially the same-no difference by what means in- duced ; but it may be preceded and followed by numer- ous phenomena which differ greatly in intensity and duration according to the agent used. These phenomena will be considered with the individual emetics. Here we 671 Emetics. Emetics, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. operation does not result from elimination through the gastric mucous membrane is proved by the fact that in- travenous injection is followed by vomiting in animals whose aorta has been previously ligated, so that no apo- morphine can be conveyed to the stomach. Apomorphine, in appropriate doses, acts speedily, cer- tainly, and gently. The time elapsing between the subcutaneous injection and the first act of vomiting may vary from two to twenty minutes, but it rarely exceeds ten minutes. In twelve careful observations by Riegel and Bcehm the average time was nine and a half minutes after injection of the aver- age dose of one-ninth of a grain. In six other observations by the same physicians vomiting took place, on the aver- age, in five and a half minutes after average doses of one-eighth of a grain. The emetic action takes place with great certainty, un- less the dose is too small or too large, when it may fail. It may also fail in certain pathological states, especially in profound sopor produced by narcotics, and in severe dyspnoea with cyanosis. In these conditions it is sup- posed that the emetic centre is so greatly depressed that apomorphine cannot excite it. Usually the action of apomorphine is gentle, and at- tended by slight incidental phenomena. Sometimes the vomiting occurs quite suddenly and unexpectedly, with very little effort, and without having been preceded by notable nausea or other symptoms. More frequently the act of vomiting is preceded for a short time, usually several minutes, by such phenomena as are incidental to the vomiting process however induced. There occurs slight nausea, with giddiness, ringing of the ears, and headache. Frequently there takes place a copious flow of saliva, and free perspiration. The patient may complain of some prgecordial distress; or he may yawn, and become languid and sleepy. Retching soon takes place, and is rapidly followed by vomiting. In rare instances the patient dur- ing the period of nausea becomes restless, and presents motor disorder, such as rhythmical movements of the head, supination and pronation of the forearms, spas- modic movements of the lower jaw, and hiccup. Before vomiting ensues the pulse becomes accelerated, but afterward slow. The blood-pressure, according to Harnack, does not become increased, from which it is inferred that the frequent pulse results from excitation of the accelerator nerves. In some patients very little or no change in the pulse-rate is observable. The respirations become rapid and superficial before vomiting, and after- ward slow. The act of vomiting, after an ordinary dose of apomor- phine, may occur but once, or be repeated several times, occasionally from four to eight times. It is usually quick and easy if the stomach is distended, but preceded by in- effectual retching if the stomach is empty. Between the acts of vomiting, when they occur several times, the pa- tient feels weak, yawns occasionally, and sweats freely. Sometimes copious salivation takes place. The nausea continues, often with eructations and retching. After the last act of vomiting nausea may persist for a short time; the patient is much relaxed, and usually very sleepy. The depression is rarely intense. All the symptoms produced by apomorphine wholly disappear, as a rule, in from thirty minutes to two hours. In young children appropriate doses generally cause vomiting very rapidly, the time elapsing between the in- jection and the first act of vomiting varying from three to seven minutes (Jurasz). In from one to three minutes the child exhibits evidences of its action. Usually it be- comes more quiet, yawns occasionally, grows pale, and has a staring look. Infants not rarely present symptoms of depression; the head droops, the extremities become cool and powerless, the face very pale, the pulse feeble, and the general appearance resembles that of narcotic poisoning. According to Jurasz, these phenomena soon vanish after the cessation of vomiting. Then the child still perspires freely, and has a copious flow of saliva, but soon becomes sleepy, and usually goes to sleep. After several hours of rest it awakes fully restored to its ordi- nary condition. Thus the effects produced by apomor- phine in infants are marked by greater depression than in adults. This is supposed to be due, not to a specific ac- tion of the medicine, but to the nausea, for which infants have great susceptibility and little endurance. Sometimes alarming depression has followed moderate doses in adults. Thus one-sixth of a grain caused intense collapse in a strong man (Dujardin-Beaumetz). In the case of an old man one-twelfth of a grain failed to pro- duce emesis, but caused agitation, dimness of sight, small pulse, yawning, copious flow of saliva, and somnolency (Moeller). After closes of one-twentieth to one-fifteenth of a grain a woman had repeated attacks of syncope, with alternating myosis and mydriasis, and convulsive twitch- ings of tlie corners of the mouth (Prevost). In young children appropriate doses sometimes produce spasmodic movements of the head, extremities, jaws, and diaphragm, with hyperaesthesia (Jurasz). Excessive doses may fail to produce vomiting, and be followed by alarming symptoms, although generally they are not followed by severer symptoms than moderate doses. Professor Pecholier, after an injection of nearly one-fourth of a grain, had ineffectual retchings, then sud- denly became unconscious, and ceased to breathe. After another injection he vomited, and fell into a state of pro- found collapse, from which he was rescued by hypoder- matic injections of sulphuric ether and the application of sinapisms. Apomorphine is appropriate in all cases indicating the use of an emetic. It should be employed whenever a speedy evacuation of the stomach is necessary, as in cases of poisoning, and when the stomach is inflamed, and hence liable to be injured by the irritant emetics. It is specially indicated when patients are unable or unwilling to swallow, as in trismus and insanity. Apomorphine is administered hypodermatically. It never produces notable irritation, even when concentrated solutions are injected. According to Jurasz and other observers, the following doses are suitable for children: From birth to three months, tzi? to grain ; three months to one year, to -4^ grain; one year to five years, to grain ; five years to ten years, to grain. For adults the dose varies from to | of a grain. Females and weakly males require somewhat smaller doses, from to | of a grain. Generally one per cent, solutions are employed for adults, and one-half per cent, for children. The solution rapidly becomes green, but retains the emetic property for a long time. It is a good rule to remain with the pa- tient for some time after the injection has been made, in order to apply restoratives should inordinate depression result. Ipecacuanha.-As an emetic ipecacuanha is characterized by slowness and mildness of action. Its activity is due to the presence of an alkaloid, called emetine, which it con- tains in greatly varying quantities. Podwyssotzki found in the best kinds of ipecacuanha from three-fourths to one per cent, of emetine, and in the poorest only from one- fourth to one-half per cent. The mode of action of emetine is doubtful. Most au- thors incline to the view that it results from an irritant action upon the peripheral termination of the vagus nerve in the stomach, because it acts, when given internally, in smaller doses than when injected subcutaneously, and just as rapidly, and because it has been discovered in the vomit after subcutaneous injection. Others hold that it acts on the emetic centre, because it causes vomiting after all modes of administration, internal, subcutaneous, in- travenous, etc.; and because they failed to detect it in the vomit or any secretion or excretion after subcutaneous or intravenous injection (Podwyssotzki). Ipecacuanha, or its active principle, emetine, acts slowly even when maximum doses are given. Rarely does vom- iting occur before twenty minutes after doses of one scruple, and usually not before thirty minutes. Emesis results in about the same time after subcutaneous injec- tions of emetine. When small or moderate doses of ipecacuanha are administered, vomiting may be delayed for a longer time. Thus Ackermann, in trials with ten- 672 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Emetics. Emetics. grain doses given at intervals of fifteen minutes, found vomiting to occur in three-quarters of an hour. Some- times, however, very small doses, two to five grains, act in twenty or thirty minutes. This is due in part to the varying quantities of the active principle, but more gen- erally to the notable susceptibility of some persons to its action. Even in very large doses ipecacuanha always acts mildly, the act of vomiting occurring but once or twice. Doubtless this is due to the expulsion of the greater part of the emetine before it can act upon the gastric nerves or become absorbed ; for in animals, after subcutaneous injections of large doses of emetine, the act of vomiting is repeated three or four times at long intervals. The incidental phenomena are usually slight. Some- times the nausea is decided, and attended by marked general relaxation ; and there may occur a copious flow of saliva, free perspiration, giddiness, shudderings, rapid pulse, eructations, and repeated retching before the act of vomiting ; but these phenomena quickly subside after- ward, the patient remaining only weak and sleepy for some time. Sometimes looseness of the bowels occurs, especially if the emetic operation is much delayed. The quantity of ipecacuanha required to produce vom- iting varies greatly-in some patients one or two grains sufficing, in others less than twenty or thirty grains not succeeding. Emetine usually acts in doses of one-twelfth to one-sixth of a grain. According to Husemann it more frequently than ipecacuanha causes loose stools. Ipecacuanha may be employed in all cases requiring emetics, if speedy action be not necessary. It has usually been preferred to other medicines when irritating sub- stances, such as indigestible articles of food, required re- moval, or when accumulations of mucus in the bronchial tubes were impeding the respiratory process. On ac- count of its gentle action it is especially suitable for feeble, old, and very young patients. For adults the dose of ipecacuanha varies from ten to twenty grains, repeated at intervals of ten or fifteen min- utes until vomiting occurs. Generally it is given in the form of powder, mixed with an equal quantity of sugar. For very feeble patients the wine is preferable, which may be given to adults in doses of half an ounce. Large draughts of tepid water, taken as soon as nausea begins, hasten the emetic operation. To infants and young chil- dren the syrup of ipecacuanha is usually administered in doses of half a drachm to two drachms every ten minutes until vomiting results. Antimonii et Potassii Tartras.-Tartar emetic is noted for severity of action, and hence is rarely employed ex- cept in combination with ipecacuanha. Small doses act slowly. In careful trials, Ackermann found that half a grain, repeated at intervals of fifteen minutes, produced vomiting in one hour and three-quar- ters. But doses of one or two grains frequently operate within fifteen minutes. Often purgation follows, espe- cially when the vomiting takes place slowly. The incidental symptoms are very pronounced. They consist of intense nausea, profound muscular relaxation, pallor of the face, shudderings, free perspiration, giddi- ness, copious salivation, distress in the epigastrium, eruc- tations, and severe, often violent, and frequently repeated, retching. The act of vomiting is usually repeated a number of times, at intervals of various length. Some- times it occurs so often, and is attended by such severe nausea and retching, as to cause profound collapse, marked by deathly pallor, sunken features, superficial breathing, and weak thready pulse. Most authorities hold that tartar emetic produces vom- iting by acting on the gastric nerves. The fact that it causes vomiting when injected into a vein, or into the con- nective tissue, does not prove that it acts on the emetic centre, for the quantity required to produce vomiting when thus administered is larger than the internal dose, and it acts slower. Besides, the medicine may be detected in the vomit after subcutaneous or intravenous injec- tion, and hence comes into close relation with the nerves of the stomach. When tartar emetic is given internally, the greater part is discharged with the vomit, and the part retained or absorbed is insufficient to cause emesis when injected into a vein. There exist no special indications for the use of tartar emetic. Formerly, when it was supposed to exert a con- trolling influence over inflammatory affections, it was often given at first in emetic doses. But this practice is now obsolete. It should never be administered to very young children, to aged or weakly patients, on account of the profound collapse which it may induce. The hyperemesis which sometimes results from tartar emetic may be allayed by giving small pieces of ice with a few drops of chloroform. The following remedies are also useful : strong coffee, tannic acid, sulphuric ether, wine, alcohol, morphia, and tincture of opium. The dose of tartar emetic for adults is from half a grain to one grain, repeated twice if necessary. It is usually combined with ipecacuanha: B • Antimonii et potassii tar- tratis, gr. ij. ; pulv. ipecacuanhae, 3 j. M. Div. in partes aequales, iv. Sig. : One powder every ten minutes until vomiting takes place. Zinci Sulphas.-This salt, in suitable doses, produces vomiting promptly, energetically, and with little nausea. In some instances it also causes colicky pain and liquid stools. According to the observations of Toulmouche, vomiting rarely occurs after the administration of two grains, in- constantly after four grains, almost always after six to twelve grains, and only in one-third of the cases after fifteen grains. Liquid stools occur in one-half of the cases after four to twelve grains, and in two-thirds of the cases after fifteen grains. Sometimes, however, it operates in doses of one scruple to half a drachm, almost as soon as it reaches the stomach, causing a single but copious ejectment. On account of its rapid action and the absence of nota- ble nausea, sulphate of zinc is adapted to cases requiring speedy evacuation of the stomach. Hence it is usually employed in narcotic poisoning. To adults it is given in doses of six to twelve grains, repeated, if necessary, every ten minutes until vomiting ensues. B • Zinci sulphatis, amyli, aa 3 ss. M. Div. in partes aequales, iij. Sig. : One powder every ten minutes until vomiting is induced. Cupri Sulphas.-This salt, like the sulphate of zinc, usually acts promptly and without marked nausea. Its emetic action is also frequently followed by colic and liquid stools. While the action of sulphate of copper is generally rapid, occurring soon after administration, it is sometimes quite slow. Thus Ackermann found that five-grain doses, administered every fifteen minutes, caused vomiting in one hour. Formerly, when sulphate of copper was used as an emetic in the early stage of phthisis, it was fre- quently observed that its operation was delayed for more than half an hour (Thompson). Sulphate of copper is preferable to other emetics in poisoning with phosphorus, because it possesses antidotal properties. It gradually becomes reduced by the phos- phorus, and then covers the phosphorus with a layer of metallic copper, and thus prevents its volatilization and absorption (Bamberger). Sulphate of copper has been especially recommended in croup. If the exudation impeding respiration be loosely attached, the powerful operation of sulphate of copper may cause its expulsion ; but it can produce no other effect. The dose of sulphate of copper for adults is from two to ten grains; for children, from one to five grains, re- peated, if necessary, several times at intervals of ten or fifteen minutes. B- Cupri sulphatis, 3j. ; pulv. acacia}, 3ij. M. Div. in chart., iv. Sig.: One powder every ten minutes until vomiting ensues (in narcotic poisoning). B. Cupri sulphatis, gr. vj. ; aquae destill., § j.; syrupi, 5 ss. M. Sig.: A dessertspoonful every ten minutes until vomiting ensues (in croup). Sinapis Alba.-Mustard in large doses rapidly induces vomiting. When other emetics and the stomach-pump are not at hand, it is employed in poisoning with narcotics. Sometimes it acts promptly when sulphate of zinc has 673 Emetics. Eininenagogues. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. failed. It should not be used when the poison is of such a nature as to produce inflammation of the stomach. A teaspoonful of mustard-flour may be administered in a teacupful of tepid water, and, if necessary, repeated once or twice at intervals of ten minutes. Alumen.-Alum, in doses of half a drachm to two drachms, produces vomiting in from twenty to forty minutes. Its operation is attended by very little nausea and depression. It has sometimes been employed in croup and in narcotic poisoning. For children the dose is half a drachm administered in syrup, and repeated, if necessary, in half an hour. General Indications for the Use of Emetics.- Emetics are used to evacuate the stomach, to expel patho- logical products from the air-passages, and to remove foreign bodies lodged in the oesophagus or upper part of the air-passages. 1. To evacuate the stomach is the first indication in many cases of poisoning. As it is essential to accomplish this as speedily as possible, only those emetics should be used which act promptly. In poisoning by narcotics, such as morphine, opium, atropine, belladonna, stramo- nium, etc., one of the following emetics should be selected: apomorphine, sulphate of zinc, sulphate of copper, or mustard. The subcutaneous injection of apomorphine is quickly followed by copious vomiting, if the nervous centres are not greatly depressed. Hence, if a long time has not elapsed since the poison was taken, and profound sopor has not taken place, this emetic should be preferred to all others. But if the patient is so comatose that he cannot be aroused, apomorphine should not be used, as it would probably fail to induce vomiting and greatly increase the depression. If some time has elapsed since the poison was taken, vomiting is not readily induced. Then sulphate of zinc and sulphate of copper may fail in ordinary doses ; hence some authors recommend very large doses, from twenty to forty grains. It is well to recollect, however, that ac- cording to the observations of Toulmouche, doses of fif- teen grains and more of sulphate of zinc more frequently fail than doses of six to twelve grains. It should also be recollected that large doses of sulphate of zinc and of sul- phate of copper, if they do not cause emesis, produce severe irritation of the intestinal mucous membrane, and, after absorption, depress the central nervous system. If mod- erate doses do not soon cause vomiting, recourse should be had to mustard-flour, which generally acts promptly. In poisoning with phosphorus, sulphate of copper is preferable to other emetics, as it prevents the volatiliza- tion and absorption of the poison. In poisoning with strychnine or nux vomica, apomor- phine is the most suitable emetic. In several instances the spasms produced by strychnine have immediately subsided after a hypodermatic injection of apomorphine. Apomorphine has been successfully employed in cases of poisoning with oil of bitter almond, with carbolic acid, and with kerosene. Emetics are contra-indicated in poisoning with corro- sive substances, such as the concentrated mineral acids and the caustic alkalies. Whenever emetics are employed in cases of poisoning by vegetable and animal substances, repeated emesis should be produced, as it is not rarely found that the vomit of the third or fourth evacuation gives evidence of the presence of some of the poison. In order to hasten and facilitate the action of the emetic, large quantities of tepid water should be given, and the fauces titillated with the finger or a feather. Emetics are indicated to evacuate the stomach when indigestible food, or the products of fermentation or putre- faction, cause severe gastric irritation or alarming dis- order of the nervous system. Sometimes convulsions in children, a comatose state in adults, intense headache, and severe cramp-like pain in the stomach, have this ori- gin. If the history of the illness and the general condi- tion of the patient clearly point to this cause, emetics should be used. They usually give speedy relief. The best internal emetic is ipecacuanha, as it produces less irritation of the gastric mucous membrane than sulphate of zinc, sulphate of copper, or mustard. Large quanti- ties of tepid water should be given as soon as nausea supervenes, in order to render the vomiting as easy as possible. A subcutaneous injection of apomorphine is, however, superior to all internal emetics, as it in no wise increases the irritation of the stomach and causes speedy evacuation. Especially should it be preferred to ipecac- uanha when convulsions in children are caused by gas- tric irritation. 2. To expel pathological products from the air-passages, emetics are occasionally indicated in bronchitis, bronchio- litis, catarrhal pneumonia, and croup. When respiration is difficult, rapid, and superficial, and moist rales are heard over various parts of the chest, emetics often give decided, although temporary, relief. Apomorphine is preferable to other emetics, as it possesses decided expec- torant properties and acts rapidly and gently. It may, however, fail in capillary bronchitis, when the breathing is very difficult and decided cyanosis has taken place. The only internal emetic which should be administered to children to eject accumulations of mucus in the air- passages is ipecacuanha. In strong adults this remedy may be combined with tartar emetic. Emetics are generally resorted to in croup to expel the fibrinous exudation or false membrane. Sometimes they accomplish this, but more frequently fail on account of the firm attachment of the membrane. If the ejectment takes place, a notable amelioration of the dyspnoea im- mediately occurs. As it is of the highest importance to prevent the depression which so rapidly occurs in croup, only those emetics are eligible which produce slight nau- sea, such as sulphate of copper, sulphate of zinc, and alum. Apomorphine has been successfully used in some cases, and in the early stage of croup deserves preference to other emetics. 3. Sometimes emetics are indicated when foreign bodies have lodged in the oesophagus and upper part of the air- passages. They are useful when the substance lodged in the oesophagus is rounded, doughy, or pulpy, but may be harmful when it is very irregular (pieces of bone, needles, fish-bones), as the efforts incident to vomiting may be followed by severe injury of the oesophagus. When foreign bodies lodge above the glottis, they may be expelled by emetics ; but if situated below, vomiting may cause them to lodge in the rima glottidis, especially if they be angular. Apomorphine should be preferred to all other emetics to remove foreign bodies, as it acts speedily and certainly. Contra-indications.-At the time, now happily past, when it was supposed that the whole course of febrile and inflammatory diseases might be favorably modified by the action of emetics, especially by such as induce severe and prolonged nausea, authors found it necessary to enumerate numerous contra-indications, such as in- flammation of any of the abdominal organs, diseases of the heart and blood-vessels, great debility, the extremes of life, pregnancy, the presence of hernia, etc. When the presence of a poison in the stomach indicates its rapid evacuation, an emetic must be given regardless of all other considerations, if the stomach-pump cannot be used. But in cases of gastric irritation in which life is not imperilled, other less rapid methods of treatment should be instituted, if the operation of vomiting itself endangers the life or future well-being of the patient. Samuel Nickles. EMMENAGOGUES (and Ecbolics). This term (de- rived from en^via, the catamenia, and aywyos, exciting') refers to all agents which excite or promote the menstrual discharge ; and as this may be suppressed from various causes, the most opposite remedies may be employed to restore it. Some writers, notably Cullen and Meigs, have been so hardy as even to deny the existence of any emmenagogue, because " the discharge from the uterus is not one of the excretions through which medicinal agents pass out of the system," and Dr. Meigs refers in proof to Professor N. Chapman's very meagre list (C. D. Meigs, on " Woman and her Diseases," p. 438). But medicines which excite 674 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Emetics. Emmenagogues. the pelvic circulation and stimulate the organs in the neighborhood of the uterus undoubtedly have a tendency to excite or increase the menstrual discharge ; and when Dr. Meigs, in his quaint and interesting work, recommends several very simple substances (aromatic sulphuric acid, or alum five to twenty grains, and nutmeg two grains, given every hour), for their power to reach the uterus, act upon its vessels, and check the excessive catamenial flow,-in which opinion we fully accord,-there are no greater theoretical or scientific difficulties in the one pro- cess than in the other. Trousseau, on the other hand, asserts that all general excitants may be emmenagogue, since the uterine system does not escape the stimulation which these agents pro- duce throughout the entire organic apparatus, and as amenorrhoea is connected with so many diverse causes, we find emmenagogues among all classes of agents in the materia medica and outside of it. Yet he esteems but three as worthy of a special description, inasmuch as they are, par excellence, emmenagogues, namely, Savin, Rue, and Saffron. The active principles of a number of plants and some chemical substances entering the blood penetrate to every portion of the system and act also on the spinal cord and the sympathetic ganglia ; they thus regulate the muscular bands surrounding the arterioles and expanding or con- tracting them; they modify and control the circulation, the nutrition, and consequently the muscular energies, the excretion and the secretion of organs. The pelvic viscera and the reproductive system in woman form no exception. We will take special care, however, to show, by citing high and recent authorities who have studied the physio- logical action of drugs, that agents do exist which act specifically upon the utero-ovarian system, and incite and provoke the menstrual discharge. It will not be our province to give, in detail, the his- tory, qualities, and actions of the special articles which are included under the caption to this paper ; but we will endeavor to embrace in the general description of the subject whatever we think will best subserve the interest of the reader, and will refer to some of the conditions which necessitate the use of these agents. We must also be allowed to include substances which, though not strictly emmenagogues, are used by the phy- sician to correct other derangements of the uterine func- tions, namely, dysmenorrheea, menorrhagia (leucor- rhoea), uterine inertia, etc. ; for if restricted rigidly to the consideration of " emmenagogues," the field will be a less fruitful one. It is almost impossible to treat of emmenagogues with- out including a notice of the ecbolics. The latter we are not inclined to regard as a distinct class, but that they differ only in the degree of power which they possess ; they are simply emmenagogues intensified in their action, and they cause such violent contraction of the pregnant uterus as to affect the expulsion of its contents, whether this be accomplished by their direct action upon the mus- cular structures, or through the intervention of the ner- vous media. This class, as Farquharson says, are used to stimulate the flagging powers of an exhausted uterus, and the principal ones he cites are, "Ergot, digitalis, savin, borax, and quinine." For the intelligent employment of these agents the practitioner must, of course, decide, first, whether the sup- pression be primary or secondary ; hence it is important for him to review and consider the condition of the re- productive organs as well as the general state of the sys- tem, including, therefore: 1. The uterus. 2. The ova- ries. 3. The natural, accidental, or pathological causes which may have produced the arrest of the function, viz., exposure to depressing emotions, to cold, to rheumatism, or gout-which are often prime factors in the production of menorrhagia, amenorrhoea, dysmenorrheea, etc. 4. The condition of the blood-whether it be anaemic simply, or be impaired by grave constitutional or malignant dis- ease, such as tuberculosis, scrofulosis, phthisis, cancer, etc., which modify or arrest almost invariably the men- strual discharge. The later stages of phthisis are gener- ally accompanied by complete suppression, which it is often extremely difficult, if not impossible, to relieve. 5. Derangements of the nervous and circulatory systems have to be carefully considered, as they lead to engorge- ment of the uterus and its appendages. 6. The parturi- ent and puerperal condition involves more or less re- motely the use, the abuse, or the avoidance of these agents-as, for example, in the restoration or the arrest of the uterine secretions or excretions-should they be mor- bidly affected at these periods. 7. Emmenagogues, or other agents endowed with the power to modify the uter- ine functions, are also employed in menorrhagia, dys- menorrhoea, leucorrhcea, uterine inertia, etc. 8. Lastly, they are used in the production or prevention of abortion. Emmenagogues are divided into direct and indirect. The direct act merely by restoring the normal functions of the uterus when these are suspended ; the indirect, by removing some constitutional condition which interferes with the due performance of the functions. Thus most of the ecbolic drugs, as Farquharson states, act as em- menagogues when given in small doses to a non-pregnant patient, "as rue, castor, and especially ergot." So they may be both ecbolic and emmenagogue ; and this shows how inexpedient, if not impossible, it is for us to attempt to confine our attention to those agents which are literally and exclusively emmenagogue. We will therefore refer in this paper to : a. Emmenagogues. b. Abortifacients, or ecbolics. c. Those agents which relieve by depleting, as in cases of suppression caused by plethora or congestion. d. Those which check discharge by an astringent influ- ence, or by contracting the capillaries. e. To which may be added : The general salutary in- fluence of pleasurable emotions, change of air, food, bathing-hot or cold,-exercise, general and ferruginous tonics which restore the crasis of the blood ; all which are essential in maintaining the integrity and the proper physiological functions of the organs upon which a healthy state of the uterine system is intimately depen- dent. We offer the following as a classification, with brief references to authorities when deemed expedient, which will best include and exhibit all these agents : Order of Emmenagogues and other Agents Modi- fying the Diseased Condition of the Uterus.- 1. Mental and Emotional Excitations.-These often act as emmenagogues by their powerful influence in deranging the circulation, or in favorably modifying the physio- logical and pathological condition of organs. Fear and anxiety stimulate powerfully the discharges from the bowels, kidneys, and uterus, while they arrest the secre- tions from the salivary glands. 2. Local Excitants and Relaxants.-Many agents which excite and increase the pelvic circulation provoke the menstrual functions: hot douches, sitz hip baths, and pediluvia, poultices, or stupes, with or without mustard, or other local stimulating applications to the pelvic re- gions, specially if used at the time of the menstrual period. Patients sometimes find speedy relief by sitting in a ves- sel filled with hot ashes and water. Leeches applied to the os uteri in a Recamier specu- lum, followed, after bleeding is checked, by hot stupes, often prove efficacious (Meigs). A tampon alone, or soaked in an astringent or styptic solution, will arrest the bleeding, if troublesome. Hot water thrown into the vagina, or rectal enemata of the same, also remedy in- ertia of the womb, hasten labor, and prove emmenagogue. Cold, on the contrary, facilitates the dilatation of the arterioles by its sedative influence upon the spinal cord and the nerve-centres which preside over the blood-ves- sels. So Dr. S. Ringer ("Handbook of Therap.," 6th ed., p. 46) quotes the assertion of Dr. Chapman, that " the peripheral circulation, and consequently bodily heat, is in- creased by ice applied along the spine," and that " applied along the lower dorsal and lumbar vertebrae, by increasing the amount of blood supplied to the pelvic organs, pro- motes menstruation, and will even restore the sup- pressed monthly flux." 675 Emmenagogues. Emmenagogues. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 8. Excito-motor Stimulants.-Electricity. Amenorrhoea, when dependent on atony of the ovaries and uterus, is cured by static electricity, by faradism, or by the inter- rupted galvanic current. A shock from a Leyden jar may be transmitted through the pelvis, or a strong faradic or galvanic current may be applied by means of one pole on the spine, the other on the hypogastric region. In the case of married women an insulated vaginal electrode may be introduced and placed in contact with the os uteri. This is a more effective way of making the appli- cation than by the electrodes placed externally. Bartho- low (" Materia-Medica"), p. 387, 5th ed.). Quinine. Its power to contract the uterus is much ques- tioned and much discussed, though Farquharson quotes it without a mark of doubt ! Many class it even among the ccbolics, as causing labor when incautiously used, and avoid its employment in pregnant women, even those suf- fering from malarial diseases. The question is still sub lite. Our own opinion is that it possesses no powers as an oxytocic, and Binz does not include this action while describing the properties of quinine. Ergot. This powerful agent affects the spinal cord, reduces the blood-pressure, produces anaemia of the womb, and active contraction. Though used generally to con- tract the uterus in uterine inertia after the os is dilated, and to arrest haemorrhage, it is also employed as an em- menagogue and in menorrhagia, for which it is extremely valuable. Uva Ursi. Mr. Harris, of Virginia, states that it has a power over the uterus which resembles that of ergot (Headland). Aromatic, Odorous, and Excitant Plants, and those Containing Irritant Oils.-The following four are gastro-intestinal irritants, their oils being absorbed; they are decidedly ecbolic and abortifacient, as they probably originate uterine contractions: Savin. To show that one substance at least produces a distinct and powerful impression upon the womb, we quote the following succinct description from J. Mitchell Bruce, one of the most recent authors, who says of savin that its oil ' ' acts as a remote local irritant to the kidneys and mucous membranes, especially those of the genital part, causing hyper®mia of the ovaries and uterus, and increases menstrual activity and contraction of the preg- nant uterus. It has been used as an emmenagogue, but requires the exercise of great care. More frequently it is given as an ecbolic for criminal purposes, and then often proves fatal as a gastro-intestinal irritant." Pereira pronounces it to be " the most certain and powerful em- menagogue of the whole materia medica," and H. C. Wood used it successfully "in menorrhagia depending on relaxation of the uterine tissues." Binz says of it that "the pelvic organs are said to be severely irritated by it, and rendered hyperaemic. For this reason savin has been much recommended and used as an emmenagogue and abortifacient medicine." Rue. Action similar to that of savin, but less active, and less employed as an emmenagogue. We translate from Trousseau and Pidoux (" Traite de Therap. et de Mat. Med., t. ii., 533): The excitants which merit dis- tinction under the title of emmenagogues, and which can- not be placed elsewhere, are rue, savin, and saffron. They are, we think, decidedly abortifacient. The oil of rue is abortifacient, not so much becapse it produces in- flammation of the gastro-duodenal mucous membrane, but because its active principle is absorbed. Many observers, the authors remark, confirm the abortifacient powers of the plant independently of any predisposition to abortion. In two cases of young women, aged eighteen and nine- teen, who had never menstruated, we used successfully the following: I). Sabin® pulv., rut® pulv., ergot® pulv., aa gr. xviii ; aloes pulv., gr. xvi. ; fifteen pills. Sig. : Take three the first day, six the second, and nine on the third day. Saffron. The infusion and tincture of the stigmas were employed as emmenagogues in amenorrhoea. The drug is now seldom used. Trousseau seemed to have no doubt regarding its powers, though it is difficult to keep, and expensive. Cotton Root. The decoction is much used by the col- ored race and by the rural population in the southern United States as an emmenagogue, and to provoke abor- tion. Dr. J. C. Martin, in a paper in the American Jour- nal of the Medical Sciences, January, 1882, and referred to by Biddle, says that it has no power on the motor and sensory nerves of frogs, rabbits, and guinea-pigs, "and that it possesses no oxytocic properties." Maisch quotes it as "an emmenagogue and oxytocic" (" Organic Ma- teria Medica "); see also our " Resources of the Southern Fields and Forests " for details of local experience with the root. Tansy. The oil " causes a vascular turgescence of the abdominal organs, increasing the secretion of urine and promoting the menstrual discharge" ("Nat. Dispensa- tory," Stille and Maisch). Very commonly used among the people to produce abortion and to restore menstrua- tion. Several of the vegetable substances which follow emit a camphoraceous smell, yield a volatile oil, and when given in hot infusion exhibit moderate emmenagogue, combined with tonic and stimulating powTers. Serpentaria. This is more of a stimulating diaphoretic and tonic than an emmenagogue. Penny Royal. One of the best adjuvants to other remedies during obstruction. Sage. Used from the earliest periods to promote the menstrual discharge, being also a warm, stimulating di- aphoretic. Most of the aromatic plants are emmenagogue ; the fol- lowing are quoted by Maisch ("Organic Materia Medica "): Balm, catnip, horsemint, rosemary, garden thyme, wild thyme, millfoil, wintergreen, marjoram. Chamomile. The infusion of the flowers is given in cases similar to those benefited by castor and camphor (Trousseau). Senega. An active excitant of the mucous membranes and secretions, and generally regarded as an emmena- gogue. Cimicifuga raises the blood-pressure ; has a remote stimulating action " which increases the activity of the skin, kidneys, and generative organs " (Bruce). The de- coction is emmenagogue (Farquharson, Maisch). Purgatives.-Those are specially active which stimu- late the lower portion of the intestines, on account of the diversion or afflux of blood which they cause, and the sympathetic irritation of the reproductive organs en- suing thereto. Warm, stimulating enemata add to their efficacy. Aloes. From its action on the lower bowels, preferred to all other purgatives when the catamenia are delayed on account of anaemia and torpor; it may be combing with iron and bitters, and also with asafoetida. Black Hellebore. Used from the earliest times in amen- orrhcea ; now seldom employed. Guaiacum. In amenorrhoea and dysmenorrlioea de- pendent upon rheumatism or gout. Dewees' ammoniated tincture has been much employed in such cases. Stimulating Diuretics.-Cantharides. This requires care in its administration, and will seldom or never be re- quired. Parsley. Parsley, or its active principle, apiol, is used in neuralgia and dysmenorrlioea. ' ' Employed as an em- menagogue in doses of four grains morning and evening " (Jour, de Pharm., June, 1861). " The evidence is conclu- sive," says Bartholow, "that apiol has decided emmen- agogue power." It is a stimulant to the uterine system, " and indicated when a state of torpor of the ovaries and uterus exists. The amenorrhcea of anaemia and func- tional inactivity is the form of malady in which apiol is serviceable " (" Materia Medica "). Pulsatilla is an irritant to the gastro-intestinal tract. A tincture made from the fresh leaves is much praised as a remedy in spasmodic amenorrhoea (Binz). It has also been recommended in functional amenorrhoea, when the menses are delayed or scanty, in suppressio mensium from fright or chill, and in functional amenorrhoea when the discharge is scanty (Biddle). Maisch does not include this among the plants possessed of emmenagogue power. 676 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. KnimenagociieR, EiniiienagoKues. Water Pepper, Smart Weed (Polygonum Hydropiper- oides Mx.). This indigenous plant increases the blood- supply to the pelvic viscera, and is applicable to cases of amenorrhcea due to functional inactivity or torpor of the uterine system. Ebberle asserts that it is remarkable for its efficacy in relieving amenorrhcea, and he reports that "with no other remedy or mode of treatment has he been so suc- cessful as with this." Bartholow confirms the statement. Dr. T. L. Ogier, of Charleston, publishes his favorable experience of it in the " Southern Journal of Medicine and Pharmacy," Charleston, 1846. The tincture, fluid extract, or strong infusion are used. See our " Resources of the Southern Fields and Forests," p. 409, second edition, for a sketch of its use. Roborants and Tonics.-Iron and its preparations are powerful and efficient by restoring a healthy con- dition to the blood, and through this renewing the ener- gies of the depraved nervous and secretory systems. Our plan is to administer such agents persistently in the inter- vals between the periods. Arsenic. Menorrhagia, when produced by anaemia, is benefited by preparations of arsenic, especially when combined with iron; and arseniate of iron and ergotin can be given in combination (Bartholow). Aurum. Amenorrhcea, dependent on torpor of the ovaries, may be removed by the persistent use of auric preparations. Chronic metritis, with scanty menstrua- tion, is often remarkably benefited by them (Bartholow, " Materia Medica," fifth edition, p. 259). Food, bathing, change of air, travel, etc., also act by improving the nutritive functions, restoring the crasis of the blood and the integrity of the nervous system, thus constituting them indirect emmenagogues of decided value. Incert^e Sedis.-The following scarcely admit of clas- sification ; some are excito-motor, some cerebral excitants or cerebral sedatives, others act on the nervous system through the blood. Mercurials " prove emmenagogue by their influence in exciting the secretions generally." Digitalis. An excito-motor. It contracts the arterioles, and, acting on unstriped muscular fibre, it has the prop- erty of stimulating the uterus to contraction ; it thus checks flooding or menorrhagia ; ' ' and may also restore its normal functions when these are suspended, as in amenorrhcea " (Farquharson). Cannabis Indica. A cerebral excitant. It is "fre- quently given as a special anodyne and antispasmodic in dysmenorrhoea, menorrhagia, and hysteria" (Bruce). A writer in the Charleston Medical Journal, for 1857, found it to act rapidly upon the uterus, not so slow as ergot, and promoting the expulsion of the child. Aconite. Dr. West de Soulz is quoted by Trousseau as recommending aconite in cases of amenorrhcea depend- ent upon a spasmodic state of the uterus, or of a chronic engorgement of this organ (" Traite de Therap. et de Mat. Med.," vol. ii.). Ringer and Phillips both declare that drop-doses of the tincture, given every half-hour, will relieve sudden suppression of the catamenial flow caused by cold ; and Bartholow asserts that it has a high degree of utility in congestive dysmenorrhoea occurring in ple- thoric subjects. Carolina Jessamine {Gelsemium) is undoubtedly bene- ficial in cases similar to the above (Bartholow). Blue Cohosh, Squaw Hoot {Caulophyllum thalictroides Mx.). Said to facilitate parturition, and to be an active emmenagogue (Griffith's " Med. Botany ; " " Resources So. Fields and Forests "). Actwa liacemosa. It depresses the force and frequency of the pulse. This plant has been long employed in this country for a reputed action upon the uterus similar to that of ergot ; also in suppression of the menses, especially when at- tended with pain, or rheumatic in character. "It is said to be useful in expelling the placenta, and in pre- venting after-pains. It has been recommended in amenorrhcea, dysmenorrhoea, and in menorrhagia. It has been given to prevent miscarriage in irritable uterus, and for the pleurodynia dependent on uterine derange- ments." Five minims of the tincture maybe given every hour, or fifteen to thirty minims three times a day (S. Ringer : " Handbook of Therap."). Black Cohosh (Cimicifuga racemosa). Dr. Suydam Knox read a paper before the Chicago Gyn®colog. Soc., 1885, and Dr. H. W. Jones, of Chicago, recommended it highly for its sedative and positive antispasmodic effect upon the parturient woman, lessening the pains of labor and greatly diminishing the duration ; it " relaxes uterine muscular fibre by controlling muscular irritability ; also increasing the energy and rhythm of the pains." Some observers denied its power ; but Dr. Jones was well known for his advocacy of the drug "as an oxytocic." Dose, fifteen minims of the fluid extract in comp, syrup of sarsaparilla each night for four weeks before the ex- pected confinement. Permanganate of Potash. Sidney Ringer and William Murrel, of London, recommend this agent very highly in amenorrhcea, preferring the pill form to the pharma- cop®ial solution. They begin with a grain three times a day, then gradually increase the dose to two grains four times a day, giving the remedy only for the three or four days preceding the expected period, and continuing it, if necessary, even after the menses have appeared. They say that " the administration of one or two grains in pill, three or four times a day, for a few days, will bring on the flow almost to a certainty. In some instances the periods were brought on after the patient had ceased menstruating for over a year." It succeeds well with the plethoric and the anaemic, with young and old, and with those who, from catching cold or getting wet, have " missed " once or twice after having been regular. In the doses used it does not produce abortion. Professor T. Gaillard Thomas is reported as declaring that, " as an excitant of the menstrual flow, it is, I think, the best emmenagogue which has yet been discovered " (Address, New York State Medical Association, Novem- ber 19, 1884). Mr. P. Maury Deas {British Med. Jour., 1885) says that it is a useful and safe emmenagogue, free from the dis- advantages which attend some other remedies of this class; that its use may be continued for months without any bad effects, and success need not be despaired of even after many months. " Even when it fails as an emmen- agogue, it acts beneficially as a general and nervine tonic." Dr. E. I. Doering (Chicago Gynaecol. Soc., 1885) also recommends it. Our own experience with it in many cases in our own field, and in a large dispensary practice of my son, is favorable. We have the pills made with fuller's earth. It is sometimes given in capsules, taken midway between meals, followed by large draughts of pure mineral water. Pain sometimes follows its use. Dr. A. II. Bampton {British Med. Journal, April 25, 1885) recommends unguentuni resin® as a convenient and suitable excipient-as kaolin is difficult to manipulate, and of a stony hardness when made up and dried. A writer in the Therap. Gazette for June 15, 1885, advises kaolin ointment as the best excipient. Mr. Deas " never found any symptom of gastric or intestinal irritation to follow its internal administration of three to six grains." Salicylate of Soda. M. Bapette says that this agent may prove very useful in dysmenorrhoea, relieving the pain and facilitating the discharge. Given in doses of one drachm to one and a half drachms, it produced marked relief in three cases within an hour {Therapeutic Gazette). Boric Acid. An action upon the uterine system and emmenagogue properties have been claimed for this agent. Stille and Maisch say, " the power attributed to borax of exciting the gravid uterus to contraction does not appear to us susceptible of well-grounded doubt ; and while believing that it is efficacious in uterine hemor- rhage, we should find a demonstration of its value diffi- cult " (" National Dispensatory"). Oil of Amber. The " National Dispensatory/' refers to the use of this agent in amenorrhcea. 677 Emmen argues. Enceplialocele. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In conclusion, we introduce agents which are not em- menago^ues, but which have a contrary effect in restrain- ing uterine discharges, and they are of sufficient practical value to interest us in this connection. Two of them re- lieve irritable conditions of the uterus, and the three last agree in being aromatic. "Black Haw (Viburnum prunifolium). Dr. Phares, of Mississippi, in 1866, introduced this indigenous plant as "a uterine sedative and antispasmodic, allaying irrita- bility, relieving dysmenorrhcea, and preventing abortion, whether habitual or otherwise, whether threatened from accidental cause or criminal drugging." Dr. E. W. Jenks, of Detroit, fully sustains these claims, and he adds: " I shall not overstate the fact if I say that no one remedy or means has proven of equal value in my hands, and I have tried faithfully all the common and time-honored methods of treatment." " In cases in which the habit of abortion has been formed a teaspoonful of the fluid extract given three times a day, for several days before the usual occurrence of menstruation, very fre- quently averts uterine contraction, and the pernicious habit is broken up." In neuralgic dysmenorrhcea Dr. Jenks uses it in com- bination with C. Indica: B. Extr. viburni prunifolii fluidi.... § ij. Extr. cannabis Indicae fluidi 3 ij- Extr. conii fluidi 3 iss. Glycerine, q. s ad § iv. M. Sig.: A teaspoonful three times a day during the interval, and every three hours during menstruation. We have formed a very favorable opinion of the value of this drug in several cases in which it has been used. Potassium Bromide. A cerebral sedative. It contracts all the blood-vessels, producing anaemia of the brail "nd spinal cord, thus diminishing the excitability of tliese organs. See experiments of Brown-Sequard, Meuriot, and Amory, quoted by S. Ringer, who says that it is of decided efficacy in removing the migraine caused by derangements of the womb, especially menorrllagia. S. Ringer says that in some forms of menorrhagia it is equal, if not superior, to any remedy we possess ; but it is more useful in the flooding of young, than of old, women. Ten grains three times a day is a dose sufficient, but much larger doses are required in the more obstinate forms depending on organic changes in the womb. We have had excellent results from the following combina- tion in cases of difficult and excessive menstruation : R. Bromide of potassium 3 ijss. Fluid extr. of cannabis Indica. Ttlxxx. Cinnamon water 3 iv. M. Sig.: A dessertspoonful twice or thrice a day in a little water. Potassium bromide is simply invaluable in calming the restlessness, and producing sleep, in those suffering from almost any form of uterine disease. We have often used it combined with ammoniated tincture of valerian, or citrate of caffeine. Cayenne Pepper. M. Cheron (in the Revue Med. Chir. des Mal. des Femmes') recommends this in all forms of uterine haemorrhage, whether due to fibroid tumors, to fungous endometritis,' or even to epithelioma. Experi- ments and its good effects in haemorrhoids led him to consider it as having a special action on organs very rich in blood-vessels. " It acts like ergot on the non-striated muscular fibres of the vessels-either directly or through the vaso-motor system-superior to ergot in being well supported by the stomach." Two grains in the pill form before each meal, increasing to four grains, may be given, or the watery extract, or the tincture much diluted {Med. and Surgical Reporter). Cinnamon. A writer has found the use of a decoction made of one-half ounce in a half-pint of water to check uterine haemorrhage recurring at variable intervals from an old laceration. He states that Stille and Farquharson both ascribe this power to it (North Carolina Med. Jour- nal, 1885). Nutmeg. We have already alluded to Professor C. D. Meigs' use of nutmeg and alum in restraining the men- strual flow, and we have repeatedly used it with good effect. ' F. Peyre Porcher. EMPHYSEMA, SUBCUTANEOUS. By this term, or pneumatosis, is meant the presence of air or other gaseous compounds beneath the skin. The resultant symptoms are these: a swelling cov- ered with skin of either normal appearance or, if the pressure upon it be great, rather pale ; this tumor pits upon pressure, like anasarca, but the pitting more quickly disappears in case of air; palpation causes a peculiar crackling or crepitation in the subcutaneous tissues. If the air have entered from without, a wound or puncture can generally be discovered ; if from within, expiratory efforts with closed lips and nostrils will generally produce immediate increase in size. It is possible for the whole subcutaneous tissue to become inflated from any super- ficial part of the body as a starting-point. In case the emphysema is that of decomposition, there may, of course, be an altered hue of the integument; but not from this as a cause. Subcutaneous emphysema may result from causes either traumatic or pathological. Among instances of the lat- ter may be mentioned ulcers or abscesses communicating with the air-passages, and, as already suggested, gangrene. We may include in the discussion of this subject e». physema of other parts external to the lungs, such as mediastinal and submucous collections of air. In the head, orbital emphysema sometimes follows a blow of sufficient violence to break one of the thin a 1 fragile bones of the inner wall of the orbit-the lachry- mal or the orbital plate of the ethmoid. If, soon there- after, the patient blows his nose, the compressed air finds a ready exit from the nose into the orbit, and distends the lids. Eustachian emphysema : here an ulcer of the tube, or a rupture following awkward Eustachian catheterization, has led to distention and approximation of the pharyngeal walls by the dissecting air. Blowing the nose and the Valsalvian experiment increase the emphysema in these cases. Von Troltsch 1 mentions a case, within his own experience, in which dysphagia consequent upon such, emphysema existed for five days. In the neck we may have escape of air as a result of foreign bodies, ulcers, or abscesses perforating the oesoph- ageal, laryngeal, or tracheal wall; but emphysema will not be produced if there is a broncho-oesophageal fistula caused by the perforation. Ulcers of the larynx or trachea may lead to submucous dissection. Wounds of the neck penetrating these parts may be followed by subcutaneous emphysema if there is not free escape for the expired air. From this cause in- flation reaching from head to scrotum has resulted.2 As a rule, the consequences are not serious; but Holmes3 quotes Hilton as stating that emphysema about the phrenic nerves may so interfere with their functional integrity as to cause death. During tracheotomy, and afterward if much inspira- tory difficulty be present, Champneys4 finds that ante- rior mediastinal emphysema, and even pneumo-thorax, are liable to occur; and this is especially so if artificial respiration by Schultze's method be employed. In the chest we may have the surgical symptom in ques- tion produced in several ways. Pathologically, as by the opening of a vomica or abscess of the lung into the pari- etes of the chest, the two pleural surfaces being adherent at their point of perforation. (Were this adhesion not present there would, of course, simply be a pneumo- or pyo-pneumo-thorax.) From traumatism we find it some- times complicating wounds penetrant and non-penetrant. In the latter instance, the air which enters the wound from without during one movement of respiraration is pre- vented in a valvular way from escaping during the op- posed movement, and is disseminated by the muscular and tegumentary pressure upon it during this movement. In the case of wounds penetrating the parietal pleura only, we may, besides the consequent pneumo-thorax, have a subcutaneous emphysema from the same reason. 678 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Emmenagogues. Eneeplialocele. Wounds proper that penetrate the lung, and puncture of the lung by a fractured rib, are alike liable to produce emphysema, air escaping from the lung with the same re- sult as in the case last given. An additional and rare variety of traumatic emphysema of thoracic origin is that consequent upon rupture of air- cells by violent expiratory efforts, with a closed or par- tially closed glottis, as while coughing, straining, or blow- ing a wind-instrument. Here the air makes its way between the lobules, and, unless it ruptures the pleura, producing pneumo-thorax, escapes at the root of the lung into the mediastina, and thence into the cellular tissue of the neck, becoming subcutaneous. Guttman5 says : "Most of the cases of this variety of emphysema are observed in connection with croup, diph- theritis of the larynx, whooping-cough, and bronchitis in children, and advanced pulmonary emphysema in the aged. " Two summers ago I met with the only case which as yet I have found complicating pertussis. The patient, a child of two years, had been suffering for about three weeks, the parents said, from violent fits of coughing. I was called to treat the sudden appearance of " dropsy" in the case. I found the skin of head, neck, and chest •distended, crepitation everywhere well marked, and no •dropsy. Whenever the child coughed the swelling in- -creased in size suddenly, apparently distending first in the left Supra-clavicular region. The respiration was rapid, but seemingly free ; the pulse rapid and feeble. The child died within a few hours. Unfortunately, no au- topsy was allowed. In the abdomen yve may have subcutaneous emphysema from ulcerative perforation of stomach or gut at a point previously adherent to the abdominal wall. Unless such adhesions prevent it, gas will escape from the viscera into the peritoneal cavity. Treatment.-As a rule, air beneath the skin is of slight consequence and requires no treatment, becoming absorbed after a time. If, however, important parts-as the phrenic nerves, or the larynx, trachea, etc.-are sub- jected to a degree of pressure injurious to respiration, or if the subcutaneous air is spreading further and further, we may employ pressure at the point of escape, or incis- ions through the skin to give relief to tension, or both. Subcutaneous emphysema possesses an interest for us ■outside of its pathological or accidental causation. It has often been induced intentionally by the malingerer ; and, moreover, its production has been seriously advocated by Dr. H. R. Sylvester6 in an article entitled " On Life-sav- ing from Drowning, by Self-inflation." Here it is rec- ommended that those in peril of the deep shall make a small runcture or cut in the cheek, leading from the mu- cous n jmbrane about opposite the first molar to-but not througa-the superficial fascia and skin ; and then, clos- ing the lips tightly, shall proceed to blow themselves up, until the skin of head, neck, and chest is distended. Dr. Sylvester alleges that a moderate and quite painless and harmless inflation is ample to keep one afloat without effort. It seems probable that Vidocq refers to such a practice when in his Memoirs-as mentioned by Gavin1-he asserts that he could make his head swell like a bushel, without giving pain, and that he could remove all traces of it by the day following. In order to test the degree of pain, and the subjective effects upon the skin of such distention, I some time ago performed the following experiment, assisted by my friend Dr. F. A. Manning: Having connected, by a piece of rubber tubing, a hypodermic needle with my compressed-air receiver, I forced air beneath the skin of my left forearm until the limb was much increased in size, the skin tense, and emphysematous crepitation could be felt from wrist to armpit. The pain was very trifling in amount. The distended skin was somewhat anaes- thetic ; whereas before the injection I could distinguish points on the anterior surface at an average distance of 4 mm., immediately thereafter I could only name them when 10 to 15 mm. apart. Still, pinching and pricking were distinctly painful. The emphysema thus induced was slow in disappear- ing. It was still somewhat noticeable on the third day after the experiment. Regarding the production of emphysema upon the human subject with intent to deceive, it has been em- ployed to simulate hernia, hydrocele, hydrocephalus, ascites, etc. Gavin (op. cit., p. 389) says : " It is a trick used every day by butchers, and has been known from time immemorial by the Ethiopians and mendicants of Abyssinia." Beck8 quotes Sauvage's " Nosology" regard- ing a mendicant who " gave his child all the appearances of hydrocephalus by blowing air under the tegument of the head near the vertex." He also cites a case of em- physema of the abdominal parietes, induced by a woman who wished to feign dropsy. Sir George Ballingall9 declares that the artificial pro- duction of this for the simulation of other diseases is reg- ulated by a recipe current in the British army. The differential diagnosis of the tumors so caused pre- sents no difficulty. Robert H. M. Dawbarn. 1 Treatise on the Diseases of the Ear. 2 Plaies du Larynx, de la Traohee, etc. Par le Dr. Paul Ilorteloup, Paris, pp. 53-77. 3 Surgery, vol. ii. 4 Med. Chir. Transactions. 1882, p. 75 et seq. 6 Handbook of Physical Diagnosis, p. 27. 6 London Lancet, January 3, 1885, and August 29, 1885. 7 Gavin on Feigned Diseases. 8 Medical Jurisprudence, vol. i., p. 74. * Military Surgery, p. 584. EMS is situated in the province of Hesse-Nassau, Prus- sia, a few miles from Coblentz, in the valley of the Lahn, at an elevation of about two hundred and seventy-five feet above the sea. It lies in a beautiful valley, but the climate in summer is rather trying, as the days are usu- ally hot while the nights are often disagreeably cool. It possesses numerous alkaline thermal springs, the waters of which are used both internally and in baths. The fol- lowing is the composition of one of the most popular springs, the Fiirstenbrunnen. Each litre contains of Grammes. Sodium Carbonate 2.036 Lithium carbonate 0.004 Ammonium carbonate 0.002 Calcium carbonate 0.217 Strontium carbonate 0.002 Barytium carbonate 0.001 Magnesium carbonate 0.205 Ferrous carbonate 0.V01 Manganese carbonate trace Sodium sulphate 0.017 Sodium chloride 1.001 Sodium bromide ( . Sodium iodide ( aces Sodium phosphate 0.001 Potassium sulphate 0.048 Argillaceous earth trace Silicic acid 0.049 Organic matters 0.016 Total solids 3.600 The temperature of the Fiirstenbrunnen is 10f' " ; that of the other springs varies from 82° to 116° F. 1 lie wa- ters are taken pure or mixed with milk or whey. Ems is much frequented during the season by sufferers from chronic catarrhs of the digestive, urinary, and respiratory organs, hepatic disorders, especially those in which con- gestion is present, gout, chronic rheumatism, and diseases of the female sexual organs. T. L. S. ENCEPHALOCELE (ev/ce^aAog, brain, hernia. Fr., Hernie du cerveau ; Ger., Gehirnbruch ; It., Ernie con- genite del capo). Protrusion of portions of the brain or of the cerebel- lum through the skull may be made the object of special study from two points of view : that of the surgeon, and that of the teratologist. Hernias of the brain through an accidental orifice of the skull, such as that made by a wound, by a necrosis, or by the application of a trephining instrument, are mentioned in all the classical works of surgery. Trau- matic hernia of the brain may follow the application of forceps in childbirth ; it is known to have occurred on extracting splinters of bone from the fractured skull; and it is a complication of wounds and fractures of the 679 Enceplialocele. Enceplialocele. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. skull by fire-arms. From the latter cause the most curious cases of traumatic encephalocele may arise. The complication may appear immediately after the trauma- tism, or, which is more frequent, after a few days, the brain escaping in a more or less voluminous mass under the form of a fungoid excrescence, which becomes black and gangrenous and gradually sloughs away. A con- siderable portion of the cerebral mass may thus be eliminated without death occurring, and numerous facts confirm the possibility of recovery notwithstanding the loss of a notable portion of the hernia from sloughing or from excision. A detailed exposition of the subject appears in the 51 cases compiled by the writer for the "Medical and Surgical History of the War of the Rebellion," surgical volume, part first, pp. 293-304. Four of the 7 survivors whose history is therein recorded recovered with full integrity of their mental faculties, while 3 suffered so much from headache and vertigo as to be incapable of much mental exertion. Eight of the 44 fatal cases appear to have been examples of primary protrusion of brain-substance from extensive gunshot fractures, and 36 illustrate the condition known as hernia or fungus cerebri. Of the 51 patients 4 were trephined, and in 25 cases fragments of bone were removed, the projectile also being extracted in 4 instances. The possibility of healing a cerebral hernia consecu- tive on a traumatic lesion is greatly increased if the dura mater remain intact, and the encephaloceles following the operation of trephining soon disappear if care be taken to preserve a little of the periosteum. Generally speaking, surgical interference in such cases is unneces- sary. In hernias of the brain covered by the integu- ment only, it is advisable to resort to gentle pressure, such as that afforded by a leaden plate, a flexible leather or gutta-percha shield, or by the application of one of these substances secured by a light bandage or ad- hesive strips. Even this external pressure on the tumor requires great caution, since it may give rise to some of the cerebral symptoms seen in compression, as stupor, dilated pupils, nausea, paralysis, and convulsion. The so-called congenital encephalocele is by far the most common of the cephaloceles proceeding from malforma- tion of the skull. Notwithstanding the rarity of the tumor and the ambiguity of the diagnosis, various synony- mous terms have been employed in its description, as craniocele, ectopy of the encephalon, cranial spina bifida, occipital spina bifida, etc., and the subject has a bibliog- raphy the mere enumeration of which would occupy many pages. Passages from Celsus, from Albucasis, and from yEginitus incline to the belief that they had some notion of the exencephalia. Surgeons of the middle ages, whose minds were tinctured with the ideas of their time, represent these tumors by fantastic phalic designs ; and Ambrose Pare, speaking of the famous monster of Turin, says that he had a horn on the top of his head. In the course of the eighteenth century the terms en- cephalocele and hydroencephalocele appeared for the first time in the works of Ledran, of Corvinus, and of Fer- rand. The voluminous memoir of Spring contains a critical study of all the facts known up to his time, and consti- tutes an authority which with all its faults seems to have been imposed on nearly all subsequent writers that have treated brain ectopies of the skull. Authors have fol- lowed in the wake of the learned Belgian professor until late years, when some powerful objections have been made to his doctrines. Briefly described, encephalocele is a hernia through a hole in the skull existing at birth or shortly after, the hole being dependent on the part of the brain protruded. The tumor is rarely double, except at the internal angle of the eye ; it is rounded, soft, salient rather than pedunc- ulate, fluctuating or not, and transparent ; the color of the skin enveloping it is unchanged, and there is little or no pain ; pulsations isochronous with the pulse, though not constant, are detected by palpation ; the volume of the tumor is sometimes increased by effort, and it may change according to the degree of inclination of the body. Diminution of volume during sleep is an authentic symp- tom in hernia cerebri only. When pressed, the reflex phenomena peculiar to compression of the brain may take place, but this is not likely to be observed unless menin- go-encephalitis exist. Touching the discussion of encephalocele opinions are at present divided, some authors claiming that the sub- ject is teratological rather than pathological. Whether the gap in the skull through which the tumor protrudes be a reversive anomaly similar to the troubles in the normal evolution witnessed in the development of the epactal bone, or whether the protrusion be formed by the existence of a watery bag within the skull, or depend upon a dropsy of a portion of one of the ventricular cavities which perforates the skull by a mechanism an- alogous to that observed in aneurism, it does not seem that these questions of pathogeny at present call for comment. In studying encephalocele, it is highly conducive to clearness at the outset to discriminate between the ac- quired and the congenital form. A distinction so natural is not always made, and in looking over the literature of the subject one finds many cases of acquired encephalo- cele reported as congenital encephalocele, and recipro- cally. It should also be borne in mind that all con- genital encephaloccles are not malformations. These distinctions have been disregarded by eminent surgeons who have reported cases of pretended encephalocele. Even Billroth (Arch. fur Klin. Chir., 1862), reports, under the name of " spurious meningocele," a case of a tumor in a child following the application of forceps, and in which iodine was injected with fatal result. Ac- quired encephalocele, whether of traumatic or patho- logical origin, is a lesion purely local ; while the con- genital form is a vice of conformation always accompanied by other hidden or apparent malformations, and is, so to speak, only a reflection of a more general teratological state. For convenience of study, encephaloceles arising from abnormal adhesions, or what is technically known as sy nencephalocelc (avv, with, lyK^aKoK^Xii, encephalocele), may first be mentioned. This condition, probably in consequence of some intra-uterine inflammation, is a cerebral hernia that has contracted adhesions with the placenta, the umbilical cord, or the membranes of the ovum. At the point of adhesion there is generally an absence of a portion of the cranial bone, or a scar in the immediate vicinity of the tumor indicating a recent ad- hesion. Brain-tumors of this kind are interesting chiefly from a pathological point of view. Meningocele, or, rather, a membranous encephalocele, is- a hernia of the membranes of the brain in which the pia mater protruding through an opening of the skull pushes and carries with it the accompanying portion of the dura mater. The membranes in this instance are pushed up by the abundance of the serous arachnoid fluid through an opening which is the result of a non-union of some of the bones of the cranial vault; and the separation of the bone is itself caused by this hernia, which is of foetal origin. Writers are in the habit of describing meningo- cele as the result either of meningeal haemorrhages and the production of false membranes, or of a hydroceph- alus. The lesion is not yet sufficiently demonstrated to> enable one to trace the symptoms, or even the diagnosis,, of meningocele ; on all sides it is admitted to be very rare, and some even doubt whether it exist. Since the existence of this variety does not appear to be proved, it would be better to include what is to be said on the sub- ject under the head of hydrencephalocele. In hydrencephalocele (u8a>p, water, and encephalocele} the hernia of the brain is complicated with ventricular- dropsy. The protruded brain-substance connects with one of the ventricles, and is contained in a sac filled with fluid. The term has been applied to protrusions of this kind since the time of Corvinus, and later researches have shown that the fluid is the essential element in such cases. The pouch-like prolongation of the ventricle opening into the ventricle itself is, according to some au- thorities, a ventricular dropsy on a small settle. Hernias of this kind are mostly found on the occipital region (seq 680 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Encephalocele. Encephalocele. Fig. 1010), and at the root of the nose, where they consti- tute a sort of spina bifida. They are spoken of as frontal drencephalocele-so rare, in fact, that a prominent Lon- don obstetrician, of four-and-twenty years'practice, states that he has never seen a case ; one Continental practitioner reports having seen but one case out of 5,000 accouche- ments; and another, three cases out of 12,900.* This anomaly of organization has been observed in foetal life Fig. 1010.-Posterior Hydrencephalocele. (After Holmes.) or sincipital; or, in other words, they may protrude at the front or back part, at the base, or at the apex of the skull. Occasionally protruding from the base of the skull, they may traverse the palatine vault, as shown in Fig. 1011. An occipital hydrencephalocele may vary in as early as the sixth week, and it is of more frequent oc- currence in girls, about two-thirds of the reported cases belonging to that sex. There are numerous intermedi- aries between the two terms encephalocele and hydren- cephalocele. In simple encephalocele the integumental coverings present little or no change ; its attachment is broad and sessile ; and in size it rarely exceeds that of an orange, although exceptional cases have occurred in which the tumor containing the greater portion of the brain, the cerebellum, and even the medulla oblongata, has greatly exceeded these proportions. Formerly writers described the seat of encephalocele Fig. 1013.-A Case Observed by the Writer. Fig. 1011.-An Irregular Tumor proceeding from the Cranial Cavity by a Large Opening situated immediately in front of the Sphenoid, and be- hind the still Cartilaginous Ethmoid. (Virchow.) size from that of a pea to an enormous pouch hanging from the back of the head down to the loins. Owing to the protrusion into the sac of one of the processes of the dura mater, the surface of these tumors is partly subdi- Fig. 1014.-Anterior Encephalocele. (After Vannoni.) to be most frequent on the occipital region and in the middle of the bone on a level with the lambdoidal suture, and they divided these posterior hernias into two varie- ties : supra-occipital and sub-occipital. A third variety of occipital hernia, known as notencephalocele, occupies both the supra- and sub-occipital regions, the two open- vided in two, giving the tumor the appearance of the nates or of the scrotum (see Fig. 1012). Protrusion of any part of the healthy brain-substance constitutes encephalocele. It is much more rare than hy- Fig. 1012.-Tumor Divided in Two. (From Reali.) * It has been the writer's good fortune, while preparing this paper, to see a case of encephalocele in an illegitimate male child of eight months. The tumor, about the size of a walnut, protruded from an opening in the right parietal bone just above and behind the protuberance. The child was club-footed, ectrodactylic, and had double hare-lip. Being unable to feed, it died after three days from inanition. The mesenteric glands were found to be enlarged. (See Fig. 1013.) 681 15 nceplialocele. Enchoudroma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 225, also confirms the statement that encephaloceles occur as frequently in the anterior as in the posterior region. The hole in the skull through which the hernia takes place varies in situation according to the part of the brain protruded. In posterior encephalocele the hole is more or less close to the middle line of the occipital bone, and may be confined to the proral part of the bone ; or the hole may be in the cerebellar portion below the protuber- ance. The two holes may be separated by a bridge of bony tissue, or merely by a fibrous band. In extreme cases the hole may extend longitudinally through the bone, splitting it in two. The deviations of the brain case are but slight in a small hernia, but in the case of a large one the skull,is so flattened backward as to recall the head of a monkey,- a cat, or a toad. In addition to these, certain atalence- phalia may manifest themselves. Deviations may take place in the cerebral mass, such as partial or total fusion of the hemispheres, with an absence of the corpus cal- losum and of the commissures, a reduction in the size of the cerebellum, and an alteration in the shape of the medulla oblongata. The arches of the upper cervical vertebrae are frequently split, and there may also exist such deviations as bifid spine, cleft palate, ectrodactylism, club-foot, and hare-lip-anomalies of organization which go to show not only the close assimilation of encephalo- cele, but that the tumor is only one of the outward 'and tangible expressions of a malformative vice. (See Tera- tology.) In anterior encephalocele, or proencephalocele, the pro- trusion occurs for the most part near the root of the nose, immediately above or on either side. Brain tumors in this region have been known to overlap the face, and even to hang down upon the chest. It should be noted that over-vascularity of the skin covering the tumor is a prominent symptom in fronto-nasal hernias. The hole in the skull through which the tumor protrudes is rarely in the frontal bone, but is most often at the point of union of the frontal and nasal bones, and just in front of the crista galli of the ethmoid. At this spot the two halves of the frontal have been noticed to be separated to the extent of an inch. The hole often lies close to the inner angle of the eye, between the ethmoid, the frontal, and lachrymal bones. There is but little deviation of the skull itself in naso-frontal hernia, but the brain fre- quently deviates from the normal shape. Deviations ob- served in other parts of the body are but few. Brain protrusion from the base of the skull may take place at either the temporal or the parietal region. In the parietal region the portion of brain protruded belongs generally to the descending horn of the lateral ventricle. A tumor of this kind may pass into the orbit through the sphenoidal fissure and drive the eyeball out of its socket, or make its way into the spheno-maxillary fossa and into the nasal fossa, and may protrude from the mouth. Protrusions at the central part of the base of the brain belong more especially to the third ventricle, and the study of their development comes eminently under the head of embryological research. The escape-hole is in the body of the sphenoid, or in its immediate vicinity. It is doubtful whether a brain tumor ever protrudes through the fontanelles. Supposed cases of the kind have always turned out to be dermoid cysts. The envelopes of an encephalocele consist of the skin, which is more or less thin, and mostly deprived of hair ; the cellular tissue, also thin, and sometimes containing cysts ; and the aponeurosis, which is stronger in posterior encephaloceles. The contained parts are the dura mater, which presents a nodulated appearance ; the arachnoid, often the source of the watery effusion into the tumor ; and the nerve-centres, which are generally distended and attenuated. The serous or seroid liquid contained in the tumor is a matter that merits further study. Apart from spermatozoids, there is said not to be the least dif- ference in the chemical composition of cephalo-rachidian fluid and that of encysted hydrocele of the epididymis. The presence of the liquid in encephalocele may be looked upon as an epiphenomenon, an accessory fact an- alogous to the concomitant malformations, or to the hy- ings being blended into one, and the tumor contains the posterior part of the cerebral lobes with the cerebellum. The tumor may, moreover, protrude through a split in •one or more of the cervical vertebrae, giving rise to what is known as derencephalocele (Hepn, neck). Tabular state- ments formerly showed cephaloceles to be more fre- quently found in the occipital than in all the other regions put together, and the fact was dwelt upon that such pro- Fig. 1015.-Section of Cranium in a Case of Anterior Encephalocele. (After Vannoni.) trusions are seated in the median line. But lately it has been shown that these tumors are situated only more or less symmetrically upon the median line, and that they occur as frequently in the anterior as in the posterior region. From Houel's table it would appear that the less frequent points of election are the regions of the forehead and of the anterior part of the base of the skull. In 97 cases he has ascertained that 68 occur in the occipital, 19 in the fronto-nasal region, and 10 at the base of the skull. Reali, in his comprehensive and exhaustive collection of 163 cases of cephalocele, states that 10 occur at the root of the nose, 9 at the frontal suture, 5 at the lesser fonta- nelle, and 22 are occipital; while the remainder may be distributed to one or the other of these points. (See Reali Fig. 1016.-Double Encephalocele, in which Anterior Tumor is cov- ered by the Skin, the Posterior by the Dura Mater. (After Taruffi.) (Giovanni), "Ueber die Behandlung der Angeborenen Schadel- und Ruckgratsbriiche und ihren Ausgang." Zurich, 1874). Wallmann's 44 cases give 20 in the an- terior and 24 in the posterior region. Larger's 98 ob- servations show 47 anterior, 46 posterior, and 2 doubtful, which were intermediary. (See Arch. gen. de Med., 1877, 6 s., xxix., 432, 569; xxx., 55.) Professor Taruffl's ex- cellent paper in Bio. Clin, di Bologna, 1873, iii., 68, 101, 682 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Encephalocele. Enchondroma. gromata and angiomata that sometimes accompany these tumors. That part of the brain contained in the tumor being developed outside of the skull, and the fact that the meninges are constantly present in encephalocele, seem to indicate that there is no hernia, strictly speaking. Absence, or extreme rarity, of the dura mater in patholog- ical encephalocele, or in traumatic encephalocele, is a valuable differential characteristic, since it, or a fibrous band that takes its place, is constantly present in the con- genital form. As for malformations in general, but little is known of the original causes of cephalocele, although various au- thors have dwelt upon them at great length in assigning such causes as rachitis, alcoholism, blows on the belly of the mother, moral emotions, etc. The assertions are, however, not supported by facts ; yet the rachitic ante- cedents of children with encephalocele, and the circum- stance that many of them are idiotic, seem to imply that this vice of conformation is dependent on malformative disease in which the influence of heredity appears to be well established. The probable causes of the congenital variety are arrest of development of the bones of the skull, hydrocele, and, in fact, every disease of the foetus occurring before complete closing of the primitive fis- sures. On account of their deceitful appearance, clear notions of the symptoms and accurate diagnosis in the case of en- cephaloceles are matters that merit careful attention from practitioners. It has often happened that an encephalo- cele, mistaken for an erectile or a fibrous tumor, or a poly- pus, has given rise to a bloody operation, or to the application of caustics, whicl 1,as cost the patient's life. A case is published in which a surgeon attempted to re- move by ligature a hydrencephalocele which he mistook for a supernumerary head. To know whether an ence- phalocele or a hydrencephalocele is to be dealt with, is a matter of great importance as regards the prognosis. Little or no material change may take place in simple encephalocele, and cases are recorded in which patients with well-marked congenital encephalocele have reached the respective ages of twenty-two, twenty-three, and thirty-three years. On the other hand, the tendency of hydrencephalocele is to increase rapidly, and the children who present this anomaly die before the adult state of meningitis or encephalitis. Encephaloceles differ in character according to the region in which they are situated. Angiomas are rare in the posterior, frequent in the anterior, form ; varicose veins are sometimes observed in the posterior, never in the anterior ; the march is slow in the anterior, rapid in the posterior; hydrocele is frequent in the posterior, en- cephalitis in the anterior; and the concomitant malforma- tions, of so little consequence in anterior encephalocele, are of the gravest import in the posterior form. In the matter of diagnosis, due regard should be paid to the congenital nature of the tumor, the exact region in which it is found, its form, volume, aspect, consistence, and coloration ; and the head and body should be exam- ined for evidences of concomitant malformations. Move- ments of pulsation and expansion are found in but few cases. Pulsating naevi at the root of the nose or about the inner angle of the eye may be mistaken for encepha- locele ; but in the recorded cases the errors in diagnosis are mostly the other way, and brain protrusions in this region have been operated upon with deplorable results. The existence of cephalhsematoma may further add to the ambiguity of diagnosis. This tumor is, however, gener- ally over the parietal bones, an unusual position for en- cephalocele ; the external table of the bone is felt to be intact in depressing the tumor ; and pressure does not give rise to the reflex symptoms that may occur under circumstances of inflammation when an encephalocele is compressed. It is advisable to determine the nature of the tumor by means of an exploratory puncture, and in this regard an aspirator may furnish instruction. The study of the exencephalic liquid, so far imperfect, re- mains to be made. The march and prognosis of encephalocele are gen- erally progressive and to death. There is no example of a patient with hydrencephalocele having reached three years; the oldest appears to be but two years and five months. In encephalocele the prognosis is less frightful and less slow, the patients having reached five, six, eight, and nine years ; and fifteen examples more or less authentic are recorded in which the subjects attained and passed adult age. Of these fifteen cases, five only relate to tumors of the occipital region, and all were idiots, ex- cept one in which no details are given, and another which was probably a cyst. All the others were in the frontal region (except one), and the intelligence was perfect ex- cept in one subject, who became an idiot in later life. In the case of an encephalocele deprived of integument the prognosis is grave. But little can be done to remedy the condition of cranial encephaloceles. The treatment at best is merely negative, and should be adopted with a view to lessening the ten- sion of the tumor. It is, however, argued on the side of operative interference that the successes in the matter of radical treatment of spina bifida are quite relatively numerous, therefore exencephalic tumors may be re- moved or treated with equal success. Compression, puncture, iodine injections, the elastic ligature, ligature and gradual excision, and removal by the ecraseur. have each given more or less deplorable results. The tumors more susceptible of being acted upon are those in the sub- occipital region. Gradual aspiration is to be recommended as a palliative. The tumor may also be transfixed with a narrow metallic thread, after the manner of De Wecker's drainage of the eye. The employment of the elastic ligature counts several successes ; but recent authorities express preference for excision by the bistouri combined with the elastic liga- ture. The details of the operation are as follows : On each side of the base of the tumor dissect a small flap of skin with a view to cover the base by glissement. The index- finger introduced into the wound recognizes the contour of the bony opening. Afterward the elastic ligature is applied to the pedicle on a level with the opening, and the tumor is to be excised as near as possible to the ligature. The remaining portion of the pedicle should be mummi- fied by concentrated alcohol. The two flaps are finally united by suture, care being taken to make the pedicle protrude from the lips of the wound at the most depen- dent portion. To avoid traumatic encephalo-meningitis, resort should be had to Listerian dressings, or to those of Guerin-ice to the head, etc. Irving C. Rosse. ENCHONDROMA. An enchondroma is a tumor which is composed principally of cartilaginous tissue. It is seldom, however, that we have a tumor of this sort com- posed in its whole mass of cartilage similar to what we are accustomed to regard as the physiological type of this tissue. The atypical nature of this tumor is mani- fested not only in its position and manner of growth, but in its structure, the cartilaginous tissue being generally different in some degree from normal tissue, and often associated with the formation of other tissues. Very often the cartilage formation in this tumor is associated with a formation of bone, and this latter may, by constant growth, finally form the chief mass of the tumor ; and since we are accustomed to name mixed tumors after that tissue which most predominates in them, we may have an osteoma formed from what started as a carti- laginous growth. Every variety of cartilage which is represented in the structure of the body may appear in the enchondroma. We find, then, tumors composed of hyaline, of fibro-car- tilage, and elastic cartilage. We may have other sorts of cartilage represented which have not their analogues in the physiological cartilages. We often have cells which are distinctly cartilaginous in appearance imbedded in a soft, semi-gelatinous mucous tissue. The flbro-cartilage is often seen, especially in that mixed form of tumor so often seen in the testicle. This form of cartilage in the tumor is also of importance from a clinical stand- point, for it is that form which represents the transition to sarcoma. Cornil and Ranvier call especial attention to the fact that we may have a form of cartilage which 683 Enchondroma. Encliondronia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. corresponds to the cartilage found in some of the lower animals. In this case we have a hyaline matrix, and im- bedded in this, large cells with long branching processes which often communicate with one an other. The inter-cellular substance of cartilage is that which most contributes to lend to the different varieties their stance, and Virchow has proposed for these the name of enchondroma albuminosum. We never have an enchondroma made up of a solid mass of cartilage. The cartilage exists ordinarily in small masses separated by bands of connective tissue. These bands of connective tissue carry the blood-vessels, and may be either well-formed fibrous tissue, or may be so rich in cells as to approach the character of embryonic tissue. In some cases the bulk of the tumor may be made up of such tissue, with only here and there small iso- lated groups of cartilage cells. Tumors of this sort are often met with in the testicle, and are designated as chondro-sarcoma. The vessels may be very abundant, especially in those of rapid growth, and generally have an embryonic character. Neither lymph-vessels nor nerves have been demonstrated in enchondromas. The enchondromas may develop from any of the tis- sues which belong to the connective-tissue group. Vir- chow has proposed, for those developing from existing cartilaginous tissue, the name of ecchondroses, in contra- distinction to the essential tumors. Most of these repre- sent merely circumscribed hyperplasias of the cartilage, have little tendency to growth, and are, except from their position, benign. They may become pedunculate, or may even break off, and in this way often form the foreign Fig. 1017.-Hyaline Cartilage from an Enchondroma of the Femur. The cells are more abundant than in normal cartilage. X 175. distinctive character. In the enchondroma the inter-cel- lular substance is either hyaline, mucous, or fibrous. The fibrous cartilage may also have in it fibres of elastic tis- sue. The cartilage cells of the tumors may be similar to normal cartilage cells, and consist of cell, nucleus, and capsule ; very often, however, they are without a capsule. The cells vary much in shape and size ; in the hyaline enchondromas they are ordinarily round and large ; in the fibrous form they are often small and irregularly shaped-they may, indeed, be similar to connective-tissue corpuscles. When the inter-cellular tissue is soft and like mucus, we find the cells often spindle-shaped, with long Fig. 1019.-Secondary Enchondroma Nodule in the Lung. The primary tumor was seated on the sacrum. The hyaline cartilage is seen passing into the mucous form. There are also numerous areas of calcification. X 80. bodies found in joints. It will not do, however, to regard all tumors which develop from the existing cartilages as being of this benign character. The most frequent place for the development of the en- chondroma is the medullary canal of the long bones. Vir- chow was the first to point out the fact that we often have remains of embryonic cartilaginous tissue enclosed in the medulla of the long bones, and that it is from such tissue that the enchondroma most often grows. The the- ory of Cohnheim, that the formation of tumors takes place from some unused embryonic tissue in the body, finds confirmation in this fact, and he uses the enchon- droma as an illustration of his theory. Not only can those developing in the bones be explained by Cohn- heim's theory, but their development in other places is in accordance with it. A singular form of enchondroma is sometimes found arising in the spheno-occipital syn- chondrosis. In this we have very large pale cells similar to those found in the chorda dorsalis of the embryo, and most writers assume that the tumor develops from em- bryonic residues of this tissue. Other favorite places for the development of the enchondroma are certain glands, as the parotid and the testicle. Cohnheim points out the. Fig. 1018.-Fibrous Cartilage from an Enchondroma of the Testicle. X 175. anastomosing processes. Virchow has seen amoeboid movements in such cartilage cells, and is disposed to re- gard the especial malignity of tumors of this nature as due to this fact. Muller regarded only such tumors as enchondromas which would yield chondrin on being boiled. Those tumors which have a soft inter-cellular substance do not yield chondrin, but an albuminous sub- 684 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Enchondroma. Encliond roma. probability of the former arising from some unused ma- terial of the branchial arches; and as the genitalia in their formation stand in such near relation to other tissues, it is probable that we may have enclosed in the testicle some of the germinal matter from the notochord. The fibrous tissue that most often gives origin to the enchondroma is the periosteum. We know the ability of this to form cartilage as shown in its formation after f racture. According to Lucke, the formation of cartilage from connective tissue arises from groups of indifferent cells which are formed in the connective tissue. These secrete an inter-cellular substance, and in this way hy- aline cartilage is formed. According to Virchow, the transition is a more direct one. He assumes that the fibrous tissue becomes denser and undergoes a sort of sclerosis, the cells increase in size, and in this way a di- rect transition into hyaline cartilage takes place. Weber assumes that osseous tissue can also pass directly into cartilage tissue, in that the cells remain in place and the intercellular substance undergoes a sort of retrogressive metamorphosis. The enchondroma is especially marked by its tendency to multiple formation. Here it seems that w-e have to do with a disposition to the formation of tumors limited to a single system. We often see cases in which all the fin- gers of an individual are at the same time the seat of en- chondromas, and it is difficult to conceive that here one tumor can stand in any genetic relation to the others. All these multiple enchondromas make their appearance at a very early stage of life, as Weber has shown-from the first to the twentieth year, which comprises the period when the skeleton demands a constant growth of carti- lage. The ecchondroses of this period are merely to be regarded as hyperplasias. In these multiple enchondromas we have another reason for believing that they stand in connection with some irregularities in the development of bone. Enchondromas on the hand are very frequent, and the figure of a finger with such a tumor on it has been so often seen that it is almost classical. The commencement of the growth of an enchondroma can often be traced to a very early period of life, and some cases have been known where they were congenital. This particularly holds good for those developing in bone. When they arise in the soft parts, as in the parotid or testicle, their development begins much later in life. Trauma is very often alleged to be the exciting cause of an enchondroma, both in the soft parts and in the bone. The trauma may consist either of a blow or a fracture of a long bone. It is the latter which is most often alleged to be the cause. Often the first steps of the tumor for- mation may be mistaken for an osteitis or a periostitis. If the course be a very protracted one, lasting for months and years, until a real tumor appears, especially when its growth is marked by a slight degree of pain, we should think of a tumor formation in the deep parts. In frac- tured bones the fracture can first heal, and afterward a tumor appear at the place. Very often, in such tumors arising after fracture, we have an osteoid formation ac- companying that of the cartilage. Although, in general, the growth of these cartilaginous tumors is slow, they may attain a very large size, even that of a man's head. The growth, though slow, is a steady one, and yet cases have been known in which a rapid growth alternated with periods of repose. The mixed forms, especially the osteo-chondroma, is more apt to grow rapidly than the pure cartilaginous forms. On section the enchondroma is always seen to have an alveolar structure, and the larger the tumor the more pronounced is this alveolar structure. On section the tumor appears to be composed of a great number of small tumors which are more or less clearly separated from one another by septa of connective tissue. Many of the enchondromas have an exquisite alveolar structure. In many cases large masses of cartilage are found entirely separated from the main body of the tumor, and it is this which gives to the tumor its rough, knobby feel. Most probably these masses become detached in some way from the pa- rent mass, and we do not have to assume, as Virchow does, that there are several centres of growth. The alveolar structure is caused by vessels and connective tissue grow- ing into the tumor. In the growth of the enchondroma the soft parts are pushed aside to make room. Vessels, nerves, sinews, and every tissue are thus crowded aside. The sinews often make deep indentations in the tumor, which may indeed be closed up over them so that they run in channels through the tumor, and in the extirpation they must care- fully be dissected out. It is interesting to know that in enchondromas of the ends of the bones the cartilages of the joints do not take any part in the development of the tumor, but are grown around and covered by its constant development. The enchondromas are often separated from adjoining tissues by a connective-tissue capsule. This capsule can be an osseous one, and is th ?n as thin as paper, and can be indented. These osseous capsules are found around the enchondromas which develop in the centre of bones, and it is usually assumed that they are formed by the en- veloping periosteum of the diseased bone, which the tumor presses up. This capsule is usually only complete in the early stages of the tumor. Later it is broken through by the persistent growth of the tumor. In the cartilaginous tumors which develop from the periosteum, this osseous Fig. 1020.-Emboli of Enchondroma Masses in the Pulmonary Artery, following a Primary Tumor of the Ilium which had grown into the Iliac Vein. (Weber: Virch. Arch., 35.) crust is either not present at all, or only thin pieces of osseous lamellae are found here and there. It is rare that we find an enchondroma without some calcification in it. It may appeal- in the form of islets scattered through the tumor, or lamellae may be formed which are exceedingly hard, and may be mistaken for os- seous lamellae. In the process of calcification calcareous granules first collect in the cartilage capsule, then in the cells, and then, secondarily, the lime deposit in the inter- cellular substance follows. Ossification takes place as often as calcification, and not only in the tumors which develop in the bones, but also in those of the soft parts. Usually a spongy bone is formed with well-marked Ha- versian canals. The ossification shows itself in the for- mation of bony spicules and septa, which push in between the groups of cartilage cells. Very often a formation of isolated osseous plates takes place. In many cases it seems probable, in enchondromas which develop in bone, that we may have remains of the old bone enclosed in the car- tilaginous tissue. Cystic softening is often found, and this can lead to the formation of large and complicated cavities, so that one has trouble in recognizing the true nature of the tumor. The cartilage cells undergo a true fatty degeneration; 685 Enclion <1 roma. Endarteritis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. they become filled with fat-drops, and changed into gran- ular corpuscles. The inter-cellular substance undergoes mucous softening, and from the blood-vessels haemor- rhages take place which give to the softened mass a dark brown color. In some rare cases ulceration of the skin takes place, and a fistulous opening forms between such a cyst and the outside. Although we so often see the multiple occurrence of enchondromas, still in general they are limited to that portion of the body in which they originate. They do not tend to produce metastases. This metastasis is more common in those tumors which are com- bined with the formation of osseous tis- sue ; still, numerous cases are known in which the pure enchondroma has given rise to them. It seems rather curious that, as little as the enchondromas do produce metastases, the most exact knowledge of the way this is brought about has been learned on them. The case of Weber's is classical. A young man, aged twenty- five, died with numerous enchondromas over his body. The largest of these was seated on the ilium; others were on the scapula, clavicle, and ribs. At the autopsy numerous emboli were found in the branches of the pulmonary artery, some of which were evidently of recent origin, while in others a distinct growth of the embolus into and around the outside of the vessel had taken place. On examina- tion they were all found to be of the same nature as the tumors on the skeleton. As the source of these emboli, a large tumor mass growing into the left iliac vein was found. Anot her case, very similar to this, was reported by Paget. The lymph-glands seem to have a comparative immunity. The metastasis usually takes place only in the lung. One case only has been reported in which a metastatic nod- ule was found in the spleen ; metastases in the liver are also very rare. It is probable that the lymphatics are so seldom affected because, owing to the compactness of the tumor and the large size of the cells, the elements cannot get into the lymphatic vessels. It is probable, also, that the relation of the tumor to the lymph-spaces is not so close a one as in the carcinoma. The cartilage tumors which spring from existing cartilage in the body seem to have no malignity ; that is, they do not give rise to metas- tases, and the separation of these from the enchondromas appear at the period of life when the skeleton is growing actively. In both forms calcification and ossification are so common that they may be regarded as almost typical. Cystic degeneration is also common, especially in those growths which have a soft, mucous matrix. The most common seat of the central enchondromas is on the phalanges of the fingers and toes. They are often multi- ple on the phalanges of the hand of children, and give rise to protuberances which were knowm by the older writers under the name of spina ventosa. The long bones of the extremities are also often the seat of these tumors. The peripheral enchondromas are most commonly found on the pelvis near the symphysis, on the scapula, and on the upper jaw. The enchondromas of the soft parts most often are made up of fibrous cartilage, though sometimes the hya- line variety is seen. They are seldom pure, but are com- bined either with myxomatous or sarcomatous tissue. Fre- quently the cartilage forms isolated, irregular masses, which constitute but a part of the whole tumor. We have the same tendency here to ossification and calcification that we have in those enchondromas which develop from bone, though in a different degree. Certain glands are most commonly the seat of these tumors-the parotid and tes- ticle are most often attacked ; the submaxillary glaud, the mamma, and ovary less often. Both the lachrymal gland and the kidney have a few times been the seat of enchon- dromas. Those appearing in the latter gland are perhaps analogous to the tumors seen here, which are composed of striated muscular fibres, and their origin is to be referred to embryonic germinal matter. The lungs are the most common seat of secondary enchondromas, though they may be the primary seat. In this latter case the tumor seems to start from the cartilages of the bronchi. Cartilage is frequently found in the mixed tumors, especially those of the sacrum. In these mixed tumors we find other tissues, such as hair, teeth, well-developed bone, etc. Virchow separates one form of cartilage tu mor and calls it the osteochondroma, the cartilage cancer. The tissue of this tumor is similar to the cartilage which we find in the ossification of the flat bones. The cells are smaller than the ordinary cartilage cells, generally do not have a capsule, and are distinguished from connec- tive-tissue cells by being more oval or round. Ossifica- tion is very apt to take place, and is produced, Virchow thinks, merely by the deposit of lime-salts in the inter- cellular substance. Such tumors are most often found on the long bones, where they produce large, even colos- sal, masses. They are generally partly surrounded by an osseous capsule formed from the periosteum. Softening is not common in such tumors, although cases are known (Langenbeck gives one) in which a large cyst was found in such a tumor. As regards the removal of these growths, a better prognosis may be given than is possible in the case of the osteosarcomas. Of the enchondromas in general, it may be said that they do not return after extirpation. This holds espe- cially for those of the soft parts, and the small tumors on the phalanges of the fingers and toes. This, however, does not hold for some which develop on the bones of the pelvis and elsewdiere. Virchow reports one case in which the tumor was removed seven times at intervals of from six months to two years. In all cases in which we find a firm, hard tumor seated on cartilage or bone, we must, in the first place, always think of enchondroma. In general the differential diagnosis will only have to be made between fibroma and enchon- droma. The enchondroma is always harder than the fibroma, except in cases in which the latter is calcified. The enchondroma is further distinguished from other tu- mors, even from the osteomas, by its rough, uneven surface. The central enchondromas can often be diagnosed from the parchment-like feel of their osseous capsules. Their growth is generally slow and painless, and they tend to develop in the earlier years of life, generally before the twenty-fifth year. The enchondromas of the soft parts are generally easy to diagnosticate. Their hardness, their slow growth, and rough, uneven surface are points which help us most in the diagnosis. W. T. Councilman. Fig. 1021.-Section of an Embolus in a Branch of the Pulmonary Ar- tery. A growth of the embolus through and around the ar- tery has taken place. (Weber: Virch. Arch.,35.) Fig. 1023.-Enchondroma Nodule on Clavicle. Taken from the same case. (Weber: Virch. Arch., 35.) under the name of ecchondroses, as was done by Virchow, has a practical clinical bearing. An important separation of the enchondromas is into those which develop from bone and those which develop from the soft parts. The enchondromas of the bones show us the purest form of the turner. The hyaline variety of cartilage is most often met with ; ihe fibrous is rarer. Mu- cous cartilage also appears in them, and most of the malig- nant enchondromas of bone are of this sort (Fig. 1019). These tumors may either develop in the medullary canal of the bone, or on the periphery. Those developing on the periphery usually have a bony capsule, and appear in the later years of life. They form large, rough, knobby tu- mors, which may surround the bone and cause it to atrophy from pressure, the soft parts being pushed to one side. The central ones have a partial or complete osseous capsule, al- though this may be entirely wanting, or may only be rep- resented by a thin osseous plate here and there. They 686 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Encliondroma. Endarteritis. ENDARTERITIS (ev^ov, within, and apTijpla, an artery) is an inflammation of the internal coat of an artery, gen- erally of chronic or subacute, rarely of acute, character. Two special forms of the affection have been described, viz., atheromatous disease, or endarteritis deformans (Vir- chow), and syphilitic endarteritis (Heubner), the latter of which most frequently affects the blood-vessels of the brain. Anatomy.-In studying the morbid process it is well to keep in mind the following anatomical facts: In im- mediate contact with the blood-stream lies the endothelium, a layer of flattened cells, and external to this is the tunica intima, composed of elastic fibres arranged longitudinally. The two membranes together constitute the internal coat of the older writers. Next to the intima comes the middle coat, made up of muscular fibres arranged transversely, and mixed, in the larger arteries, with elastic tissue. Fi- nally, there is the outer coat, tunica externa, consisting of longitudinally fibrillated connective tissue, carrying the vasa vasorum. 1. Acute endarteritis is occasionally met with as a very circumscribed inflammatory lesion, eventually leading to ulceration. The exciting cause of the inflammation may be an embolus, detached from a cardiac valve and block- ing a distant artery. Dr. Moxon has drawn special atten- tion to the occurrence of endarteritis in the aorta, near its origin, with a freely moving, hard, valvular vegetation ; flagellation having been the exciting cause. He has also seen in the arteries of young, hard-working men circum- scribed spots of softening (inflammatory mollifies), gradu- ally involving all the coats and leading to outward bulg- ing and the formation of aneurism. It is difficult to see how such degeneration could occur, unless the arteries were already in an abnormal condition through some form of general malnutrition. It can only be recognized after it lias led to thrombosis, with its local or more seri- ous general effects upon the circulation. The treatment would be the same as that of periarteritis, and care should be taken to prevent the evil consequences of thrombosis. 2. A theromatous disease, endarteritis chronica, arterio- sclerosis, is the arterial disease most frequently met with, and the one whose consequences are often serious. It presents three pretty well-defined stages, (a) In the first we see the lining membrane irregularly thickened by grayish patches, which seem to lie on the surface of the membrane, but are in reality deeper seated ; the endo- thelium covers them, and is, at least at the beginning of the morbid process, unaffected. These patches are situ- ated between the media and intima, and consist of a material of semi-cartilaginous consistence, formed by an abnormal proliferation of the deeper cells of the tunica intima, the new growth pushing up this membrane with its lining endothelium, and so causing a bulging into the lumen of the vessel. This process exhibits the charac- teristics of an inflammatory change, but we are ignorant of the nature of the irritant in the blood which causes the cells of the intima to take on morbid action, (b) In the second stage the cellular elements of the new growth undergo a process of fatty degeneration, and the patch becomes yellowish in color and pasty in consistence ; it was the paste-like appearance of the mass in this stage which originally gained for the process the designation Atheroma (a^pn = meal). Not infrequently the entire intima, with its endothelium, is involved in the softening, and gives way under the pressure of the blood, leaving an excavation the floor of which is formed by the middle and external coats of the artery, (e) In other instances, however, the pasty mass is not washed away, but be- comes the seat of calcareous deposits. This is the third stage of the disease, in which the affected vessel assumes a very striking appearance ; plates which present to the naked eye the' appearance, but do not show the minute structure, of bone are observed at intervals in the walls of the vessel, their sharp spiculae projecting into its lumen. In the aorta it is not uncommon to find such plates an inch long and half an inch broad, and in the smaller arteries the calcareous matter sometimes forms a ring around the vessel, the morbid process having passed from the first to the third stage without the intervention of soft- ening. Atheromatous disease invades sometimes both the aorta and the small vessels, but the aorta may be exten- sively diseased and the small arteries unaffected ; or, on the other hand, the cerebral, temporal, and coronary ar- teries may be atheromatous, while the great vessels are healthy ; occasionally the disease is limited to a few ves- sels. Next to the aorta, the cerebral, coronary, and splenic vessels, and those of the lower extremities, are prone to atheromatous disease. The pulmonary artery is very rarely the seat of atheroma, but it may occur in the course of syphilis or of disease of the mitral valve. Ex- amined microscopically, the atheromatous matter is found to consist of fat granules, crystals of cholesterine, and tissue debris. When calcification occurs, the lime-salts are deposited in the degenerated cells of the intima, and the calcareous lamella) so formed, being concentric with the vessel, and gradually contracting as their watery con- stituents are absorbed, may erode the intima by their sharp edges. From the injury thus inflicted may arise an aneurism or an interstitial thrombosis. In the latter case the vessel may be entirely occluded, and gangrene of the extremities result. In consequence of the foregoing changes the vessel loses its elasticity and becomes dilated ; its internal sur- face is mottled with yellow patches, and is also rough, fissured, and spiculated; and thus the condition is es- tablished which is described by Virchow under the name of endarteritis chronica deformans. Virchow has also de- scribed, under the name of fatty erosion, a form of pri- mary fatty degeneration of the cells of the intima not preceded by inflammation, commencing on the free sur- face and gradually extending outward. Disintegration of the internal coat, followed by aneurism, is the usual result. Fatty degeneration of the external coat of the smallest arteries has also been noticed, and seems to be a senile change and to play a part in the production of car- diac and cerebral degeneration. A person afflicted with atheromatous disease is exposed to various dangers. The stream of blood is retarded by the projection of the new growth into the vessel, and still more by the loss of elasticity of its coats ; and hence en- sues a failure in the nutrition of the organ depending upon the diseased artery for its blood-supply. When the pasty mass is washed away, it sometimes happens that the blood forces its way between the coats of the vessel, producing a dissecting aneurism ; or the portion of the artery which has been weakened by the removal of the internal coat yields to the pressure of the current, and a sacculated aneurism is formed. Sometimes rupture of the diseased vessel occurs. The delicate cerebral arteries are especially liable to rupture from this cause; and occasionally a diseased coronary artery gives way, filling the pericardium with blood. Complete occlusion of an artery from deposition of fibrin on the spiculated edges of calcareous plates may occur, and thus act as one of the causes of senile gangrene; or sometimes embolic plug- ging of distant vessels results from the detachment of such fibrinous clots, and the washing away of atheroma- tous debris. Atheromatous rigidity of the larger arteries is likewise a frequent cause of hypertrophy of the left ventricle of the heart, on which increased work is im- posed in consequence of the destruction of the elasticity of the vessels. Anasarca of the lower extremities in elderly men, which J. Little mentions among the conse- quences of atheroma, the writer has also found in some cases to be mainly due to this condition. Areas of tissue- softening through obstruction of sclerotic arterioles are often formed in the brain, but have also been observed in the cardiac muscle. In consequence of atheroma of branches of the coronary arteries, fatty degeneration and softening of muscular tissues may take place and lead to fatal rupture of the ventricular wall. Chronic endarteritis rarely occurs before the fortieth year, but is very frequent after the fiftieth. It is more common in men than in women. Among the predisposing influences, alcoholism, gout, rheumatism, renal disease, syphilis, lithsemia, and perhaps also lead-poisoning, are the most noteworthy. The direct cause is now generally admitted to be overstrain of the.vessel. Besides violent 687 Endarteritis. Endothelium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. exertion, which imposes a strain upon all the arterial system, there are other influences which act upon certain vessels. Thus in the atrophic form of diffuse nephritis many capillaries are destroyed; hence the renal arteries are kept overfilled, and atheromatous disease is the al- most constant result. In atheromatous disease we frequently find dilatation and hypertrophy of the left ventricle, when the ascending aorta, or some other large artery, or an extensive arterial territory at the periphery is involved. A. L. Galavin found in 23 cases of pure arteriosclerosis (without ne- phritis), 17 with moderate cardiac hypertrophy. The dis- ease may spread from the ascending aorta backward, and affect the valves and endocardium, leading to stenosis of the ostium aortae, or to incompetency of its valves. In dilatation of the atheromatous aorta we may some- times get dull percussion-sound at the right border of the manubrium sterni. Sclerosis of the superficial arteries ren ders these vessels rigid and tortuous. This condition can be readily seen or felt in certain arteries, and those who are not familiar with the resisting feel of the radial artery, when it is the seat of atheromatous change, are liable to form an erroneous estimate of the strength of the pulse. Again, the existence of aortic regurgitation might be in- ferred in these cases in consequence of the tortuous course and visible pulsation of the superficial vessels, but they do not collapse suddenly under the finger as they do during the receding wave in aortic incompetency. The pulse is tardus et durus, and the sphygmograph shows the upstroke to be vertical and the summit of the tracing extended. Treatment is mainly preventive, and consists in the avoidance of all those influences which have been men- tioned as predisposing causes of atheromatous disease, and all excesses, mental as well as physical, which hurt the heart or the brain-indulgence in Baccho et Venere, mus- cular over-exertion, excessive mental application, and de- ficient sleep. 3. Syphilitic Endarteritis.-The second form of chronic endarteritis is of syphilitic origin, concerns the cerebral vessels mainly, and may lead to local anaemia and soften- ing, with various symptoms. Gummatous degeneration of large and small cerebral vessels has long been recog- nized and described by various authors, but after an ex- tensive study of the morbid anatomy of the affection Heubner insists upon a strict separation of the specific endarteritis from the ordinary chronic form. Syphilitic endarteritis, according to him, may develop in a few months, and is limited in extent; the other form develops in the course of years, has a larger area of infiltration, and affects generally also other arteries of the body. In syphilitic sclerosis more cellular elements are present, more leucocytes ; there is greater tendency to the forma- tion of cicatricial tissue, and very little fatty degenera- tion. Heubner believes that the process begins with an irritation of the endothelial cells, followed by inflam- mation, and that it differs considerably from other forms of syphilitic disease. The large arteries at the base, and the minute arterioles in the cortical substance of the brain, may be involved. The wall is thickened at circumscribed areas by a fibro- nuclear growth, which causes nodular projections on the outer surface of the vessels, and diminishes also their calibre. The structure of the growth resembles that of syphilomata elsewhere. As the disease progresses the middle coat of the artery may disappear, and vessels may form in the substance of the new growth, and its centre may undergo softening. The disease is sometimes symmetrical, involving the corresponding arteries of the two sides. Softening of brain-tissue may take place when the growth itself, or secondary thrombosis, has led to oc- clusion of a vessel. The symptoms of this affection will vary greatly according to the size and locality of the ves- sel obstructed ; hemiplegia is most commonly present when the basal arteries are involved, and various paraes- thesias and mental symptoms when those that supply the cortex are concerned. The disease belongs to the tertiary form of syphilis, is more varied in its seat than that pro- duced by the ordinary atheromatous changes, and affects younger persons. A random succession of brain-symptoms, to use the words of Hughlings Jackson, affords strong grounds for suspecting syphilitic disease within the cranium. No symp- toms are produced by the arterial disease until it causes local anaemia or softening. They then may develop slowly or rapidly; cortical symptoms generally appear first, and after they have existed for days or months paralysis of some of the external muscles of the eyes and hemiplegia may come on suddenly or gradually. Later on the mind becomes more and more affected, although the mental symptoms are observed to be as changeable here as in senile softening. Iodide of potassium, in increasing doses, alternated with inunctions of mercurial ointment, are the principal means of overcoming syphilitic arteritis. Rest in the recum- bent position is recommended to encourage the flow of blood through the narrowed channels. But it must be remembered that the removal of arterial disease may not restore the damaged cerebral tissue. A complete cure is possible, but has rarely been observed. Leonard Weber. ENDERMATIC MEDICATION. The endermatic, oren- dermic, method of medication is that in which certain remedies are applied to the skin, previously denuded of its epidermis. Though formerly employed to a considerable extent, it has, since the introduction of the hypodermatic method (which see), become almost obsolete. And yet it should be preserved, if only as an alternative measure to be employed when, from any cause, other methods are impracticable. Mode of Employment.-As remarked above, the skin is first denuded of the epidermis. This may be accom- plished in a variety of ways. One of the readiest is by means of strong aqua ammoniae. A dossil of lint or cotton saturated with the solution is placed upon the skin, and covered with a watch-glass or other convenient article. Vesication will occur in about fifteen minutes; after which the epidermis may be carefully cut on one side and folded back upon the sound skin, in order to be used as a covering for the denuded surface after the medicament has been applied. In the absence of ammonia any other mode of quick vesication may be employed, if the case be urgent-as, for example, an iron heated in boiling water. Not infrequently advantage is taken of an already abrad- ed surface, as a blister produced for counter-irritation ; and sometimes recourse is had to surfaces from which the epidermis has been removed by disease. It is to be remembered, however, that absorption is more active from recently denuded surfaces, and consequently, when the method is to be employed for a number of times, it is better to denude a small space each time than to make re- peated applications in one place. Remedies to be Employed.-The chief agents to be employed in this manner are such as are readily and com- pletely soluble in water, and possessing neither irritating nor caustic properties. They should, moreover, be capa- ble of producing physiological effects in comparatively minute doses. In a word, the more potent alkaloids are most suitable for this method of medication. Morphia, strychnia, and atropia, for example, are much more suit- able than quinia, since they are active in such minute doses. Although, as stated above, ready and complete solubility is one of the requisites of a remedy for endermatic use, it does notappear to be always absolutely essential, for mor- phia in its basic form is little less active than as commonly used, in its salts; nor is strychnia, so far as known, much less active than its sulphate, though the latter is much more readily soluble. And again, some agents possessed of actively irritant properties may be employed in this manner quite efficiently, though in general such are inad- missible. Mode of Action.-Agents employed epidermatically act in two ways: (a) superficially upon the cutaneous nerve- filaments, and (b) by absorption into the blood ; in other words, the drug produces both local and general effects. The local effect is, however, more commonly sought in the employment of drugs endermatically, and it is chiefly in local affections that the method is at all applicable- 688 Endarteritis. Endothelium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. such as localized hyperesthesia and spasm, intercostal and facial neuralgia, rheumatic pains, etc. By far the greater proportion of such cases are, of course, at the present day treated much more efficiently by the hypo- dermatic method ; but, as already remarked, when from any cause the latter cannot be practised, the endermatic method may well serve as a substitute. One of the disadvantages of the method has already been hinted at, namely, the necessity of denuding a fresh sur- face for each dose. As this process is not only painful, but also productive of at least a superficial sore requiring some little time for perfect healing, this must be con sidered a drawback of no little importance. But more important than this, perhaps, is the impossibility of esti- mating the proportion of the medicament absorbed. When used solely for local effect in relieving pain, this might not be of great importance, provided small doses were employed ; but if a freshly-blistered surface were freely sprinkled, say, with a salt of morphia, absorption might proceed to a dangerous extent before the fact were rec- ognized. In this respect the method compares very un- favorably with the hypodermatic, in which, knowing that absorption is always complete, the operator can easily keep within the limits of safety, and at the same time be sure of obtaining the full effect of the dose administered. Laurence Johnson. pleura than elsewhere. They have never been met with on the serous surface of the peritoneum. On the pleura they may be confounded with the large fibrous tubercles which occur here. Most of the cases reported have formed metastases, though they are less common than in the carcinoma. Some authors have placed the endotheliomas, not with the epithelial tumors, but with the sarcomas ; if the later theories as to the development of the endothelium, its ori- ENDOTHELIOMA. The endothelioma is a tumor which originates in the cells lining the blood- and lymph-vessels, and the serous cavities. The general arrangement of its histological elements is similar to that which gives the type of the carcinoma, viz., groups of cells lying in a connective-tissue stroma. It approaches the carcinoma also in the tendency to invade surrounding tissues and to form metastases. The cells of the tumor have the gen- eral shape, size, and appearance of epithelial cells. They may be flat, polygonal, or cuboidal in shape. In certain cases, notably in one described by Pagen- stecher, the cells are arranged in the form of long chains, which are joined together to form a continuous network. When the tumor develops from the epithelium of blood and lymphatic vessels (of the skin), it often presents, both in the macroscopic and microscopic appearances, a great similarity to the ordinary epithelioma (cancroid) of the skin. It differs from it, however, by having less tendency to ulceration, and on section no connection between it and the epidermis or glandular appendages of the skin can be made out. Koster has described such a tumor of the skin, in which he was able, by injections of nitrate of silver, to demonstrate a continuity between the alveoli of the tumor and the normal lymphatic vessels. Koster did not, however, separate these tumors from the true carcinomas, but used his case to demonstrate the origin of the alveoli of the carcinoma from the lymphatics. Other authors have agreed with Koster, that the cell series did fill up the lymphatics or took their place, but held that they were derived from the surface epithelium, and in some way grew into and filled up the lymphatics. In the pleura these tumors appear primarily as groups of small whitish nodules, often connected with one an- other by firm cords. Metastases from these are most often found in the peribronchial tissue, in the interlobu- lar septa, and in the bronchial glands. The cells in the periphery of these tumors have a greater tendency to take a cylindrical form than have those in the centre. When they have this cylindrical form they are often arranged around a central lumen, and may exhibit similarity to a simple glandular tumor (adenoma) on cross section. In the skin these tumors form firm, irregular nodules ; they are seated, not in the subcutaneous tissue, but in the true skin, which is not movable over them. The case de- scribed by Pagenstecher was seated in the skin of the nose, and was very similar to the ordinary epithelioma which occurs in this place. The epidermis covering it was un- broken. Arnold has described a tumor of the pia mater which reached the size of a small nut, and which evi- dently should be included with these tumors. On the serous surfaces they seem to be more common on the Fig. 1023.-Section of an Endothelioma of the Skin of the Nqse. (After Pagenstecher.) AA, Part of cellular network of the tumor ; B. prolif- erating connective tissue. gin from the true epithelial layer, should prove to be cor- rect, they should be included with the carcinomas, and regarded only as a variety of this. They would natu rally belong here, both from their structure and their clin- ical course. The endothelioma is a very uncommon tumor. Cases have only been seen in the serous membranes, in the men- inges of the brain, in the skin, and in the testicle. W. T. Councilman. ENDOTHELIUM. Various larger and smaller internal cavities and channels in the body are lined with a single thin layer of polygonal or irregular-shaped cells, which, for convenience, are classed together under the nameen- dothelium. This name is etymologically quite incorrect, but it is convenient, as it has come into general usage, for the purpose of classifying together a large group of cells which appear to have a very similar structure. These flat cells-endothelium-line the great serous cavi- ties of the body-pleura, pericardium, and peritoneum ; the cavities of joints, tendon sheaths, and burs® ; the en- closing membranes of the central nervous system, and of some nerves, and all the blood- and lymph-vessels. The grouping together of the cells lining all of these cavities and channels is, as above stated, very convenient, but it must be confessed that it entirely ignores a very important genetic factor, namely, the totally distinct origin of some of the cells from that of others. This factor does not seem to be very important on simple mor- phological grounds, but it does assume a good deal of significance in reference to certain pathological conditions to which the parts covered by the so-called endothelium are subject. Allusion is now made to the different modes of origin of the cells lining the great body cavities- pleura, pericardium, and peritoneum-from that of those lining the other above-mentioned cavities and channels. In order to explain this difference, it will be necessary to give a very brief outline of the more modern views of the origin of the tissues, particularly those of His and Waldeyer. The primitive tissues of the body are divided into two great groups : those of archiblastic and those of parablas tic origin. As the process of cell division goes on in the very early stages of foetal development, the products of 689 Endothelium. Enemata, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cell multiplication at first arrange themselves in three layers, to which collectively the name archiblast is ap- plied. Of these three archiblastic layers, the outer, called the epiblast, furnishes the material which develops into the skin and its adnexa ; into the terminal portions of the alimentary canal, and into the nervous system. The middle layer, the mesoblast, furnishes the material for the epithelium of the genito-urinary organs, and for the muscle tissue. The in- ner layer, the hypoblast, furnishes material for the development of the epithelium of the res- piratory and digestive systems, with the va- rious glands and pass- ages which develop out of, and in connection with, them. The parablast, which is of later development than the archiblast, and whose exact origin is still a matter of con- troversy, furnishes the material out of which are formed the connec- tive tissues-including cartilage, bone, teeth, and fat ; the blood-cells and blood-vessels ; the lymph- vessels and lymphatic tissues, and the genuine endothelial cells. Now, while it was formerly believed that the great serous cavities were simply large lymph-vessels, and were formed by a splitting apart of layers of connective tissue of the mesoblast, from which, as it was believed, the en- tire connective-tissue group, as well as the blood- and lymph-vessels and muscles, were formed, it is at present known that the great primitive serous cavity, which is later divided into the pleural, pericardial, and peritoneal ticularly the development of neoplasms, in the pleura, pericardium, and peritoneum. Endothelial cells are, for the most part, very thin, and are cemented together, edge to edge, forming a mosaic- like covering to the surfaces which they invest. They are frequently polygonal or polyhedral (see Fig. 1024), sometimes much elongated (see Figs. 1025 and 1026), and may have quite irregular outlines (see Fig. 1027). The nuclei, which are usually spheroidal or oval, are frequently thicker than the larger part of the cell body, so that they project above its free sur- face (see Fig. 1028 a.) The body is sometimes almost transparent, some- times finely granular. The cell bodies are so thin and delicate that, as a rule, their outlines are not visible when they are in situ upon the surfaces which they cover, unless subjected to special prep- aration. Their shape is most readily brought into view by treating the sur- faces covered by them, when quite fresh, with a dilute aqueous solution of silver nitrate, 1-500. If now the specimen be exposed to the light, the small amount of albuminate of silver which has been formed in the cement substance between the edges of the cells will become brown or black, and thus the cell outlines will be distinct. The nuclei may then be stained in the ordinary way. (The specimens from which the draw- ings illustrating this article were made were prepared in this manner.) See article on Histological Technique. The endothelial cells form a complete covering to the sur- faces which they invest, even when these surfaces are quite irregular. Thus in the omentum (see Fig. 1028), which in man and in some of the lower animals is fenestrated or net-like, all the irregularities of its surface are com- Fig. 1024.-Endothelial Cells from Peri- toneum of Babbit. Fig. 1027.-Endothelial Cells from the Lymph Capillaries of the Central Tendon of the Babbit. Fig. 1025.-Endothelial Cells Lining the Blood-vessels. From bladder of frog. sacs, is originally an outgrowth from the alimentary canal. The alimentary canal, however, is derived from the hypoblastic layer of the archiblast, while the connec- tive tissue and blood- and lymph-vessels are developed later from the parablast, and grow in around the various parts of archiblastic origin. Genetically, therefore, the endothelial cells lining the pleural, pericardial, and peri- toneal cavities are of archiblastic origin, and belong to the epithelium (see Epithelium) ; while all of the mor- phologically similar flat cells lining the other above-men- tioned cavities-joints, lymph- and blood-vessels, etc.- are of parablastic origin, and consti- tute tlie true endo- thelium. Notwithstandi n g the fact that the classifying together of cells of such wide- ly different origin is somewhat illogical, convenience a n d usage seem to justify us in doing so, at least for the present, until we know more about them. But the difference of origin should not be lost sight of in considering the diseases, and par- Fig. 1028.-Omentum of Dog. a, Projecting nuclei; b, trabecula; of fibrillar connective tissue covered with endothelium ; c, spaces between the trabeculae. pletely invested by the endothelium ; and here some of the cells may readily be seen in profile with their project- ing nuclei. In parts of many of the serous surfaces some of the en- dothelial cells are thick, more or less spheroidal and granular, and quite unlike the ordinary typical form. These are the so-called germinating endothelial cells (Fig. 1029). They may be scattered singly among those of the ordinary form (see Fig. 1029 d), but they often occur in larger and smaller clusters. The exact nature of this germinating endothelium is not well understood; but it is asserted by Klein that white blood-cells may be pro- duced from it, and that it is active during the formation of neoplasm of the parts, and of inflammatory products. Fig. 1026.-Endothelial Cells from Larger Lymph Channels of the Central Tendon of the Diaphragm of the Babbit. 690 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Endothelium. Enemata. Some of the serous membranes-pleura and perito- neum, for example-are in direct communication with the underlying lymph-vessels and channels by means of minute openings between the endothelial cells called sto- mata (Fig. 1029 6). The edges of these stomata are often bordered, and sometimes appear to be quite filled, by germinating endothelial cells. These direct communica- tions between the great serous cavities and the lymph- vessels were formerly regarded as indicating the close fully introduced through or beyond the faecal mass, when the lavement may be administered. Where it becomes necessary to introduce clysters into the colon for any pur- pose, a recto-colonic tube will greatly facilitate the oper- ation. O'Beirne's tube fulfils every purpose, and if judiciously used, will often save life where it would otherwise be sacrificed. This instrument may be safely introduced into the sigmoid flexure if due care be exer- cised. In order to readily introduce it the rectum should be previously emptied, all unnecessary dress should be removed from the patient, when he ought to be brought near the edge of the bed and placed on his left side, with the thighs drawn near to the abdomen. Warm the in- strument, oil it well, then slowly and carefully introduce it into the sigmoid flexure. When it has been introduced the patient should be placed on the right side and a syr- inge or force-pump fastened to the tube, and the fluid slowly pumped in. The introduction of the tube is sometimes difficult of accomplishment, and occasionally impossible, owing to tortuosity, displacement, or com- pression of the canal. It is sometimes necessary to fill the rectum with water or oil in order to pass the instru- ment into the sigmoid flexure. When the tube passes into the colon gaseous and liquid contents frequently flow out through the instrument. The quantity of liquid for a colonic enema varies from two to four quarts for an adult. Colonic enemata are usually retained with less difficulty than when introduced into the rectum. Enemata may be forced through the entire alimentary canal and ejected through the mouth. Haller demon- strated the feasibility of this operation in 1767. A rectal tube greatly facilitates this operation, though it is not indispensable. When turpentine, castor-oil, etc.-which are lighter than water and float to the surface-are to be added to clysters, they should be agitated with sev- eral ounces of gruel- or soap-water and injected, when an additional quantity of water should be thrown in to force the first substance higher up the bowel. As a general rule, physicians fall far short of paying the attention to administering enemata which their importance demands. This operation is usually entrusted to a nurse or some member of the family, and as a consequence it is often awkwardly and inefficiently done. Wherever enemata are given for the purpose of removing faecal or other ac- cumulations in the intestinal canal, or for reducing in- tussusception, or hernia, the physician should always perform the operation. Purgative enemata act in consequence of their quan- tity or bulk, temperature, stimulant or irritant properties, or through absorption of medicines into the system. When- ever it is found advisable to avoid irritating the stomach, or interfering with digestion by contact with medicines, clysters offer a feasible and reliable substitute for admin- istration by the mouth. It should be remembered that the habitual use of lavements proves harmful by remov- ing the mucus which lubricates, as well as protects, the lining membrane of the intestine from undue irritation, and also produces torpor of the bowel. The following formula?, are the ones most generally in use, though they are not recognized as officinal in the United States Phar- macopoeia : Enema of Aloes.-Aloes, 9ij.; carb, of potassa, gr. xv.; barley-water, half-pint. Cathartic Enema.-Olive oil, § j.; sulphate magnesia, § ss. ; senna, § ss. ; boiling water, § xvj. Infuse the senna for an hour in the water, then dissolve the salt and sugar, add the oil, and mix them by agitation. Enema of Colocynth.-Extract colocynth, 3 ss. ; soft soap, § j. ; water, 1 pint. Mix and rub together. Common Enema. - Common salt 3 j. ; warm gruel, 3 xij. ; add oil or molasses. Mix and inject. Gaseous enemata are of late highly recommended for relief of intestinal obstruction. In a case of this kind ac- companied by stercoraceous vomiting, Dr. Terres relieved it by recto-colonic clysters of bicarbonate of soda and tar- taric acid, introduced separately. Antispasmodic Enemata.-A clyster of this class is in- tended to allay irregular nervous action. Anyone familiar with the results of antispasmodic enemata must have no- Fig. 1029.-Portion of the Peritoneal Surface of the Great Dorsal Lymph- sac of the Frog, a, Ordinary endothelium ; b, stomata leading from the peritoneal cavity into the dorsal lymph-sac ; c, germinating endo- thelium at edges of stomata ; d, germinating endothelium among the ordinary endothelial cells. alliance in nature of these two sets of spaces; but it is now known, as above indicated, that the two originally develop in a quite distinct manner, and that the com- munications are established at a later period. T. Mitchell Prudden. ENEMATA. Synonyms: Clysters, Lavements. Definition.-An enema is a simple, medicated, or nu- trient liquid, or semi-liquid, introduced into the rectum by a suitably instrument. By this means medicated and nutrient substances may be placed in the intestinal canal, and thence find their way into the system. Varieties and Uses.-The principal varieties of ene- mata are the purgative, antispasmodic, astringent, emol- lient, anthelmintic, febrifuge, and nutrient. Purgative Enemata.-Where water or medicated fluids are used as clysters, they are given for the purpose of relieving constipation, or removing obstructions from the bowels? They rarely act simply by washing out the faeces from the rectum, for they act efficiently when the faecal accumulation is at the sigmoid flexure of the colon, or at the caecum. Their mode of action is by exciting the peristaltic motion of the entire intestinal canal, there- by causing a propulsion along the tract. These clysters should, therefore, be of sufficient quantity to distend the rectum and adjacent intestine. The quantity of fluid to be used varies with the age of the patient ; for an adult from one to four pints, and for a child from two to six ounces. Whenever a copious enema is to be adminis- tered the individual should be placed on the left side or in the knee-chest position, when the liquid should be slowly forced into the rectum. Soon after beginning the opera- tion the patient feels an urgent desire to empty the bowels, when the operator should let him rest for a short time, and when the desire to empty the bowels has passed off the pumping can be again renewed, and a large quan- tity be forced into the bowels. Where the desire to ex- pel the fluid seems uncontrollable, pressure should be made against the rectal sphincter for several minutes. Occasionally the rectum and colon are obstructed by ac- cumulations of faeces which prevent the outflow of fluid from the instrument, or it returns through the anus. In such cases the accumulations must be removed by the finger or a scoop, or a flexible rectal tube should be care- 691 Kneniata. Enemata. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ticed the rapidity with which they affect the patient; and when it is remembered that they may be used where it is impossible to administer medicines by the mouth, the physician soon learns to regard them as his chief reliance in various spasmodic diseases. Baron Dupuytren said : " Medical agents, when introduced into the rectum, in consequence of the absence of digestion, pass more di- rectly, more purely, and more surely to their destination than they do when taken into the stomach." Hydrate of chloral, which is now regarded as our chief reliance for relief of various spasmodic affections, is more readily ab- sorbed by the rectum, and more certain in its results than when given by the stomach. Puerperal convulsions are promptly controlled by clysters, of thirty grains each, of hydrate of chloral and bromide of potassium, repeated ac- cording to the indications. In the treatment of traumatic tetanus, enemata of hydrate of chloral and bromide of po- tassium constitute the chief means of relief. These injec- tions are likewise among the most powerful and reliable antispasmodic agents in the treatment of epilepsy, laryn- gismus stridulus, and convulsions of children. The same treatment readily controls hysterical convulsions, and is of great value in the treatment of delirium tremens and spas- modic asthma. Morphine, laudanum, valerian, bromide of sodium, musk, asafoetida, conium, lobelia, gelsemi- num, belladonna, stramonium, cannabis indica, etc., may also be used by enema. It is impossible in a limited treatise to give the various formulae in which these medi- cines are most suitably given by enema. As- a general rule, solutions, infusions, and decoctions are more speed- ily absorbed by the rectum, and produce less irritation than tinctures. Where antispasmodics and other medi- cines are intended for absorption into the system, the quan- tity of fluid should be small-from half an ounce to two ounces. It is a very prevalent idea that the dose of a medicine to be administered by the rectum should be from two to three times greater than when given by the mouth. This idea is erroneous, and attended with great danger if put into practice. Narcotics, sedatives, and other power- ful medicines act more quickly and powerfully by the rec- tum than when given by the mouth. Some authorities lay down the rule that narcotic and sedative remedies act as efficaciously when one-third the quantity usually adminis- tered by the mouth is given by the rectum. This has not been my experience. I prescribe the same quantity in either mode of administration. Anthelmintic Enemata.-Anthelmintic clysters are usually administered for removal of thread-worms or oxy- uris, or, as sometimes called, seat-worms ; this latter desig- nation is intended to call attention to the rectum as their habitat. This is erroneous ; the caecum is the place where they are chiefly located. There can be no question that they are frequently found in the rectum, and often pass out of the anus, but this is due to their tendency to mi- grate. These worms are a great source of irritation in the rectum, and in the female they may produce much irritation in the vagina also. Attention is called to the fact that they are located at the caecum, in order that the enema may be of sufficient quantity to reach them. Vari- ous medicines are used as anthelmintic enemata. A strong solution of salt and water, or quassia and water, or a drachm of spirits of turpentine diffused by yolk of egg in four to eight ounces of water, or two drachms of asafce- tida or aloes in water, should be thrown into the rectum, from time to time, until the destruction of the worms is accomplished. Astringent Enemata.-These are administered for relief of diarrhoea or dysentery, to arrest haemorrhages from, and to cure inflammation, ulceration, etc., in the bowel. The treatment of the later stages of diarrhoea and dysentery by astringent clysters was a favorite method with the Greek physicians, especially when the diseased process was located in the large intestine. Various vegetable and mineral astringents are used for this purpose. The mineral astringents, such as alum, sulphates of copper and zinc, acetate of lead, nitrate of silver, corrosive sublimate, astringent salts of iron, etc., are generally preferred. I prefer, of the vegetable as- tringents, gallic acid, two grains to each ounce of water ; of the minerals, nitrate of silver, one grain to each ounce of water. The astringent, whether vegetable or mineral, should be largely diluted, say half a grain to two grains to each ounce of fluid. If corrosive sublimate be used, the strength of the solution should not exceed one grain to four or eight ounces of water. In the treatment of chronic diarrhoeal diseases of children or adults astringent ene- mata are often of marked benefit. For arresting profuse haemorrhage from the bowel copious injections of ice-cold water are indicated. In the treatment of the diarrhoea of typhoid fever astringent clysters are often beneficial. Emollient Enemata.-Clysters of starch-water, gum- water, flaxseed-tea, barley-water, etc., often prove ser- viceable in allaying irritations of the mucous membrane of the intestine. Where they are administered for this purpose, cleansing lavements should precede the use of the demulcent. Febrifuge Enemata.-In the treatment of malarial and other febrile diseases, where it is important to thor- oughly impress the system of the patient with quinine, many circumstances arise whereby it becomes impossible to do so through the channel of the stomach. In cases of nausea or vomiting existing at the time of giving the drug, or produced by it, as well as in cases of delirium or coma, the physician is precluded from administering quinine by the stomach. In such instances the medicine may be advantageously given by the rectum, as it is more rapidly absorbed when given by the latter than by the former. The dose of quinine is the same in either method of administering it. It should be given in one or two ounces of starch-water, to which an opiate may be added if necessary to secure its retention. Before administer- ing the clyster of quinine a cleansing enema ought to be given. Salicylic acid, digitalis, aconite, and other febri- fuge remedies may also be administered by the rectum. Nutrient Enemata.-While the use of medicated enemata of various kinds can be traced to a remote an- tiquity, the subject of rectal alimentation has never re- ceived the attention which its importance demands. The- earliest report upon the use of nutrient enemata which I have been able to trace was in the case of a patient of an Italian physician, Dr. Rammazzini, in 1691. In this in- stance life was sustained for sixty-six days by rectal feed- ing-during which time the patient was unable to swallow either solid or liquid food. In this country, and, so far as I am informed, in all others, the value of rectal nutri- tion has been almost wholly unknown, or unappreciated by the profession, until ten or fifteen years ago. It is. true that occasionally some physician would advocate rectal alimentation, but his views were ignored. It is im- possible in a limited treatise to enter upon an extended historical review of the subject of rectal nutrition. Suf- fice it to say, that numerous recent experiments have dem- onstrated the feasibility of sustaining life indefinitely by rectal feeding in cases in which no necessarily fatal disease exists. Well-attested cases have been reported in which life has been sustained for months and years by means of rectal alimentation in part or wholly. In some of the dis- eases of the pharynx, oesophagus, and stomach, dire ne- cessity requires temporary or permanent abandonment of all attempts to nourish the patient by food introduced into the stomach. In such cases rectal feeding is the sole ■way of prolonging life. Nutrient enemata, therefore, are worthy of more than cursory notice. As the literature of the subject has, so far, been almost wholly confined to the pages of medical journals or transactions of societies, which are frequently inaccessible to the busy practitioner, a resume of the methods and rationale of rectal nutrition will be given here. Among the valuable contributions to the literature of this subject may be mentioned the writ- ings of Drs. Leube, Austin Flint, Henry F. Campbell, Wyman, and A. H. Smith, and the discussions of the subject by Drs. Barker and Peaslee. While numerous experiments have demonstrated the fact that food intro- duced into the rectum is assimilated, and proves ample to maintain the normal temperature and weight of the pa- tient, yet the rationale of this method of feeding is the subject of much controversy and doubt. Some writers deny the possibility of rectal feeding, and assign as their 692 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Enemata. Enemata. reason the fact that the rectum and colon are devoid of digestive fluids necessary for the digestion or preparation of alimentary substances for absorption into the blood. To overcome this theoretical objection, it has been pro- posed to artificially digest the nutrients before placing them in the rectum. Others, however, contend that arti- ficial digestion is unnecessary. Three theories have been advanced by the latter, showing why artificial digestion is unnecessary. Two of these theories are by Dr. Austin Flint, of New York ; the third is by Dr. Henry F. Camp- bell, a distinguished physician and physiologist of this city [Augusta, Ga.]. 1 quote the writings of Drs. Flint and Campbell on this subject. Dr. Flint says : " With reference to this inquiry (about articles of rectal diet) I cannot pass by the physiological question, How is di- gestion in the large intestine effected ? From their failure to procure, from the mucous membrane of the colon and rectum, a digestive juice, and from experiments on lower animals, physiologists have been led to doubt the ability of these portions of the alimentary canal to perform the function of digestion. Yet secreting glands analogous to those of Lieberkuhn are found in considerable numbers in the large intestine, and it is not difficult to understand that they may take on a vicarious activity when the glands of the stomach and small intestine are not excited by the presence of ingesta. This supposition is not in- consistent with the absence of digestive juice in the large intestine when digestion in the stomach and small intes- tine is not interrupted. ' ' Another supposition which I will venture to make is, that food introduced into the rectum excites secretion by the gastric and intestinal glands, and, in the absence of ingesta in the stomach and small intestine, the fluids se- creted by these glands pass into the large intestine in suf- ficient quantity to effect digestion within the latter." Dr. Campbell says: "I have already defined the method by which I account for the digestion, absorption, and assimilation of food when placed in the rectum. It is this-differing from all others with which I am ac- quainted-that digestion in either rectum or colon is not at all contemplated. Neither by direct absorption on the part of the walls and vessels of these cavities, nor by the means of artificial digestive principles added to the food after the manner of Leube, nor by the glands of the large intestine vicariously secreting the digestive fluids of the small intestine, nor lastly by the alimentary mass in the large intestine exciting the secretions of the stom- ach and small intestine, and then attracting or in some way acquiring them, in order that rectal digestion may take place. My proposition is distinctly the reverse of this last, and asserts that instead of the digestive prin- ciples descending to the food to digest it, the food as- cends to these fluids in the small intestine, and that it is there digested and prepared for absorption by the proper organs in precisely the same manner as after buccal in- gestion." In my opinion Dr. Campbell has solved the problem as to the rationale of rectal feeding. While it is true that the ileo-csecal valve was formerly called "the apothe- caries' barrier," it cannot, in the light of numerous re- corded experiments to the contrary, be contended that this valve is a complete barrier to the ascent of fluids from the rectum and colon into the small intestine. In the fifteenth century A. Guaynerius reported the fact that a man vomited a suppository which had been previously introduced into the rectum. J. Matthias De Gradibus, in 1502, reported a case in which clysters administered to a girl were vomited shortly after being thrown into the rectum. In the same patient suppositories introduced into the rectum were also vomited, and when he at- tempted to keep the suppositories in place by a string, the string broke, and it was speedily vomited. J. Optheus observed a case in which a piece of a tallow candle used as a suppository was vomited shortly after its introduction into the rectum. I. de Diemerbroeck relates the history of a case in which a suppository was vomited, and another in which a clyster was vomited. Morgagni cites a num- ber of such cases. Gustav Simon succeeded in forcing water through two patients with intestinal fistula; the fistula was in the small intestine in one of these patients. Mosier made observations upon a patient with an intes- tinal fistula, in whom the finger was introduced through the fistulous opening, and rested on the ilio-caecal valve. By this means he ascertained that, in two minutes from the time the water was thrown into the rectum, it began to rqn through the valve. Dr. Robert Battey, of Rome, Ga., reports several cases in which clysters of castor-oil were vomited. Hearn reported a case in which an enema of castor-oil was vomited within forty minutes from the time of its introduction. Dr. I. L. Harris, of Mil ledgeville, Ga., saw a patient vomit beef-tea which had been introduced into the rectum. Drs. W. L. Atlee, of Philadelphia, and J. B. Ficklen, of Washington, Ga., saw the same thing occur in patients under their pro- fessional care. Dr. H. F. Campbell experimented upon a kid, by giving enemata of milk colored with a decoc- tion of madder and solution of cochineal. Three ounces of milk thus colored were injected into the rectum sev- eral times daily for eighteen days, when the goat was killed and the intestinal tract examined. The coloring matter of the injected aliment was found in all parts of the intestinal canal from the anus to the maw. A great number of cases similar to the above might be cited, but these are sufficient to undeniably establish the fact that reverse peristaltic action of the intestinal canal is of fre- quent occurrence. If suppositories and a piece of tallow candle introduced into the rectum have been known to be vomited, it does not require "a wild flight of the imagination" to detect the philosophy of Dr. Campbell's theory. Various kinds of food may be used for rectal feed- ing. Where nutrient enemata are to be used for any great length of time, a variety of food is better than any one kind constantly prepared in the same way. Milk, custards, broths, meat emulsion, raw eggs, etc., either alone or in combination with gruel, can be used with marked benefit. While it may not be necessary to pep tonize these substances, it is well to do so. In this con- nection it is well to remember Catillon's experiments. For two months he fed two dogs upon eggs injected into the rectum. To the first dog he gave eggs only, and he lived with difficulty and showed great loss of weight. With the eggs given the other animal glycerine and pep- sin were mixjed, and the dog enjoyed usual health and maintained his weight and temperature. On the thirty- seventh day the pepsin was discontinued, when the dog began to lose weight and his temperature fell 3° F. The following are the most approved formulae recom- mended for rectal alimentation • Leube's Pancreatic-meat Emulsion.-"Take about five ounces of finely scraped meat, chop it still finer, add to it one and a half ounce of finely chopped pancreas free from fat, then add about three ounces of lukewarm water, and stir to the consistence of a thick pulp ; this is given at one time, care having been taken to wash out the rec- tum with water about an hour before." Mayet's Preparation.-" Take of fresh pancreas of the ox from one hundred and fifty to two hundred grammes, and of lean meat four hundred to five hundred grammes. Bruise the pancreas in a mortar with tepid water at a temperature of 37° C., and strain through a cloth. Chop the meat and mix it thoroughly with the fluid which has thus been strained, after separating all the fat and tendi- nous portions. Add the yolk of one egg. Let stand for two hours and administer at the same temperature, after having cleansed the rectum with an injection of oil. This quantity is estimated by Brown-Sequard to be sufficient for twenty-four hours' nourishment, and should be ad- ministered in two doses." Hennie's Formula.-" To a bowl of good beef-tea add half a pound of lean, raw beefsteak pulled into shreds. At 99" F. add one drachm of fresh pepsin and half a drachm of dilute hydrochloric acid. Place the mixture before the fire and let it remain for four hours, stirring frequently. The heat must not be too great, or the artificial digestive process will be stopped altogether. It is better to have the mixture too cold than too hot. If alcohol is to be 693 Enemata. Engadine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. given it should be added at the last moment. Eggs may also be added, but should be previously well beaten." Dr. E. R. Peaslee's Formula.-" Crush or grind a pound of beef-muscle fine ; then add one pint of cold wa- ter ; allow it to macerate forty minutes, and then gradu- ally raise it to the boiling point ; allow it to boil for two minutes-no more-and then strain." Dr. Flint prefers a clyster composed of " milk 3 ij., whiskey § ss., to which add half an egg."* I have given the above formulae in order that they may be examined and used in preference to many of the costly, unreliable, and worthless meat-extracts offered for sale to the profession. There are several details necessary to be carried out where rectal feeding is resorted to. 1. The rectum should be washed out once daily. 2. Rest in recumbent position during and for thirty minutes after receiving the enema. 3. The temperature of the fluid should be about that of the body. 4. The quantity should be from four to six ounces at one time if the nutrient is to be placed in the rectum ; if in the colon, eight to twelve ounces at a time. 5. From two to four clysters may be used daily-the number varying with the quantity and quality of the nu- trient used, and also according to whether rectal feeding is intended as supplemental to buccal ingestion, or wholly to substitute the latter. 6. In the early use of nutrient enemata the rectum may be intolerant of the invasion, and may attempt to expel the aliment. When this is met with the operator should firmly press a folded cloth over the anus for a few min- utes, until the desire to empty the rectum shall have passed away. The rectum can be educated to tolerate the fluid where at first it was intolerant. The patient should be impressed with the necessity of trying to re- tain the enema. Where there is much irritation in the rectum the enema should be placed in the colon through a rectal tube, or the bowel should have rest for twenty- four hours, and, if necessary, opium suppositories may be inserted as frequently as indicated. 7. The best instrument for rectal feeding is a soft-rub- ber bag-syringe. The absence of valves in this instru- ment gives it a great advantage over all others, for where valves exist they are liable to be gummed over and choke the syringe. An ordinary soft-rubber female syringe may be used if care be exercised to thoroughly cleanse it. A flexible rubber rectal tube can be readily adjusted to either of these instruments if the nutrient is to be depos- ited in the colon. In using either of these instruments care should be exercised to expel all air from it prior to its introduction into the rectum, and the fluid should be slowly and cautiously injected. In February, 1879, Dr. A. H. Smith, of New York, read before the'New York Academy of Medicine a paper detailing his experience with, and advocating the use of, defibrinated ox blood for rectal feeding. He advocated giving from two to six ounces by injection twice daily. I have never used this substance, nor am I favorably impressed with it from reports which I have read in relation to its use. There are two very serious disadvantages attendant upon the use of defibrinated blood for rectal nutrition : the first is that the sight of the blood is repulsive to nervous pa- tients ; the second, and most serious, is that an intolerably fetid odor is occasionally emitted from the bowels of the patient using it. The diseases in which it may become necessary to resort to rectal alimentation are mainly as follows : In obstruc- tive diseases of the oesophagus, or of the cardiac or pyloric extremity of the stomach, in paralysis of the muscles of deglutition, in tetanus and similar affections, nutrient enemata are necessary for complete or supplemental ali- mentation. In the treatment of ulcer of the stomach, haematemesis, acute gastritis, etc., it is all-important to give complete rest to the stomach for some days, and in no other way than by the rectum can nutriment be intro- duced into the digestive canal. In cases of uncontrollable nausea and vomiting of pregnancy nutrient enemata may be given, and with the best results. In irritability of the stomach from various causes, and in anorexia of typhoid fever and other febrile diseases, complete or supple- mental alimentation must be secured by injections of nu- trient substances into the rectum. Eugene Foster. ENGADINE, UPPER. In the article on Davos refer- ence has already been made to the upper portion of the valley of the Inn, which is commonly called the Upper Engadine. In point of fact this district of the Upper Engadine may more properly be termed, not the upper, but the uppermost division of the Inn Valley; for the entire Engadine, both Upper and Lower, is included with- in the limits of the higher portion of this valley. The total length of the Engadine from the Maloja Pass (Lat. 46° 23' N., Long. 7° 22' E.) to Martinsbruck (Lat. 46° 52' N., Long. 10° 27' E.) is about sixty-flve miles, of which distance rather less than half represents the length of its southern and most elevated portion, known as the Upper Engadine. The width of this upper portion of the En- gadine varies from half a mile to a mile ; its mean height above sea-level is 5,500 feet, " being, after the Avers and Spol valleys, the highest inhabited region of Central Europe" (Encyclopaedia Britannica, art "Engadine"). The Upper Engadine extends from the Maloja as far as the bridge called the Punt Auta, between the villages of Zuz and Zernetz. The Lower Engadine comprises that portion of the Inn Valley lying between the Punt Auta and Martinsbruck. With this portion of the valley we shall have nothing to do in the present article; its scenery is very picturesque and beautiful, and in this respect the Lower Engadine is considered decidedly superior to the Upper Engadine ; it is also much resorted to by tourists during the summer months, as well as by invalids who have recourse to the celebrated mineral waters of Tarasp ; but inasmuch as the chief attraction of this portion of the Inn Valley, when regarded from a sanatory point of view, are these said waters of Tarasp, its discussion belongs more properly to the article describing this watering- place. Although mineral springs of very considerable celebrity exist also at St. Moritz, in the Upper Engadine, and such a spring has recently been discovered on the Maloja also, nevertheless special interest attaches to both these points (in common with several other villages of the Upper Engadine,) on account of their reputation as purely climatic or "air-cure" stations ; and for this reason they deserve attention at the hands of the writer of the present article. The direction of the Upper Engadine, from the Maloja to Punt Auta, is from southwest to northeast ; the mountains which border the valley to the northwest and southeast are many of them very lofty, rising to a height of five or six thousand feet above its river bed. The highest of these mountains are those (constituting the group of the Bernina Alps) which lie to the south- east of the more southerly half of the Upper Engadine, and which separate the valley from the next adjoining valley in this direction, the Vai Tellina. Of this group the two loftiest peaks are those known respectively as the Piz Bernina and the Monte della Disgrazia, the former attaining an elevation of 13,294 feet, the latter an elevation of 12,074 feet, above sea-level. A glance at Baedeker's map of the Eastern Alps will show the reader that the Upper Engadine is separated by a very considerable distance from any extensive district of de- cidedly lower-lying country ; and it is to this fact, and not to the mere elevation above sea-level of the Engadine itself, that Dr. J. Burney Yeo (" Climate and Health Re- sorts," page 51) is disposed to attribute certain peculiar features of the climate of this region. Dr. Yeo divides the Upper Engadine into two portions, an upper and a lower, the boundary line between these two portions con- sisting in a ridge which traverses the valley just below the village of St. Moritz, and which affords to this town some degree of shelter against winds coming up the val- * I have recently observed a case of typhoid fever attended with anor- exia, in the practice of my friend, Dr. John S. Coleman, of this city, in which nutrient enemata were administered with most gratifying results. Clysters composed of from one to four drachms of ■' Reed & Carnicks' beef peptonoid," to four to six ounces of milk, beef-tea, or rice-water, were given twice daily for a number of days. 694 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES Enemata. Engadine. ley, that is, against those blowing from the northeast. The difference in elevation existing between these upper and lower portions of the Upper Engadine Valley does not amount to more than a couple of hundred feet. The two portions differ materially, however, in the character of their scenery ; thus Dr. Yeo (op. cit., pp. 187, 188), describes them respectively as follows: "The upper half, viz., that between the Maloja and St. Moritz, is narrower, its mountain boundaries on each side are grander and wilder, and much loftier, and their summits are covered with extensive glaciers and snow-fields; while the floor of the valley is occupied by a series of small but beautiful lakes abounding in trout, and linked together by the stream of the Inn, which flows through them. In some parts the mountains, covered with dark- green pine forests, rise gradually in gentle slopes from the shores of the lakes, in others they rear themselves as wild rocky barriers precipitously from the surface of the water. The lower half, that which extends from the ridge above mentioned to the termination of the Upper Engadine, has a very different appearance. Here there are no lakes, the floor of the valley is much wider, and is occupied by broad stretches of meadow-land through which the Inn quietly and tamely flows along. The mountains on each side are of lower elevation, they all rise in gentle slopes from the floor of the valley, and pre- sent no bold or striking features of form or outline." The lakes alluded to in the passage just quoted are four in number, and are called, respectively, the Lake of Sils, of Silva Plana, of Campfer, and of St. Moritz, deriving their names from the villages which stand upon their borders. They occur in the order just mentioned along the course of the river Inn, between the Maloja and St. Moritz, a distance of not over ten miles. Of these four lakes, that of Sils is the largest, having a length of three miles, and a width, at its broadest part, of one mile. None of these lakes lie more than 150 feet below the level of the summit of the Maloja Pass (the outlet of the Engadine Valley toward the southwest) ; thus, the Lake of Sils, the highest of the four, is hardly one hundred feet below the level of the Maloja, while St. Moritz Lake is lower than the pass by only 142 feet. The Maloja itself is 5,942 feet above sea-level. The height above sea-level of St. Moritz Kulm, the highest point of the village of St. Moritz, is 6,032 feet. The village of Sils Maria stands 5,880 feet above sea-level, while Silva Plana village, Campfer village, and even the villages of Samaden and Zuz, in the more northerly or lower half of the Upper Engadine, stand respectively at elevations of 5,900 feet, 5,950 feet, 5,700 feet, and 5,680 feet above sea-level. Mention of this fact serves to bring into prominent notice two peculiarities of this upper extremity of the Inn Val- ley ; to wit., the uniformity of level existing along its bed, and, what is even more remarkable than this, the absence of any enclosing wall at the head of the valley. In point of fact, the Inn Valley can hardly be said to have a head at all, in the sense in which this term is commonly applied to the upper end of a valley bordered by lofty mountains, and it does not terminate in a cul-de-sac after the manner of most of the Alpine valleys. The Inn Val- ley, instead of resembling a trough closed at one ex- tremity, is rather, therefore, like a trench hollowed be- tween the surrounding mountains and open at both ends. In this respect the Upper Inn or Engadine Valley is in its conformation decidedly inferior to the neighboring and exceptionally well-sheltered valley of Davos, when each is considered from a climatological point of view; for this open southern end of the Engadine affords a ready ingress to storms of wind and rain approaching the valley from the southwest and sweeping up the Vai Bregaglia (on the other side of the Maloja Pass) from the lower valley of the Maira, and from Lago di Como, which lake, in a line following the bed of these valleys, is distant not more than twenty-five or thirty miles from the summit of the Maloja. "The only vulnerable point (of the Upper Engadine), speaking climatologically, is toward the west, or rather southwest, where it descends somewhat, sud- denly into the Vai Bregaglia; this descent continues steadily toward the southwest, till it reaches the Lake of Como. It is from this quarter that nearly all the clouds and rain come that visit the Engadine " (Dr. Yeo, op. cit., p. 52). Climate.-The climate of the Upper Engadine is very similar to that of the neighboring valley of Davos. Its mean annual temperature is the same, viz., about 36.5" F. At Bevers, near Samaden, the observations of M. Kratlli, extending over a series of years, showed the mean temperatures of each of the four seasons of the year to be as follows : Winter, 17.5" F.; spring, 35.4° F.; au- tumn, 37.8° F.; summer, 50.8° F. In 1854 M. Kratlli observed an absolute minimum temperature (in Febru- ary) of 25.8° F., and an absolute maximum temperature (in July) of 79.7° F. (Dr. Yeo, op. cit., p. 183). Accord- ing to Dr. H. C. Lombard, the mean temperatures at Be- vers, Sils Maria, and Pontresina, for each of the four seasons, are as follows : Winter. Spring. Autumn. Summer. Bevers .. 16.74° F. 34.41° F. 36.98° F. 52.35" F. Sils Maria.... .. 19.30° F. 33.42° F. 36.19° F. 50.63° F. Pontresina . .. .. 18.41° F. 33.33° F. 36.21° F. 50.00° F. At all three of these stations the months of extreme mean temperatures are the same, January being the cold- est month, with a mean temperature of 15.8° F. to 17.6° F. (-8° or -9° C.), and July being the warmest month, with a mean temperature of 51.8° F. to 53.6° F. (11° or 12° C.). During the five months from November to March, inclusive, the mean temperature is always below the freezing point (" Traite de Climatologie Medicale," vol. iv., p. 654). Dr. Julius Hann gives the following mean temperatures for the village of Sils : January, 17.42° F.; April, 33.62° F.; July, 53.06° F.; October, 36.32° F.; year, 34.88° F. The mean of the yearly max- ima at the same place he states to be 72.86° F. (" Hand- buch der Klimatologie," pp. 475 and 480). The follow- ing table is made up from figures extracted from the very full meteorological tables of Dr. A. T. Tucker Wise, which show the weather as observed by himself, on the summit of the Maloja Pass, during the winter season (No- vember to February) of 1883-84. 9 A.M. Noon. 3 P.M. a s I 1 8 S 3 S a § a § H s 8 S « i g s s .s Q e3 a a 8 ass ass November, 1883 26.4 44 11.0 30.5 43 15.0 50.5 42.0 19.5 December, 1883 19.3 45 -2.0 25.0 43 0. 24.8 43.5 7.0 January, 1884 19.3 40 -4.0 25.7 39 0. 27.3 41.0 13.5 February, 1884 17.3 47 -7.5 26.5 38 -2.0 27.5 38.0 15.0 Average 20.0 .. 26.9 .. | .. 27.5 .. .. Temperatubes on the Maloja, 1883-84. The maximum and minimum temperatures given above are the absolute maximum and minimum temperatures ob- served throughout the course of each month at the hours specified. The figures were read from a maximum and minimum thermometer three times a day. A note by Dr. Wise, preceding the tables (" The Alpine Winter Cure"), states that "the maximum and minimum thermometers were noted three times a day for the purpose of determin- ing the variation of temperature during forenoon and after- noon." The absolute maximum temperature noted dur- ing the course of the four months was 45° F.; the abso- lute minimum was -7.5° F. The average temperature for the season was 25° F. Dr. Yeo (op. cit., p. 246) quotes part of a letter written from St. Moritz to the London Times, and describing the weather experienced in the Engadine during the winter season of 1869-70. The mean temperature at St. Moritz in January, 1870, according to the writer of this letter, was 16.31" F. ; the mean of the minimum temperatures during the same month was but 5.56° F. ; while an abso- lute minimum of -13° F. was observed on the 24th of the month. The following table, showing the mean temperature on 695 Engadine. Enuresis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the Maloja, at the hour of 7 a.m., during the winter season of 1883-84, is quoted from Dr. Wise's book already referred to. The figures were "calculated from the ob- servations of M. Kuoni." tures at that place as high as those of Davos (Ziemssen's " Handbuch der Allgemeinen Therapie," vol. it, p. 156). The number of hours of possible sunshine in winter ap- pears to be a trifle greater in the Engadine than at Davos. Pontresina (about three miles east of St. Moritz, and lying in a side valley of the Engadine), the Maloja, and St. Moritz are mentioned by Dr. Wise as among the especially sunny stations of the Upper Engadine ; the number of hours of possible sunshine at these three stations on January 1st, according to this author, being respectively as follows : Pontresina, 6 hrs. 40 min. ; Maloja, 6 hrs. 10 min. ; St. Moritz, 5 hrs. 5 min. Wiesen, in the Davos Valley (see article "Davos"), has 5 hrs. 10 min. of possible sunlight on that day; i.e., a little more than St. Moritz, but less than the Maloja or Pontresina. The hour of sunset on January 1st at these four places is as follows : Maloja, 3.45 p.m. ; Wiesen, 3.45 p.m. ; Pontresina, 3.10 p.m. ; St. Moritz, 3.05 p.m. " It will be seen," says Dr. Wise, " that Wiesen and Pontresina stand next to the Maloja, the late departure of the sun being of most consequence." To explain more fully this remark, it may be useful to state that the sunrise hour at Wiesen (10.35 a.m.) is later than either at St. Moritz, the Maloja, or Pontresina ; the hour of sunrise at St. Moritz on January 1st being 10 a.m., while at the Maloja it is 9.35 a.m., and at Pontre- sina 8.30 a.m. These data are all taken from the table on page 68 of Dr. Wise's "Alpine Winter Cure." A more detailed table, giving the hours of sunrise and sunset at the Maloja, Wiesen, Davos, and St. Moritz, will be found in the appendix of Dr. Wise's book, and has already been partly quoted in the article on Davos. Respecting the cloudiness of the winter sky in the Up- per Engadine, we have already quoted Dr. Wise's figures for the mean cloudiness of the Maloja. Dr. Lombard claims that the Upper Engadine is inferior to the Davos Valley in regard to the number of clear or partly clear days occurring during the winter season. During the five months, November to March, he states that there are but 15 perfectly cloudless days in the Engadine, as against 67 at Davos ; while the partly cloudless days are as 61.5 against 45, and the days of snow or rain in the Engadine are 53 against 40 such days at Davos. Dr. Weber, on the other hand, states that the number of rainy days is less in the Engadine than it is at Davos, and that the rain-fall in the former is also less than in the latter valley. Whether his figures for clear, partly clear, and rainy days at St. Moritz and at Bevers are intended to cover more than the winter season does not appear clearly (to the present writer) from his text. Thick fogs are mentioned by Dr. Yeo as occurring at Bevers during the months of November and December. Whether these fogs are purely local and confined to the neighborhood of Bevers, or whether they are of gen- eral occurrence throughout the Engadine, does not very clearly appear from what Dr. Yeo says (op. cit., p. 183) ; but in his comments on the climate of the Upper Enga- dine, as a whole, made on the preceding page (p. 182), he remarks that "the damp fogs which are common in the lower Swiss valleys are almost unknown at this great elevation." On the Maloja, during the winter of 1883-84, mist or fog was observed only five times : twice in Janu- ary, twice in February, and once in December (Dr. Wise, op. cit., p. 85). The reader desiring to compare the Engadine climate with that of any of those health-stations in the United States for which full climatic charts appear in this Hand- book, in respect to the number of "fair" and "clear" days characteristic of each during the winter season, may easily calculate the actual number of such days oc- curring on the Maloja in each of the months, November to February, 1883-84, from the figures in the larger tables at the back of Dr. Wise's book. (See article " Climate " for U. S. Signal Service rule in making such calcula- tions.) No figures for the relative humidity of the Upper En- gadine have fallen under the notice of the present writer. Dr. Wise gives absolute humidity figures for the Maloja in his larger tables, and of the air at St. Moritz he says (op. cit., p. 16) that "it is similar in quality and effects to Mean for the whole winter. 21.38 November. 26.42 December. 20.66 January. 20.30 February. 17.78 A comparison of these figures with those for Davos (given in the second table on page 358 of this volume of the Handbook) would seem to show that, at least during this particular winter season (1883-84), the temperature on the Maloja was a trifie higher than at Davos ; and yet most authorities agree in stating that the mean tempera- ture of the Upper Engadine is rather lower than that of the Davos Valley, and Dr. Lombard (op. cit., vol. iv., p. 654) says: " The winter in the Upper Engadine is very se- vere, the mean temperature at the three stations (Bevers, Sils Maria, and Pontresina) for that season being only - 7.70° (18.14° F.); while at Davos we have seen that it is no lower than -5.86° (21.45° F.)." The mean winter temperature of Davos, calculated from Dr. Yeo's figures (see first table on page 358 of this volume), is also a trifle higher than the mean winter temperature of the Upper Engadine given by this same author-the figure for the first would be 21.32° F.; the figure for the latter (17.5° F.) we have already quoted in the present article. Unfort- unately we have not at our command a sufficient num- ber of reliable and suitable data to enable us to make a really accurate comparison between the winter tempera- ture of the two valleys; but it is pretty evident that there exists no very marked difference between them in respect to this climatological factor. Dr. Hann (op. cit., p. 477) alludes to Bevers as having an exceptionally low mean winter temperature. The mean winter minimum temperature of this place he puts as low as -17.32° F., and he calls attention to the very low tem- perature figures reported from this place as indicating for the Bevers Valley (a side valley of the Upper Enga- dine), the peculiarity of showing "perhaps the lowest winter minima of any of those valleys of Switzerland which are inhabited throughout the course of the year." The mean minimum temperature of Sils Maria, according to this same authority, is -8.32° F. As in the Davos Valley, so also in that of the Upper Engadine, the radiant heat of the sun, even in the dead of winter, is very great. " Twice in January," says an invalid, writing in the visitors' book at one of the St. Moritz hotels, "we dined on the terrace, and on other days had picnics in our sledges ; far from finding it cold, the heat of the sun was so intense at times that sunshades were indispensable-one of the party even skating with one" (quoted by Dr. Yeo, op. cit., p. 245). According to Dr. Wise's observations, made on the Maloja during the winter season of 1883-84, the mean temperature in the sun (taken by black bulb thermometer in vacuo) was 104° F. ; the lowest sun temperature, re- corded as occurring on a cloudless day, being 65° F. (December 3, 1883), the highest temperature so recorded being 143° F. (February 13, 1884). The mean sun tem- perature for each of the four months was as follows : November, 113° F. ; December, 89° F. ; January, 105° F. ; February, 108° F. With the exception of that for December, these figures are seen to be about the same as those given for Davos and representing the mean maxi- mum sun temperatures at that place during the winter sea- son of 1876-77. (See table on page 358 of this volume of the Handbook.) The cause of the comparatively low sun temperatures in December, 1883, does not fully appear from the data presented in Dr. Wise's tables, but these comparatively low temperatures seem to have depended chiefly upon the greater cloudiness of that month. Thus the mean cloudiness of that month (scale 1 to 10) was 4.8, as against 4.3 in February, 4.0 in November, and 2.8 in January. The mean temperature (in the shade) of each of the four months was as follows: November, 29.1° F.; December, 23° F.; January, 24.1° F.; February, 23.7° F. According to Dr. Hermann Weber, observations which were made at St. Moritz during the years 1868-71 (by Messrs. Greathead and Townsend) showed sun tempera- 696 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Engadine. Enuresis. that of Davos, but, being a little colder, has less absolute moisture in suspension." Dr. Weber also states that the absolute humidity is somewhat less (" etwas geringer ") at St. Moritz than at Davos. The relative humidity of the two valleys, the Davos and the Upper Engadine, is probably about the same. The snow-fall in the Engadine is heavy. On the Ma- loja Dr. Wise's tables show a total fall of nearly five feet (57.36 inches) during the winter season of 1883-84. The snow- begins to fall earlier in the autumn than it does at Davos, and it lies on the ground later in the spring. Even in the summer-time a fall of snow is a phenomenon of occasional occurrence in the Engadine. Throughout the year the Engadine Valley seems to be more exposed to winds than is the valley of Davos. In both the winter season is the least windy. The " fohn " wind, Dr. Wise tells us, is rarely felt on the Maloja ; and both there and at St. Moritz (Dr. Yeo, op. cit.,. p. 273) this wind, when it does occur, has an entirely different character, being far less warm and dry than is the more genuine "fohn" of Davos, and, ill fact, being rather a rain-bringing or a snow-bringing wind. Dr. Wise alludes to the "proximity of immense glaciers to the south and southwest" as partly explaining the comparatively low temperature of the " fohn " winds on the Maloja. To return once more, in conclusion, to the subject of temperature, it is but fitting to say a few words respect- ing the variability characteristic of the temperature in the Engadine, as in all high-lying valleys. These few words we shall quote from Dr. Yeo's book (pp. 181 and 182): " All observers," says this writer, " agree that one of the chief characteristics of the climate of the Upper Enga- dine is very sudden and great diurnal variations of tem- I lerature. The thermometric variations in the same day are often so very considerable that in summer a temperature below freezing-point will be registered, and on the same day a temperature of from 40 to 50 degrees above freez- ing ; while a westerly wind in winter will cause the ther- mometer to mount from -13 degrees Fahrenheit to +42 degrees Fahrenheit! a range of 55 degrees. These sud- den changes are admitted by the resident physicians to induce, even in the acclimatized, attacks of inflammation of the lungs, of pleurisy, of chronic rheumatism, and of catarrhal fever." The water-supply at the Engadine stations ("at the high-level stations," are his exact words), Dr. Wise tells us, appears to be wholesome and of excellent quality. The soil is similar to that found elsewhere in the high-lying valleys of Switzerland. The reader will have observed that in the climatological section of this article special attention has been bestowed upon the winter climate of the Upper Engadine. The reason for this is that while this valley, in common with several of the other high-lying valleys of Switzerland, has long been tested as a good summer resort for invalids re- quiring an especially bracing or tonic climate, it has of late years attracted attention chiefly as a "high altitude " winter health-station, being in this respect a rival of the neighboring valley of Davos. So far as its purely cli- matic features are concerned, the Upper Engadine-would seem to be somewhat less suited for the winter residence of invalids than is the Davos Valley ; but its scenery is more attractive and varied ; it is less cramped and lim- ited in its extent, and consequently less subject to the dangers attendant upon overcrowding; and, finally, it is easier to get away from, in case the climate is found by the invalid not to agree with him as well as he had hoped and anticipated. The road traversing the Maloja Pass descends very rapidly into the Vai Bregaglia, and, through this valley and the Lower Maira Valley, the dis- tance to the Lago di Como is only about thirty miles. Good hotels for the accommodation of invalids are to be found at various points in the Upper Engadine, and for winter residence the Maloja, St. Moritz, Pontre- sina, Samaden, and Zuz seem to be all well suited. A great deal of detailed information respecting individual health-stations of the Engadine, including comments on their hotels and lodging-houses, will be found in the book by Dr. J. Burney Yeo already so frequently re- ferred to. No less than sixty pages of this useful and entertaining work are devoted to the discussion of Upper Engadine. Dr. Wise's little book (" The Alpine Winter Cure") will also well repay perusal on the part of a reader desiring to obtain more accurate information re- specting this region. Attention is especially called to the comments of the author of this latter work upon the ex- cellent sanitary arrangements of the Maloja hotel, as well as to the most useful climatic tables (already partly quoted in the present article) which he inserts at the back of the book. Concerning the class of invalids who may be properly advised to pass one or more winters in the Upper Engadine, it may be said that in general they will be such persons as might be expected to derive benefit from a so- journ at Davos or at Colorado Springs. All things con- sidered, the present writer would be disposed to prefer the last mentioned of these three resorts to either of the other two. For a fuller understanding of their points of simi- larity and of difference the reader is referred to the arti- cles on " Davos" and " Colorado Springs;" and he may perhaps attain a more accurate understanding of this "high altitude" class of health-stations by consulting also the article on " Denver." Huntington Richards. ENGHIEN-LES-BAINS is a very popular watering- place, situated in France, a few miles north of Paris, at an elevation of about one hundred and fifty feet above the level of the sea. The climate is mild, and the place is frequented throughout the entire year. There are several sulphur-springs, which are nearly identical in their com- position. The waters are taken internally, and used also in baths, douches, and inhalations. They enjoy a consid- erable reputation in the treatment of catarrhal diseases of the respiratory organs, pertussis, the early stages of phthisis, asthma, chronic rheumatism in all its forms, chronic skin affections, especially those of a scrofulous or rheumatic nature, and syphilis. The following is the analysis of the Source Cotte. Each litre contains of Gramme. Calcium carbonate 0.217 Magnesium carbonate 0.016 Potassium sulphate 0.008 Sodium sulphate 0.050 Calcium sulphate 0.319 Magnesium sulphate 0.090 Aluminium sulphate 0.039 Sodium chloride 0.039 Silicic acid 0.028 Ferrous oxide trace Total solids 0.806 The gases are nitrogen, carbonic acid, and hydrogen sulphide. T. L. S. ENTODERM, also called entoblast, and occasionally hypoblast, is the innermost layer of cells in the embryo ; it is an epithelium which, in the adult, lines the digestive canal and its appendages, lungs, liver, pancreas, etc. (see Germ-layers). C. S. M. ENURESIS (Jv and ovpyais), sive Incontinentia Urinse. The involuntary passage of urine, or the inability to hold the urine. For practical purposes, incontinence of urine in chil- dren is always treated of separately, although nearly every cause which operates in adult life may act to cause incontinence in a child. When, however, we^ sp^ak of the enuresis of children, we refer to that condition whose only symptom is incontinence, the urinary apparatus being perfectly healthy. The French authors have, therefore, called this condition "Incontinence essen- tielie." h2 Mechanism.-I. It is now conceded, on all hands, that, in the normal condition, the urine is retained by the con traction of muscular fibres which act as a sphincter mus- cle. Whether this is that mass of muscular fibres known as the sphincter vesicte,3 or those muscles coming from the prostate gland and surrounding the urethra, or those others acting as circular fibres for the urethra (Henle, Landois, Sigmund Mayer, et al.), is immaterial for our purpose. That the voluntary muscular fibres assist, at 697 Enuresis. Enuresis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. least, in holding the urine must be taken for granted, as the result of the simplest experiment. That other mass of muscular fibres, involuntary, called the detrusor urinae, assisted by the action of the abdominal muscles, causes the expulsion of the urine. It is manifest, therefore, that to retain urine there must be a fixed relation of power between these two muscular bodies, the sphincter and the detrusor. Whenever this is disturbed, by whatsoever cause, incontinence will take place. II. The male bladder holds from 500 to 1,375 grammes of urine (Barkow9), the female somewhat less. If there be an obstruction to the exit of the urine, somewhere be- tween the neck of the bladder and the external opening of the meatus urinarius, the bladder will become filled up to its full capacity. The urine is constantly being emptied into the bladder from the ureters; each drop causes the pressure to increase. Then there takes place inactivity of both muscular bodies described above, be- cause they are over-distended ; and now the urine, if the obstruction is not a complete one, passes away involun- tarily. This overfilling of the bladder may also take place if, for some reason or another, the detrusor urinae is made inactive. III. When we come to consider, with Goltz, that mic- turition is essentially a reflex act; that there exists for this act a centre in the spinal cord (Budge); and that there is both a motor and an inhibitory tract from the brain (crus cerebri, through the anterior columns of the cord : third and fourth anterior sacral, third, fourth, and fifth posterior sacral, roots-Landois), it becomes neces- sary to take into consideration a nervous mechanism. As far as the bladder is concerned, incontinence can be pro- duced only by one of the two first-mentioned methods. Experimentally, incontinence can be produced by dis- turbing either the motor or inhibitory tract, or the reflex act. The latter can be effected by cutting the afferent or efferent nerves of the centre for micturition, or by inter- fering with the centre itself. Etiology.-The causes are very numerous, and can be referred either to the urinary organs or to organs remote. Anything acting in such a wTay as to cause an abnormal mechanism in the passage of urine in the three ways de- scribed will produce incontinence. In adults the most common causes are strictures of the urethra and the en- larged prostate gland of advanced life. In general we have, in the penis, an elongated prepuce, phimosis and paraphimosis, urethral calculus, and, perhaps, the collec- tion of secretions behind and upon the glans, as causes. As far as the bladder alone is concerned, the causes pro- ducing incontinence can be referred either to the organ itself or to its contents. Malformations of the bladder, ectopia, wounds, or fistulae presuppose incontinence. Tumors, polypi, papillomata, or cancers, if they interfere seriously with the muscular mechanism, will also pro- duce this symptom. Boyer and Desormeaux 1 speak of ulcers and abscesses at the neck of the bladder as being followed by incontinence. Tuberculosis and diphtheritis of the bladder, when followed by a marked loss of sub- stance in the sphincters, and fatty degeneration of the muscular tissue (Dittel3), have been looked upon as causes. To the latter especial attention is called as existing in old or senile persons. The condition of the urine, per se, rarely seems to cause incontinence. Catarrh of the blad- der, in such subjects warranting the conclusion of debility of the muscular apparatus, sometimes provokes incon- tinence. Some authors claim that an increased acidity, or a marked increase in the urates, may be looked upon as a cause. In children diabetes mellitus, and commonly gravel and calculi, small as well as pipe-stem-shaped stones, are particularly liable to produce incontinence. Sometimes the operation for stone in the bladder is fol- lowed by incurable incontinence. Foreign bodies may act as do calculi, and may, therefore, be followed by the same symptoms. Of organs remote, the rectum, vagina, kidneys, and the nervous system can be looked to as etio- logical factors-worms, troubles of the sphincter ani; pyelitis and renal calculi; oxyurides crawling into the vagina and producing leucorrhoeal discharge. Small polypi are sometimes found at the opening of the female urethra, which cause sufficient irritation to produce enu- resis. For the nervous system we have a general irrita- bility of the urinary tract found in hysterical patients, especially women ; sometimes associated with spasm of the bladder. Then there is paralysis of the bladder, from some extraneous cause in the nervous system. Whenever there is profound unconsciousness (high, con- tinued fevers, apoplexy, narcosis, etc.), then we may have enuresis. Any lesion of the nervous system that causes the reflex act to be abolished will produce involuntary passage of urine-lesions of the crus cerebri, of the cord (locomotor ataxia). A lesion in the cord affecting the fibres going from the crus cerebri to their final termi- nation (spinal apoplexy, compression, trauma), or lesion of the brain producing great structural changes (apo- plexy, softening-Hertzka4), can be looked upon as ac- cepted causes. In children we may find any or all of these causes, ex- cepting those due to structural changes the result of age. In regard to the cause of "essential incontinence," we find various views expressed. They can all be summed up under three heads : 1. Those claiming that the condi- tion is a neurosis. 2. Those claiming that it is due to the want of development of the muscles. 3. Those claiming that it is due to general debility, scrofula, lymphatic temperament, etc. Among those who claim that we are dealing with a neurosis we find Bretonneau, Trousseau, and Ultzmann. Trousseau8 says that "true enuresis nocturna is a neurosis, which consists principally in an excess of irritability and tonicity of the detrusor muscle. " Enuresis continua, diurna et nocturna, depends, according to him, "upon atony of -the sphincter vesica?." Ultz- mann 6 believes that the sphincter is not sufficiently in- nervated, which is the normal condition until the comple- tion of dentition, but becomes abnormal after that time ; and, therefore, that enuresis is due to a persistency of an infantile condition in the nerves going to the bladder. Then there are those who maintain that the child sleeps so soundly that the brain does not receive the impressions from the bladder, and, therefore, does not prevent the outflow of urine by contraction of the sphincter (Petit, J. L.2); in other words, that volition is affected in one way or another. The second class of authors claim, either with Voillemier,2 that there is simply an atony of the sphincter, or with Dittel,3 that there is a something more, which can be best expressed by a quotation from the latter author : ' ' The normal condition in the newly born is as follows : Rather powerful detrusor, prostate gland of respectable size, small sphincter; in addition, ex- clusively fluid food, and with this, copious secretion of urine." Bokai5 thinks that the condition " is the result of a disturbance of equilibrium in the function of the antagonistic muscles of the bladder-the sphincter and the detrusor." The last of the views, causation by diath- esis, anaemia, chlorosis, scrofula, plethora, lymphatic temperament, etc., is one that can be classed with those of by-gone days, when these were the only etiological quantities known for children's diseases. It would be safer to say that these conditions might result from en- uresis, than that they could be looked upon as its cause. The fact of the coexistence of any of these conditions with enuresis does by no means bring them into causal connection with it. Symptomatology.-In the adult the symptoms vary with the cause producing incontinence. In the form pro- duced by an overfilled bladder, the urine usually dribbles away almost constantly. At times there comes contrac- tion of the detrusor muscle, almost rhythmical in its nat- ure, producing great pain to the patient. As a rule, this patient is unconscious of the overfilled condition of his bladder, and takes cognizance only of the fact that he can- not pass water when he tries, that this gives him great pain, and that he has not passed as much urine in a given time as is his custom. In that form due to diseases of the nervous system, or profound unconsciousness, the incon- tinence is almost continual. In fevers, involuntary pas- sage of urine and faeces is always looked upon as a grave prognostic sign, indicating, as it does, the profound im- pression made by the disease upon the brain. In epilepsy 698 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Enuresis. Enuresis. there is usually present incontinence, either during or after the attack. Enuresis of children can be divided symptomatically into three groups: enuresis nocturna, enuresis diurna, and enuresis diurna et nocturna (continua). In the first group the little patient is only unable to hold his water during the night. He is put to bed perfectly well; he has been told to empty his bladder, has done so, and an attendant coming to look after him in a few hours after he has been put to bed is astonished to find him, his clothes, and his bed sopping wet with urine. Per- haps he may be dried, his bed changed, and yet, when the child is taken up in the morning the same condition exists as before. When the patient is asked about the occurrence, he will feel ashamed of it, but disclaim any knowledge concerning it, and usually says "he could not help it." In the diurnal form it is only muscular contraction-laughing, sneezing, climbing, coughing, or great psychical activity; fear, joy, excitement of any sort- that causes the patient to be unable to hold his urine dur- ing the day only. In the continuous form the patient is wet during the day and night. In all these forms the urine is passed in a stream-not drop by drop-which when once started seems to be utterly beyond the control of the patient. In the nocturnal form, in many cases, although the patient be taken up from his sleep several times during the night in order that he may void his urine, wetting of the bed will still occur, showing that it is the loss of control of the sphincters which is the cause. These three forms cannot be, in the individual case, strictly separated from each other-thus, a patient may, for a time, be affected with enuresis continua; this may change to enuresis nocturna, and finally leave, as a reminder of the condition, an enuresis diurna. The condition is said to be more commonly met with in males than in females. This, if true, is to be ascribed to the more direct closure of the female bladder, not to the difference in capacity of the bladder, which would be in favor of the male. Most children, especially if they be bright, and seven or eight years of age or over, are affected very unpleasantly by this condition. Senseless parents will taunt them with their affliction, or even pun- ish them, and many a child's days are darkened by de- pression resulting from this inexcusable method of treat- ment. The child becomes shy, avoids its associates, remains indoors, loses its appetite, and becomes anaemic. The disease usually occurs between the third and tenth or twelfth years of life. It ceases with puberty, but sometimes may extend far beyond this time. Diagnosis.-The diagnosis must establish the cause of the incontinence. In all cases, whether adult or child, the urine must be carefully examined. After this, it be- comes necessary to examine all the organs which can be implicated as causal. In children it is especially im- portant to examine the anus, the penis in the male, and the urethra and vagina in the female. If there be any suspicion of worms, and there is hardly any case in which the physician or the parents do not suspect their presence, a microscopical examination of the faeces ought to be made in order to discover their ova, provided no worms can be detected. It is unnecessary to state that worms rarely cause incontinence of urine, yet more fre- quently in the female than in the male. Prognosis.-This depends entirely upon the cause underlying the symptom. If the cause can be removed, the symptom disappears. Enuresis in children is usually limited by the age of puberty ; in some cases there seem to be intermissions lasting for some time, months-and intercurrent affections, especially febrile in character, will also cause a cessation of symptoms. In these cases it is necessary to determine what produces the intermission ; usually a diminution in quantity of urine, and upon this is to be based an opinion of a possible exacerbation. Treatment.-It is not within the scope of this article to discuss the methods of treatment for all the causes of enuresis, or incontinence of urine. It will be seen by re- ferring to the etiology that they must be of an exceed- ingly varied nature, and must differ as widely from each other as do the causes producing this symptom. The principle of treatment must be based upon a knowledge of the interference with the normal mechanism of mic- turition, and of the methods for removing and overcoming it. All these methods will be discussed under their proper heads in this work. In regard to the enuresis of children, the methods of treatment can be divided into two classes: 1. Means ap- plied locally. 2. Remedies administered by the mouth. 1. Under the first heading comes the treatment of worms in the vagina, by injections of cold water, infusion of quassia, turpentine, carbolic acid, etc. Furthermore, circumcision may be resorted to, if the prepuce be very nar- row and long and no other cause for the enuresis can be established. In girls, small polypoid growths are some- times found at the external opening of the meatus urina- rius; when these are cut off with a pair of scissors the en- uresis is usually cured. Vulvitis or balanitis caused by masturbation must be treated by the proper remedies. All mechanical appliances for the treatment of enuresis must be avoided, as they can, at best, give but temporary relief. For this purpose all kinds of devices have been recom- mended, from closing the orifice of the prepuce every night with a layer of collodion to ligating the prepuce (!) with an elastic ligature. If the physician thinks that bene- fit can be obtained from any mechanical appliance, let him, at least, use such a one as will be harmless. The intro- duction. of instruments into the bladder of young children should be avoided, if possible. Sir Henry Thompson1 rec- ommends the injection of a solution of nitrate of silver, from gr. x.- 3 j. to the ounce, into the prostatic portion of the urethra and the neck of the bladder. One drachm of this solution is to be used, and the injections are to be made once every one or two weeks. It is recommended especially in young women from eighteen to twenty years of age, in whom the injection is to be made into the ure- thra and the bladder. In children this treatment will not be necessary, as we have in the following method one which rarely fails us when properly applied. Almost since the introduction of electricity as a scientific method of treatment, this force has been used for the treatment of enuresis in children. The objection to all the methods, with the exception of that of Ultzmann (loc. cit.), has been that they were either applied too indirectly, or the opposite. Thus, it was found that when one electrode was applied directly to the bladder the remedy was worse than the disease, on account of the production of a cystitis in the majority of cases. In order to obviate this, one pole is introduced into the rectum in boys, into the vagina in girls, and the other is placed upon tlie perineum. Ultz- mann has had an electrode constructed for the rectum or vagina, but the ordinary electrode, such as is used for the bladder or the rectum, is sufficient for all purposes. The faradic current must be used, the strength to be increased gradually, the sitting to last from five to ten minutes, and the application to be made daily or every other day. The duration of the treatment varies greatly ; there are cases in which the moral suasion of one application seems to be sufficient to cause the patient to so influence his volition that the incontinence ceases. As a rule, however, tonicity of the muscles is not sufficiently increased until the treat- ment has continued for a month, when the result will be permanent relief, as a rule. 2. Of the remedies which are applied by the mouth, we have those calculated to change the composition of the urine: first, by regulating the diet; secondly, by the internal administration of alkaline mineral waters or alkalies. The diet is to be changed so that the quantity of urea and urates shall be diminished. The waters of Waukesha are, in this country, the most readily administered, and are very serviceable in acting upon the reaction of the urine. Belladonna or atropine is probably the medicament most commonly used, and which benefits the greatest number of cases. Trousseau, who " adopted " this remedy from the practice of Bretonneau, as he says, made a method of its administration which is the one to be followed. The remedy is given at night; either the extract or the tincture of belladonna may be used. Atropine is more certain in its effects, but not so universally used, although it is ex- ceedingly well borne by children. Trousseau begins with 699 Eli u rests. Epilepsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 0.01 Gm. of the extract of belladonna, and increases the dose with every relapse, up to the maximum of tolerance (in some cases 0.20 Gm.). In giving belladonna one must always be careful to get the same preparation, as various extracts differ very much in respect to the amount of atropine which they contain. For this reason it is always best to use atropine itself (from 0.0001 to 0.0005 Gm. of atropine sulphate, according to age and strength of pa- tient). After continuing its use for from three to five months, the remedy should be administered in diminishing doses, until at the end of ten months or one year it should be withdrawn altogether. In cases of enuresis diurna et nocturna the belladonna does not, as a rule, give any results ; here it becomes necessary to use nux vomica, strychnia, or ergot. In very young children strychnia may not be used, but nux vomica, in the form of the tincture, or ergot, in the form of the fluid extract, may be given. In regard to the general treatment, little need be said. When necessary, if anaemia be present, tonics in the form of iron or malt preparations, small doses of arsenic or cod-liver oil, can be tried. With this there must.be combined plenty of fresh air, wholesome food, and a sufficient amount of exercise. The moral treat- ment ought to be that of encouragement. The child is to be made as cheerful as possible, and always to be as- sured that he is suffering from a condition entirely be- yond his control. #. Forchheimer. used than any other. Since, however, it is rather violent in action when pure, it is commonly diluted with wheaten flour or flaxseed meal, then made into a paste with water. When obtainable, the fresh leaves of many cruciferous plants, such as mustard and horse radish, bruised and ap- plied to the skin, may be employed as substitutes for mustard-seed. Onions and garlic are also employed for the same purpose, but, aside from the disadvantage of their odor, are less efficient. Terebinthine preparations are also used as rubefacients, but commonly in a differ- ent class of cases. The oil of turpentine, pure or diluted with olive-oil, liniment of camphor (camphorated oil), etc., is very frequently employed &s a local epidermatic, and often with most excellent effect, but differs decidedly in its action from mustard, in that it is absorbed to a con- siderable extent. As an illustration, it is only necessary to cite its action when applied to the abdomen, in the form of stupes, for the relief of tympanites. The terebinthine preparations generally, whether in the pure form or as plasters, ointments, cerates, etc., act epi- dermatically through the irritating properties of their es- sential oils. When it is desired to pass beyond rubefaction to vesi- cation, we may either continue the application of the agents above enumerated for a longer time, increasing the strength of the preparation if advisable, or have re- course to a new class of agents, namely, direct vesicants, such as cantharides or croton-oil. Of these also we may modify the action to some extent by diluents. Of can- tharides we may choose any one of half a dozen prepara- tions, while croton-oil may be diluted to any desired ex- tent with olive-oil. Both cantharides and croton-oil are readily absorbed, whether through the sound skin or by virtue of having raised the epidermis it is unnecessary to inquire, and consequently should be used with discrimi- nation, for absorption of the former may induce distressing strangury, and of the latter, over-purgation. In another class of cases neither rubefaction nor vesi- cation is desired, at least, as an object distinctly in view, though rubefaction naturally occurs as an incident, namely, where stimulant or soothing agents are employed by means of more or less vigorous friction. Here oleaginous or saponaceous substances are employed as the vehicles for suspending or dissolving the active agents. Liniments and ointments are extensively used in this manner. In still another class of cases agents are employed epi- dermatically, not only for counter-irritant effect, but also .to stimulate local absorption. As an illustration, the lo- cal use of tincture of iodine may be cited. By repeated paintings of the skin the epidermis is raised but not de- tached, and the drug penetrates to the deep tissues, and, as is well known, greatly stimulates absorption. The ointment of iodide of potassium acts in a similar manner, though less violently, and, in most cases, less efficiently also. Lastly, agents are locally applied to the skin for their direct effect upon underlying organs, as, for instance, belladonna to the breast, for the purpose of suppressing the secretion of milk. Here also discrimination is re- quired, for any drug thus readily absorbed through the unbroken skin may, even when locally applied, produce serious constitutional effects. There remains for brief consideration the epidermatic use of medicinal (or nutritive) agents for their effect upon the system at large. Of course, this distinction is purely arbitrary, since, as noted above, many of the agents already considered are absorbed to some extent, and must necessarily affect the general system at least in some de- gree. Of strictly medicinal agents, none others are employed epidermatically for constitutional effect as often as mer- cury. In the form of the officinal ointment, or the more recent and elegant oleate, there can be no question of its efficiency. In infants and young children, and often in adults with irritable stomachs, mercury can be admin- istered in this manner for a considerable length of time with happiest effect. Regarding the epidermatic use of certain agents for nutritive effect, as, for instance, cod-liver oil, much has 1 Desormeaux: Nouveau Dictionnaire de M6decine et de Chirurgie Pratiques, xii. Paris, 1873. 2 Voillemier et Le Dentu : Trait6 des Maladies des Voies Urinaires, ii. Paris, 1881. 3 Dittel, L.: Pitha u. Billroth, Chirurgie, Bd. iii., 2, p. 216, from Med. Jahrbuch, Heft ii., 1872. 4 Hertzka, Carl : Journal f. Kinderkrankheiten, Bd. lix., 1872. 5 Bokai, Johann : Gerhardt's Handbuch der Kinderkrankheiten, Bd. iv„ 3. 1878. 0 Ultzmann : Neuropathien d. Miinnlichen Harn u. Geschlechtsor- gane. Wiener Klinik, 1879. 7 Thompson, Sir Henry : Quain's Dictionary ; article, Diseases of Mic- turition. 6 Trousseau : Medecinische Klinik des Hotel Dieu in Paris, Bearbeitet von L. Culman, ii., 1868. 9 Henle : Handbuch d. Systematischen Anatomie, ii., 1873. Bibliographical References. EPIDERMATIC MEDICATION (epidermatic, from on, and Sep^a, the skin) has reference, medicinally, and in the broadest sense, to anything applied to the skin for palliative or curative purposes. Originally, and even now chiefly, employed as a surgical measure for the dis- cussion of visible swellings and tumors, the epidermatic method of employing drugs and medicines has of late years gained ground, at least in certain directions. As contributing to this result, it is only necessary to mention the widespread interest and popularization of real or so- called medicated baths-epidermatics surely, and of nat- ure's own preparation, originally-and massage, which have directed professional and popular attention to the .skin as an absorbing surface. Passing the subject of baths, whether of water alone, of saline solutions, of aqueous or mineral vapor, with the mere mention, since this is treated of elsewhere (see Baths), we will consider first the use of epidermatics in local affections. In the endermatic and hypodermatic methods (which see) the practitioner is limited in his choice of agents to a comparatively small number ; here, however, he is prac- tically without such limitation, and consequently almost everything has been employed, and, it may be added, with almost every conceivable object in view'. Beginning, for example, with affections in which it is desirable to produce local rubefaction for the purpose of relieving pain or diverting blood to the cutaneous sur- face, one might readily be embarrassed in making a choice from the great number of agents at his command, wrere he not, as is commonly the case, prejudiced in favor of some one or more with whose powers he is thoroughly famil- iar. As, however, a simple local irritant is required, it is ordinarily best to employ such as are least likely to be absorbed by the skin ; in other words, such as are under absolute control. Of this class ground mustard-seed is one of the best, and, being nearly always at hand, is more 700 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Enu rests. Epilepsy. been written, and many highly colored, not to say exag- gerated, statements have been made. There is, however, to my mind, substantial ground for belief in the efficacy of the method in properly selected cases. Leaving out of account, altogether, cases in which friction of the cu- taneous surface, rather than the oleaginous agent used to facilitate the friction, is the real curative agent, there still remains a considerable number of patients, particu- larly those of tender years, who may be greatly benefited by inunctions of cod-liver oil. For a number of years I have employed the method with great satisfaction in in- fants and young children wasted with summer diarrhoea, or greatly worn with bronchitis or pneumonia. In such cases the stomach will, in general, tolerate the oil with difficulty, if at all, and I have found from considerable experience that inunction is quite as efficacious. With adults I have not been as successful, partly because of the lessened activity of the skin, and partly because of the difficulty attendant upon the employment of the oil in sufficient quantities. Laurence Johnson. with great rapidity ; or the chin is thrust forward and upward to one side, giving the individual the appearance of a person suffering from torticollis. These attacks may simply consist in a temporary aphasia, the so-called epileptic aphasia, during which the patient is speechless or substitutes words. Petit mal is found alone, or the attacks occur in associ- ation with those of a more grave character. There are numerous cases in which light seizures alone exist, or for many years precede a more dramatic manifestation. Jackson is disposed to regard a great variety of tempo- rary mental derangements as epilepsies, and in his several " West Riding " articles gives numerous examples of ab- sences. By many people these conditions would not be regarded as pathological states. The grand attacks are frequently preceded by certain warnings or aura, which may exist in a simple or compli- cated form. These, in their order of arrangement as re- gards frequency and constancy, are sensory, psychical, motorial. The sensory prodromata of an attack are of the most diverse character, and the patient complains of such transient subjective sensations as tickling or tingling in the cutaneous surface, chiefly commencing in the ex- tremities, on one or both sides, and centripetal in charac- ter, the morbid sensation appearing to advance toward the head from some distal point. This is a peculiarity of what is known as the epigastric aura, which consists of a very disagreeable sense of pressure beginning below the sternum and ascending. Patients complain of con- striction of the throat, a sensation as if ants were running, or wind was blowing over the surface, of fugitive pains, and of a great number of sensory troubles. Certain vis- ual warnings are complained of as immediate precursors of the attack. The epileptic is occasionally apprised of the coming on of an attack by the perception of colored rings, spots, or broad fields of color, in which red or blue most commonly predominate. Scintillation and musca voli- tantes constitute the auras in some cases. The existence of these latter is of much shorter duration than the distal sensory warnings referred to above, and so sudden is their onset that the patient is frequently unable to describe them. Sometimes the optical illusion is likened to the recession of objects or their advance ; or again, the patient alludes to his environment by a cloud. It is by no means uncommon for patients to complain of double vision and of hemiopia, and, as a rule, this accompanies a grave form of the malady dependent upon coarse cerebral disease. There are sometimes auditory hallucinations, such as rushing sounds, the ringing of bells, or the whistling of the wind. In some instances the sound of ordinary conversation of those persons in the room may be greatly intensified in pitch. Psychical warnings of a more com- plex nature take the form of imaginary voices which speak imperatively or give commands ; and in rare cases a visual hallucination is the immediate precursor. Foul odors, such as that of smoke, ordure, or those of aro- matic substances, are sometimes perceived by the epilep- tic. Vile tastes of nauseating substances is spoken of. In such cases the individual often carries his hand to his nose, or smacks his lips, or makes efforts at expectora- tion. Sensations of great heat or cold are mentioned (Champier, Delasiauve). A desire to defecate, or urinate, or vomit, are rare prodromata, and certain patients belch forth large quantities of gas. The patient in some cases talks unintelligibly or utters meaningless cries, occasion- ally with something like regularity in expression. There are many motor disturbances, such as limited trembling of the small muscles, blepharospasm, or twitch- ings of the facial muscles or fingers. Some epileptics present automatic disorders of motility which are con- tinued some seconds. The condition of the patient may be such, for several days preceding the attack, as to indicate impending- trouble. There may be despondency of manner, listless- ness, malaise, and a sense of danger ahead. The eyes are often injected, and the temporal vessels rather promi- nent. There may, on the other hand, be a state of un- usual vivacity or excitement, possibly headaches, tremor EPILEPSY. Synonyms : L'Epilepsie, Fallsucht, Epilep- sia, Falling Sickness, Mal Caduceo, Morbus Hurculeans. Definition.-A disease in which sudden losses of con- sciousness are attended by more or less convulsive mus- cular action. The seizures of epilepsy have been called-because of their varying degress of severity-epilepsia gravior, or grand mal, and epilepsia mitior, or petit mal. The first is characterized usually by the severe attack, which con- sists ordinarily of great loss of consciousness and corre- sponding violence of muscular movement; w-hile the latter is manifested by a trifling seizure with transitory men- tal obscuration, and little or no muscular convulsion. There are irregular varieties which have been called masked or aborted epilepsy, with reference to the imper- fect development of the more familiar symptoms, the attack taking the form of psychical derangement with- out definite motorial expression. There is also a form known as I'epilepsie partielle, or hemi-epilepsy, which is always dependent upon cortical degeneration or unilat- eral disease, and a variety to which I have given the term sensory, in which more or less disturbance of the special senses exists with imperfect mental and motorial symptoms. A number of special names have been given to epilepsies with reference to their etiology, " gastric epilepsy " being a familiar illustration. The lighter form, or petit mal, may consist simply of a momentary loss of consciousness, during which the patient becomes suddenly very pale, the color receding from his lips and cheeks, and with this respiration for the moment is temporarily arrested or afterward increased. The eyes may remain open and be rolled upward, or the lids are less often closed. While in the midst of some occupation the patient may be taken, and the particular act is interrupted in its performance. The glass or spoon drops from the hand, the pen is arrested in the middle of a half-written word, and oftentimes the patient's trouble is so transitory as to escape notice, he himself as a rule, being utterly unconscious of it. The sentence is finished, and beyond an occasional residual dizziness there is no reminder. In other cases, or at other times, the seizure is more grave, both as regards the unconsciousness and the se- verity and extent of the spasms. The patient may be- come rigid and then agitated by limited twitchings and cramps of the fingers. The color leaves the face, and the pupils are widely dilated. In a few seconds he is able to arise and go about his business. Delasiauve1 and other French writers speak of absences, vertiges and acres in- termediaire as forms of petit mal, while Reynolds divides the light attacks into those without evident muscular spasm and those with spasm. The light attack may, ac- cording to writers generally, consist simply in interrup- tion of speech or the act of writing such as I have detailed ; or of sudden deviation of the eyes, or head ; or mo- mentary confusion of ideas. The mouth is drawn to one side or the other, or widely opened, and there is rapid alternate contraction of the muscles of the neck, so that the head executes movements backward and forward 701 Epilepsy. Epilepsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the lips or tongue, and varied subjective disturbances, which in some cases are very peculiar. Aurse are by no means constant ; in fact, the majority of patients cannot give a satisfactory account of any special warning. Of 519 cases collected by Delaisauve, of which 229 were personal, but half presented any history of aurse. Of 980 cases I have examined or treated, but forty per cent, gave the history of anything that could be called a true and distinct prodromal symptom. If I counted the by no means clear description of the patients the number would be larger. Gowers' experience is that of 1,000 cases, "it was always absent in 495, while some aura existed, at least occasionally, in 505," which is a very large showing. The major attack consists of three stages, viz.: the stage of tonic convulsion; the stage of clonic convulsions ; the stage of subsidence. The first of these is much the shortest, and is sometimes merged in the second. The last includes the condition after the subsidence of con- vulsive movement, during which the patient regains con- sciousness or sinks into a more or less profound sleep. The attack may or may not be preceded by a warning, but it generally is by some exclamation or cry. The epileptic cry, which is a purely psychic feature, is loud, shrill, and terrible, and may either be the result of an unconscious cerebral action or the direct expression of fright. It lasts sometimes but a few seconds, and is rarely repeated before the actual debut of the convulsion. In other cases the noise made by the patient is alone due to mechanical causes, the tonic spasm of the muscles of the thorax forc- livid, and the lips, ears, and finger-nails show how im- perfect is the decarbonization of the blood ; the skin of the hands is purplish, wrinkled, and cold, and all about the mouth is a dusky ring fading off to white at the points where pressure is made against the teeth. The rigidity is so great that, if there be time to make such a test, it will be found that the exhibition of ordi- nary force will not enable the observer to overcome the extension. According to Mercier, who studied the dis- ease very closely in an interesting case, "the rigidity is greatest in the hands, less in the wrists, still less in the elbows, and not very great in the shoulders. It is less in the legs than in the arms or neck; the head being re- tracted with a force approximating to that which immo- bilizes the elbows." The inequality of this rigidity, which may sometimes be unilateral, suggests certain structural cerebral defects, either due to previous disease, hemi- atrophy, or traumatism. Sometimes the mouth is drawn to one side, the head being turned to the other, there being a distinct cramp of the muscles of one side more than the other. The pupils are now found to be widely dilated, insensitive to light and touch. The face becomes engorged, and with such a change the breathing is noisy and rapid. The lips flap loosely with each inspiration and expiration, churning the froth, which is perhaps tinged with the blood that may come from a wounded tongue. As Mercier has observed in his case, the spasm of the oral muscles may be synchronous with the respi- ratory movements. The movements of a clonic nature now occur, which may be more or less violent. There is little regularity in their happening, though I find it the rule for a succession of jactitations to mark the discharge of fresh groups of cortical cells; the spasms in one ex- tremity disappearing as another is more prominently agi- tated. The spasms, as a rule, are disorderly, and in no sense rhythmical. There is in some cases a fine tremor which is more or less pronounced, and this takes the place of active spasm. Mercier observed a patient in whom the tremor began in the periphery and spread toward the trunk. The clonic spasms of the upper extremities con- sist sometimes of alternate pronation or supination, flex- ion and extension of the hands, the thumbs being doubled under the fingers, which are strongly flexed. The movements which, as a rule, affect the extremities at first, finally become so general that the trunk is in- volved, and a diversified number of contortions take place, the pelvic movements being very marked. These clonic convulsions are so severe that the patient very often throws himself from the bed upon which he may be lying, and in severe cases it requires the exhibition of much force to keep him from injuring himself. This stage continues for a variable time, which usually seems much longer than it really is. There may be fresh acces- sion of clonic spasm, but ordinarily the attack is short- lived, and the patient gradually becomes more quiet; the color returns to the face ; there are some signs of subsi- dence, for the breathing grows regular and perhaps sigh- ing ; the pulse is more regular and less full, the rigidity disappears, and the patient makes movements, especially of the mouth, which are semi-volitional. The head may now be rolled uneasily from side to side, and some effort to arise may be attempted. He may open his eyes and look vacantly about, or murmur indistinctly. Some- times the confusion of ideas which attends the glimmer- ing return to consciousness may manifest itself in in- coherent talk and transposition of words. During the convulsive stages the patient often has involuntary discharges from his bowels orbladder, and it happens that seminal emissions even may occur. This is true especially of the nocturnal attacks, and is often a valuable diagnostic point to observe; and in adults the existence of nocturnal incontinence of urine often exists with unsuspected epilepsy. The cutaneous reflexes are lost during the attack, but after the subsidence of the clonic stage we find that there is a return, and that the tendinous reflexes are very much exaggerated, and that the ankle clonus is sometimes quite exaggerated. In one case, elsewhere reported, I found that an epi-rotulian blow would produce a response in the ing the air suddenly through the unprepared vocal cords. A coarse, gurgling noise is the result, of low pitch and short duration. Then we see the development of the seizure. The victim usually falls to the ground rigid and helpless. The fall is ordinarily backward, though sometimes he pitches forward or to one side, and this may be preceded by throwing upward of the arms. Sometimes the head is thrown back, the forearm and hands being rigidly flexed ; and then more conspicuous appearances are beheld. When recumbent, the patient is in a position of pleurothotonos or opisthotonos, the body perhaps being laterally curved one way, while the head is drawn in the other direction. The eyes are usually widely opened, the whites of the eyeballs exposed, there being perhaps some tendency to conjugate deviation, or strabismus. The mouth is firmly closed or opened, or if the onset of the attack be sudden and severe, the tongue or lips maybe caught between the teeth, often- times to their severe injury. The arms and legs may be extended very violently, the dorsal surfaces of the hands approximated, and the fingers flexed (see Fig. 1030); the feet overlap each other, and the toes are often ex- tended ; the abdominal muscles are flatly contracted, and for a moment breathing seems to be suspended ; the pa- tient's face, which at first was momentarily pale, becomes Fig. 1030.-Period of Tonic Convulsion (Mercier). 702 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epilepsy. Epilepsy. opposite leg. The patient gradually regains his normal state and arises, or more commonly sinks into a deep slumber, from which he awakens exhausted and with headache. The temperature and pulse of the epileptic undergo very important changes. In the status epilepticus there may be a very great exaggeration of the former, but during the attack there are but slight variations. The pulse is quite thread-like, especially during the first stage ; while (luring the stage of clonic convulsion it is much more full and rapid. The urine passed after the attack is found to contain an increase of urea and phosphate, and occasionally albu- men. Huppert holds that the presence of the latter is constant, and I am fully able to confirm his conclusion. Immediate Results of Attack. - After the attack we sometimes find a variety of disturbances of the nervous system. These are exceedingly variable, and may con- sist of sensorial or motorial manifestations, and in the former I include the immediate mental derangement. I have already alluded to the headache, which is dull and vertical or frontal. Of course the injuries the patient may have sustained are quite apt to leave behind their painful effects, but there are disturbances which are con- nected with the fit itself which are exceedingly annoy- ing. Excessive muscular violence may give rise to fibrillary rupture, and, in rare cases, to dislocation of the large bones. Spots of cutaneous anaesthesia are complained of some- times, and the skin is covered with petechise. The post-epileptic mental state has been studied by Jackson, and is of especial interest in light or imper- fectly developed attacks. The aphasic state has been spoken of, and I will only add that, when there is a dis- turbance of speech of appreciable duration, the return is marked by the use, first, of words containing vowel sounds, and the employment of consonants is later, a fact first observed by Jackson and formulated in his rule-that simple and quasi-automatic processes suffer least, and are soonest recovered, while complex arrangements suffer most, and are more tardily recovered from. The post- mental state is often expressed by peculiarities in the be- havior of the individual, by automatism, and occasion- ally by violence or the commission of purposeless acts. The patient may be dull, forgetful, or slow in all he does or says. Sometimes, however, the attack acts as an ap- parent vent, for the epileptic who is dull before the paroxysm is afterward exceptionally bright. In certain cases a blunting of the moral sense, with impulsive promptings, is shown in the performance of various mis- chievous and dangerous acts. The motor disturbances are chiefly paralysis and sub- sidiary spasm. A condition known as post-epileptic pa- ralysis is an occasional sequence of hemi-epilepsy, and may last for some time. In some instances there may be simply a loss of power, which is present for a few hours or days, and in others the paralysis is permanent, and perhaps is indicative of the commencement of wide- spread coarse cerebral disease ; and it is by no means rare for subsequent convulsions to begin in the paralyzed members. Sometimes, though rarely, a vesical weak- ness may follow an unusually severe attack, or, as a result, a peripheral paralysis may follow the injury of some nerve-trunk, either in connection with dislocation or by violence connected with the patient's fall. Some diagnostic interest is connected with these cases. Remote Effects of Epilepsy.-The epileptic whose dis- ease is deep-seated presents certain conspicuous indica- tions of his disorder. His expression is dull, the eyes lacking lustre, and the lines of his face are by no means well marked. His facial muscles may be the seat of a low grade of paresis, or an hemiatrophy may give rise to an easily recognizable asymmetry. Fibrillary tremors are by no means uncommon, and the lips are puffed and rather inclined to present a purplish tinge. Acne is com- mon, even when bromides are not used to excess, and the tongue often presents old scars, the evidence of former attacks. The patient's movements are not characterized by vigor. Mentally he may present evidences of great weakness, especially if the form of attack has been petit mal, but it does not follow that epilepsy should bring in its train any decided degeneration of this nature. Many epileptics who have occasional grave attacks preserve their original strength of intellect. There are many epileptics whose paroxysms are purely the expressions of the insane neurosis, and this is true especially of children with deformed crania and irregular teeth, and who are imbeciles or idiots. These subjects are, perhaps, able in a weak way to perform acts requiring little intellectual energy, or grow up presenting characteristics which are overlooked by fond parents. The ' ' strange " child does unlooked-for things, is vicious, or unduly mischievous ; applies itself to certain studies, learning with great ease, while it is hopelessly deficient in others. Shows a smart- ness in the matter of a limited range of "accomplish ment " which astonishes everybody. Its heritage is from drunken or insane parents, and perhaps at ten it becomes epileptic. Its " queerness " increases, and its fits are not cured ; dementia follows, or the type of disease changes, and the infantile attacks arc substituted by epileptic in- sanity. The epileptic whose paroxysms are alternated with, or follow, migraine is quite apt, if the subject be a woman, to develop mental trouble in connection with menstrual derangement, a trying pregnancy, or at the menopause. Epileptic attacks may be divided into three classes as regards their time of occurrence-matutinal, diurnal, and nocturnal; the mode of occurrence may be regular or irregular, the patient at no time being free from them. So far as my experience goes, the greatest num- ber of severe attacks occur in the early morning, or during the night, while attacks of petit mal may occur alone during the day or coincidentally. The attacks may be very numerous, many hundred perhaps occurring within the twenty-four hours. Axenfeld reports a case in which one hundred and fifty in one day, and Newing- ham another in which no less than six hundred and twenty-two convulsions were counted in the same time ; this is unusual however. In point of rarity, I have had several patients who have had well-defined attacks as far apart as two years ; and one gentleman comes to me al- most yearly to report that he has had one or two attacks within one week after an interval of many months. By far the greater number of patients have attacks every two or three weeks, and women have them chiefly at the cata- menial period, or shortly afterward. Of course, if the disease becomes established the intervals become shorter, and in hospitals for the epileptics the case-books show that most of the patients have from one to a dozen attacks daily. Attacks of petit mal are of course much more frequent when the disease is well established. There is a tendency in epileptic attacks to occur in groups. Isolated attacks, as Gowers very properly says, are more common, and when in cycles there is little reg- ularity, so far as number is concerned. Young children are very apt to have one or two con- vulsions, which are looked upon simply as eclamptic, and to be entirely free from any return until the eighth or tenth year, when several entirely unexpected seizures make their appearance. In many cases there is no an- tecedfent history of trouble, but, without any cause what- ever, one or more paroxysms appear. The possibility of further trouble is one of doubt and uncertainty. Gowers publishes a table which includes 160 cases. Interval between First and Second Severe Fit in 160 Cases of Epilepsy. Less than one week 18 One week to one month 37 Cases under one month 55 One month to three months . 13 Three months to six months 21 Six months to one year 18 Cases more than one month and less than one year.. . 52 One year to two years 18 Two years to three years . 6 Three years to five years . 7 Over five years . 22 Cases more than one year 53 703 Epilepsy. Epilepsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It will, therefore, be seen that the risk of a second at- tack within one month is considerable, and that such risk does not disappear for a long time. Too great caution cannot be taken in advancing an opinion, and while I do not wish to be understood as saying that all early eclamp- tic attacks are suggestive of subsequent epilepsy, I do say that the early spasms of childhood occurring perhaps at the third or fourth year, between the periods of the first and second dentition, are quite likely to be the precursors of others in regard to the character of which there can be no possible doubt. The status epilepticus is a condition which marks the occurrence of a great number of attacks, and when con- sciousness does not return between them, there is a deepen- ing coma, with a great rise of temperature (105° -107°) and final collapse, which may end in death in a very short time. Recovery is not impossible, however. Sensory Epilepsy.-Under the caption of " thalamic epi- lepsy," Dr. William A. Hammond,2 several years ago, de- scribed a form of the disease in which sensory disturb- ances predominated, and which he believed to be due to a lesion of the optic thalamus. The attacks, which be- long to nothing more nor less than a sensory epilepsy,3 are characterized by few or no disorders of motility, but by the occurrence of hallucinations of a more or less elaborate character, by hemiopia, and more commonly are found in association with some headache of a migrainous type ; by occasional anaesthesia, or sometimes the loss of the voli- tional power of speech. Jackson,4 in his earlier articles, freely and fully explains the pathology of various sensory aurae and minor attacks. The symptoms I have observed in these cases all belonged to Exner's third group of GesichtshaUucinationen,*' and are undoubtedly cortical in- stead of thalamic. The following two cases may be referred to as exam- ples : Case 1.-Miss J. D--, aged twenty-nine, comes of a neurotic stock ; a brother and sister both suffering from incomplete epilepsy, and her mother has had headache and incident hystero-epilepsy. The maternal grandfather was extremely eccentric, and possibly insane, and there is a history of other neurotic disease. Since her early childhood she has suffered from vertigo and headache, and at the commencement of menstrua- tion she became hysterical. She is at present a healthy- looking woman, somewhat nervous and excitable in man- ner, but clever, intelligent, and possessing an unusual memory. Her present attacks became quite marked three or four years ago, and during the past eighteen months have occurred every three or four weeks-with- out relation to menstruation, but at any time. They are not influenced in any way, except by occupation and ex- citement, which seem to prevent the frequency of their recurrence. She first noticed a unilateral dimness of sight, and afterward a blindness which was sudden and absolute, and she invariably " lost half of the object at which she was looking." Her first attack of this kind was in a railway station, and while looking at the clock the fig- ures from " XII" to " VI" disappeared. This abolition lasted for a period of ten or fifteen minutes, and shortly after its event she noticed a numbness of the tongu^ and pain on the left side. This numbness next appeared in the fingers of the left hand and slowly extended up to the elbow, when it stopped. The right hand next be- came involved, and after a " furry feeling" of the tips of the thumb and forefinger her hand became "dead and without feeling " as far as the wrist. After continuance of this state for a period which I estimate varied from five to ten or even fifteen minutes, she lost consciousness, and while so, made quasi convulsive movements which were undoubtedly psychical, as she rubbed the hands over each other, and made attempts to remove her rings. She stated that her fingers were swollen, and her sister corroborated this, and an attempt by the latter to remove the patient's rings was attended by considerable difficulty. Two or three minutes after the development of the anaes- thesia there is often exquisite pain over the right eye, which augments in severity and extends over the entire head. This lasts sometimes for an hour or so after the attack, and is not relieved by any application. During the unconsciousness, which is complete, she neither breathes stertorously, bites her tongue, nor shows any epileptic appearance, except it may perhaps be a slight pallor and dilatation of the pupils. It is impossible to arouse her for several minutes. The attacks are often aborted by strong mental effort, or by diffusible stimu- lants. Upon several occasions she has been suddenly deprived of the power of speech, and could not express herself, but this is exceptional. Such mutism was coin- cident with the hemiopic stage, and not subsequent to the loss of consciousness. She has neither menstrual nor other disturbance of the pelvic organs. She has slept soundly, and has had dreams nearly every night, but is not a somnambulist. After the attacks she passes large quantities of clear urine. There is no color-blindness. Physical examination reveals almost nothing except it may perhaps be a suspicious bulging of the left optic disk, and a tortuous and enlarged condition of the veins. The tongue points slightly to the right. There is no ero- togenetic sensitiveness. Case 2.-Major T . This patient is an army officer, forty-four years of age, of good habits, and was perfectly well until the battle of Gettysburg, when he was shot in the head, the bullet passing through the left orbit, destroy- ing the eye upon that side, and passing out on the right side. The right eye miraculously escaped injury. He was led back to the rear, soon became unconscious, and was delirious, and in the hospital for weeks after the ac- cident. He lost the senses of smell and taste at the time, the latter being now greatly impaired. He has had since the injury a series of very severe headaches, which lasted only a few minutes at a time and then completely disap- peared. There was facial neuralgia of the lower branches of the fifth, and some severe pain in upper frontal region upon the right side, with the seizure. For the past two or three years he has suffered from a most curious form of epileptic seizure. At any moment (and usually several times daily), he becomes dizzy, and perceives a purely subjective odor which he cannot define, but which is not unpleasant. This becomes more and more concentrated and intense, and then is suddenly lost. Simultaneously there is ocular dimness and constriction of the visual field, but no diplopia or hemiopia, no color rings or spectra. There is momentary confusion of ideas, and occasionally clumsiness of speech. There is absolutely no disturbance of motility. At other times he has temporary loss of memory. Upon one occasion he performed a number of purposeless acts, straying into the room of a perfect stranger at his hotel, wandering aimlessly into the streets, with no sub- sequent idea of how he had spent his time. He has had lapses lasting several days, and neglected to keep appoint- ments, or entirely lost sight of important engagements. His wife says he has had slight twitching of the left side of face with his "absences," but this is rare. His hear- ing is good, and there are no indications of coarse brain lesions except those I have mentioned. Dr. Cornelius R. Agnew, who sent him to me, had carefully watched the case, and saved his right eye. The patient cannot distinguish cologne, ammonia, camphor, acetic acid, etc. This case resembles somewhat another6 which I reported some years ago, and in which the main feature of the attack was a constant aura of smell, the patient perceiv- ing a foul odor. In this case a destructive lesion of the uncinate gyrus and adjacent parts was found after death. Whether the impairment of smell in major T 's case is due to destruction of the bony parts containing the spe- cial apparatus of smell, or to an ascending degeneration or not, I am unable to say, but from the nature of the paroxysms an autopsy w'ould probably disclose the latter. Masked Epilepsy.-There are many forms of irregular seizures which are quite interesting. In some there may be a few of the ordinary manifestations of the familiar attack in association with others which are quite bizarre. In several cases with which I am familiar the patients began to run violently about the room, and finally became 704 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epllepsy. Epilepsy r convulsed. In others the whole attack consisted in con- tinued running, the subject being unconscious through- out. In two or three patients there was a tendency to re- move all their clothing, without the least appreciation of what they were doing. A form of the disease in which the epileptic remains in a species of trance is occasionally presented. Sometimes the attack will take place without attracting attention. I have recently had under my care a clergyman who wandered in an aimless sort of way about the country, and when afterward found could give no account of himself for the week previous to his dis- covery. While in this dual state the patient will get into altercations with strangers, or commit purposeless acts. Such cases are of great interest from the standpoint of medical jurisprudence. As a rule, the reprehensible acts are motiveless, and are not remembered after commission. The inter-paroxysmal state may be one free from any nervous trouble whatever, the patient being perfectly well until the occurrence of a new explosion. At other times there is a change of manner which betrays itself in an ap- prehensive melancholy, which may change to a condi- tion of great irritability as the impending paroxysm ap- proaches. Occasionally an aphonia may exist during the entire inter-paroxysmal period, but this is rare. Rom- berg speaks of dysphagia, tympanitis, trismus, and is- churia as possible sequelae, which may last a long time. Romberg believes that epileptic individuals are less likely to contract contagious diseases, but, as Axenfeld very properly says, these observations lack sufficient proof. The pupils during the inter-paroxysmal period are, as a rule, very mobile, and act too readily to light stimulation. The pulse during the inter-paroxysmal state is usually soft, slow, and compressible, the cutaneous cir- culation is poor in old epileptics, and the hands are inclined to be livid and dry. Hang-nails and other evidences of malnutrition are quite common. The influence of pregnancy has been the subject of much controversy. The burden of proof goes to show that epilepsy does not interfere with the process of gesta- tion in any serious way, and, as a rule, does not induce miscarriage. Pregnancy, on the other hand, seems to ag- gravate the epileptic state itself, though quite exceptional cases are reported where a cure was effected through the institution of this condition. Such cases are mentioned by Landre, Beauvais, and Delasiauve. Suppression of the menstrual flow is apt to precipitate the convulsions. In certain rare cases the course of epilepsy is greatly modified, if not cured, by the occurrence of one of the eruptive fevers. Minor attacks may be transformed into major through the agency of an illness which may, per- haps, be of this character. Etiology.-It is an undeniable fact that heredity plays the most extensive part in the causation of epilepsy. Of the 980 cases I have mentioned, no less than 435 presented some family history of neurotic or pulmonary trouble.* Thirty-five per cent, of Gowers' cases were characterized by the same state of things, and with other authors- among them Reynolds and Echeverria-the proportion of cases in which there is a neurotic inheritance varies from thirty-five to forty per cent. As the result of such in- heritance we find that female cases rather preponderate. Of very young subjects this is the rule, but, when the dis- ease begins after twenty, it appears that there are more males who become epileptic than females. The greater part of all cases begin before the twentieth year. Of my own 980 collected cases in which the beginning of the disease was known, there were- gone pre-ossification are quite apt to suffer from irregular forms of epilepsy. Ten or fifteen per cent, of children, according to Delasiauve, present epilepsy conjointly with idiocy. The convulsions are quite apt to be associated with curious intellectual perversion. The subject of the appended sketch, whose cranial conformation is certainly remarkable, in addition to a light and frequent epilepsy was unable to rea- son from abstract premises, was in- clined to commit cruel acts at times, or at others manifested most shock- ing and eccentric phases, mental ex- plosions. The traumatic causation of the dis- ease is exceedingly interesting, be- cause of the occasional strange char- acter of the injuries. As a rule, blows which leave little or no exter- nal signs of their violence are re- motely apt to be followed by the out- burst of epilepsy. Depressions over the paracentral lobes may be found in connection with unilateral parox- ysms ; while bullet-wounds which perhaps have caused extensive ero- sion of bone may be mentioned as causes. Such was the case in the example men- tioned under the head of sensory epilepsy. In a case referred to me by Dr. Sayre, several years ago, the patient presented a large cavity which existed in the pe- trous and mastoid portions of the temporal bone, and by transmitted meningeal inflammation gave rise to a very severe epilepsy with maniacal outbursts. Blows produc- ing fracture of the internal table of the skull frequently account for the disease. A scar left from a head injury may be the starting-point of a painful aura which is the precursor of an attack, and various writers allude to injury of the nerve-trunks, the sciatic especially, as an impor- tant though rare factor. Syphilis, either in its secondary or tertiary stages, but more often the latter, may give origin to an epilepsy which is peculiar. The seizure, as a rule, is preceded by head- ache, and is often associated with other neurotic changes and mono-plegiae. The inter-paroxysmal state is quite apt to be characterized by more or less loss of memory, in- tellectual weakness, and, in some cases, a great desire to sleep at odd times and places, such a tendency being ap- parently irresistible. In many cases there is disease of the cranial bones as an intermediate factor. Fournier says that when epilepsy manifests itself in a patient of twenty or thirty it is of specific origin in eight or nine cases out of ten. The exanthemata may be followed by the development of attacks which are often very intractable. Especially true is this when it is scarlet fever that has preceded the paroxysms. Not only may this disease have such an in- fluence, but measles, small-pox, diphtheria, and a number of maladies of like nature, may directly cause the epilepsy. Metallic poisoning is a rare cause, and when we find epileptic convulsions in such cases it is usually symp- tomatic of some advanced encephalopathy. The use of absinthe and alcohol, when excessive, is quite apt to give rise to convulsions, which are violent. The latter, as a rule, are imperfectly formed, and the loss of conscious- ness is peculiar. In some the mental derangement is of the nature of trance, and the patient's seizures resemble the form of the disease known as " masked epilepsy." Malarial poisoning may underlie an epilepsy which is seemingly periodic, and attended by great rise of tem- perature. Such a case has been reported by Gray, and I have seen one which was completely cured by large doses of quinine. In certain cases great and repeated losses of blood will give rise to an epilepsy. In some cases there is an initial migraine, which exists for some time before the occur- rence of the seizures. Sunstroke occasionally is the excit- ing cause of a series of convulsions, which, however, can rarely be called epileptic. With the commencement of the menstrual function we Fig. 10.31. Under ten years Females. .... 103 Males. 95 Total. 198 Between ten and twenty years .... .... 171 97 268 Between twenty and thirty years. .... 145 92 237 Between thirty and fifty years .... 81 136 217 Over fifty years .... 11 49 60 511 469 980 Cranial deformities, especially microccphalus, are found with epilepsy, and children whose crania have under- * Drunkenness included. 705 Epilepsy. Epilepsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are sometimes apt to find epilepsy as an accompaniment. Herpin reports the case of a girl whose convulsions ap- peared at the menstrual epoch, and recurred with each succeeding period, and Maisonneuve reports others. The suppression of vaginal fluxes is naturally a determining etiological influence. Sexual excesses are, I think, too often supposed to give rise to epilepsy, and masturbation especially, is given great prominence as a cause. Onanism is very common among those epileptics of low moral gauge, with physi- cal anomalies of development, and in this connection can hardly be considered to be a cause. Excessive copulation and lustful excesses are mentioned by Continental writers as playing a part in the creation of the disease. Of fear and mental worry and anxiety, many authors are disposed to speak as important exciting or predispos- ing causes. There is no doubt of the bad influence of the latter, but the importance of the former is to be ad- mitted with some reluctance, although it cannot be denied that a sudden shock or fright has caused attacks. I am disposed to regard fear rather as an exciting cause of the attacks, and cannot believe that when no predisposition exists a simple revulsion of this kind can inaugurate the malady. Various exciting causes are quite likely to be dis- covered, especially among young subjects. Many so- called eclamptic, or rather epileptic, seizures are caused by intestinal worms, or undigested food. With phimosis as a cause I have had but little experience, but it may, like many other reflex causes, such as the irritation attend- ant upon difficult dentition, act prejudicially. Intestinal worms, while they are often responsible for infantile eclampsia, rarely produce the disease in adults. Luykx and Michel report cases dependent on taenia, and in that of the latter the seizures occurred during five years, and ceased with the expulsion of the worm. Muscroft7 reports a case of stone in the bladder which gave rise to epileptic convulsions, and a cure followed its removal. Irritation of the auditory apparatus is likely to pro- duce epilepsy, and the paroxysms may follow such simple excitation as blowing into the ear. The attacks from such a cause may even be very violent and general. So far as the influences of diet are concerned, we find that continued or excessive indulgence in animal food is likely to predispose to the disease in some persons. Many first attacks may be dated back to an engorgement of the stomach or some act of gluttony, and in many cases im- moderation often constitutes an exciting factor. Portal speaks of several subjects who became epileptic after gluttonous indulgence in beans (Delasiauve), and cases are referred to by the older writers where the ingestion of poisonous fungi or ergot has been the undoubted cause. Morbid Anatomy and Pathology.-There is noth- ing that can be called constant or characteristic in the way of a morbid anatomical appearance in the epileptic brain. This disease has existed in connection with al- most every variety of pathological change. Meningeal or osseous thickening, exostoses, vascular dilatation and sclerosis, atrophy and hypertrophy, the presence of tu- mors, may all prove to be lesions in epileptic cases. Epi- lepsy is found among children whose sutures have closed prematurely, and I have seen a number of such cases where the fits have appeared between the fifth and tenth years-which I suppose is due to the fact that the brain rapidly develops at the fifth year, and owing to preossi- fication and consequent cranial limitation, does not get sufficient room for expansion. In traumatic cases we find all varieties of fracture and depression, and occasion- ally the existence of old subdural cysts. Lunier8 found that the crania of many epileptics pre- sented various abnormalities. In some he found a flatness or depression of the frontal bone ; in other cases an asym- metry between the lateral halves of the skull, which was the result of undue prominence of the parietal bone of one side. Lasegue called attention to a fronto-facial asymmetry which was the result of a consolidation of the sutures of the base of the skull, the union being a slow one, and requiring for its accomplishment the space ordi- narily of eighteen years, when the attacks would appear. The resulting deformity would be a difference in the halves of the frontal, the depression most often noticed being upon the right side (Axenfeld). Certain facial pe- culiarities were associated with this, as well as deformi- ties of the vault of the palate. Echeverria,9 Van der Kolk,10 Luys and Voisin,11 and others, have observed morbid appearances in the me- dulla, the presence of amylaceous cells, an exudation of a granulo-albuminous nature, cell degeneration and pigmen- tation, as well as destruction, in part, of certain important nuclei, notably of the hypoglosus and pneumogastric nerves. Echeverria, as well as others, found lesions of that portion of the great sympathetic which is located in the neck. Ogle and Jackson have reported very many cases with cortical degeneration, especially of the paracentral lobule. In cases where dementia or other mental troubles are found, and especially in those in which the mental disturb- ance takes the form of general paresis, we may expect to find a well-diffused cortical sclerosis. Some years ago Delasiauve, Bouchet, and Cazauvieihl Meynert, Sommers, Bourneville, and others, found in many epileptic brains a peculiar induration of the cornu ammonis, which they regarded as peculiar to epilepsy. I have repeatedly found this appearance, and certainly it is worthy of consideration, though it cannot be regarded as pathognomonic. Sommers found this induration in thirty per cent, of his cases, while Bourneville in only seventeen per cent. The other authors I have mentioned regard it as almost constant. Kussmaul and Nothnagel disbelieve in the importance of this lesion. Epilepsy has been experimentally produced in various ways. Kussmaul and Tenner, Astley Cooper, and others, have by ligation and carotid compression given rise to seizures which disappeared when the constriction was removed. Other experimenters have, by ligation of the superior and inferior vente cavae in animals, obtained the same result. Nothnagel found that by tapping the heads of guinea- pigs an epilepsy was originated, and various mechanical means of jarring the cerebral contents have been devised. The theory enunciated by Brown-Sequard was in effect, that epilepsies might be provoked by certain sections of the cord in the lumbar region ; that injury of the sciatic in certain animals (guinea-pigs chiefly) would give rise to convulsions ; that the progeny of animals thus mu- tilated were the possessors of certain so-called epilepti- ginous zones which, when irritated, would give rise to genuine epileptic paroxysms. These epileptiginous zones were located about the face and neck, and irritation, especially of certain branches of the fifth-the suboccipital chiefly-would produce the lit. In man such zones are, as a rule, not to be found. Injury of the medulla oblongata has been found to be followed by epilepsy, and electrical or mechanical irrita- tion of the cortex cerebri, cerebral peduncles, or resti- form bodies would have the same effect. The cortical experiments of Hitzig and Ferrier have done much to elucidate the nature of Jacksonian epilepsy. Finally, certain toxic agents, among them alcohol, absinthe, and other substances have been used. Poulet found that the subcutaneous injection of the salts of am- monia gave rise to epilepsy. The existence of epilepsy depends, undoubtedly, upon an instability of the cellular elements, and when a lesion exists it is, as Jackson has shown, undoubtedly of an " ir- ritative " character. The starting-point of the convulsion is probably primarily in the cortex cerebri, and second- arily, in the medulla. Theview'of Vander Kolk, whichhas been accepted with modifications by Reynolds and others, is that the locus morbus of the disease is the medulla oblongata. In the established epilepsy this centre is in a condition of excitability, and through the receipt of reflex impressions, either from higher parts of the cerebrum or from the periphery, an altered inhibitory vascular state ensues, the parts lying at the floor of the fourth ventricle become the seat of hyperaemia, and then follow various pathological changes and their consequences-a second- 706 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epilepsy. Epilepsy. ary anaemia and hyperaemia of the cerebrum results ; irritation of convulsive centres, and tonic and clonic con- vulsions of the nuclei of lower cranial nerves, with con sequential spinal accessory and other disturbances, and resulting spasms of muscles of neck, asphyxia, compres- sion of jugulars, secondary stupor, tongue biting, etc. This latter Van der Kolk believes to be due to irritation of the nucleus of the hypoglosus. Diagnosis.-The diagnosis of the ordinary epileptic attack should not be a difficult matter. It is dramatic, pronounced, and usually not to be mistaken. Its sig- nificance, however, is another matter, and its etiological relations are important and should be gone into. The minor seizures are sometimes confounded with attacks of syncope, but when we exclude the disorders of motility, which do not belong to the latter, there should be no chance for mistake. It must be remembered that seizures of petit mal do not occur in an isolated form, but that there is a history of numerous previous attacks. Then, too, the faint is usually traceable to some cause. It is important to diagnose whether or not the parox- ysm is the manifestation of coarse disease of the brain ; and, in such cases, limited or rather extensive paralysis will be found, as well as optic nerve atrophy, disturbed reflexes, and distal sensory trouble. Hysterical epilepsy (see Hystero-Epilepsy) is, as a rule, a complaint of women, and the attacks seem to bear some relation to the occurrence of the menses. Charcot speaks of the hysterical modifications of epilepsy as fol- lows : 1. A form in which hysteria is engrafted upon primary epilepsy. 2. A form of primary epilepsy which is complicated after marriage by hysteria. The hysteri- cal influence is destroyed by pregnancy. 3. Primary hysteria with superadded epilepsy at a later date. 4. Con- vulsive hysteria with co-existent petit mal. 5. An epi- leptic attack with residual hysterical contraction and hemi-anaesthesia. I have observed another form, viz., that in which an epileptic patient was seized with hystero-epileptic parox- ysms at the menstrual period. The diagnosis of the grand attack is sometimes a very important matter, and quite commonly the convulsions of uraemia or alcoholism are to be differentiated from those of the malady under consideration. The uraemic convul- sion is usually preceded by a history of mental obscura- tion, perhaps some ataxic aphasia, and headache. The presence of oedema, albuminous urine, and the skin pallor, are also confirmatory indications. The alcoholic convulsions, unless due to chronic alco- holism, are preceded by a debauch. If the urine be ex- amined it will be found that the bichromate of potash test will reveal the presence of alcohol-a very peculiar and striking change of color to green. Sometimes we may confuse the lighter attacks with auditory vertigo, or lithaemic or gastric vertigo, but the rotary character of the disturbance in the former, and the connection of the latter with digestive disturbance, are to be borne in mind. It is of the utmost importance that the medical man, especially if he be called upon to treat and inspect sol- diers, prisoners, or the inmates of the pauper asylums, should be on his guard in regard to the simulation of epi- lepsy. This form of imposture is common enough, and is very difficult of detection. Numerous cases are recorded by the various authors upon medical jurisprudence where the deception has been kept up for some years by a ma- lingerer. The case of "Clegg, the Dummy Chucker," reported by Dr. Carlos MacDonald, is of this kind, the subject be- ing an habitual criminal who repeatedly threw himself from high platforms in the jail to the stone floor below, and bore many self-inflicted injuries withofit a murmur, that he might escape certain duties or punishments. He was finally detected by MacDonald. The impostor can- not change the size of his pupils, nor can he counterfeit the color of the skin which belongs to the real fit. The epileptic, as a rule, doubles his thumb under his other fingers, which are strongly flexed, a thing neglected by the impostor. The latter is ordinarily on the alert to see how his behavior will impress the bystander, and an occa- sional suggestion from an outsider will be acted upon by the designing person, who will thus betray his conscious- ness as well as-his anxiety to make an impression. Prognosis.-Epilepsy is certainly one of the most dis- couraging of all diseases of the nervous system so far as the hope of cure is concerned, but the prognosis is much less bad than before the introduction of the bromides. Those forms which are of idiopathic origin, or dependent upon coarse cerebral disease, osseous lesions, or advanced syphilis, are well-nigh hopeless, but there are cases owing their genesis to less profound causes, w'hich are modi- fied or cured. It is impossible to give satisfactory statis- tics of cure, from the fact that most of the cases are im- perfectly watched. Sex seems to have little or nothing to do with the patient's chances. The cases beginning before the tenth year, or after adolescence, are more read- ily helped than those beginning between the tenth and twentieth (Gowers), and this is probably due to the fact that the idiopathic causation is more common before twenty. The form with grave attacks alone is more easily cured than that in which petit mal is a feature- and uncomplicated petit mal is perhaps the least hope- ful of any form. The curability of the disease depends much upon its duration and the number of attacks, and one author believes that all cases in which live hundred attacks have occurred are absolutely beyond the reach of any treatment. Cases of hereditary origin are commonly regarded as the least amenable, but Gowers is not of this opinion. Fifteen per cent, of Gowers' successful cases were those in which heredity existed. My own experi- ence does not confirm this. Those cases where the fits are separated by long intervals are most readily cured, but if the attacks be severe and repeated, such is not the case. Attacks which seem to be connected with disor- dered menstrual function are sometimes very readily abolished. The existence of an aura renders prognosis slightly more unfavorable, although in one way this is not so as such a condition of affairs enables the patient to abort the fits. Cases in which cranial deformities exist are usually bad, and the attacks are irregular and eccen- tric. The existence of mental impairment or aberration of any kind is always unfavorable. Fatal cases are rare, that is, when the patient's death has been directly due to the disease. When death occurs, we find that asphyxia is usually the immediate cause. It occasionally happens that epileptics are suffocated from the lodgment of a piece of meat in the air-passages, while a number of accidents, among them falls, are apt to lead to death by drowning or cranial fracture. In sev- eral instances of which I know, the patients fell into an open fire-place or against a hot stove. I have already alluded to the danger of muscular rupture and dislocation; another rare accident is the amputation of the tongue that may occur when it happens to get between the teeth. According to Axenfeld and other French writers, the complication of epilepsy with hysteria is one calculated to favorably modify the prognosis of the former. Treatment.-In our management of epilepsy, wre are to avoid everything that smacks of routine treatment. The mere administration of a much recommended drug, without studying the indications for its use, will do little or no good. The epileptic paroxysm, after all, is but a discharge from over-excitable and unstable nerve-cells, and is a symptomatic condition, the pathological states varying greatly. As a general plan of treatment it should be the earnest of our endeavors to maintain a condition of circulatory equilibrium, so that the cerebral blood- pressure shall not undergo very rapid, sudden, or great changes. Cardiac stimulants or sedatives should, per- haps, form a part of the treatment in different cases, and these may be combined with remedies having specific, neurotic, or alterative effects. In some cases the use of digitalis is almost a necessity, and in others remedies of an opposite class are required, where there is a tendency to cerebral hypera;mia. In what the older writers called ansemic epilepsy, the use of digitalis is absolutely impor- tant, or we may use a remedy which I first recommended 707 Epilepsy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epithelium. a few years ago, nitro-glycerine, in doses of one one-hun- dreth to one twenty-fifth of a grain thrice daily. There are a great number of remedies which have been used empirically almost from time immemorial. In many cases no intelligent idea is entertained as to their physio- logical action. I do not propose to refer to many of them, except in the most superficial and passing way, or not at all, for but few possess any virtues. No general remedies have been of so much service as the bromides, especially those of sodium, ammonium, and potassium, and since their introduction, about twenty years ago, the number of cures has greatly increased, and the prognosis improved, as our knowledge derived from experimental therapeutics has broadened. In 1865- 70, five or ten grains of the bromide of potassium in di- vided doses was considered a maximum quantity, and a few years later certain American physicians advocated immense doses-even an ounce daily. In 1876, in a paper read before the American Neurological Association, I pointed out the danger of using these large doses, and re- ferred to many cases in which I found that maximum doses of twenty grains, repeated thrice daily, controlled the convulsions in cases that were amenable to treatment, and in which the attack had been aggravated before by very large doses. This latter form of treatment I think is now used quite generally. The bromides cannot, however, always be employed, and some patients do not bear them at all, or only in the smallest doses. Dr. Gray, in a most practical paper, sums up his conclusions in regard to this : " But there are certain individuals, constituting a very troublesome minority, who are dangerously susceptible to the action of the bromides. An epileptic patient of mine, a boy of ten, although robust in appearance, was yet re- duced to a condition of imbecility and such general weak- ness that he could not rise from bed by a three days' treatment with ten-grain doses of the bromide of potas- sium. He passed out of my care into the hands of a gen- tleman who ordered him to take the bromide for three months. He took to bed as before, and when he came out of it he went to Greenwood Cemetery. An epileptic, demented youth was brought to my clinic. I ordered him a mixture containing potassium bromide, gr. xv., and sodium bromide, gr. x. I was sent for in hot haste shortly after he had taken his first dose, found him in a state bordering on collapse, and had great difficulty in restoring him. I saw in consultation, some three years ago, a young lady who had had a few epileptic at- tacks, for which she had been steadily treated with large doses of the bromides during a period of about six months. She was in bed, almost pulseless, pallid, thin, exhibiting great mental sluggishness, being made to an- swer questions with great difficulty, weeping at times without cause, somnolent. Her life had been despaired of, and two eminent gentlemen had made a diagnosis of grave organic nervous disease. I recommended the with- drawal of the bromides, the substitution of stimulants, tonics, and a nourishing diet, and the patient was about in a few weeks." My own large number of cases bear out these state- ments. I may add that after a time large doses of the bromides, injudiciously administered, not only lead to brominism, but greatly aggravate the number of the attacks. Most cases of this grave disease must be considered first as to the qdestion of interval, the time of day at which the attacks occur, and the general condition of the individual. The amount of bromide to be given daily, say of the sodic salt, which is the best, may be fixed at from one to two drachms, to be divided up, the largest dose to be given just before the attack. Should the lat- ter occur in the early morning, it is best to administer it at night, and perhaps to reinforce the quantity. In some cases where the periodicity of the paroxysm can be defi- nitely determined the dose may be enlarged, and the drug more freely used for several days before the ex- pected explosion. Many practitioners commence by in- ducing a mild brominism, which is manifested by anaes- thesia of the fauces, and some appearance of acne upon the forehead, or by the bromic breath. It is exceedingly inju- dicious to go beyond this point, for when the nutritive pro- cesses are interfered with, the medicine does harm instead of good. The bromic salts should always be given in plenty of water, and Vichy is a decided improvement, be- cause of its advantage in securing tolerance of the drug by the stomach. When epilepsy is dependent upon or- ganic changes, either syphilitic or otherwise, a separate saturated solution of the iodide of potassium or sodium may be used and either of these salts given in milk, or Vichy should be used in large quantities. The so-called " American System" should be followed, and even half an ounce or more should be given daily. In cases where the attack is preceded by headache, the iodide is espe- cially serviceable. The bromides may be given in com- bination with tincture or infusion of digitalis, and small quantities of arsenic may be incorporated for the purpose of preventing skin troubles. In other cases the combina- tion of chloral hydrate or aconite is advisable. The bromic treatment should be continued in a modified form at least two or three years after the attacks disappear. It will be found, in some cases, that the combination of the three principal bromides sometimes acts more energetically and efficaciously than either singly. The use of fats, espe- cially cod-liver oil, is often of the greatest service when the bromides fail alone. I have been enabled in this way to help many cases where the bromides had been used before without any considerable success. The hypophosphites act admirably where there is weak digestion, and if the bromic state becomes too profound it will be found that some preparation of iron, strych- nine, .and quinine will dispel the symptoms. Great care should be taken not to push the latter too far. Bromide of nickel, which was first introduced by Da Costa, is a very valuable substitute for the other bromides in obstinate cases, especially where there is regularity in the recurrence of the seizure, and a considerable interval. There is comparatively little digestive derangement follow- ing even its long-continued use. It is best given in five- or ten-grain doses in soda water, or as an effervescing salt, or in the form of syrup. Leaman, of Philadelphia, who has used it for some time, thinks it is of the greatest service in hypochondriacal or hysterical forms of the disorder. I have used this salt for several years, and have cured or relieved several very bad cases when the other bromides had done no good whatever. Hydrobromic acid, which has to be given in immense doses to be of the least service, is so disagreeable and inefficacious that I never think of resorting to it. The hydrobromate of conia, which is a new remedy, I have thoroughly tried with no good result, and my experi- ence has been equally bad with curare, which has always failed. Delasiauve refers to no less than eighty-nine reme- dies or forms of treatment, and this is but a small num- ber when we consider that his book appeared nearly half a century ago, and new remedies are frequently recom- mended. The only real advance, as I have said, has been made in the discovery of the bromides. I may enumerate chloride of potassium, sulphate of zinc, oxide of zinc, sulphate of copper, chloride of gold, nitrate of silver, phosphorus, as remedies which have had their day-and are occasionally of service-while the list of vegetable remedies is simply legion. Valerian, camphor, the camphor monobromate, assafoetida, musk, castor, opium, belladonna, aconite, indigo, turpentine, conium, may be mentioned. Galvanism is the only form of electricity that ever does any good, and this is only in exceptional cases. The current from no more than ten or fifteen Leclanche cells should be used, one electrode being placed anteri- orly and the other posteriorly upon the head. Static electricity is useless ; chloroform and ether may be re- sorted to whfti the status epilepticus is found, but unless the convulsion be very severe, I prefer nitro-glycerine or the amyl nitrite. The lighter attacks are very obstinate, and are not helped as are the more severe. Belladonna, ergot, and hyoscy- amus have all been tried with various degrees of success. Nitro-glycerine I have found to be of great benefit in some 708 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epilepsy. Epithelium. cases, and its exhibition should be for the production of a continued state of moderate cerebral hyperaemia. An important indication is the provision of remedies for the abortion of attacks. When the aura is of a sen- sory character and begins in an extremity, the use of an encircling blister or ligature about the arm will, if the paroxysms are frequent, or the patient has time to take preventive measures, stop the progress of an attack. One of my patients, whose aura often begins in the arm, pro- vides himself with a rubber band which he hastily slips over his hand. Brown-Sequard recommends forcible flexion of the wrist. The inhalation of ammonia, nitrite of amyl, or the prompt resort to a tablet containing from Too-A of a grain of nitro-glycerine, will ward off the fits. A glass of sherry or some alcoholic stimulant will often act very promptly. It is well for the patient to keep a draught by his bedside to take as soon as he awakens, if he has morning seizures. The diet of the epileptic should be of a vegetable nat- ure. Meats are highly injurious, but moderate use of game, poultry, fish, and oysters is to be advised. Fresh vegetables, fruit-except grapes-milk and cold bread, should form the chief articles of diet. Stimulants are, of course, out of the question in most cases, but coffee, which is usually denied the patient, is (if mild) by no means so hurtful a thing as it is ordinarily supposed to be. Friction, cold baths, and exercise are to be insisted upon, and mild intellectual labor is good for the subject. Steam and furnace heat is responsible as an exciting cause in many cases, and if possible open fires, properly guarded, should be placed in the patient's room. Surgical measures have been of avail, if we are to be- lieve all the reports ; yet the experience of many success- ful surgeons, who have watched their cases for a long time, is against its efficacy. Sands does not favor it. If it is used the etiological diagnosis should be very clear, and its employment should be confined to traumatic cases. Dr. W. Briggs12 seems to have had extraordinarily favor- able results from trephining, for of 30 cases of the traumatic variety where, he performed the operation, 25 were cured, 3 relieved, 1 was not helped, and 1 died. Walsham's13 re- sults were not quite so favorable. Of 130 cases of trau- matic epilepsy operated upon, 75 were cured, 18 improved, 7 not helped, and 30 died. In some examples it will be found that the aura pro- ceeds from a cicatrix upon the scalp, and the exsection of this, even if no removal of bone is undertaken, may be sufficient. In such cases as those reported by Lande,14 in which a neuritis was the cause of the convulsion, ex- section or nerve-stretching might do good, but of course such hopeful results are problematical. Allan McLane Hamilton. 1 Traite de I'Epilepsie, p. 55. '2 Archives of Medicine, iv., 1, 1880, p. 1. 3 N. Y. Med. Jour, and Obstet. Review, June, 1882. 4 West Riding Reports, vol. iii., p. 315; vi., p. 266; Brain, iii., 2, p. 192. 5 Untersuch ungen uber die Lokalisation der Functionen der Grosshirn- rinde des Menschen, p. 63. 6 Loc. cit., p. 11. 7 Archives for Practical and Scientific Medicine and Surgery, Phila- delphia and New York, 1873, i., 360. 8 Annales Med.-Psych., 1852. 9 On Epilepsy, etc. 1870. 10 The Medulla Oblongata, etc. 11 Archives de Med. Die. 1869. 12 American Practitioner. July, 1884. 13 St. Bartholomew's Hospital Reports, vol. xix. 14 Mem. et Bulletin Societd de Med. et Chirurgie de 1874, i., 56-65. cavities, or form the ducts or parenchyma of glands which, at any period of life, have been in genetic connec- tion with the above-mentioned passages, belong, strictly speaking, to the epithelium, although in the process of development they may have become widely separated from them. Thus, the cells lining the great body cavities -the peritoneal, pleural, and pericardial-and commonly called endothelium, are, from the genetic standpoint, epi- thelial in character : because these cavities are originally derived from the alimentary canal, and at one time stand in direct connection with it. However, on account of the great similarity in structure between the cells lining the great serous cavities of the body, and the true endothe- lium of the blood- and lymph-vessels, joint cavities, etc., and because of the sanction of usage, we shall consider the former cells under the heading Endothelium, which see. The layers of epithelial cells which occupy the above- mentioned positions contain no blood-vessels, but are formed of single or of superimposed layers of cells, closely packed together, with a small amount of albumi- nous cement substance between them. This cement sub- stance, in some cases at least, serves to conduct nutritive material along between the cells. In certain parts of the body-cornea-nerve-fibrils also pass between the cells. Epithelial cells present the greatest variety in shape and size. They may be cylindrical, cuboidal, polyhedral, pyriform, fusiform, flattened, spheroidal, ovoidal, or quite irregular ; and while some are very large, others are small. This variety in size and shape is partly due to the different positions which they occupy, and func- tions which they perform ; partly to their different modes of grouping, as well as to the existence of imma- ture forms. The nuclei of epithelial cells are usually well defined, and ovoidal or spheroidal, with a more or less well-de- fined intra-nuclear network. The bodies are usually, though not always, sharply outlined, and may be coarsely or finely granular, or striated, or nearly trans- parent. Epithelial cells are classified in a variety of ways, but for our purposes it will be convenient to consider them in two classes, depending largely upon their shape and grouping : 1. Those which form a single layer-simple epithelium. 2. Those which are arranged in superimposed layers-stratified epithelium. We shall briefly consider the more prominent forms of cells in these two classes, one after another, without special regard to their relation- ships. 1. Simple Epithelium.-Epithelial cells of this class, which form a single layer, are sometimes flat, forming a Fig. 1032.-Squamous Epithelium Lining the Capsule of the Glomerulus of the Human Kidney. X 800 and reduced, a, Wall of the glomerulus capsule; b, epithelium. thin, mosaic-like covering over the surfaces which they invest. Such cells are called squamous-or sometimes pavement or tessellated-epithelium, and are found lining the capsules of the glomeruli and a portion of Henle's loops of the kidney (see Fig. 1032); while in a modified form they line the air-vesicles, alveolar passages, and parts of the smallest bronchi of the lungs. The so-called endothelium of the great serous cavities belongs, strictly speaking, in this group of cells, but, as above stated, it will be convenient for us to consider it elsewhere. Sometimes the cells of simple epithelium are cuboidal in shape, and are then called cuboidal-sometimes also pavement-epithelium. Such cells line certain parts of the uriniferous tubules ; the acini of the thyroid and some other glands ; the smaller bronchi ; many gland ducts, etc. These cells, although more or less cuboidal when EPITHELIUM. Theclassof tissues called epithelial, al- though distinctly enough characterized for practical pur- poses by the position, arrangement, and general form of the cells which compose it, is yet rather difficult to define accurately, because, in addition to these characters of the cells, w'e must take account of their genesis, which, in not a few cases, is still insufficiently known. In general, how- ever, we may say that epithelial cells are those which form a continuous layer over the external surface of the body ; which line the alimentary, genito-urinary, respiratory, aural, and lachrymal passages ; and which line the ducts and form the parenchyma of the glands which communi- cate with them. All of those cells, moreover, which line 709 Epithelium. Epithelium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. seen from the side, are Usually polyhedral in shape w hen seen from the free surface (see Fig. 1033). Finally, simple epithelium may be cylindrical or columnar in shape. This form of simple epithelium is most abundant, lining as it does a large part of the gas- tro-intestinal canal and several portions of the generative apparatus. It is seen in most typical form in the lining epithelium of the intestine. The cells are in reality rather prismatic than cylindrical in shape, since, owing to mutual pressure from the sides, they usually have a poly- hedral shape when seen from the ends. They are, more- face is thickly beset with broad, cilia-like projections which give the appearance of striations. Whatever the exact nature of the border, it is doubtless instrumental in the absorption of fat from the intestinal contents into the epithelial cells, on its way to the chyle vessels. Not infrequently the protoplasm of cylindrical epi- thelial cells undergoes a transformation into mucin, and this, either with or without contact with water, is apt to swell, causing the cell to bulge at the sides, and finally it may be poured out at the free border of the cell. Owing to this swelling of the cell contents, the nucleus is usually crowded down to the lower or attached end of the cell, and is often so much squeezed as to be considerably distorted. After the mucin has been discharged, the outer lay- ers of the cell are left as a thin, distended shell, with the nucleus and some- times a portion of the un- changed protoplasm at the attached end. Cells in this condition frequently have a goblet shape, and are called " beaker " or " goblet " cells (Fig. 1035). When goblet cells are formed from the cylindrical epithelium of the intestine, the thickened border is thrown off when the cell contents are discharged (Fig. 1034 B). Certain cylindrical and cuboidal epithelial cells exhibit a delicate striation of a part of the body. Thus, some of the cells lining the excretory ducts of the submaxillary gland are striated at the basal end, the striation some- times reaching up beyond the nucleus (see Fig. 1036, A). Certain ciliated cells-those, for example, lining the uterine cavity-belong in the group of simple cylindrical or cuboidal epithelium ; but the ciliated epithelium will be considered in detail further on. Epithelial cells in various parts of the body may con- tain, sometimes as constant factors, sometimes as tem- porary ingredients, fat droplets or par- ticles of pigment(see Fig. 1036, B). Gland Epitheli- um. - There is a large class of epi- thelial cells, pre- senting the greatest variety in shape and function, which constitute the so- called parenchyma of organs. These may be mentioned briefly here, but will receive fuller con- sideration in parts of this work in which the histology of the various glandular organs is treated. The cells constituting the gland epithelium, or par- enchyma of organs, are, as a rule, cells which have ad- vanced far in the specialization of function, in accordance with the principles of the physiological division of labor. Many of them present rounded contours, so that cells of this class are sometimes spoken of as spheroidal epi- thelium. But, modified as they are in form as well as in function to suit the requirements of their various situa- tions and purposes, their shapes are as varied as are the positions which they occupy and the purposes which they serve. Certain gland cells, moreover, are constantly changing in shape and character as they pass from a con- dition of rest to that of functional activity. This is seen in the peptic glands of the stomach, represented in Fig. 1037, in which the large granular external cells, which are destined to replace those more transparent and in- ternally situated, are constantly changing in size and ABC Fig. 1035.-Beaker Cells from Adeno- ma of Ovary. In A and C there is nearly complete conversion of the protoplasm into mucus, the nucleus being crowded into the base of the cell. In B the conversion is only partial. Fig. 1033.-Cuboidal Epithelium, from Straight Tubules of Human Kid- ney. X 800 and reduced, a, Cells seen from side ; b, cells seen from surface. over, very frequently considerably smaller at one end- usually the inner or attached end-than at the other. These cells (see Fig. 1034) are set together side by side, and joined to one another by a small amount of albu- minous cement substance. They are usually granular, and contain a well-defined, rather large nucleus, which is frequently situated somewhat nearer to the basal than to the free end of the cell. Not infrequently, at the level of the nucleus, the cell is bulging at the sides. Small spheroidal or irregular-shaped cells, a part of which, at least, are probably destined to replace the cylindrical cells as they are destroyed, are frequently present between them, causing indentations in their sides. It will thus be seen that the cells of this group, al- though, in general, spoken of as cylindrical or columnar, A B Fig. 1036.-A, Striated epithelium from ex- cretory duct of submaxillary gland of dog (the striation is a little too sharply defined in the cut); B, pigmented epithelium from retina of ox. Fig. 1034.-Columnar Epithelium from Human Small Intestine % hour after death. X 800 and reduced, a. Striated border; b, "beaker cells." may present considerable departures from the typical form. At the free surface of the cylindrical epithelium of the small intestine, Fig. 1034, there is a narrow but distinct, strongly refractile border, sometimes called the " basal membrane," which with high powers shows a regular series of fine striations running across it in the direction of the long axis of the cell. The exact nature of this striated border is still undetermined, some observers be- lieving that the striations are pores passing through the membrane-like covering of the cell; others, that the sur- 710 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epithelium- Epithelium. number as the process of digestion is established and pro- ceeds. The epithelium of certain other organs, as the submaxillary gland, exhibits also changes in for«i corre- sponding to the varying con- ditions of functional activ- ity and rest. In certain glandular epi- thelium, as in the convo- luted tubules of the kidney (see Fig. 1038, C), the out- lines of the cells are not distinct, the functionating substance being composed rather of an irregular mass of protoplasm than of dis- tinctly outlined cells. In some organs, on the other hand, as the liver, the indi- vidual cells (see Fig. 1038, B) are sharply outlined. 2. Stratified Epithe- lium.-In the stratified epi- thelium, the cells are piled on top of one another to form several irregular layers. While there is the greatest variety in the stratification, as well as in the shape, of the cells which compose the layers, there are two main types which are especially characterized by the shape of the cells which constitute their most superficial layers, namely: 1, stratified squamous ; and 2, stratified cylindrical epi- thelium. The anterior corneal epithelium is a typical ex- ample of stratified squamous or scaly epithelium. The deeper layers of cells, as will be seen in Fig. 1039, which stratified epithelium, are formed from those of the deeper layers, which constantly approach the surface as they are replaced by new-formed cells in the lowest stratum. Now, in the skin the more superficial cells, as they ap- proach the surface, undergo, hand in hand with the changes in form, chemical changes by which keratin is produced in their bodies. As this transpires the nucleus disappears, the body becomes thin and dry and scaly, and finally, as epidermis scales, the superficial cells are re- moved from the free surface by attrition, washing, etc. Of the depart- ures in structure of the epithelium of the skin from this type, in dif- ferent parts of the body, we can- not speak here, but refer to the article treating of the structure of the skin. There is a very pecul- iar kind of cell, however, which should be men- tioned here, oc- curring in its most marked form in the middle layers of the strati- fied squamous epithelium, namely, the so-called "spined cell" or "prickle cell." If thin sections of well-pre- served skin, or of mucous membranes which are covered with stratified squamous epithelium, are examined with high powers, the edges of the cells, particularly those of the middle layers, appear not straight but jagged, as if beset with short spines ; or, when the cells lie in apposition with one another, their borders appear to be crossed by a series of short lines which pass from the edge of one cell to the edge of another, and sometimes appear to pass over a considerable portion of the cell body (see Fig. 1040). These lines seem to be the expression of delicate prolon- Fig. 1037.-Peptic Gland from Stom- ach of Dog. Transverse Section. a, Large surface cells ; ft, inner active cells. Fig. 1040.-Spined or Prickle Cells from Human Skin. X 900 and reduced. B C Fig. 1038.-B, Human liver cells: C. epithelial cells from convoluted tubules of human kidney, outlines of cells not distinct. rest upon the substantia propria cornese, are irregularly cuboidal in shape, while the layers above are composed of cells which become flatter and flatter as they approach the surface. The cells of the more superficial layers lap over one another at their edges. Similar epithelium oc- curs on the mucous membrane of the mouth, pharynx, oesophagus, and elsewhere. In the skin, whose epithelium belongs to this type, the deeper layers of cells are similar to those of the cornea ; Fig. 1041.-Epithelium from Human Bladder, condition when the organ is empty, a. Large irregular-shaped superficial cells; b, fusiform or pyriform cells of the middle layer; c, spheroidal and polyhedral cells of outer layer, resting upon muscular wall of bladder; d, pits or de- pressions in superficial cells caused by pressure from cells below. Fig. 1039.-Stratified Epithelium from Anterior Surface of Human Cor- nea. X 000 and reduced. gations of the cell protoplasm which bridge over the narrow spaces intervening between the cells. These in- tercellular spaces appear to serve, according to the re- searches of Arnold, Thoma, Bizzozero, and others, as conducting channels for nutritive material supplied to the epithelial cells. In the lining cells of the urinary bladder, we have an but the more superficial layers are composed of much thinner, flatter cells, which, at the free surface, consist merely of dry scales in which there is little cell-structure evident. The superficial cells in the skin, as in other 711 Epithelium. Epulis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. example of stratified epithelium which differs from the squamous stratified epithelium just described, in that the deeper layers of cells are small and spheroidal, fusiform or pyriform (see Fig. 1041), while the free surface is cov- ered with larger irregular-shaped cells, which send down processes filling up the interspaces of the cell layers be- neath. The constant pressure from the growth of new cells from below, which change their form and ultimately replace the superficial cells as these are cast off from the inner surface of the bladder, causes indentations in the attached surfaces of the superficial cells (see Fig. 1041, d), which often give them a very peculiar appearance. More- over, the superficial cells approach the squamous type only when the bladder is considerably distended. Then they, as w'ell as to a certain extent the underlying cells, yield to the pressure and are more or less flattened. But when the bladder is empty, or nearly so, the cells again assume the form shown in the figure. This change in shape, as well as the peculiar forms resulting from the mutual pressure of the cells themselves, are rendered possible by the soft, yielding character of the cell proto- plasm. It should be borne in mind, however, that when the superficial cells (Fig. 1041, a) are seen under the microscope, from the free surface, as is apt to be the case when they peel off in clusters into the urine, they may readily be mistaken for flat cells, although they may really have considerable thickness. Stratified Cylindrical Epithelium.-The most common representative of this type of cells is the ciliated epithe- served cells, a series of delicate, approximately parallel lines may be seen passing from the free border of the cell toward the nucleus (Fig. 1043, D). Beyond the nucleus, toward the basal end of the cell, the writer has never been able to trace the protoplasmic lines. The free end of the cell appears to be covered by a strongly refractile membrane from which the cilia spring. According to some recent observers-Eimer, Engelmann -each cilium may be regarded as springing from a tiny, Fig. 1043.-Ciliated Epithelial Cells from Trachea of Dog. X 800 and reduced. A, separate cells ; B, group of cells united at free border to form a smooth surface ; C, process at basal end of cells which lie between cells of the deeper layers ; D, striations in protoplasm above nucleus. more or less cuboidal or prismatic, mass of strongly re- fractile substance ; and it is the arrangement of these tiny basal prisms of the individual cilia, in the form of a mosaic over the free end of the cell, which causes the ap- pearance of a membrane. The cilia themselves, which vary considerably in size and shape in different animals and in different parts of the body, are homogeneous and flexible. They are usually exceedingly delicate, measuring in the human trachea from 1-4,000 to 1-2,500 of an inch in length. In some parts of the body, as in the epididymis, and in many of the lower animals-frog, oyster, mussel, etc.-they are considerably larger. They are slightly thicker, as a rule, at the base than at the tip, and it has been urged by some observers that they are in direct connection with the above-mentioned intra-cellular lines which pass toward the nucleus. But whether this be true or not, and whether Fig. 1042.-Ciliated Epithelium from Human Trachea. X 250 and re- duced. a, Ciliated cells forming superficial layer ; b, intermediate layer of fusiform cells; c, deep layer of spheroidal or polyhedral cells; d, basal membrane. lium, such as lines the trachea and larger bronchi, in which the cells are dove tailed into one another, in the manner represented in Fig. 1042. The deeper layers which rest upon the underlying connective tissue are composed of spheroidal or polyhedral cells. Above these are pyriform or fusiform cells, whose long axes are, for the most part, directed toward the surface of the mucous membrane, while the free surface is covered with more or less cylindrical cells from whose free borders delicate hair-like processes, called cilia, project, which during life are in active vibratile motion. The basal ends of the ciliated cells are usually more or less pointed, and some- times send off branches which pass out between the cells of the deeper layers (see Fig. 1043 C). Sometimes, as in the tympanum and in the ventricles of the brain, and in the mucous membrane of the uterus and Fallopian tubes, the ciliated epithelium occurs in a single layer, and may, as in the tympanum, be short or cuboidal in shape (Fig. 1044).. While the ciliated cells vary thus in shape from short cylinders or wedge-like forms to much elongated, pris- matic structures, their nuclei are much more uniform, being usually large and well defined, with a distinct intra- nuclear network. The protoplasm of the cell body presents the usual granular character, but in addition to this, in well-pre- Fig. 1044.-Ciliated Cells from Frog's Mouth. X 500 and reduced. the alleged connection would explain the mechanism of the ciliary movement, it is not yet possible to say with certainty. It is not unlikely that the movement is due to a contraction in the cilia themselves, analogous to that of the tails of the spermatozoa, although the possibility of a contraction of the protoplasm of the cell body, as at least a factor contributing to the result, cannot be denied. The movement of the individual cilia consists in the striking forward of the free extremity of the cilium, which at the same time bends in its entire length in the direction of the stroke. Then, as the cilium recovers its upright position, which it does instantly, it straightens itself ready for another stroke which immediately follows. 712 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epithelium. Epulis. These movements, which occur with great rapidity under favorable conditions, are not simultaneous in all the cilia over a given surface, but pass, wave-like, along it. These wave-like movements, however, when the cilia are mov- ing actively, follow one another in such rapid succession that its character is not usually very evident. But if the movement be artificially slowed, it is quite appreciable. Various external influences affect materially the vigor of the ciliary movement. Thus, elevation of tempera- ture up to a certain point favors it, while cold retards it. Various chemical agents exert a marked influence upon the movement. Strong saline solutions, chloro- form vapor, dilute carbolic acid, etc., exert a retarding effect. The movement often continues for a considerable time after the death of the animal, or after the separation of the individual cells from their connection with the body. The length of time to which the movement may continue under these conditions varies in different ani- mals. In warm-blooded animals, according to Sharpey, it may continue from two hours to two days. In the gullet of the turtle it has been observed to continue for fifteen days after decapitation. The direction toward which the cilia strike varies in different parts of the body, corresponding to the office which they serve. Thus, in the bronchi and trachea the stroke is in a direction from within outward, so as to carry mucus or foreign particles up out of the passages. In the Fallopian tubes the movement is toward the cavity of the uterus. In the frog the movement in the trachea is in a direction to carry foreign particles out from the lungs to the mouth ; while in the mouth and gullet it is in a direction which will carry small nutritive particles toward the stomach. The actual power of the moving cilia is in the aggre- gate very considerable, as has been shown by a series of experimental researches, which the scope of this article does not permit us to enter into. In man the ciliated epithelium occurs in the mucous membrane of the nose ; in the larger respiratory tubes; in the Eustachian tubes and parts of the tympanic cavity; in the mucous membrane of the uterus and Fallopian tubes ; in the coni vasculosi, vasa efferentia, and parts of the excretory duct of the testicle ; in the central canal of the spinal cord, and in parts of the cerebral ventricles. The gills of the oyster, teased in one-half per cent, salt solution, afford a very excellent object for the study of various phases of the ciliary movement. While the above description embraces most of the prominent types of epithelium found in the human body, it should be remembered that there are many inter- mediate forms between the types here described; and furthermore, that there are many modifications of epi- thelium by which supplementary structures, such as hair, nails, etc, are produced. The regeneration of epithelium, which is necessary either on account of the destruction of cells by normal functional activity, or by injuries, inflammation, etc., takes place by a multiplication of epithelial cells by the indirect mode of cell division (see Cell). In the stratified epithelium, it is in the deeper layers of cells, among the less differentiated forms, that this reproduction chiefly oc- curs. It seems probable, in so far as our knowledge at present enables us to judge, that new epithelial cells are produced only by the multiplication of old epithelial cells, or under their direct influence, or, at any rate, from cells of the archiblast (see Endothelium), and not from cells of parablastic origin. Bibliography.-Consult " Quain's Anatomy," 9th ed., vol. ii., p. 54, for structure and movements of ciliated epithelium, also article by Engelmann, Die Flimmerbewe- gung, in Hermann's " Handbuch der Physiologic," Bd. i., Erster Theil, p. 382 et seq. T. Mitchell Prudden. word epulis, as, e.g., Epulis sarcomatosa, Epulis myxoma- tosa, etc. Most of these tumors belong to the distinct sarcomas, and may vary in their histological character from the soft round-cell sarcoma, which in turn varies but little from pure granulation tissue, to the hard, firm fibro-sarcoma. Formerly they were divided into two classes according to their origin from the bone or the periosteal tissue. This division is purely an arbitrary one, for the epulis, like all the other periosteal sarcomas, most often has a mixed origin, the osseous tissue taking part as well as the perios- teum. We find the same difference here as in other peri- osteal sarcomas : sometimes the tumor is seated on the smooth bone ; at other times the bone beneath it is eaten out and eroded. There may be considerable new forma- tion of bone in the tumor itself, which shows itself in spic- ulae running in all directions through the tumor. In their histological character these tumors are espe- cially distinguished by the number of giant cells which they contain. In no other tumors are these found in the same number and size ; they are often branched and may form the chief mass of the growth. Most often the other cells are spindle-shaped and of a size correspond- ing to that of the ordinary spindle-cell sarcoma. Fig. 1045, taken from a tumor the size of a hickory-nut, which Fig. 1045. was removed from the gum of a boy of thirteen, gives an illustration of the ordinary histological character of these tumors. The epulis is essentially a tumor of youthful life, but may, like other sarcomas, also appear in advanced age. It appears as a growth which starts either in front of or behind the teeth, and is at first covered with mucous mem- brane and of a reddish color. It may be attached by a broad basis to the bone, or may assume almost a polypoid form. By its further growth the teeth are dislocated, the mucous membrane ulcerated through, and an irregular knobby mass is seen which has a great tendency to necro- sis on the surface. The growth of these tumors may be very rapid or slow, this depending generally on the histo- logical character-those in which the cells show a dis- position to complete their development into fibrous tissue being of the slowest growth. When no fibrous tissue is formed and the cells remain in the condition of embryonic tissue, the growth is often a very rapid one. They are often very vascular, and, from the occurrence of haemor- rhage, a considerable amount of pigment may be deposited in the tumor. The presence of this pigment has led some authors to give the name of pigment epulis to this variety. None of these tumors are malignant. There is no case EPULIS.-Epulis (e7n, upon, ovXov, the gum) is the name given to tumors which appear on the alveolar processes of the maxillary bones. The word is used only in a topo- graphical sense, and may include any of the varieties of tumor which appear here. Virchow has proposed that the particular sort of tumor shall be coupled with the 713 Epulis. Ergot. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. known in which they formed metastases either in the neighboring lymph-glands or in distant organs. They all have, however, a strong tendency to invade the surround- ing tissues and to recur after removal. The cause of this local recurrence lies in the incompleteness of the removal, as when this is attempted, without removing at the same time a portion of the jaw. The connection of the tumor with the jaw is in most cases such an intimate one that the whole tumor is not taken away unless this be done. When the tumor has a narrow base and can be felt to have no firm connection with the bone, it is often sufficient to remove the tumor and the periosteum beneath it. Most of what has been said applies only to the sarco- mas. Other varieties of tumor may appear here, just as from the periosteum elsewhere. After the sarcoma the most frequent form is the fibroma. A few cases only of myxomas appearing in this situation have been noted. These other tumors do not offer any marked macroscopic appearance differing from the sarcomas, and generally the character of an epu- lis can only be told from the his- tological examination. W. T. Councilman. velops and permeates the ovary ; as it grows the latter be- comes disorganized and disappears, and the mycelium of the Ergot, as this structure is called, takes its place. In a short time after, a very redundant and much wrinkled layer of perpendicular cells covers the surface of the myce- lium, and produces an innumerable number of minute ob- long false spores (conidia), which are discharged into the adhesive " honey dew " just mentioned. These are capa- ble of reproducing the plant, and are the first method of propagation. In this stage it was at one time considered to be an adult and perfect plant, and named Sphacelia, segetum (Leveille, 1827), (see Fig. 1047). A further develop- ERGOT (Ergota, U. S. Ph., Br. Ph. ; Secale cornutum, Ph. G. ; Ergot de Seigle, Codex Med.), Fungus Secalis ; Mutterkorn; Spurred Rye, etc., consists of the entire plant, Clariceps purpurea Tulasne, Order Ascomycetes, col- lected from infected heads of rye (Secale cereale Linn.) at the close of its first season's vegetation. This remarkable parasite is de- veloped in the flowers of several cultivated grains and of a consid- erable number of wild grasses, germinating upon the ovaries, which it aborts and finally de- stroys, and growing in the place of these organs like some mon- strosity of the flowers themselves. It attains to a sort of maturity as the grain ripens in the fall, and in this condition remains quies- cent until the following season, when, if in a suitable situation, as upon the surface of damp ground, it produces fruit in time to attack the blossoming grasses and grains of the succeeding year. The first noticeable evidence of the presence of this fungus in a spikelet, say of rye or wheat, is a sticky, unpleasant smelling, very sweet, liquid exudation from the interior of one of the flowers, which accumulates in considera- ble quantity, and may even drop off or run down the stem. It consists mostly of some sort of sugar, and is probably a decom- position product of the affected pistil, etc. Like similar results of the irritation of vegetable tissues by other fungi as well as by aphides, etc., it is known as " honeydew," and designated the " honey dew of rye." It is a certain sign that ergot will follow. Ants and beetles are fond of it, flock to the ears where it is to be found, and as it contains cells capa- ble of developing into ergot in other flowerS, they assist in spreading the blight. Bees are said to avoid it. A soft, spongy or cottony, mould-like tissue, consisting of long, fine, weak filiform cells, felted together at this time, en- Fig. 1047.-a, Ovary of rye with commencing growth of claviceps in the sphacelia stage, b, The same, with the parasite further devel- oped ; the hairy styles and the remains of the ovary are borne at the top of the mycelium, the commencing sclerotium or ergot is shown at the base, c, Section of specimen a little older than b, and rather more magnified ; the two styles and aborted ovary are seen at the top. the ruminated sphacelia in the middle portion, and the compact smooth ergot below. (Luerssen.) ment next takes place in the formation and growth of the so-called Sclerotium, which is the commercial Ergot. This begins as a condensation of tissue at the base of the " sphacelium" just described, the cells of which become shorter and thicker-walled, as well as more closely packed together. The mass becomes firm and brittle as it de- velops, the outer surface assumes a purple-black color, and it finally grows to a long spur-like, curved, irregularly cylindrical body protruding half its length or more be- yond the plumes and paleae of the rye. The " sphace- lium " atrophies as the sclerotium grows, and is carried up on the apex, as are also any remains of the unfortunate pistil (see Fig. 1047). When the Ergot is fully grown and gathered, scarcely any traces of either of these are to be found. At this stage ergot was also considered a distinct plant from the above, and has received separate names (Sclerotium clavus De Candolle, 1816, etc.). The growth of the first season terminates with the sclero- tium, but in the early sum- mer of the next year several minute globular heads raised upon stalks, half an inch or more in length, and looking like miniature "toadstools," grow from the sides of this organ and bear, in numerous cavities (perithecia), a multitude of groups of long and slen- der spores (see Figs. 1048 and 1049). These spores, ap- plied to the flowers of suitable grasses, are capable of re- producing the whole series of forms described above, and complete the life history of the fungus. It is interesting to note that this stage of claviceps was also known long Fig. 1046.-Ear of Rye with two Ergots. Natural size. (From Luerssen.) Fig. 1048.-Ergot in its Final Fruc- tifying Stage. (Luerssen.) 714 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Epulis. Ergot. before its connection with the others was made out, and described and named by several authors (e. g., Spharia, Cordiceps, etc.). The first botanist to follow the course of this plant through all its changes was M. Tulasne, who gave it its present name, and finally published his report upon it in the Annales des Sciences Naturelies for 1853. His in- vestigations were so thorough, and his illustrations so fine, that but little has been added to either so far as the botany of ergot is concerned. Habitat.-Claviceps purpurea is found in most tem- perate countries where the grains and grasses upon which it flourishes grow. It is, however, much less abundant in this country than in Europe, and there occurs most gen- erally in the warmer and moister countries. It is gath- ered in Central Europe, and especially in Spain and Cen- tral and Southern Russia. It is an incidental product of agriculture, and sorted out from the grain at the harvest with the double purpose of collecting the ergot and of re- moving its baneful influence from the grain. Ergot of wheat is occasionally saved ; it is shorter and thicker than that of rye, and medicinally equally good. History.-Ergot has long been known as a blight upon grain and as -a poison, but its medicinal history is comparatively modern. It appears to have been used by the peasantry, in some parts of Europe, in childbirth as much as three hundred years ago, and is mentioned by several authors of the sixteenth and seventeenth centuries in this connection ; but its formal introduction into mod- yellow oil, consisting chiefly of olein, with some palmitin and traces of glycerides of several common volatile, fatty acids. It has no therapeutic value, but is reported to be not without disagreeable action. It is recommended by Hager (as it is obtained in considerable quantity as a by- product of ergot preparations) for soaps and as a lubri- cant. A little cholesterin and resin, some mycose (sugar), several common acids, a fragrant camphoraceous sab- stance, etc., are ingredients,of no medicinal importance. In regard to the more active substances, scarcely any two chemists are agreed. Ergotin is a name given to various products, none of which are chemically pure. First, Bon jean's " Ergotin " is prepared by treating a watery ex- tract of ergot with alcohol, and evaporating the alcoholic solution to the consistency of a soft extract. It is a deep brown, strong-smelling, bitter substance, soluble in water and alcohol, of considerable activity and of frequent em- ployment, but not an active principle properly so called. Wigger's Ergotin is obtained by exhausting the ergot of wax, fat, etc., by means of ether, and then extract- ing with alcohol, evaporating the tincture, and washing with water. It is a sharp, bitter, reddish-brown powder, insoluble in water. Wenzell's ergotine (1864) is obtained by a more complicated process, and has more claim to the rank of a chemical compound. It is a brown, amorph- ous, bitter, alkaline substance, soluble in alcohol and water, but not in ether, and uniting with acids to form amorphous salts. Wenzell also separated another alka- loid, which he has named ecboline, resembling his ergot- ine in most respects ; on the other hand, other chemists assert that both Wenzell's two alkaloids are practically the same, and that neither is pure. Tanret has isolated a crystalline alkaloid, which he has named ergotinine, soluble in ether, alcohol, and chloroform, but not in water. Its solutions rapidly decompose, and its value is not yet proved. A still more recent and very thorough analysis of ergot was made a few years ago in the la- boratory of Dragendorff, with the result of separating the following, more or less well defined, amorphous sub- stances : 1. Sclerodic acid, a (yellowish-brown) hygro- scopic, faintly acid, tasteless powder, obtained to the ex- tent of from two to four per cent. 2. Scleromudn, a nearly related substance, two or three per cent. 3. Sclererythrin. 4. Sclerojodin, a coloring matter. 5. Scler- oxanthin. 6. Sclerocrystalling, etc. Of these the first two are now generally considered to represent, in part at least, the activity of the drug, but not to a degree of in- tensity proportionate to their percentage. Sclerotic acid is an article of commerce, but not much called for. The others, excepting Bonjean's ergotine, are scarcely known excepting to the chemists who have isolated them. Ergotic acid is a doubtful substance. "The most recent re- searches are those of Kobert, who states that ergot con- tains three active principles: ergotinic acid, sphacelinic acid, and an alkaloid, cornutine."-Brunton. The two latter are the most important. " What one regards as the only thing valuable, another rejects as useless ; and what a third has found unfit to use, a fourth considers the very quintessence. "-Hager. Action and Use.-For an article whose sphere of use- fulness is so well defined as that of ergot, its physiolog- ical action has been the subject of much controversy and uncertainty ; even at present there is scarcely any view of it which is accepted by all experimenters. There are several circumstances which have made its study pe- culiarly difficult. In the first place, the drug itself is very variable, even when fresh and living; and. prob- ably, although this is not proven, varies in the quality of its action, as well as in its intensity or strength. The two types of epidemics attributed to chronic ergotism suggest, although they do not establish, this difference. Secondly, the preparations which have been used in studying its action, excepting possibly the very latest, are not definite active principles, but only more or less puri- fied and concentrated extracts. Of course, they partake of all the uncertainty of the crude ergot, and have added the chance of change produced by the manipulations used in their manufacture. In the third place, both ergot and all its preparations and " principles " deteriorate rapidly Fig. 1049.-Details of Fig. 1048. (Luerssen.) ern medicine is due to the efforts of Dr. Stearns, of New York, in the early part of the present century. Description.-The above described " sclerotiums, " which constitute Ergot, are slightly curved, elongated, obscurely three-angled, subcylindrical, or fusiform bod- ies, with a furrowed or rough, brownish or purplish- black surface, and a brittle, grayish-white interior. They are usually from one to three centimetres in length, and from twenty-five to forty millimetres in transverse dimen- sion (| to 1 inch long by 1 inch broad), but vary con- siderably, and may exceed these limits in both directions ; that is, be either smaller or larger. The ends are usually tapering and rounded ; occasionally the apex bears re- mains of the shrivelled mycelium; very rarely some trace of the flower of the rye may be found upon it, but generally these appendages, if they had not already dis- appeared in the growth of the ergot, become rubbed or broken off in harvesting and handling it. Ergot has a peculiar heavy, sourish smell, and an oily, dis- agreeable taste. It moulds and spoils rather easily, and should be kept fresh and dry ; that which is more than a year old should be thrown away. It should not be broken or ground until needed for use. Microscopically it con- sists of closely entwined, elongated, thick-walled cells containing an abundance of oil-drops. Composition.-Ergot has been repeatedly examined within the past half century, with the result of exhibit- ing a more and more complex composition with each suc- cessive investigation ; but its active principle, if indeed there be any one substance entitled to the name, is still in doubt. One of its most abundant constituents is a fat, of which it contains from one-fourth to nearly one-third of its weight. This is a thick, bland, non-drying, light 715 Ergot. Erynghim. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with time (although this even has been contradicted). And finally, the experiments upon it have been conducted at different times during the past half century, by a great many investigators, with almost as many different prep- arations ("Ergotins" of several kinds-ecboline, ergo- tinine, ergotic, ergotinic, and sclerotic acids, etc.), with- out always making it clear what, or how fresh, the par- ticular one used was. As most, at least of the older experiments and observations, were either made with ergot itself, or with some extract supposed to represent all its qualities, the following resume is predicated as the action of "ergot In frogs, large doses produce com- plete paralysis, beginning at the posterior extremities and extending forward, without much disturbance of cardiac or respiratory action. Only in dangerous and fatal quan- tities does it gradually retard and weaken the pulsations ; recovery is very slow, and a fatal relapse is common (Nothnagel). After death the heart is found in diastatic arrest, and is insusceptible to stimuli (Eberty). In warm- blooded animals it is capable of producing anaesthesia, disturbance of co-ordination, and paralysis, with, as later symptoms, coldness of the surface, dilatation of the pupils, weakness of heart action and respiration, con- vulsions, and death. Salivation, vomiting, diarrhoea (sometimes constipation), and many other symptoms, are also recorded as more or less occasional. The above-de- scribed phenomena of ergot poisoning are pretty well established, but the explanation of them is involved in uncertainty. Its action on particular organs is a subject upon which there is much contradiction as well of facts as of theories. The following are the most important particulars: It is generally conceded that it has no action upon the red muscular system, but little upon the periph- eral motor nerves, or upon the sensory ones, unless di- rectly applied to them. The paralysis which it produces is, therefore, of central origin. The respiration is but little affected, excepting by large doses, when it is di- minished, and by fatal ones, when its failure is the im- mediate cause of death. The heart also is not much dis- turbed by small doses ; by large ones it is weakened, especially if directed into a vein, or otherwise applied di- rectly to it. The blood-vessels in general are contracted by ergot, and their calibre is notably reduced. This has been repeatedly confirmed by a large number of observers.* The arterial pressure is increased after moderate quan- tities, excepting when the ergot is injected into a vein, when it is temporarily lowered. The unstriped muscu- lar tissue of the uterus is contracted, especially if preg- nant. If during the period of labor, this action takes place in a still higher degree. The intestines are said to have their peristalsis much increased by ergot. Chronic ergot poisoning, as it may be called, or ergot- ism, has been more common than that occasioned by pharmaceutical preparations. This occurs as the result of eating food made from grain containing a large quan- tity of ergot, and has prevailed in distressing epidemics at various times in the history of Europe, from the be- ginning of the Christian era. It has, at present, become happily rare, owing to the recognition and removal of its cause by better cultivation, and the more careful separa- tion of the fungus from the grain in harvesting ; but smaller outbreaks of it are now and then reported. There appear to be two forms of the disease in which, re- spectively, gangrene of the extremities and convulsions are the principal symptoms. In the first, nausea, giddi- ness, listlessness, itching of the hands and feet, Coldness and weakness, are followed by dry gangrene of the nose, or of one or more of the extremities, exactly like that of old men with atheromatous arteries ; gradual extension of the gangrenous spots, exhaustion, and death follow. In the spasmodic form, numbness, anaesthesia, formica- tion, gastro-intestinal disturbance (colic, vomiting, diar- rhoea, etc.), are accompanied by violent tetanic convul- sions, and various disturbances of vision, consciousness, and reason. In both cases pregnant women abort, and nursing ones lose their milk. Menstruation is also sup- pressed. If death does not follow, recovery is often slow or incomplete-epilepsy, mental disability, blindness, and loss of extremities may remain as evidences of the scourge. Both classes of symptoms are said to be some- times present in the same cases. Domestic cattle appear to be susceptible to ergot poisoning, as epidemics of loss of calves in cows have been traced, even in this country, to ergotized grains. Ergot, however, in single or few doses, is but very slightly poisonous to warm-blooded animals and man, very large quantities (more than two drachms to the pound in dogs, for instance) being required to cause death. The usual medicinal doses, and even up to twenty or thirty grams of the fluid extract, do not generally give rise to any urgent symptoms in non-pregnant women or in men. Wood (l)isp.) reports having given "three ounces of the fluid extract daily for one or more weeks, without perceiving any marked effect." It is to be ques- tioned whether his preparation was not at fault. A large portion of the fluid extract in common use a few years ago was of very poor quality. In the very few cases where acute ergot poisoning has been observed from me- dicinal preparations, decided prostration, weakness of pulse, coldness of the surface, with more or less paraly- sis, tingling or burning of the extremities, and convul- sions-in short, the symptoms given as the action of the drug upon warm-blooded animals in general-have been observed. The greatest value of ergot in therapeutics depends upon its action upon the uterus, and especially upon that organ in the course of labor-when it seems to be espe- cially sensitive to it. Small doses, from one to two grams, if of good quality, intensify and prolong the natural con- tractions or arouse them when temporarily quiescent. Larger ones (from two to six grams) not only intensify the natural pains, but also stimulate the organ to a tonic tetanoid state of intense compression of its contents. In it the accoucheur has a powerful addition to the mechan- ical process of labor, which only has to be directed aright to be of very great assistance in certain conditions ; but its action, although brilliant when appropriate, is not so gen- erally needed as at first would be supposed. In the first place, most cases do not need any assistance whatever, the pains being better adapted to their purpose than any modi- fication of them that we can make is. If there is a delay in the labor due to obstruction, malposition, rigidity of the os or of other soft parts, etc., relief is to be effected in some other way than by the use of ergot. If the womb and the patient have become exhausted by prolonged trav- ail, stimulants, and especially quinine, should be given in- stead of or in addition to the present article. Early in the labor it should never be used, as by its continuous pressure it is liable to suffocate the child by suppressing the placental circulation. Even if given half or three-quarters of an hour before the final delivery, the child is often difficult to re- suscitate. The proper time and place for it is when at the last end of labor, after the os has become fully dilated and the head of the child has reached the lower outlet pf the pelvis, the pains grow more infrequent instead of more frequent, and finally stop or threaten to do so, or if fre- quent enough they become short and trifling, and the patient is nervous and impatient without being exhausted. Then the medicine accomplishes the double duty of putting an end to the labor and of diminishing the danger of post- partum haemorrhage, to which this class of cases is prone. The pains revive in frequency, intensity, and length, the woman takes courage, feeling that her relief is near, and adds her voluntary efforts to the action of the ergot, and the child, which might have lain for hours in the pelvis, is rapidly expelled. The same result could easily have been obtained by the forceps, but the ergot insures the after-contraction of the womb which the others would not have done. A combination of the medicine and instruments is probably the most common way of meet- ing such cases. Many obstetricians have the habit of al- ways administering a dose of ergot, at or just before the close of labor, to contract the uterus after birth, assist in expelling the placenta, and reduce the risk of flooding. * Nothnagel, however, asserts that only the vessels of the bowel and of the uterus are contracted ; that its value in hsemoptysis is due to its low- ering the general arterial pressure, and in intestinal and uterine haemor- rhage to the anaemia of these organs which it produces. 716 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ergot. Eryngium. While it appears to be a harmless procedure excepting as it increases the after-pains for a while, it is generally unnecessary. In flooding, however, in addition to other more immediate applications, it should always be given subcutaneously if the means be at hand, otherwise by the mouth. In prolonged subinvolution, in uterine hyper- plasia, in profuse menstruation, in assisting unavoidable abortions, etc., it is also indicated. Ergot, and especially subcutaneous injections of Bonjean's " ergotin," have been strongly recommended in the treatment of uterine fibroids, and are undoubtedly the best medicinal agents for the purpose-which is saying but little. A few instances of cure are reported, a good many Of more or less marked relief, and numerous ones of failure. It is but fair to the patient in suitable cases to give it a trial. The subcutane- ous method has the disadvantage that it is very irritating; considerable pain follows the injections, and local inflam- mation and even suppuration are not infrequent, A com- bination of medical and surgical treatment is usually ne- cessary, unless the tumors are so situated that their strangulation by uterine compression is very easy. Ergot is also to be recommended in all forms of capil- lary haemorrhages, epistaxis, haemoptysis, haematemesis, purpuras, etc., as, from its power of reducing the size of the minute vessels, one of the most efficient remedies in our hands. It is also useful on the same account in the colliquative sweating of wasting diseases, and perhaps in chronic diarrhoea and dysentery, and in hyperaemia of the brain and cord. Besides these, it has been employed in many other diseases-aneurisms, tumors, neuralgias, etc., with less certain advantage. Administration.-The old and simple method of using an extemporaneous infusion from freshly-powdered ergot is not a bad one. In fact, the dose in which the ergot itself is regarded as efficient in labor is smaller than the proportionate ones of any of the preparations now in use (0.3 to 1 Gm. Hager = Gr. v. ad xv.; Maximum dose, 1 Gm., maximum daily quantity, 5 Gm., Ph. G.; 20-30 gr., Brit. Pharm.). It is not a difficult medicine to take, and a return to using it in substance might make it- more certain in its action. The preparation in most gen- eral demand in this country, and, if carefully made, without doubt the most uniform and best, is the Fluid Extract (Extractum Ergotre Fluidum, U. S. Ph., extracted with a dilute alcohol, and slightly acidified, theoretical strength |). From three to six grams will be required for any prompt result; for continuous use, from two to four may be taken several times a day. (If no effect is pro- duced in labor within twenty minutes by a dose of four or five grams = a teaspoonful, the stock should be thrown away as useless). Wine of Ergot (Vinum Ergots, U. S. Ph., strength, ; menstruum sherry wine) is passing by. Extract of Ergot (Extractum Ergot®, U. S. Ph.) is macle by evaporating the fluid extract to one-fifth ; it is useful for suppositories, pills, etc., and subcutaneous injections, when diluted. Bonjean's "Ergotin," a watery extract evaporated to a syrupy consistency, mixed then with spirit, filtered, and finally evaporated again to a pill mass, has been extensively used, especially for hypodermic ad- ministration, but has no real advantage, even for this, over a diluted and carefully-filtered U. S. Ph. extract; both are painful and liable to cause local inflammations. The yield is said to be from fourteen to eighteen per cent, of the ergot used ; the dose should be, theoretically, about one-sixth that of the powdered drug; but twice this pro- portion is usually given, if by mouth (0.2 to 0.6 Gm. = gr. iij. ad x.). Of the active principles the following doses are mentioned, but they are uncertain, and very little used. Sclerotic acid, 0.05 to 0.3 Gm. = gr. i. ad v. (Nothnagel); Tanret's Ergotinine (crystallized), 0.005Gm., subcutaneously (Dispensatory). Suppositories and other local applications of ergot have not proved to be especially useful. Hypodermic injec- tions are said to give less trouble, if made deep. Allied Plants.-The same species growing upon wheat (Ergot of Wheat), which is shorter and thicker, and upon the oat (Ergot of Oat), which is more slender, and a very large ergot from an African species of Arundo, have been collected and used ; the two former are proba- bly occasional in commercial ergot. All have similar properties, but are said to vary in strength. The other species of Claciceps have no particular medical interest. Ustilago maidis, Corn Smut, has composition and proper- ties resembling ergot. Of other cryptogams the proper- ties are most variable, as the following examples of a few of those'used in medicine will show. Lammaria digitata Lam. The dried and prepared stems are " Sea Tangle Tents." Chondrus crispus Linn. " Irish Moss." Gigartina spinosa, etc. Agar Agar. Cetraria islandica Ach. " Iceland Moss." Agaricus campestris, etc. Linn. Mushrooms and Toad- stools (see edible and poisonous mushrooms). Polyporus igniarius Fr. " Spunk." Polyporus officinalis Fr. Purging Agaric. Sphagnum (various species), used as a surgical dressing. Aspidium, Filix mas. Sw. Male Fern, etc. Allied Drugs, etc.-There isno other medicine which has exactly such an action upon the pains of labor as Er- got, unless the Corn Smut be one. But certain forms of stimulation, in suitable cases, may accomplish the same results. Quinine in full doses (0.6 to 1 Gm. = gr. x. ad xv.), manipulating the womb through the abdom- inal walls, pressing the breasts, dilating the os, heat, etc., are all useful. The various emmenagogues have little value in this respect. In post-partum haemorrhage the other means used are mostly mechanical: pressure, hot or cold douches, ice, removal of clots, etc., titillation of the inner surface of the uterus, catheterization, etc., or styptics, injections of solutions of tannin, perchloride of iron, etc. For the collapse of haemorrhage nothing be- sides alcohol is so useful as opium in large doses (forty to eighty drops, say of laudanum). In haemoptysis ergot is assisted or substituted by mineral and vegetable astrin- gents (chloride of iron, gallic acid, etc.), rest, cold, and salt; in intestinal haemorrhage, by the same means and turpen tine ; in night sweats by belladonna, mineral acids, etc. ; in the treatment of subinvolution and of fibroids of the uterus, there is no other drug of specific value. A great many substances, mostly of local reputation and very little value, are styled emmenagogues, from a supposed power of stimulation of the uterus to menstru ation. Ergot is sometimes classed among them, but it is doubtful if any medicine is entitled to such a name. Tonics, stimulants, astringents, cathartics (especially aloes), iron, arsenic, electricity, local irritants, sitz-baths, are all at times useful indirectly by correcting some con- dition of which the amenorrhoea is one of the symptoms. Among those sometimes considered specific emmena- gogues, the following are a few : Cotton Root, Rue San- guinaria, Senega, Apiol, Tansy, Pulsatilla ; but they are but little used. W. P. Bolles. ERKENBRECKER'S SALT WELL. Location and Post- office, Ludlow Grove, Hamilton County, O., about six miles from Cincinnati. Analysis (E. S. Wayne).-One pint contains: Grains. Carbonate of magnesia 1.758 Carbonate of lime 0.792 Chloride of sodium 537.512 Chloride of calcium , 98.326 Chloride of iron 6.683 Chloride of magnesium 67.755 Sulphate of lime 0.759 Bromide of sodium 3.526 Silica 0.152 This well, two hundred and seventy-two feet deep, was undertaken with the view of supplying fresh water to the workmen in a large manufactory. The proportion of so- dium chloride renders the water a very strong brine, from which common salt might be obtained in remuner- ative quantities. The proprietor employs the water for private baths. George B. Fowler. 717.263 ERYNGIUM CAMPESTRE Linn.; Order, Umbellifera (Chardon Roland [Panigaut], Codex Med.). This plant, as well as one or two other species of Eryngium (E. mari- 717 Eryngiiiin. Erysipelas. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. timum, Bauh, of Europe, and E. aquaticum Linn., of the United States), furnishes roots that have been formerly used as tonics, diaphoretics, etc., or for reducing the se- cretion of milk. There is no occasion for giving them further notice ; they are only mentioned because the one at the head of this article is not yet omitted from the French Pharmacopoeia. IF. P. Bolles. fatally from the continuous febrile condition, and conse- quent increasing exhaustion. In other cases the disease assumes a chronic form, and either continues for a long time without interruption or makes frequent relapses, which sometimes recur with a distinct periodicity, as at certain seasons of the year, or accompanying certain climatic or other local or telluric conditions, when it generally runs a limited course, and again subsides, to return at the next period, and pursue the same course anew. Erysipelas may also, occur during the existence of other acute systemic diseases, such as the various forms of fever, and in these cases, also, the infection of the system with erysipelas occurs from an injury to the skin or mu- cous membrane. It is sometimes observed in the form of an epidemic, in which it somewhat resembles diphtheria in the manner of its dissemination and the virulence of its course. It is probable that sudden changes in temperature often have much to do with the dissemination and severity of the disease. Erysipelas also occurs in hospitals, where it is due, to a great extent, to lack of cleanliness and to overcrowding. Since the advent of aseptic surgery and the antiseptic treatment of wounds, together with the recent improve- ments in hospital construction and management, the fre- quency of erysipelas as a complication in other diseases has been greatly reduced and its severity mitigated. It now prevails only in large and crowded establishments, such as military hospitals, or in those institutions in which the evils mentioned as formerly existing have not yet been fully removed. The occurrence of erysipelas at the pres- ent time as an epidemic, or in the hospital treatment of wounds, can only be regarded as a reproach upon the management of such cases, and is wholly unjustifiable in the existing state of surgical science. It is no longer to be regarded as a misfortune-it is a crime. The course of hospital erysipelas is quite irregular ; at times it is confined to a single bed, or to a certain part of gome particular ward, and is then often due to imperfect sanitary arrangements, and subsides when the hygienic defects have been remedied. Erysipelas is communicable from man to the lower ani- mals, and vice versa. It also readily passes from one hu- man being to another. Its power of contagion seems to be feeble in comparison to that of some other of the com- municable diseases, and very simple measures, such as bathing and the observance of the ordinary precautions of surgical practice, with scrupulous cleanliness of hands and instruments, are quite sufficient to afford perfect im- munity from its ravages. The principal pathological conditions produced by ery- sipelas are found in the spleen, kidneys, liver, the muscu- lar tissue of the heart, in acute oedema of the brain, etc., and seem to indicate grave changes in the composition of the morphological elements of the blood. The characteristic features of erysipelas upon the skin disappear immediately after death, and the pathology of the cutaneous process is quite obscure. The local clinical changes due to erysipelas are in no perceptible manner different from those due to a non-infectious dermatitis, such as is produced by a super- ficial burn ; and from the integumentary features alone it is impossible to determine the specific nature of the pro- cess. There is found, however, in the tissues and fluids, in the blood, and in the lymph canals, as well as in the contents of the erysipelatous vesicles, a distinct form of bacterium (coccus). These organisms seem to be the bearers of the specific virus of the disease, and its spread and severity appear to depend in a great measure upon the degree of rapidity with which the bacterial germs are developed, and the ease with which the surrounding tis- sues are invaded by them. Course and Symptoms.-As erysipelas requires an eroded or denuded surface for gaining entrance into the system, it follows that those persons who are subjects of recent or open wounds are most exposed to infection from this disease. It is under such conditions, and upon such patients, that the phenomena attending the development ERYSIPELAS (Fr., Erysipele; Germ., RothlaufY By the term erysipelas is understood a peculiar form of in- flammation of the skin or mucous membrane, which is characterized, when situated upon the skin, by a sharply defined area of redness, which gradually advances to a larger surface, and is accompanied by relatively very in- tense febrile action, and which generally terminates in complete recovery, with exfoliation of the epidermis upon the surface which was the seat of the disease. The diagnostic marks of erysipelas are generally so typically pronounced that there is little chance for an error in diagnosis in this affection, and they are properly regarded as a specific clinical group of symptoms. Erysipelas takes its origin in all cases in some injury of the skin or mucous membrane. This may vary from a deep gaping wound to the smallest cut, scratch, or prick of a pin. In certain cases it would seem that the absence of epidermis or epithelium is in itself sufficient to allow the entrance of the poison of erysipelas into the system. In this direction the occurrence of erysipelas in young and imperfect cicatrices from recent injuries is interest- ing, as the immature cicatricial covering appears to allow the virus of the disease to pass through the tissue, when no lesion of continuity of the surface can be discovered. In this respect erysipelas resembles certain cases of hospital gangrene, in which the uninjured thin surface of a recent cicatrix is the point of invasion of the disease. The mode of entrance of the virus of erysipelas can generally be found if sought in the early stages of the disease; but a small erosion or superficial scratch may be entirely healed before the symptoms of erysipelas have become prominently developed. The origin of erysipelas upon surfaces covered with mucous membrane is not so easily determined. In the eyes, mouth, and nose it may be often impossible to dis- cover the wound through which entrance to the system was effected, as these mucous surfaces are extensively reflected, or are concealed to a great extent from view. Erysipelas is a frequent accident after confinement and during the puerperium, at which time the great ex- tent of eroded surface within the uterus, together with the liability to lacerations and other injuries of the ma- ternal passages, afford an easy road to infection. The subjects of erysipelas of the mucous surfaces, other than those of the genital tract, are usually persons already weak and sick from other causes, and they frequently, if not invariably, present a history of long-continued ante- cedent mucous or purulent discharges from the same sur- faces. The lymphatic glands of these persons are often found in a state of chronic induration, and these patients usually present the features of the so-called "scrofulous diath- esis." Erysipelas follows certain conditions of the skin in its spread. It is not often found upon the chin, nor upon the skin over the crest of the ilium. Those portions of the body over which the skin is tightly drawn, or in which it is closely bound to the subjacent structures, are not usually invaded by erysipelas. The scalp is a frequent seat of the disease, from which location it may pass downward to the back of the neck, and thence to the skin of the chest and back. The neck, however, is rarely the pri- mary seat of erysipelas. The necessity of a wounded surface for infection con- stitutes a marked characteristic of erysipelas, in distinc- tion from the other febrile affections which are accom- panied by exanthematic eruptions. Another no less striking feature is the fact that ery- sipelas shows a decided tendency to relapse in the spot originally affected, or in other parts of the body, so that the disease sometimes lasts for months and may result 718 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eryngium. Erysipelas. of erysipelas are best studied, and its course and symp- toms most easily observed. The clinical picture which is then presented is substantially as follows : In persons who are free from fever from any other cause, the ad- vent of erysipelas is usually announced by the occurrence of an initial chill of a more or less pronounced character. This may consist at times only of a feeling of chilliness, which may quickly subside, or the chill may take the form of a severe and prolonged rigor, with shivering, chattering of the teeth, and sometimes the symptoms of threatened collapse, from which the patient can be with difficulty restored. The chill is frequently accompanied by an acceleration of the pulse, and there are usually the symptoms of profound disturbance of the general sys- tem. The chill is quickly followed by a rapid elevation of the temperature, which may reach the most alarming figures. The patient is generally delirious, the skin hot and dry, the tongue and lips parched, and all the signs of a serious disturbance of the vital powers of the system are present. Soon the local signs of the erysipelatous in- flammation begin to show themselves at the seat of inva- sion of the disease, as above indicated. In persons who are already in a febrile condition from some other cause the constitutional symptoms of the in- vasion of erysipelas may be more or less marked, or they may not become noticeable. Thus, there may be no in- itial chill, the constitutional disturbance may be very slight, the temperature and pulse may not be so affected as to attract attention, and the local condition may not excite apprehension. Under these conditions the advent of erysipelas may not be suspected until the swelling and other characteristics of the local lesion have become well established. At other times the onset of erysipelas is accompanied by vomiting, with or without a more or less distinct chill. Under these circumstances, the disease is usually quite unsuspected until the local manifestations are distinctly developed and the disease has already commenced to spread. Soon after the initial symptoms of erysipelas a red spot appears upon the skin or mucous membrane, more or less raised above the surrounding surface, with a sharply defined, often irregular or zigzag border, which gradually becomes larger by extension of one or more of its boun- daries, and thus encroaches more and more upon the healthy skin, from which it is always clearly to be dis- tinguished by its slightly raised surface, its color, and es- pecially by its sharply-marked contour. The redness of the diseased surface may be more or less vivid in inten- sity, but it usually disappears on pressure by the finger, and a temporary depression of the skin is usually formed by the displacement of a certain amount of serous infil- tration or oedema in the parts beneath. The redness soon extends rapidly but irregularly, and follows especially those directions in which the skin is loose. The lymphatic glands of the affected region soon be- come swollen and indurated, and are generally painful on pressure, and the lymphatic channels of the part are seen as raised lines of a red color, extending from the seat of the disease to the swollen glands. The erysipelatous process generally advances from its original seat to other parts of the limb or the body, and has been therefore called " erysipelas migrans." In some cases the disease is of so intense a nature that the epider- mis becomes separated from the rete mucosum by the ef- fusion of fluid, and large blebs are formed containing a fluid which is often clear and transparent, but at times is of a red, or even of a purple, color. This variety of the disease is called "erysipelas bullosum." If the oedema and infiltration is so extensive as to cause pressure upon the blood-vessels of the part, the circulation may be more or less impeded or entirely suspended in the immediate vicinity or in remoter parts supplied by these chan- nels, and portions of the skin or deeper structures may slough and be cast off. The necrosis of tissue may at times bei so extensive as to cause death from interference in the functions of vital parts or from exhaustion. These features constitute that form of the disease which has been called " erysipelas gangrenosum." The constitutional symptoms of erysipelas are gener- ally of a severe character. The tongue is heavily coated, and is often dry and cracked, the sense of taste is viti- ated, delirium frequently supervenes, and is frequently followed by coma, which may last until the fatal issue. In a large majority of cases the disease follows a mild course. The fever, though intense during the period of invasion, becomes reduced, the tongue may be heavily coated, but remains moist, the pulse may be full and strong, and the heart's action not seriously deranged. The erysipelatous inflammation may be confined to a lim - ited area, and after a moderate extension from the point of infection may subside, and after a few days entirely disappear, when the parts return to the normal condition by gradual diminution of the inflammatory process, and subsequent desquamation of the epidermis over the sur- face occupied by the disease. Erysipelas may result fatally in three ways : 1. From the primary intensity of the disease, in which the patient sinks rapidly during the early course of the disorder, as from shock ; or 2, from exhaustion induced by the con- tinued spread of the inflammatory process, and the inten- sity of the febrile reaction ; and finally, 3, from its occur- rence as a complication of other serious diseases, or from the fact that the poison of erysipelas seems to render the system more vulnerable to various acute disorders which thus appear as sequelae of the erysipelatous affection. Certain individuals exhibit a marked predisposition to erysipelas, and in these persons the disease may assume a serious aspect even when the constitution of the patient is not otherwise impaired ; though this is more generally associated with advanced age or a debilitated condition of the system in the person attacked, or in the presence of some other acute or chronic disease. Erysipelas sometimes shows a marked tendency to re- lapse in the same individual, and in this way produces increasing exhaustion of the vital powers and hastens a fatal termination. In this condition an extension of the erysipelatous inflammation to neighboring synovial and serous cavities is sometimes observed, which materially depreciates the chances of recovery in cases otherwise hopeful. Occasionally the symptoms of septicaemia are developed, and are usually of fatal import. During convalescence from erysipelas the patient is liable to certain intercurrent affections ; particularly to pneumonia ; and is often also the subject of bed-sores (decubitus), which may become extensive, and quickly exhaust the vitality ; or death may result from septic infection from the sloughing tissues. In a certain num- ber of cases there is a tendency to the formation of ab- scesses after erysipelas, which, however, do not usually threaten the life of the individual. Certain forms of infectious disease during the puerperal condition have been considered to be of erysipelatous character, the disease being introduced by means of the placental surface within the uterine cavity, or by lacera- tions or other wounds of the vagina or perinaeum. The infectious material is supposed to be conveyed thither by the unclean fingers or instruments of the accoucheur or nurse. The general character of the symptoms in this condition is that of acute septicaemia, and when there are appreciable local lesions they are usually covered by a grayish coating which presents the appearance of a diph- theritic exudation. The pathology of this class of affec- tions cannot at present be considered as definitely settled. It is a curious fact that acute erysipelas sometimes ex- erts a curative influence upon certain pathological forma- tions, particularly glandular carcinomata. This effect is supposed to be due to a change in the nutrition of the cancerous cells, or to a direct destructive influence upon the elements of the foreign growth by the micrococci of erysipelas. This ingenious theory needs the support of more extensive observation for its entire confirmation. At the present time it would hardly be thought judicious to employ so serious a measure as the voluntary infection of the system of a human being with the virus of ery- sipelas for a doubtful therapeutical purpose in the treat- ment of disease. In like manner, the effusion of fluid within the thorax, 719 Erysipelas. Erythema. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. following an acute attack of pleurisy has been observed to rapidly diminish, and at times to undergo complete ab- sorption as a sequence of an invasion of the skin of the chest and trunk by erysipelas ; though it would not be possible to say that the erysipelatous process has any di- rect influence upon the fluid contained within the chest, nor is it easy to determine how the course of the pleuritic disease can be influenced by the local phenomena attend- ing the march of the erysipelatous inflammation over the surface of the body. Treatment.-The treatment of erysipelas is chiefly to be directed to the complete isolation of the patient from all other sick persons, and the employment of all possible means for the establishment of sanitary condi- tions about the patient. This includes scrupulous clean- liness, pure air, water, sunshine, and the rigid antiseptic treatment of existing wounds or other lesions. The local symptoms may be treated according to the varying requirements of the case ; as by tincture of iodine, which may be applied to the healthy skin at the borders of the erysipelatous process, and sometimes seems to check its progress. The application of strong solutions of nitrate of silver, of turpentine, the subcutaneous injection of a three per cent, solution of carbolic acid, etc., have been advocated, and are doubtless occasionally of benefit. Recently the various surgical antiseptic solutions have been considerably employed in the local treatment of the cutaneous manifestations of erysipelas. In a recent case much benefit was derived from the application of a solu- tion of mercuric bichloride of the strength of 1 to 500. Painting the diseased surface with contractile collodion is also sometimes followed by complete arrest of the dis- ease. When sloughing or gangrene occurs, the case must be treated according to general surgical principles, i.e., by free incisions, drainage, etc. In the puerperal condi- tions which were mentioned above, the treatment adapted to other similar septic disorders of the genital tract would be most imperatively indicated. These consist of local disinfection by antiseptic irrigation of the genital canal, or by other appropriate measures, the administration of large doses of quinine, of stimulants, opium, etc., and the speedy removal of any sloughing portions of placental or other tissue in or about this region. The application of cold has also been found of service in many cases of erysipelas, both in the reduction of temperature locally, as well as the amelioration of the general symptoms, and at times the diseased action has appeared to be definitely controlled and permanently benefited by this means. Cool baths may be employed with the result of dimin- ishing the general temperature of the body, and the in- ternal administration of the salicylates has sometimes been of service in the same direction. The general treat- ment must naturally be directed by the special condition of the patient in each case. Should general erysipelas occur as a sequel to confinement, the disease is usually of very grave character, and is almost inevitably fatal. The measures to be employed in its treatment are in a general way those by which the pyrexia may be modified, and the strength maintained, in the hope that the powers of the system may be able to eliminate the morbid process. Local treatment may be instituted for the purpose of pre- venting decomposition in the genital canal, and for the treatment of existing lesions in these parts, but its effect on the systemic disease is frequently overrated, and cases of this disease usually result fatally. From what has gone before it is evident that the treat- ment of erysipelas should be directed principally toward the isolation of the disease, especial care being given to the removal of all means of infection of patients with wounds or external injuries of any kind. In few dis- eases is prophylaxis more properly advocated than in erysipelas, and in none, perhaps, is transmission of infec- tion by means of unclean instruments or careless attend- ants more clearly traceable and more thoroughly prevent- able. Cases of this disease should be visited after the surgeon has seen all other patients, and the hands and instruments should be thoroughly cleansed and disinfected afterward. The linen, clothing, bandages, etc., of erysipelatous pa- tients should not be mixed with those of other patients, but should be carefully disinfected by means of immer- sion in a solution of corrosive sublimate, chloride of zinc, or by other suitable means, and washed separately. The patient should not be considered safe from a recurrence of the disease, nor should the precautions against infec- tion of other persons be relaxed until the disease lias en- tirely disappeared from every portion of the body which was at any time invaded ; and the danger of a relapse or of communicating the disease to others is not entirely absent until the process of desquamation of the epidermis in the regions affected by the erysipelatous inflammation has been completed. When the skin has fully returned to its normal condition, it is advisable that the entire sur- face of the body should be carefully bathed in warm water, made alkaline by means of sodium bicarbonate, and perceptibly impregnated with carbolic acid. A com- plete attire of fresh and uninfected clothing should re- place the clothes previously worn. The patient may then be allowed to go at large. One of the remoter dangers associated, with erysipelas, which, however, is not of frequent occurrence, is an in- terference with the function of the kidneys. This com- plication may assume a variety of forms, and its presence as a complication of the erysipelatous process is of suffi- ciently grave importance to make the daily examination of the urine advisable. The renal condition often seems due not so much to the specific character of the erysipela- tous infection, but rather to the septic processes which accompany the graver forms of the disease. Should this or any other unusual complication arise in the course of erysipelas, the same rules should be observed and the same measures adopted as in other cases of similar dis- turbance of these important organs. The strength of the patient should be carefully husbanded, and tonic meas- ures should be cautiously employed to support the sys- tem until the natural vigor may be re-established. For this purpose the diet should be carefully selected, and should consist of nutritious but unstimulating food, with the addition of some of the artificial digestive ferments if the functional ability of the alimentary organs has been seriously impaired. A very excellent addition to the or- dinary diet of a weak and debilitated patient is the ex- tract of malt in some of its more acceptable forms. Per- haps the best preparation, at present, for this purpose is that known as "Arne," or the Japanese extract of rice. It is of pleasant taste and possesses great nutritive power. To overcome the debility often remaining after a pro- longed attack of erysipelas, a change of scene and climate is often of great service. The excessive indulgence in stimulants, or the undue exhaustion of the system from any cause, should be sedulously avoided, and the patient should be instructed to take measures for securing ample time for sleep. Excessive fatigue or prolonged bodily exertion should be prohibited, and the patient should be directed to pass a portion of each afternoon in a reclining posture, and if possible to obtain an hour's sleep in the middle of the day. In cases in which the attack of ery- sipelas is followed by the formation of abscesses, a so- journ at some of the watering-places, particularly at one of those whose waters are of an alterative and chalybeate character, is often of much benefit. Albert N. Blodgett. ERYTHEMA. By the term erythema is understood a circumscribed or diffuse redness of the skin, or of the vis- ible portions of the mucous membranes, dependent upon hyperaemia of an acute character. The disease-process may or may not be accompanied by exudation, but even when exudation takes place the disturbance in the nu- trition or regeneration of the affected tissues is insignifi- cant. There are two varieties of erythema: E. hyperamicum, in which there is nothing more than redness, and E exsu- dativum, in which there is redness with exudation. Erythema Hyper^micum includes a number of mild forms of erythema, which are in themselves insignificant, but which are apt to be taken for much more serious af- 720 DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Erysipelas. Erytliema. ness ceases abruptly at the articulation of the first and second phalanges. In addition to the points of predilec- tion, this form of erythema may occur, though rarely, upon the face, or upon the extremities ; now and then the genitalia alone are involved. In extremely rare instances it may be generalized over the entire surface. The prodromal erythema of small-pox, which is oc- casionally accompanied by itching, usually appears on the second or third day of the disease. Its color darkens and rapidly changes to a brownish tint, beginning to dis- appear in about twenty-four hours-which it does with- out desquamation. It precedes the pustular eruption by about one day, and continues from one to two days after the appearance of the latter. A secondary erythema of small-pox occurs during the period of suppuration and desiccation, but this is without the importance of the pro- dromal rash. Erythema, raccinium, erythema medicamentosum, and erythema traumaticum may be classed together as due to foreign material of one sort or another circulating in the blood. The first will be found described under the head of Vaccinia, the second under Dermatitis Medica- mentosum. Under the third head are to be included cases of puerperal and pyaemic "scarlatina," as well as the various rashes observed after wounds, injuries, poi- soning by coal gas, etc. Erythema Exsudativum.-The exudative erythemata, in contrast to the hyperaemic erythemata, comprise those forms of the disease which tend to inflammation, or at least to show the exudation of inflammatory action. While on the one hand they are thus separated from the merely hypersemic erythemata, they are, on the other hand, connected with these by the fact that the two forms are occasionally found running into one another. More commonly, however, they differ markedly in clinical aspect and course. Two varieties are known : E. multiforme and E. nodosum. Erythema multiforme comprises a number of exudative diseased processes which resemble each other chiefly in possessing, as the typical lesion, brick-red or brownish-red, flat papules with a peculiar, highly characteristic, dusky mulberry tint. These may be of various sizes, from that of a large pin-head to that of a finger-nail, and may be scattered or closely grouped. They are often surrounded by a fugacious areola. Most commonly the eruption oc- curs upon the backs of the hands and wrists, and upon the upper surface of the feet and front of the ankles. This localization is a marked diagnostic feature of the disease, and in connection with the peculiar tint makes it, when occurring in these localities, almost unmistakable. Less frequently the eruption occurs upon the palms, arms, or face ; and still less frequently in other parts of the body. In well-marked cases the eruption may invade the visible mucous surfaces, as the mouth and the female genitalia. When it occurs in these localities, particularly in the former, it may lead to the eruption being thought syph- ilitic, In addition, however, to the diagnostic points given above, the lesions on the mucous membranes are seen to be yellowish erosions surrounded by a narrow, red areola of the same tint as that seen on the skin ; while mucous patches are pearly-gray in color with no areola, or with a narrow, dark-red line about them. The lesions may almost cover the buccal surface of the mouth, and may appear upon the lips, causing consider- able disfigurement and pain, especially on eating and drinking. When they occur on the female genitals, a pro- fuse blennorrhagia may be produced. Fuchs saw one case in which the conjunctiva was attacked. To this variety of erythema multiforme the name of E. papulatum or E. tuberculatum has been given. The papules change rapidly, often beginning to fade in a few days, and disappearing entirely within a week or ten days. Modifications in the development of the lesions are not infrequently met with which give rise to a great diversity of appearances, various names being given to denote these modifications, which, though varying so greatly in form, are not in any way distinct affections. Sometimes the lesions enlarge considerably, flattening in the centre, be- coming of a livid bluish tint, and developing on the pe- fections. They run a brief course, tending to spontane- ous recovery. Hyperaemic erythemata appear in the form of red spots from split-pea to finger-nail or larger sizes, the lesions often touching at their borders, so as to give the skin a marbled appearance. Sometimes the lesions are so ex- tensive as to form large stripes or areas of diffuse redness. Willan gave the name erythema only to this last form of the affection, while the eruption in smaller spots he named roseola. There is, however, no clinical ground for such a division. Occasionally this form of erythema is met with in the form of minute pin-head sized patches closely set, so as to look like a diffuse redness at first, while inspection shows them to be distinct lesions, with inter- vals of sound skin. The color of the hyperaemic erythe- matous eruptions varies from bright rose-red to a deep mulberry-red, depending upon the portions of the surface attacked, the deeper color being usually upon the more dependent parts. Among the hyperaemic erythemata of an apyretic char- acter are included those of a physiological nature, as blushing and the redness of new-born infants, and those of a pathological nature, as the erythema produced by blows, rubbing, the application of mustard, the contact of certain caterpillars, or of certain physiological secre- tions of the body-nasal mucus, sweat, urine, vaginal mu- cus, also diarrhoeal discharges. The contact of neighbor- ing parts may also produce this form of erythema, of which the chafing of infants-erythema intertrigo-is an example, Heat and cold give rise to a form of erythema to be included under this head; the more excessive ac- tion of cold gives rise to a true dermatitis. (See above, under Dermatitis.) A considerable number of fevers are accompanied, at one period or another of their course, by hyperaemic ery- thematous eruptions, sometimes showing themselves in pin-head sized lesions, sometimes in patches of various sizes, sometimes as a diffuse redness. None of these eruptions are in themselves important, but they are apt to be mistaken for measles, scarlatina, etc., and for this reason their existence and characteristics should be known. One of the most common of these rashes is that known as erythema infantile or roseola infantilis, which occurs upon infants and young children as a symptom of various slight ailments, chiefly those of the gastro-intestinal tract; but also of slight fever, teething, intestinal worms, bronchitis, meningitis, etc. This form of erythema is most common over the sacral region and buttocks, occurring less fre- quently on the face and extremities. The eruption lasts from a few hours to a day or so. It is much more rare in adults than in children, but it may occur at any age. This form of erythema must be distinguished from measles and from the rudimentary forms of scarlatina. When the eruption itself is not sufficiently characteristic, regard must be had to the course of the accompany- ing fever, the condition of the respiratory tract, etc. (see Measles). Sometimes erythema accompanying febri- cula (roseola febrilis), occurring in adults, may be mis- taken for typhoid fever. But the fact that the eruption begins with the fever instead of at the end of the first week, as in typhoid, and also the fact that the tempera- ature in typhoid increases gradually instead of being con- tinuously high, as in erythema, will make the diagnosis usually not difficult. Erythema variolosum, or the variolous rash, is the pro- dromal exanthem of small-pox. It appears in punctate lesions of a dark scarlet color, or in diffuse patches. In the former variety occasional pin-head ecchymoses are at times seen distributed through the eruption. The localization of the disease is usually typical. Most com- monly it occurs upon the abdomen and the inside of the thighs, in the neighborhood of the adductor group of muscles. The genitalia are usually free. The other seats of election for this important variety of erythema are the flexor surface of the elbows and knees, the backs of the hands and feet, the axillae, and a triangular space over the sternum. On the backs of the feet the redness frequently appears in a strip along the line of the ex- tensor proprius pollicis pedis. On the hands the red- 721 Erythema. Ether. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. riphery an imperfect herpetiform papulo-vesicle of annular shape. The central portion of the lesion may then fade out, forming the variety known as E. annulare. Occasionally a new papule forms in the centre of this ring, which grows in the same manner, and successive concentric rings may form to the number of four, five, and even six, giving a tar- get-like appearance to the lesion. The various colors and shades brought out by the various stages of the lesion in different parts, produce a play of colors which has caused this variety to be known as erythema iris. Now and then involution of the lesion takes place irregularly, so that por- tions of a ring may disappear, leaving segments of circles. When these are numerous a peculiar gyrate pattern is pro- duced, which has given rise to the name E. gyratum. In some cases of erythema multiforme there is a ten- dency for the process to go further on to the formation of vesicles or bullae. It has been mentioned above that the annular variety is apt to show an incipient and abortive papulo-vesicular arrangement. This may proceed to the development of perfect vesicles, though these occur on the smaller solid lesions, and even bulke may form. The names E. vesiculosum, E. bullosum, herpes iris, and hydroa, have been given to these appearances. The writer, however, is inclined to consider hydroa as an indepen- dent affection (see Hydroa). Now and then the process may go on to haemorrhage. , The involution of erythema multiforme takes place without desquamation, and with occasionally slight pig- mentation. When there has been vesiculation, however, a slight crust forms, which soon falls. The subjective sensations connected with the eruption of E. multiforme are usually insignificant-occasionally there is some burning, more rarely slight pruritus. When the eruption is widely distributed over the surface it does not appear at all points simultaneously, but pro- ceeds from point to point, spreading progressively like an exanthem, so that involution may be taking place in one locality, while the eruption has just reached its acme in another. While in localized eruptions of erythema there is no febrile reaction, in extensive cases the tem- perature may rise even to 104° F. The fever reaches its height at the moment of the outbreak of the eruption, or in some cases a little before, and the temperature falls again with great rapidity to the normal. With the involution of the eruption, which in mild cases terminates by the eighth day, but in generalized eruptions sometimes not for six weeks, the process is con- cluded. Occasionally, however, relapses or fresh attacks occur after a longer or shorter interval. Some persons suffer at about the same time every year. The etiology of erythema multiforme is obscure. Like hyperaemic erythema, it is in all probability an angio- neurosis, but this refers rather to its pathogenesis than to its true etiology. The affection is supposed to occur more frequently in spring and fall, but an analysis of the cases which have come under the writer's observation fails to show a predilection for any particular time of year. Gall reported a series of cases occurring in Bosnia as a sort of epidemic. The affection may occur in anae- mic and poorly nourished persons, and also in those en- joying otherwise perfect health. In certain cases, rheu- matic articular affections, endocarditis, pericarditis, and pleuritis have been observed concomitantly. It has fre- quently been observed to occur just before the outbreak of syphilitic exanthemata. Lewin observed it in women suffering from gonorrhoeal urethritis, the affection relaps- ing with relapses of the latter. Other similar observa- tions have been made in the male, and although the asser- tion has been made that the erythema in this case was the result of the ingestion of copaiba, yet this has been denied. Lewin observed two cases in which the introduction of a sound or of chemical irritants could arouse an eruption of erythema. The conclusion reached by Lewin was that the affection is due to reflex action by irritation of the sensory nerves of the uro-genital apparatus, but this view is too narrow to cover all cases. Other writers connect the affection with a functional disturbance of the sympathetic nerve. Erythema multiforme has been observed as a precursor to, or accompanying, cholera. Finally, certain medicines may produce an eruption hav- ing many of the characters of the one under consideration (see Dermatitis Medicamentosa). The diagnosis of erythema multiforme is not always easy, for the multiplicity and variety of its forms and lesions make it peculiarly liable to be mistaken for other affections of a widely different character. Thus herpes, tinea circinata, urticaria, lupus erythematosus, and syphi- lis may all at times be confounded with it. A due con- sideration of the history of the attack in connection with possible previous outbreaks, its localization, its character- istic color and other appearances, and its course, taken in contrast with the symptoms characterizing the other affec- tions, will almost invariably lead to a correct diagnosis. Erythema nodosum.-Closely connected with E. multi- forme, sometimes running into it or seeming to be with diffi- culty distinguishable from it, is E. nodosum. This affec- tion is characterized by the formation of rounded or somewhat oval, variously sized, more or less elevated, red- dish nodes. The disease is apt to be ushered in with some disturbance of the system ; the nodes often appear sud- denly ; they may come on any part of the body, but are commonly found on the legs and arms. They vary in size from a small nut to an egg, are reddish in color, tending to become bluish or purplish. As they disap- pear they undergo various changes of color, like a bruise, and it is often difficult to distinguish the lesions from ordinary contusions, especially when they occur over the shins. When the disease is at its height, the lesions have a tense, shining look, as if they contained fluid, and often an indistinct sense of fluctuation is percep- tible. They never suppurate however. In rare cases they are more or less haemorrhagic in character. They vary in number from a few to a dozen or more. They come out, as a rule, in crops. They are painful or tender on pressure, and are usually attended by burning sensa- tions. Sometimes the lymphatic vessels are involved. The affection usually terminates in recovery in from two to four weeks. An " ominous " form has been described by authors, which is said to be the precursor of tuberculosis. The writer has seen one such case in which a little boy, after suffering for three or four weeks with erythema nodosum, fell into a delirious condition and died with the symptoms of tubercular meningitis. Erythema nodosum is a rare disease ; the statistics of the American Dermatological Association show that it oc- curred only 27 times in 16,863 cases of skin disease. The pathology of the erythemata, and particularly of E. multiforme, has recently been investigated by Leloir. It appears that the simple redness is characterized, histo- logically, by a dilatation of the vessels of the derma, es- pecially at the level of the papillary layer, and by a slight diapedesis of the white globules. When there is in addition some thickening of the skin, the dilated vessels are surrounded by " muffs " of extra - vasated lymph-cells, and are engorged with red globules. There is at the same time extravasation of some red glob- ules, with a certain amount of serum colored red by hae- moglobin. Where papules have formed, there is considerable hy- peraemia, with exudation in the derma and even of the hypoderm, which in the slighter forms remains intact. Some cells of the rete show dilated nucleoli, while mi- gratory cells are found in considerable numbers in the deep layers of the epidermis. When the erythema takes on a haemorrhagic charac- ter the diapedesis of red globules becomes considerable. Sections show numerous dilated lymph-spaces, very rarely containing fibrin. In the papulo-tubercular form and in E. nodosum the hypoderm is more markedly invaded, the cells of the con- nective tissue tend to proliferate, and the exuded liquid often contains fibrin. The signs of exudation, hyperae- mia, or congestive oedema, however, predominate. Abun- dant diapedesis of red globules is usual. In bullous erythema the rete is early invaded by a large number of migratory cells, and cavernous alteration of the epidermis begins. In the second stage a superficial phlyctenula is formed, limited above by the horny epi- 722 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Erythema. E tlier. dermis with some portions of the stratum lucidum, be- neath by the stratum granulosum and the remainder of the stratum lucidum. The liquid of the bullae contains only a few traces of fibrin and occasional leucocytes. The affection is, as has been said, essentially an angio- neurosis. The treatment of the various forms of erythema dif- fers somewhat according to their nature and the accom- panying symptoms. In the hyperaemic erythemata the removal of the obvious cause is usually alone sufficient in those cases in which indigestion, worms, etc., are the ex- citing influences. In other forms the internal disorder to which the cutaneous manifestation is due must be dili- gently sought out and treated. Locally, cooling and as- tringent lotions may be employed. A much-used lotion in erythema, when the skin is unbroken, is the following ; R. Acid, hydrocyanic, dil., Gm. 3.75 (f 3 j.) ; pulv. bis- muthi sub-nitrat., Gm. 4-8 ( 3 j.-ij.); aquae aurantii flor., Gm. 120 (f § iv.). M. Dilute lead water and laudanum, or simple alcohol and water may be used with satisfaction in most cases. When powders can be conveniently used, starch, alone, or with •oxide of zinc, may be employed. If there is much burn- ing, camphor in the proportion of one or two parts to ten of oxide of zinc and starch will be found efficient. Oint- ments generally disagree. In many cases, especially of 'erythema multiforme, no local treatment is required. In erythema nodosum rest in the horizontal position, with the correction of any functional derangement, is usually all that is required. Arthur Van Harlingen. amount of mineral ingredients except iron, which is pres- ent in about the average proportion of the best chalyb- eate waters. George B. Fowler. ETHER. In medicine and pharmacy the word ether, un- qualified, means, as it does in common parlance, the body ethylic oxide (C2H6)2O, formerly, but improperly, called sulphuric ether. Ether is a product of reaction between sulphuric acid and alcohol, and is obtained by distilling a mixture of these two bodies, purifying the distillate by contact with potassa solution, and redistilling. Such second distillate, containing still some twenty-five per cent, of alcohol, is treated with water for removal of such contamination, then with calcic chloride and lime for re moval of the water, and is finally again distilled. The U. S. Pharmacopoeia recognizes under the simple title ^Ether, Ether, ether upon which the process for removal of alcohol has not been practised, and applies the term EEther Fortior, Stronger Ether, to the finally purified ar- ticle. But since the alcohol-contaminated "ether" is fit only for pharmaceutical, and not at all for medical pur- poses, the same is scarcely known to physicians, and a pre- scription for ether is universally and properly filled by dispensing the "stronger ether" of the Pharmacopoeia. Stronger ether, which alone needs discussion here, is thus defined and described by the U. S. Pharmacopoeia : " A liquid composed of about ninety-four per cent, of ethyl oxide, and about six per cent, of alcohol, containing a little water. Specific gravity not higher than 0.725 at 15° C. (59° F.), or 0.716 at 25° C. (77° F.). A thin and very diffusive, clear, and colorless liquid, of a refreshing characteristic odor, a burning and sweetish taste, with a slightly bitter after-taste, and a neutral reaction. It is soluble in all proportions in alcohol, chloroform, benzol, benzin, fixed and volatile oils, and dissolves in eight times its volume of water at 15° C. (59° F.). It boils at 37° C. (98.6° F.). Ether is highly inflammable, and its vapor, when mixed with air and ignited, explodes vio- lently. If a piece of pale blue litmus paper, moistened with water, be immersed ten minutes in a portion of the ether, the color should not change. On evaporating at least 50 C.c. in a glass vessel, no fixed residue should appear, and on evaporating a portion dropped upon blotting-paper, no foreign odor should be developed. When 10 C.c. are agitated with an equal volume of glycerin in a graduated test-tube, the ether layer, when fully separated, should not measure less than 8.6 C.c. It should boil actively in a test-tube half filled with it, and held a short time in the hand, on the addition of small pieces of broken glass. It should be preserved in well stopped bottles, or in soldered tins in a cool place remote from lights and fire" (U. S. Ph.). According to Squibb the definition in the above quotation is faulty, in that an ether of specific gravity 0.725 at 15° C. is composed of not less than 95.9 per cent, of ethyl oxide, and 4.1 per cent, of alcohol containing a little water, instead of the quantities alleged ; and further, in that an ether of specific gravity 0.725 at 15° C. will have at 25° C. the specific gravity 0.714, and not 0.716 as alleged. The same author- ity declares the statement that ether dissolves at 15° C. in eight volumes of water to be erroneous, trial showing that, upon prolonged agitation of 10 C.c. of officinal ether with 80 C.c. of water at the prescribed tem- perature, 1 C. c. of ether remains undissolved ; and yet another criticism is that, in the description of the glycerin test, "8.6 C.c." should read " 9.6 C.c."for the volume of the ether layer. Ether tends to decompose by prolonged keeping, de- veloping, as one product, acetic acid. For use as an anaesthetic, ether ought to be pure and of standard strength. In all cases of suspicion, therefore, the sur- geon should test his sample by the following simple pro- cedures : test for acidity by pale blue litmus paper wetted with water; for impurities by the odor as the last of a portion (at least two fluidrachms [Squibb]) evaporates from blotting-paper; and for strength by shaking to- gether equal volumes of ether and water, and observing the loss of volume of the ether by solution in the water. To make this test, Squibb advises pouring 10 C.c. of ESCULAPIA SPRINGS. Location, Lewis County, in the northeastern corner of Kentucky, about twenty miles east of Maysville, Mason County, Ky., and on the Ohio River. Analysis.-None received. Dr. Frazer's " Mineral Waters of Kentucky " reports that the water, from an an- alysis by Dr. Peters, contains free sulphuretted hydro- gen gas, bicarbonate of lime, bicarbonate of magnesia, chloride of sodium, chloride of magnesium, sulphate of soda, and sulphate of magnesia. G. B. F. ESTILL SPRINGS. Location and Post Office, Irvine, Estill County, Ky. Access.-By Kentucky Central Division of Chesapeake & Ohio Railroad to Richmond. Irvine is about fifteen miles east. Analysis. -One pint contains : Irvine Spring. Robert Peter, M.D. Red Sulphur Spring. Robert Peter, M.D. Chalybeate Spring. Robert Peter, M.D. Carbonate of magnesia Grains. 0.321 Grains. 5.605 Grains. 0.335 Carbonate of lime 3.841 1.472 1.159 Carbonate of iron Carbonate of soda 0.106 0.168 0.233 Chloride of sodium 2.201 0.612 0.066 Chloride of calcium 0.211 Sulphate of potassa 0.313 0.670 0.080 Sulphate of magnesia 32.910 0.073 1.224 Sulphate of lime 3.987 2.084 Sulphate of soda 1.254 0.087 Alumina and trace of phosphates Silica 0.503 6.044 0.233 Organic and volatile matters 10.736 0.292 1.028 55.189 5.190 6.529 Gas. Cub. in. Carbonic acid (Red Sulphur) 5.01 Carbonic acid (Chalybeate) 4.15 Sulphuretted hydrogen (Red Sulphur) 0.07 Therapeutic Properties.-The Irvine Spring is a strong purgative water, on account of its large proportion of sulphate of magnesia ; the Red Sulphur is a very mild sulphur spring, and the Chalybeate contains a very small 723 Ether. Ethidene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. water into a graduated test-tube, adding carefully 10 C.c. of ether, shaking actively for two or three minutes, and allowing an equal time for the separation of the twTo fluids. When fully separated, the ether layer should measure not less than 8.8 C.c. , and each deficiency of 0.12 C.c. below such limit corresponds, in samples of not less than ninety per cent, strength, to a one per cent, dilution of the ether. By reason of its extreme volatility ether is best kept in hermetically sealed tins. In bottles, whether cork or glass-stoppered, leakage by evaporation is almost certain to occur, especially during transportation. Extreme in- flammability is another property of ether requiring es- pecial precautions in handling the fluid, and a point often overlooked is that air even moderately charged with ether vapor is explosive. Hence happens every now and then the ignition of an ether-inhaler during anaesthetiza- tion by the leap of fire through intervening ether-charged air from a candle, or hot cauterizing iron, several feet re- moved. Ether is a conjoint local irritant and constitutional nar- cotic. Being of high diffusion power, it is readily ab- sorbed by living tissues, and so speedily declares its influ- ence. Applied of full strength to the skin, and prevented from evaporating, it quickly reddens, and in time will blister. Absorbed into the blood, ether disturbs nerve- function by attacking first and more profoundly the nerve-centres, and secondly, and with less intensity, the nerves themselves. Of the nerve-centres the cerebrum seems to be the most sensitive to the ether influence, the disturbance being first a conjoint excitation of the emo- tional and blunting of the intellectual faculties, and finally an abrogation of all mental phenomena, uncon- sciousness being so absolute that upon awaking there is not even that vague appreciation of the duration of the narcosis that follows after ordinary sleep. Next to the cerebrum suffers the sensory tract of the spinal cord, the affection being a progressive blunting of perceptivity, and next again the motor tract, suffering first by paresis and irritation, and finally by full paralysis. Lastly the me- dulla oblongata becomes involved, its sensory centres, as in the case of the cord, succumbing firstand its motor cen- tres last. Upon the nerves ether has a paralyzing power similar to what it exerts upon the centres, but the influ- ence is comparatively so feeble as only to be producible by direct application of ether to an exposed nerve. In impregnation of the blood with ether, death of the sub- ject by paralysis of the medulla will take place before any obvious impairment of conductivity on the part of the nerve-trunks. Of the great functions, heart-action is stimulated by ether, the pulse of a healthy subject rising in force and frequency, and maintaining such quickened and deepened action even through a long and full narcosis. In death by ether, furthermore, the heart retains its irri- tability. Arterial tension is also increased, in part, doubt- less, as a result of the increased heart-action, but in part also, apparently, by vaso-motor spasm. Respiration is primarily stimulated, but secondarily depressed, until in full ether narcosis the breathing becomes slow and shal- low, and, in case of overdosing, respiration is the function whose failure produces death. From the experiments of Knoll it would appear that these respiratory derange- ments are caused by direct action of the ether upon the respiratory centres. Functions presided over by the sympathetic nervous system are little disturbed by ether. The stomach is easily upset by ether; full doses given by swallowing are repulsive and sickening ; and after ether inhalation, also, nausea and vomiting are common occur- rences, especially if the narcosis have been of consider- able duration, and especially, further, in case of use of an ether of an inferior quality. Clinically, the effects of ether are as follows : In ad- ministration by the stomach, the medicine is so offensive that enough cannot be given to produce more than a moderate grade of the peculiar ether effect. Doses of from four to eight cubic centimetres (from one to two fluidraclnns) can be swallowed, dissolved in a sufficiency of iced water, with the effect of stimulating the circula- tion and respiration, and producing mild exhilaration. Such a draught is powerfully reviving in conditions of heart failure or of depression of the vital powers gen- erally, and also tends to steady the nervous system and to break spasm. Given by inhalation of the vapor, in as concentrated condition as possible, ether produces its fullest effect. Such is the common method of adminis- tration for the production of ether anaesthesia, and the phenomena following the inhalation are as follows : Sub- jectively, if the attempt be made to breathe the vapor, at the start, in concentration, the pungency is intolerable ; spasm of the larynx occurs, and despite all willingness to be etherized, the subject involuntarily gasps for breath and fights for release. Soon, however, the mucous mem- brane of the larynx becomes anaesthetized by the vapor, and inhalation can then proceed without distress. Fol- lowing the cessation of laryngeal irritation come an in- describable thrilling and tingling throughout the body, a sense of physical lightness and mental exhilaration, a ringing in the ears, and exaggerated appreciation of sounds-phenomena that speedily give way to a con- sciousness of failure of cerebral power and command. Blunting of tactile sensibility is clearly appreciable, and, in the self-experience of the writer, a sensible interval- whether real or apparent only, it is, of course, impossible to say-occurs between the willing of a motor act and its ex- ecution. With ever-progressing rapidity, now, the grasp of the centre of consciousness upon the outer world through the nerves of sense slackens, until, following a whirl of mental confusion, even the consciousness of consciousness fails, and the next act of cerebrating is the realization of an awakening from a sleep of whose duration the subject has absolutely no conception nor even suspicion. In a self-administration of ether in an absolutely quiet room at night, the writer, awakening from what seemed, and was intended to be, a momentary unconsciousness only, found to his utter amazement, on glancing at the clock, that two hours had elapsed since the beginning of the in- halation-two hours of a coma as dreamless and blank as that attendant upon a compression of the brain. After awakening from an ether narcosis there is more or less tendency to nausea, headache, and feeling of debility and wretchedness generally. Objectively, the phenomena are first a rise in the frequency and force of pulse and respi- ration, a suffusion of the face, and a tendency to the ex- hibition of emotional excitement, varying, naturally, with the temperament and disposition of the subject, exactly as in the analogous condition of alcoholic drunkenness. While, therefore, the phlegmatic or the self-contained may sink quietly into coma, the excitable or the ungov- erned subject may be outrageously jolly, or fearful, or pugnacious, or amorous, according to natural bent. At this period the proper test will show already a decided blunting of tactile sense and impairment of co-ordinating powrer. Speedily, next, the emotional displays become feeble and incoherent, sweat starts out from the brow, the saliva flows, the face congests, the pupil contracts, and the muscles at once both stiffen and tremble. And, now, testing shows tactile perception to be abol- ished everywhere except in parts of high natural sensi- tiveness, such as the eye, the "quick" of the nails, and the ano-genital region. If the inhalation continue, the muscular rigidity and trembling give way, often with striking suddenness, to a condition of absolute paralysis and relaxation. At the same time the pulse falls some- what, the respiration becomes slow and stertorous, the pupil dilates, all outward signs of conscious existence cease, and anaesthesia is absolute even in the most sensi- tive parts. During the maintenance of this condition the face sweats freely, and the saliva flows in considerable quantities. Such a condition is the extreme to which narcosis should be pushed, since it represents an abroga- tion of all nerve-action save that of the functions of or- ganic life, and that determining the play of the heart and lungs. If the ether be further pushed, the respirations become slower and shallower, the sphincters give way, and soon thereafter breathing stops altogether-the heart, however, continuing to beat for a short time still. On discontinuance of an ether inhalation, sleep may follow, more or less prolonged, according to circumstances and 724 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ether. Ethidene. according to the amount of ether consumed. Retching and vomiting may come next, often taking place quite suddenly and while sleep is still profound. On awaken- ing, the subject is generally stupid and miserable, with still imperfect power of co-ordination and blunted tactile sense. Occasionally, but exceptionally, emotional excite- ment now appears, and in such cases there is sometimes a strong erotic excitation, it may be with vivid illusions. Deceived by such experiences, female patients have been known to believe and make honest accusation against the administrator of the ether or the surgeon, of the taking of improper liberties, and even of the commission of rape. The therapeutically valuable effects of ether narcosis by inhalation are insensibility to pain and muscular re- laxation, and the degree of the narcosis necessary to at- tain a practical result of either kind will vary according to the circumstances of the case. In the line of blunting of sensation, if it be for the relief of existing pain, a few whiffs of ether may suffice, without the production of narcosis at all, or it may be that the pain will yield only to the general unconsciousness of full coma. If it be for the abrogation of sensation during a surgical operation, the grade of narcosis necessary will depend upon the part to be attacked. In the case of all but the highly sensi- tive parts already enumerated, the ether effect need not be carried farther than to the production of the stage characterized by general muscular rigidity and trembling; but for operations on those same very tender portions spoken of, the narcosis must be pushed to the stage of muscular relaxation and stertorous breathing. For the purpose of affecting motility, if it be for the breaking of a cramp or spasm, a few whiffs of ether are often all-suf- ficient, ether being indeed a quite potent antispasmodic ; but if relaxation be sought for the easier reduction of a hernia or a dislocation, full narcosis to the stage of ster- torous breathing will once more be necessary. The ac- tual quantity of ether required for narcotizing by inhala- tion varies according to the inhaler used, the skill of the administrator, the fulness of respiration by the subject, the condition of his stomach, whether full or empty of food, his habit in the use of narcotics, and even, to a certain extent, depends also upon idiosyncrasy. With a good inhaler, with care to prevent waste by evaporation into the room, with a subject whose susceptibility is not impaired by habitual indulgence in either ether itself or in alcoholics, whose stomach is fairly empty, and who will and can breathe with forced inspiration and expira- tion, so small a quantity as from twenty to forty cubic centimetres (roughly, from half a fluidounce to a fluid- ounce), may suffice to produce full unconsciousness. But with the average want of skill of administrator, want of fit of inhalers, and want of willingness of co-operation of subjects, far larger amounts than those mentioned are commonly required, so that it is rarely safe to provide less than half a pound for an intended anaesthesia of even ordinary duration only. Ether can also be administered, for the production of its constitutional effects, by rectal injection of its vapor. This method was experimentally tested so long ago as 1847, by Pirogoff, of St. Petersburg, and has been recently revived in association with the names of Axel Yversen, of Copenhagen, and Daniel Molliere, of Lyons-a re- vival likely to end in a new lease of deserved oblivion. By such method full narcosis is possible, with, of course, an avoidance of respiratory distress, and perhaps also with less gastric derangement than in the method by in- halation ; but, on the other hand, with the grave feature of a tendency to dangerously irritate the intestines. Diar- rhoea and bloody dejections have repeatedly followed the practice, with resulting death in at least two instances. In another case, still, death ensued from rupture of the intestine at the site of an old ulcer, through overdisten- tion by the ether vapor. The practical administration of ether to the develop- ment of narcosis is a special topic, treated of in this work in the article on Anaesthetics, to which, therefore, the reader is referred. As used for medicinal purposes, in the narrower sense of the word, ether is administered by in- halation or by swallowing. As regards the giving by in- halation, since, for the effects under consideration, a very little suffices, it is enough to direct that a teaspoonful of ether be poured upon a crumpled handkerchief, which handkerchief is then to be held directly against mouth and nostrils, and the fumes inhaled during a few deep inspirations. In this prescription the precautions must be enjoined, first, that in case of self-administration the subject must lie down or sit so reclining or so braced as that, in the event of unconsciousness being produced, he will not fall to the floor ; and, secondly, that the whole procedure shall take place at a distance of at least six feet from any exposed flame, as that of a candle, lamp, gas- light, or open fire. In giving by swallowing, from one to two teaspoonfuls is the average dose, best given in from eight to ten measures of ice-cold water, sweetened, if so preferred. Ether so taken is, how'ever, a repulsive medi- cine, offensive to the taste, and disagreeable by reason of the choking sensation that attends its swallowing, because of its pungency. Ether is far more commonly given internally, when so given at all, in the form of the Phar- macopoeial preparation entitled Spiritus ^Etheris Com- positus, Compound Spirit of Ether, or Hoffman's Ano- dyne. This preparation is compounded of thirty parts of stronger ether, sixty-seven of alcohol, and three of ethereal oil. It is a colorless volatile fluid, smelling and tasting of its three powerful ingredients. It forms a milky emul- sion on admixture with water. It is used as an antispas- modic and general nervine and cardiac stimulant, and is given in average dose of from half a teaspoonful to one or two such measures, in water, plain or sweetened. In the IL S. Pharmacopoeia there is also now officinal a prepara- tion entitled Spiritus ^Etheris, Spirit of Ether, a prep- aration consisting of thirty parts of stronger ether and seventy of alcohol in mutual solution. This spirit may be given as an internal medicine in doses of one or two teaspoonfuls, administered in a goodly quantity of iced water, plain or sweetened. A peculiar application of ether is the driving of the fluid, in atomized spray, upon the skin for the purpose of freezing that texture by the cold developed by the evapo- ration of the ether-sueh freezing being for the sake of the anaesthesia that attends it. In this application the ether is delivered from an atomizer of good capacity, the nozzle being held about an inch and a half from the skin. The first sensation, that of cold, is followed by a severe burning feeling, which is in turn succeeded, as the skin freezes, by loss of all sensation. When so frozen the skin appears pale, shrunken, and of tallowy hue and feel, and can be cut without pain. The effect is superficial only, and if a deep incision is to be practised, the tissues beneath the skin must, after section of that covering, be themselves frozen by a renewed application of the spray before cutting. Freezing by ether spray is rapidly accomplished, and, if not maintained beyond a short time, is not followed by any deleterious effect. The procedure is, by the conditions of its effecting, appropriate only for brief and superficial surgical operations, and is often itself more painful than the cutting whose pain is thus sought to be avoided. Edward Curtis. ETHIDENE DICHLORIDE, Ethylidene Dichloride, C2 H4C12. This is an ethereal body, isomeric with and much resembling ethylene dichloride. It has been experi- mented with as an anaesthetic, and has been found to operate after the general manner of chloroform, includ- ing the occasional killing of a subject by cardiac paralysis. It is administered similarly to chloroform. Edward Curtis. ETHIDENE POISONING. Ethidene, Ethylidene, or Chloride of Ethidene, was first used as an anaesthetic by Snow, later by Liebrich, and more recently by the British Anaesthetic Committee, Clover, Bird, Hodges, and others, with conflicting testimony regarding its toxic properties and the dangers attending its use. Snow very early abandoned its use, believing that it is very likely to cause sudden death, and his belief is shared by Steffen ; Lieb- rich, however, looked upon it as being safer than chloro- form, and Bird considered it as a cardiac stimulant, while 725 Ethidene. Euphorbiiim. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the British Committee concluded that " it presents all the advantages of ether without any of its disadvantages," and reported that in six cases in which it was used there were no injurious effects upon the respiratory mechanism ; the pulse was lowered in frequency, but increased in volume, and even in the deepest anaesthesia was steady, regular, full, and compressible. In a later communication, how- ever, the Committee found, in experiments on animals, a decided failure of the circulation ; the arterial pressure gradually but slowly fell, and, after repeated doses in prolonged and constant use, was gradually brought down to seven millimetres of mercury, or what is practically zero. These results are confirmed by the experiments of Liebrich and Reeves on dogs, and also, unfortunately, by the record of deaths resulting from the clinical use of this anaesthetic. It seems obvious, from the knowledge we have of the physiological action of this drug, that the two chief dangers attending its use are a likelihood : 1, to cause sudden death, or, in other words, to act at times wholly out of proportion to the dose ; 2, to cause death by fail- ure of the circulation. Up to the present time the record shows an average of one death for each thousand ad- ministrations, with many additional cases in which the most alarming symptoms ensued, and the patient was res- cued from death only by the most active and persistent ef- forts of the attendants. The histories of these cases testify most unequivocally to the above dangers attending the use of this substance. It is unquestionably a dangerous anaesthetic, and since it is likely to cause sudden death by failure of the circula- tion, amyl nitrite, or some such circulatory stimulant, should be at hand during its use. Edward T. Reichert. purpose some consider it efficacious, or for relieving op- pression of breathing in pulmonary complaints. It is administered by inhalation, in dosage of fifteen drops. Edward Curtis. EUCALYPTUS, U. S. Ph., Codex Med., the leaves of Eucalyptus globulus Labillardiere, Order, Myrtacem, "col- lected from rather old trees." In the British Pharma- copoeia the leaves are not included, but the oil {Oleum Eucalypti, U. S. Ph., Br. Ph.) is, and is defined as col- lected from the fresh leaves of E. globulus, E. amygda- lina Labill., and probably of other species. The U. S. Pharmacopoeia definition of the oil is similar. Eucalyp- tus globulus (see Plate X.) is a large and elegant tree, in some countries one of the largest known, attaining to three hundred feet, or more, in height. It has a smooth, gray, exfoliating bark, and a hard, resinous, rapidly growing wood. The young branches are smooth, quadrangular, or slightly winged. The leaves vary with the age of the plants ; on young trees (see woodcut, also Fig, 11 on the ETHYLENE DICHLORIDE, Ethene Dichloride, Dutch Liquid: C2II4CI2. This body is a thin, colorless, oily fluid, smelling and tasting much like chloroform; vola- tile and inflammable ; dissolving sparingly in water and freely in alcohol and ether. Its only medical interest lies in its attempted substitution for chloroform, as an anaes- thetic which should retain the advantages of chloroform while free from its dangers. It seems to operate much like chloroform, and, according to Reichert, has little tendency to paralyze the heart. It is, however, very irritating to the throat. Administration, in mode and dose, is the same as with chloroform. Edward Curtis. ETHYLIC BROMIDE, Hydrobromic Ether: CaH5Br. This body is a thin, colorless, very volatile ether, of a strong smell and hot taste ; practically non-inflammable ; sparingly soluble in water, but freely so in alcohol and ether. It affects the human system very similarly to chloroform, producing profound anaesthesia rapidly and pleasantly. It was strongly urged, a few years ago, as an anaesthetic fulfilling the long-sought requirement of pos- sessing happiness of action combined with safety ; but in the extended experience that followed several cases of death occurred, some by exhaustion from persistent vomiting, but some also by heart-failure. There is little chance, therefore, of ethylic bromide again becoming fashionable. It is given similarly to chloroform. Edward Curtis. Fig. 1050.-Young Eucalyptus Tree. (Baillon.) ETHYLIC CHLORIDE, Hydrochloric or Muriatic Ether: C2H5CI. This body is a thin, colorless, inflammable, and very volatile ether, acting upon the human system much after the manner of common ether. It has occasionally been prescribed as an internal medicine, in doses of from ten to thirty drops in a vinous mixture. Edward Curtis. plate) they are opposite, ovate, or cordate, with a tapering- point, and have a pale greenish-blue color. Upon well- grown trees they are alternate, with flattened and twisted petioles, which support the blades in a vertical plane; thick and coriaceous, entire, dark-green, and punctated with translucent oil reservoirs. They are from lifteen to thirty centimetres long (six to twelve inches), scythe-shaped, narrow, rather blunt or heart-shaped at the base, and very much attenuated at the apex. Venation pinnate, mid-rib prominent. The flowers are large, axillary, solitary, or in clusters of two or three. The calyx tube supports in- numerable stamens at its throat and encloses a four- or five-celled'inferior ovary. Petals in the bud coalesced into an irregular conical or convex cover (operculum), which at the time of flowering separates transversely at its in- sertion upon the border of the calyx tube, and falls away like the lid of a box, so that the blossomed flower is en- ETHYLIC IODIDE, Hydriodic Ether: C2HSI. This body is a colorless ethereal fluid, non-inflammable, prac- tically insoluble in water, but freely soluble in alcohol. It has a sharp taste and a smell simply penetrating if pure, but if impure often offensive. Ethylic iodide af- fects the human system after the manner of the volatile ethers generally, but is used in medicine-so far as it is used at all-either for the sake of iodizing, for which 726 Reference Handbook of THE Medical Sciences. PLATE 10. 1 2 3 4 5 6 11 10 9 7 8 EUCALYPTUS GLOBULUS. H.BKKCKK^ITH-N.T. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Ethldene. Eupliorbium. tirely apetalous. Fruit woody, consisting of a dehiscent capsule, enclosed in the lignified calyx tube. Seeds nu- merous. The flowers and fruits are also fragrant with oil, but only the leaves are used for its extraction. This tree is a native of Australia, Van Dieman's Land, Tasma- nia, etc., where it has been known for about a hundred years. Eucalyptus was discovered by Labillardiere in the island of Tasmania, in 1792, and introduced into Europe, in 1856, by M. Ramel, who had observed in Australia its value in overcoming the insalubrity of unhealthy marsh- lands. Within the past thirty years it has been intro- duced into most warm countries, either as an ornamental tree, or for its sanitary value. It is now cultivated-or rather planted, for it grows with great facility-in large tracts of low and malarial land in California and some of tiie Southern States, in Southern and Eastern Europe, Algeria, Brazil, and also in its native countries. The leaves, for medicinal use, are imported from the East. They are leathery and stiff in texture, but little broken by transportation. They are of a gray-green color, and strong camphoraceous odor. Taste pungent, aromatic, astringent, and slightly bitter, frequently accompanied by the smaller twigs. Composition.-Besides the oil, which will have a sepa- rate paragraph, the leaves contain tannic acid, resins, wax, etc. (Hager). Oil of Eucalyptus (U. S. Ph., etc.).-This liquid, which is principally imported from Australia, where it is distilled from the fresh leaves, is a pale-yellow, or when re-distilled a colorless, liquid of a strong characteristic aromatic odor, and pungent, camphor-like, cooling taste. Its reaction is neutral, and it is "soluble in an equal weight of alcohol." Specific gravity, about 0.900 ; boil- ing point 170° C. The commercial oil is the product of several species of Eucalyptus. Its specific gravity, odor, and other characters, are therefore subject to slight vari- ation. It consists of one or two terpenes, cymol, and a camphor. The so-called Eucalyptol is a redistilled oil, composed, according to Cloez, of seventy parts of eucalyp- tine (one of the terpenes), and thirty of cymol. The oil of E. globulus, according to H. Schultz, does not contain cymol. Those of other species of this prolific genus have been examined and found to have, with minor differences, a very general resemblance in sensible properties and medicinal value. Action and Use.-The value of the Eucalyptus tree as an atmospheric purifier is pretty well established. First, by the exceedingly rapid growth of the young trees, they draw off quite effectively the surface water of low and marshy spots, and make them more habitable; secondly, their free secretion of an antiseptic oil, and its exhalation into the air, is considered also to still further improve the neighborhood in which they grow. It is pretty certain that these two effects combined have made great changes for the better in many exceedingly unhealthy swamps, where they have been planted, and this method of land improvement has become an established one in many parts of the warm temperate world. The action of Eucalyptus as a medicine, either locally or internally, may be considered as that of the oil, al- though the leaves are imported and a Fluid Extract is made from them (Extractum Eucalypti Fluidum, U. S. Ph., strength -}-). The constituents other than the oil (tan- nin, wax, resin) are so ordinary and inert that they may be disregarded. The oil, however, has been in consider- able demand for a number of years. First, it is a useful antiseptic, of about the same power as a good many essential oils, although probably not as valuable as thy- mol. It is, for the time being, the favorite of Sir Joseph Lister, who pours a few drops of it into his dressings, has his gauze made of it, as well as ointments, etc. Its agreeable odor and but slightly irritating properties are in its favor. It is not very poisonous. Internally ad- ministered, the oil, up to one or two grams (TQ, xv. ad xxx.) produces no marked symptoms further than its burn- ing taste, the sensitiveness to cold which it causes in the mouth and throat ; from two to four grams produce distress in the epigastrium, eructations, headache, in- crease of temperature, and acceleration of the pulse, and general discomfort. The eructations and the stools are impregnated with the odor of the oil; the urine is in- creased. Very large doses produce symptoms of general collapse, but no stupor. It is eliminated, like other es- sential oils, by lungs and kidneys as well as by the skin. Locally the oil is among the less irritating ones, but if kept in contact with the skin without opportunity to evaporate it reddens and blisters it. Oil of Eucalyptus has, like most new remedies, been recommended for many troubles ; as a parasiticide it is probably less valu- able than turpentine, and much less so than kooso, pelle- tierine, etc.; as an antirheumatic it ranks with oil of caje- put as of little value ; in migraine, etc., it is also of little use. In gastric catarrh, biliary colic, etc., it has already had its day. As an expectorant it appears to have some value, but less perhaps than grindelia. As an anti- periodic it has some advocates, but has not taken a high place. It certainly cannot be compared to quinine in this respect, but is worth a trial where the other cannot be given; in vesical and urethral catarrh it is useful. In short, the oil resembles in general the other essential oils, and is applicable to the same uses. Dose :-of the Fluid Extract three or four grams ; of the oil, from one-half to one gram (gtt. x. ad xx.). Allied Plants.-The genus comprises a hundred spe- cies of magnificent, fragrant trees, most of which are na- tives of Australia and Polynesia. For the order Myrtacea, see Cloves. Allied Drugs.-Oil of Cajeput and other essential oils ; also the moderate antiseptics (see Antiseptics). With quinine its right of comparison is rather slight. W. P. Bolles. Explanation of Plate X: Eucalyptus globulus Labill.: 1, Flowering branch, natural size ; 2, section of flower; 3, staminiferous disc of same ; 4, stamens, enlarged ; 5, section of ovary; 6, fruit; 7-8, sections of same; 9, seed; 10, ovary; 11, short blunt leaf from a younger tree, copied with some alteration from Bentley and Trimer-The leaves should have been represented as smooth and not rugose. EUPHORBIUM, Ph. G. (Euphorbe [Gomme-resine d'], Codex Med.), An irritating and drastic gnm-resin, ob- tained from Euphorbia resinifera Berg; Order Euphorbia- cece. This is a large, leafless, cactus-like perennial, grow- ing from four to six feet high (one or two metres), having a thick, gray, woody stem, and numerous very fleshy, quadrangular, green branches ; the leaves are represented by minute tubercles, ranged along the angles of the stems, each supporting two divergent, sharp-pointed, spinous stipules. Respiration is performed, as in cactuses, by the green surface of the stems. The flowers are minute, monoecious, in small clusters surrounded by petaloid, flve-lobed, yellow, corolla-like involucres, which them- selves grow in groups of threes near the ends of the branches. The plant is laden with a milky juice, which exudes when it is wounded, and dries readily in tears upon the surface or entangled among the spines. It is a native of the interior of Morocco. The resin is exported from Mogador. It has been known in European commerce from a very remote pe- riod, is mentioned by numerous older medical writers, and had its place in most pharmacopoeias. It is col- lected by incising the stems early in the season, and collecting the hardened tears some weeks later. These are usually irregular, from the size of a hickory nut down : yellow, translucent, with a dull, waxy surface, and a brittle fracture. They often enclose or fasten spines or other portions of the plant. Frequently they are per- forated. The odor is slight, unless heated, but the dust raised by gathering, sorting, or powdering it is ex- ceedingly irritating to face and nose, so that those hand- ling it should wear veils, or take means to avoid the dust. Fliickiger's analysis of Euphorbium gives it the following composition . amorphous resin, 38 ; euphorbon, 22 ; mucilage, 18 ; malates, 12 ; inorganic ingredients, 10. Of these, the irritating and active principle is the amor phous resin. It is soluble in alcohol. Action and Use.-Euphorbium is a violent irritant, like Cashew Nuts, Chrysarobin, Croton Oil, etc.; it is also, like the latter, an irritant drastic. Formerly it was 727 Euphorbium. Eustachian Tube. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. used internally for this quality, but is now never so given. For external use as an irritant, or, more generally, diluted with other things, as a rubefacient (ointments, plasters, etc.), it is occasionally called for, and in the more obstinate chronic skin affections has some value ; but the necessity which cannot better be met with other medicines must be rare. Allied Plants.-Many other Euphorbias have some medical reputation, mostly as purges ; they are generally violent and debilitating. Epurge (Codex Med.), the root and seed of Ei Lathy r us Linn., are purgative and emetic ; the oil of the former is intermediate between castor and croton oils. ' ' American Ipecac " is the root of E. Ipeca- cuanha Linn., a native of this country; it is a good emetic, but apt also to move the bowels. (Dose about a gram.) E. corollata, "Flowering Spurge," another in- digenous plant, has similar qualities, but is less gentle, etc.-For the order, see Castor Oil. Allied Drugs.-These are sufficiently mentioned above. IK. P. Bolles. mm. (not quite half an inch) long, or one-third the length of the entire tube. At the junction of the cartilaginous and bony portions, the lumen of the canal is the narrow est, and is here called the isthmus tuba, of which the ver- tical diameter is 1| mm., and the transverse diameter 1 EUREKA SPRINGS. Location and Post-office: Eureka Springs, Carroll County, Ark. Access.-By St. Louis & San Francisco Railway (Ar- kansas Division) to Seligman, thence by Eureka Springs Railway to Eureka Springs, twenty miles distant. Analysis.-Each gallon of 231 cubic inches contains the following, viz. : Grains. Chloride sodium 0.19 Sulphate soda 0.09 Bicarbonate soda 0.15 Sulphate potash 0.13 Bicarbonate lime 4.43 Bicarbonate magnesia 0.47 Iron and alumina 0.08 Silica 0.31 Fig. 1051.-M. external auditory meatus; T, membrana tympani; 77, malleus ; A, incus ; S, stapes ; P, promontory ; Eu. Eustachian tube; Mt. tensor tympani muscle; Ac, tendon of this muscle; Ca, internal carotid artery ; F, jugular vein. Total 5.85 mm. (1.5 to 2 mm., Burnett; | to 2 mm. high to i to f mm. wide, Politzer). The osseous canal is simply a continuation of the ante- rior portion of the tympanic cavity or middle ear, directed inward, and its boundaries are : externally, part of the tympanic bone ; above, the canal of the tensor tympani , below and to the inner side, the carotid canal. The inner wall is longer than the outer. Its calibre, large enough to Free ammonia 0.14 Albuminoid ammonia .-. 0.07 parts in a million. Therapeutic Properties.-Although the amount of min- eral constituents of these waters is strikingly meagre, their reputation for the cure and alleviation of chronic disease dependent upon perverted nutrition, dyspepsia, liver and renal affections, etc., appears well established. Eureka Springs is situated in the White River Moun tains, on a site formed by the intersection of several gulches, from which the hills rise very steeply. The alti- tude of the mountains varies from eleven hundred to nineteen hundred feet. The city itself is about eighteen hundred feet above sea-level. There are within the city limits forty-two springs, the most prominent being the ''Basin." The characteristic rock is granite and lime- stone, covered at the lower portion of the hills by a flinty gravel. The climate is delightful-never oppressively warm during the day, and always cool at night in summer. The winters arc mild. From the topography of the coun- try the drainage should be perfect. There are numerous hotels and boarding-houses. Though only five years ago these springs were in a se- cluded wilderness, the city now boasts of a population of over eight thousand, with churches, schools, and other at- tractions of an enterprising community. George B. Fowler. EUSTACHIAN TUBE, Anatomy and Physiology of ; Diseases of. The Eustachian tube derives its name from Eustachius, who described it more fully than other writers, although it had previously been discovered by Vesalius. It serves to connect the tympanum and pharynx, and is the passage by means of which air enters the mid- dle ear from the external atmosphere. The direction of the tube is oblique, extending from the tympanum for- ward, downward, and inward, and its axis forms an angle of 135 degrees with the horizontal axis of the meatus. Its approximate length is 35 to 36 mm., (1£ to inch), and it is wider at either extremity than in the intervening por- tion. The tube is composed of two portions, one carti- laginous and the other bony, the latter being about 12 Fig. 1052.-Eustachian Tube and Tympanic Cavity, a, membrann tym- pani; 6, head of malleus ; c, lower end of the handle of the malleus; d, body of the incus; e, short process of the incus; /, tensor tympani muscle ; g, pharyngeal opening of the Eustachian tube ; A, isthmus tuba? ; i, tympanic orifice of the tube. (Right ear.) admit a small probe, is somewhat triangular, and its average diameter is about 2 mm. (greatest diameters vary from 4 to 4.5 mm., Burnett ; average diameter of the 728 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Isu phorbin in. Itustacliian Tube. tympanic orifice, 5 mm. high, 3 mm. wide, Schwartze). The tympanic orifice of the tube is situated a little above a point where the anterior wall of the tympanum curves toward the inferior wall of the osseous canal. The cartilaginous, or longer portion, of the Eustachian tube is attached to the rough and irregular margin of the bony canal, and opens into the naso-pharynx. The in- ferior wall of the bony canal being longer than the others, allows the lateral walls of the cartilaginous portion to ap- proach nearer the tympanic cavity than the lower wall, 'rhe canal is not composed entirely of cartilage, being partly cartilaginous and partly membranous. The pos- terior and upper walls are cartilaginous. The anterior wall, though composed of cartilage above, is muscular, according to Rudinger, in its lower portion. The mem- branous portion forms the lesser half of the circumfer- ence of the tube, while the cartilaginous portion forms the boundary of one side and the superior portion. The calibre of the tube is cleft-like and slightly sigmoid in shape. That part of the tube which is formed of cartilage being stiffer, is more open, and so prevents complete closure of the lumen of the canal. The membrano-cartilaginous tube is not permanently open in its entire length ; the opposite surfaces of the mu- cous membrane lining its walls come together except at the pharyngeal orifice and at a point very near the union of the cartilaginous and bony portions. This portion of the tube performs the function of a valve, allowing a proper supply of air to reach the tympa- num. Politzer has made transverse sections of hardened prep- arations in the supe- rior portions, near the osseous canal. He says, " A small space will be found below the curvature of the hook, the walls of which do not come into con- tact with each other. In the middle por- tion, however, the central and lateral walls of the tube are completely in con- tact, and only near the ostium pnaryn- geum do the walls again diverge a lit- tle." Moos and Von Troeltsch have ar- rived at similar con- clusions. Rudinger also agrees with these writers, although formerly he as- serted that an open space existed below the cartilaginous hook along the entire length of the tube, therefore allow- ing a permanent and constant passage of the air between the pharynx and tympanum. Zuckerkandl and Moos have described islands of cartilage which act as real sesamoid cartilages in the tube; histologically, they always are composed of fibrous cartilage, are connected with the submucous tissue, the tendon of the tensor veil palati, and the sal pingo-pharyngeal fascia. In a trans- verse section of the membrano-cartilaginous canal (see Fig. 1053), it will be seen that the tube consists of a triangu- larly-shaped cartilaginous plate, called the median cartilage (a), curved upon itself and formed into a tube by means of a membranous portion. This cartilaginous plate (a) curves around in its upper portion and forms a hook (b). The cartilage is composed, on the surface, of a hyaline, but in the deeper portions of a fibrous, fundamental substance. According to Zuckerkandl and Urbantschitsch, there are frequently in the cartilage numerous irregular fissure- clefts, and occasionally a division of the cartilage into several separate portions. Attached to the extremity of the hook, the membranous portion, delicate and tine at first, gradually becomes thicker in passing down, and, sup- ported by adipose and glandular tissues, joins below with the salpingo-pharyngeal fascia. The membranous portion forms the lesser half of the circumference of the tube, viz., the lower portion of the lateral wall (z) and the base (d), while the cartilaginous portion forms the boundary of the other side and the superior wall, the hook (ft). The basilar fibro-cartilage gives attachment to the upper portion of the inner car- tilaginous wall, also to the upper wall of the tube, while the inner wall at its lower extremity is movable. The pharyngeal orifice is situated on the external wall of the cavity of the naso-pharynx, just behind the pos- terior extremity of the inferior turbinated bone ; it is rounded in the child, but oval-shaped in the adult, with a vertical diameter in the latter of 7 to 9 mm., and a horizon- tal one of 4 to 5 mm. (average diameter of the pharyngeal orifice 8 mm. high, 5 mm. wide, Schwartze). In adults the pharyngeal opening of the tube is not always funnel- shaped, but frequently of a triangular or crescentic form. According to Luschka the average distance of the pharyn- Fio. 1053.-Transverse Section of the Carti- laginous Portion of the Eustachian Tube, a, Cartilaginous plate; b, cartilaginous hook; c, space below the hook; d, base of the Eus- tachian canal; e, e', folds of mucous mem- brane ; f, cylindrical ciliated epithelium ; g, tensor palati mollis muscle; h, levator palati mollis muscle ; i, lateral wall. Fig. 1054.-Vertical Section of the Naso-pharynx, with the Catheter in- troduced into the Eustachian Tube, a, Inferior spongy bone; b, mid- dle spongy bone; c, superior spongy bone; d, hard palate; e, velum palati; f, posterior pharyngeal wall: g, fossa of Rosenmuller ; h, pos- terior lip of the orifice of the Eustachian tube. geal orifice from the posterior extremity of the lower nasal cartilage is 7 mm. The diameter of the canal is subject in adults to great variations. The superior and posterior part of the circumference of this orifice is quite prominent, being a continuation of the median cartilage and forming the anterior boundary of the fossa of Rosen- muller ; it serves as an excellent guide for the introduc- tion of the Eustachian catheter, and it is very important to locate this ridge with the beak of the instrument. In children the Eustachian tube is wider, shorter, its direction more horizontal, and it contains less cartilage than that of the adult. The opening into the tympanum is situated somewhat lower, and is larger in proportion. The pharyngeal opening exists only as a slit, and the pos- terior part of the tube, so prominent in the adult, is very small. Consequently, in children, the secretion passes more readily from the middle ear to the pharynx, and it is much easier to inflate the tube. Von Troeltsch says: "Although the pharyngeal orifice of the child's tube is narrower and less open than it is in adults, the portion of the cartilaginous tube just above the orifice is not only 729 Eustachian Tube. Eustachian Tube. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. relatively but absolutely wider than in later life ; the closure of the tube is, therefore, more lax and more easily overcome. " The mucous membrane lining the Eustachian tube is of the ciliated cylindrical variety, the cilia moving in a direction from the tympanum toward the pharynx, and thus aiding the flow of mucus or fluids from the middle ear and tube to the pharynx. It is of a light-yel- low color, firmly adherent to the deeper tissues, though somewhat projecting at the pharyngeal orifice. It is very smooth and thin in the bony portion of the tube, and closely adherent, and contains few acinose glands (glands 6 mm. in diameter, and 15 mm. in thickness) ; while in the cartilaginous portion the mucous membrane is more fully developed, and a great number of these glands open on its surface. Some glands are found in the con- nective tissue outside of the tube, especially near the pharyngeal orifice. The upper concave portion of the cartilaginous Eustachian tube is free from glands, while both sides of the tube near the pharynx are rich in aci- nose glands, as demonstrated by Riidinger. There are few glands in the upper portions of the tube near the tympanum. Gerlach has found in the child numerous sebaceous glands in the whole cartilaginous portion of the tube, analogous to the pharyngeal tonsils of Luschka, and which he proposes to name tonsils of the tube. Koellner and the older anatomists described a valve-like duplicature of the mucous membrane as a normal formation at the pharyngeal orifice. According to Schwartze this is path- ological, and due " to a relaxation or wrinkled swelling of the mucous membrane." Moos (" Beitrage zur Anat- omic u. Physiol, der Eust. Rohre," Wiesbaden, 1874, S. 29), however, maintains that this is a "true valve, which, although varying in different individuals, is never absent in the normal condition." The pharyngeal tonsil, spongy in substance, and with a maximum diameter of 7 mm., described by Santorini and Luschka, is found in the roof of the posterior nasal space. Muscles.-The muscles of the Eustachian tube are very important, as they open the tube during the act of swallowing and thus allow air to pass to the tympanic cavity. The principal ones are the tensor palati mollis, levator palati mollis, and salpingo-pharyngeus. Of these the salpingo-pharyngeus, or inner dilator of the tube, has its origin from the extremity of the posterior cartilaginous wall of the Eustachian tube, and extends toward the su- perior constrictor of the pharynx. The tensor palati mollis (spheno-salpingo-staphylinus s. circumplexus palati) arises partly from the under sur- face of the sphenoid bone and also from the extremity of the cartilaginous hook, and from the membranous wall of the cartilaginous portion of the tube. It passes down- ward, firmly attached to the lateral wall of the mem- branous part of the tube, around the hamulus pterygoi- deus as a tendon, and spreads out in the fibrous prolonga- tion of the hard palate. As the tendon is quite firmly attached to the hamulus pterygoideus, when the muscle contracts it acts more fully on the Eustachian tube than on the soft palate. Its action on the tube is to separate the outer or membranous wall, together with the carti- laginous hook, from the inner wall. As its action is quite limited on the soft palate, Von Troeltsch has pro- posed the name of abductor or dilatator tubie. The levator palati mollis (petro-salpingo-staphylinus) has its origin from the surface of the petrous bone, ad- joining the carotid canal. Passing along parallel to the Eustachian tube, it is joined by a band of connective tis- sue partly to the membranous portion which forms the base of the tube, and partly to the cartilaginous plate, and spreading out is inserted into the soft palate below the pharyngeal opening of the tube. This muscle is much less important as a muscle of the tube. Its action seems to increase the transverse diameter of the cartilaginous canal by pulling upward and backward the lower wall of the tube. Rudinger has proved that there is a direct connection, not only between the tendinous fibres, but also between the muscular fibres of the tensor palati and tensor tympani muscles at the upper part of the Eu- stachian tube. Ligamenta-salpingo-pharyngea. Zuckerkandl has given this name to a number of tendinous cords passing between the Eustachian tube and tlie pharyngeal constrictors. He believes that when the superior and middle constrictors act the Eustachian tube is freely opened. The plica salpingo-palatina and plica salpingo-pharyn- gea are two folds of mucous membrane which have con- siderable to do with the shape and expansion of the mouth of the Eustachian tube, not only during a period of rest, but also during the active and passive movements of the soft palate. The plica salpingo-palatina, closely connected with the tensor palati muscle, forms the anterior border of the pharyngeal mouth of the Eustachian tube, while the plica salpingo-pharyngea is simply a continuation, according to Zaufal, of the lower part of the tip of the pharyngeal mouth of the Eustachian tube. It is very rich in glands, and is a fold of mucous membrane extend- ing from the posterior and inferior end of the tubal ridge to join with the posterior border of the levator-palati muscle. Blood-vessels.-The arteries supplying the Eusta- chian tube are : (1) the pharyngeal, a branch of the ex- ternal carotid artery ; (2) the middle meningeal, from the internal maxillary artery, and (3) several small branches from the internal carotid artery. The veins of the Eustachian tube are numerous, and form a plexus which runs along the lateral tubal carti- lage and anastomoses with the cavernous sinus and partly with a vein on the superior portion of the temporal bone. These veins anastomose freely with the plexus near the temporo-maxillary articulation, and empty into the facial or internal jugular vein. In the cartilaginous portion of the tube the lymphatics are found in great number, and are connected with those of the mucous membrane of the pharynx and the soft palate. Nerves.-A branch from the otic ganglion, and a motor branch from the internal pterygoid nerve, which is itself a muscular branch of the inferior maxillary nerve, supply the tensor palati mollis muscle. The levator palati mollis is supplied by a branch of the vagus, as well as by the facial, through the Vidian and petrosal nerves. The glosso-pharyngeal nerve supplies the salpingo-pharyngeus muscle, and the tympanic plexus, formed in the middle ear, sends branches of distribution to the mucous mem- brane of the tube. In regard to the function of the Eustachian tube, Polit- zer concludes as follows : "1. The Eustachian tube is not constantly gaping ; its permeability varies individually, as in a number of cases a current of air from the pharynx toward the tympanic cavity takes place even during quiet respiration, while in other cases an act of deglutition or a powerful expiration •with opened or closed nostril is necessary to make the tube passable for the current of air. "2. The Eustachian tube is opened during the act of swallowing chiefly by the action of its muscles, especially the abductor tubae (v. Troeltsch), as is proved by the ex- periments of Toynbee and myself. "3. When the air pressure in the tympanum exceeds that in the pharynx, or vice versa, equalization of the pressure will be brought about by the passage of air from the one cavity to the other ; but the passage of air from the former to the latter takes place more readily than from the latter to the former." Diseases of the Eustachian Tube.-1. Foreign Bodies.-Foreign bodies when found in the Eustachian tube are usually pieces of cotton which have become de- tached from probes used in making applications ; lami- naria bougies occasionally break off and are left in the tube. Hecksher, of Hamburg, had an interesting case in a patient who was in the habit of introducing a whale- bone probe with a feather attached, through a Eustachian catheter, for the purpose of removing the secretion in the tube, and on one occasion, on withdrawing the probe, the feather was left behind. Severe inflammation ensued, and the feather was finally removed by the patient him- self. Urbantschitsch {Hosp. Gazette, Oct. 4, 1879) mentions a case in which an oak-leaf entered the Eustachian tube 730 REFERENCE HANDBOOK 01 THE MEDICAL SCIENCES. Eustachian Tube. Eustachian Tube. from the pharynx, and passed through the middle ear and membrana tympani into the external auditory meatus. Schalle had a case in which a portion of a hard-rubber syringe, used in douching the nose, entered the tym- panum through the Eustachian tube, and caused suppu- ration, and was finally removed through an incision made in the membrana tympani. Other foreign bodies are particles of food, which are sometimes, though rarely, forced into the Eustachian tube during the act of vomit- ing. An ascaris has been found in the tube, also a barley-corn. Clots of coagulated blood are sometimes found in the Eustachian canal, as the result of fracture of the base of the skull, and from haematemesis and hae- moptysis. The nasal douche is frequently the cause of fluids entering the tube, also the act of ducking the head, a common practice among children while bathing ; and suppurative otitis media is sometimes caused by water entering the tubes. 2. Hypercemia.-Uyperaemia of the tubal mucous mem- brane may be slight or deeply marked. When it occurs in connection with hyperaemia of the pharynx, the hyper- aemia is most marked in the cartilaginous portion of the tube, with the redness gradually becoming less toward the tympanic cavity. Just the reverse occurs with simul- taneous hyperaemia of the tympanum. Haemorrhages and extravasations are found in some cases in the tissue of the mucous membrane. 3. Inflammation. - Inflammation of the Eustachian tube, catarrhal in character, commences with hyperaemia and dryness of the mucous membrane, followed by in- creased secretion and more or less swelling of the mucous membrane, which is due to the congestion and serous and cellular infiltration. In certain cases hyperplasia of the gland follicles occurs, producing a granular appear- ance of the mucous membrane, while in chronic cases the glandular layer may be hypertrophied, associated with thickening of the submucous connective tissue. The swelling of the parts is generally most marked at the pharyngeal orifice, which may then exist only as a slit. Wendt ("Arch, der Heilkunde," xi., S. 261) has shown that genuine croupous inflammation of the mucous mem- brane of the tube may occur during an attack of croup, and, according to the same authority, in the lower third of the tube, and especially at the pharyngeal orifice ; the epithelium may undergo peculiar changes and give rise to cavities filled with pus-cells. During operations in the naso-pharyngeal cavity the parts may be injured and traumatic inflammation ensue. With chronic swelling of the Eustachian tube the folds of mucous membrane disappear more or less, except those of the median wall; the epithelium in these cases' is more liable to undergo degeneration, and there is hypertrophy of the submucous and interacinous connective tissue, and prolongations from these tissues connect with projections (hypertro- phied) of the salpingo-pharyngeal fascia and with the perichondrium. Changes occur in the glands, their walls become thicker,, and atrophy of the glandular substance takes place. In several cases examined by Politzer, in which during life suppurative inflammation of the middle ear had existed, he found, "in sections, that the mucous* membrane of the cartilaginous portion of the tube was covered by an opaque and fatty epithelium, stratified several times ; the lumen of the dilated canals was filled with a crumbling substance consisting of secretion and dead epithelial cells ; the closed follicles of the so-called tonsils of the tube were dilated; the interstitial connec- tive tissue greatly hypertrophied ; the cartilage cells of the tube fatty and partly stained, of a brownish color, by a finely granular pigment." In the adhesive form of middle-ear catarrh the pathological changes in the tube are more or less dependent on the character of the inflam- mation in the tympanum. In those forms of diffused in- flammation which are associated especially with chronic naso-pharyngeal catarrh, a diminution in the calibre, some- times slight, sometimes very considerable, occurs. This narrowing of the tube is due to hypertrophy of the mu- cous membrane, followed by thickening and contraction of the submucous connective tissue. In cases of circum- scribed interstitial inflammation of the tympanum the mucous membrane of the Eustachian tube, as a rule, re- mains unchanged, although in some instances there maybe a well-defined stricture. Moos has found and described small spots of ossification as occurring in the tubal car- tilage ; and calcifications of the cartilage are also some- times found in chronic inflammation of the middle ear. 4. Ulceration.-Various diseases, as syphilis, scrofula, diphtheria, variola, and tuberculosis, may give rise to ulcerations, not only at the pharyngeal opening.of the tube, but also in the lower portion of the canal. In catarrh of the naso-pharynx, of the purulent follicular variety, small, superficial, follicular ulcerations are sometimes seen at or near the pharyngeal orifice. The ulcers in variola are usually round, superficial, generally confined to the pharyngeal orifice, and rarely extend into the cartilaginous portion of the tube. The syphilitic and tuberculous ulcerations extend deeper into the tissues, sometimes pen- etrating the cartilage itself. According to Schwartze, "higher up in the tube, ulcerative processes only, occur with caries and tumors (epithelial cancer), which may partially or wholly destroy the osseous tube." As the result of syphilitic ulcerations in the naso- pharynx, cicatricial adhesions are occasionally found at the pharyngeal orifice, and adhesions due to hyperostosis and inflammation occur at either opening of the tube. The pharyngeal orifice is sometimes closed by cicatricial tissue due to diphtheria, variola, and scrofula. Chronic suppuration from the middle ear and caries are sometimes the cause of adhesions at the tympanic opening of the tube, due to increase of the connective tissue. Bridges of connective tissue are also seen in the tube. 5. Stenosis or Contraction.-A narrowing or stenosis of the Eustachian tube occurs most frequently in catarrh. A contraction of the tube is produced, though rarely, by hyperostosis and exostosis. In caries or proliferous in- flammation of the tympanum, sometimes new connective- tissue growths occur at the tympanic orifice and thus cause stenosis. Stenosis in the middle portion of the tube is quite rare. According to Schwartze, "real strictures in the sense in which urethral strictures are formed, by thickening and atrophic shortening of the tissues, appear not to occur in the Eustachian tube. " The tympanic orifice is frequently contracted in cases of otitis media by hypertrophy of the mucous membrane or of the connective tissue. Magnus and von Troeltsch found bands of tissue extending across the tympanic orifice. Occasionally the calibre of the tube is very much encroached upon by the carotid canal. Toynbee relates a case of osseous stricture of the tube through which a bristle could with difficulty be passed. Mechanical closure of the tube is produced by an en- croachment upon the pharyngeal opening, due to polypi, adenoid growths, large cysts or swellings, hypertrophy and thickening of the neighboring tissues. Enlarged tonsils and adenoid vegetations cause the soft palate to be pressed against the tube, and adenoid growths may cover over the mouth of the tube itself. Thickening and hy- pertrophy of the mucous membrane of the soft palate may impede the muscular contraction of the tensor palati and levator palati muscles, and thus interfere with the proper approximation and separation of the walls of the membrano-cartilaginous portion of the tube. Congestion of the superior vena cava may produce oedema of the tubal prominence, and anything that interferes with the action of the palato-tubal muscles, as fissure of the palate, cleft palate, etc., may bring about changes in the calibre of the tube. 6. Dilatation.-Occasionally the tube is more dilated than usual throughout its entire length ; this is apt to occur in connection with sclerosis of the tympanic mu- cous membrane, or chronic suppuration of the middle ear may lead to partial dilatation in the osseous portion of the tube. The pharyngeal orifice may be more dilated than usual, this condition being due to atrophy of the mucous membrane of the pharynx, thus causing the tu- bal prominence to project. 7. New-growths.-Polypi within the tube have been re- corded by some writers, while polypi in the middle ear 731 Eustachian Tube. Evolution. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are frequently attached in whole or in part to the tym- panic opening of the tube. Syphilitic growths, very similar to condylomata, have been observed in some cases at the pharyngeal opening, as well as caseous nodules in miliary tuberculosis. In the Eustachian tube and tym- panum osteophytes are frequently seen. Voltolini has described a case of polypus filling the entire length of the tube. 8. Changes in the Muscles.-The muscles of the Eusta- chian tube undergo fatty degeneration, especially around the pharyngeal orifice, in chronic inflammation of the naso-pharynx of long standing. Syphilitic and scrofulous ulceration of the mucous membrane may lead to atrophy and cicatricial contraction of the muscles. These changes in the muscles, acting on the tube, are of importance, be- cause proper ventilation of the middle ear may be inter- fered with. 9. Congenital Diseases.-J. Gruber has reported a case of congenital absence of the Eustachian tube, but asso- ciated with absence of the meatus, ossicula, and rudimen- tary development of both the tympanum and labyrinth. Cases of congenital obliteration and stenosis, and congeni- tal widening of the tube, have been described, but are very rare. According to Schwartze, " congenital anomalies of the tube in the form of angular bends in the osseous por- tion, of ossification-gaps in the wall of the canalis caroti- cus, of unsymmetrical position of the pharyngeal orifices, are more common." A fact of great importance in diseases of the ear in children is the marked development of the mucous mem- brane and lymph glands : this is the case with the throat tonsils in their normal condition. Consequently, in the diseases common to childhood, as scarlet fever, measles, coryza, etc., these tissues and glands become swollen. At first the Eustachian tubes may not become affected, but frequent attacks of catarrh in the naso-pharynx lead to closure of the slit-like openings of the tube. Owing to the small size of the naso-pharyngeal cavity, the tubes are much more liable to be closed by an enlargement of the glands or swelling of the mucous membrane, and closure of the canal, due to a permanent cohesion of the opposed surfaces, may occur along the length of the tubes as well as at the pharyngeal orifices. Of the greatest im- portance, therefore, are the hygienic surroundings of children. Crowding them together in tenement-houses, and constantly breathing in impure air, cause indirectly diseases of the middle ear and Eustachian tubes. Gorham Bacon. sional capacity. One of the most important of these is that touching upon the secret communications made to him by his patient. These communications are usu- ally called privileged, and the same rule of exclusion ap- plies to the physician, the lawyer, and the clergyman. These three classes are forbidden by professional honor, and very frequently by positive legal enactment, from dis- closing secrets made known to them in a professional ca- pacity. The common law of England, which is the basis of all our law, gives a medical man no privilege at all, but requires him to answer all inquiries concerning the knowledge derived from personal investigation of a pa- tient's ailments, and also requires him to make known what the patient has told him confidentially. The principal case in which this rule was distinctly laid down was in what is called the Duchess of Kingston's case, tried about one hundred years since. It was stated in this case that a physician was bound to disclose, when called upon to do so in a court of justice, every communication, no matter how confidential, made to him by a patient while being treated professionally. The words of Lord Mansfield, be- fore whom the case came for decision, were : " If a medi- cal man were voluntarily to reveal those secrets, to be sure he would be guilty of a breach of honor and of great in- discretion, but to give that information which by the law of the land he is bound to do will never be imputed to him as any indiscretion whatever." This rule seems to be changed in England now, and it never had a wide acceptance in this country. On the contrary, the great majority of the States make commu- nications between the physician and his patient privileged, and the physician is either not permitted or else not obliged to make them known. Most of the States do not allow the disclosure. In the case of Wisconsin, the phy- sician may, if he desire, testify to the communications, but cannot be compelled to do so. In Minnesota, the rule applies only to testimony in civil cases, and the disclosure is required in criminal actions. In Iowa, Indiana, and Minnesota, the patient can, if he desire, permit the disclosure to be made. The law in New York is as follows : " No person duly authorized to practise physic or surgery shall be allowed to disclose any information which he may have acquired in attend- ing any patient in a professional character, and which in- formation was necessary to enable him to prescribe for such patient as a physician, or to do any act for him as a surgeon." The privilege is closely confined to matters relating to the professional treatment of the patient, and other subjects are required to be made known. The courts have also decided that a comprehensive pro- hibition like that contained in the New York Statute shall not be construed to shield a criminal. It was intended to be a protection to the innocent patient, and will not be extended further. Communications, to be privileged, must all be lawful, and not against morality or public policy. It is not permissible, for instance, for a physician to re- fuse to make known that he was consulted as to the best means of procuring an abortion, or of evading the conse- quences of a crime. It has also been decided that the information claimed to be privileged must be acquired entirely during professional attendance, and was really necessary to enable the physician to prescribe. It is said in one case, " It will not do to extend the rule of exclu- sion so far as to embarrass the administration of justice. It is not even all information which comes within the letter of the statute which is to be excluded. The exclu- sion is aimed at confidential communications of a patient to his physician, and also such information as a physician may acquire of secret ailments by an examination of the per- son of his patient. The policy of the statute is to en- able a patient, without danger of exposure, to disclose to his physician all information necessary for his treatment. Its purpose is to invite confidence and to prevent a breach thereof. Suppose a patient has a fever, or a frac- tured leg or skull, or is a raving maniac, and these ailments are obvious to all about him: may not the physi- cian who is called to attend him testify to these matters ? The court must know somewhat of the circumstances EVIDENCE. Medical evidence, as here treated, is con- sidered to mean the testimony proper to be given in courts of justice by physicians as such. It differs from Expert Evidence, which is the subject of a separate article, in that the latter relates strictly to evidence given by a physician or surgeon concerning matters which he has no personal acquaintance with, but which he is allowed to give an opinion on because of his professional and technical knowledge. The physician is likely to be brought in contact with the forms of law either through the coroner's inquest or the higher courts of justice. The investigation before the coroner's jury only relates to deaths supposed to be by violence, and is ex parte. The physician reports upon the circumstances as ascertained by his examination of the body, and upon that and the testimony of other witnesses the coroner's jury bases its verdict. This verdict gives the cause of the death as known or unknown, and may state at whose hands or in what way the death occurred. ' If the case ultimately finds its way into the criminal courts the physician will be called to testify in regard to his knowl- edge or opinions. In civil cases, such as actions for damages from personal injuries or from malpractice, the physician may also be called to testify either on his own behalf or for others. It will be important, therefore, to know in what ways the rules of evidence affect him as a physician, but the broad field of evidence will not be here discussed. A medical witness is bound by the same rules of evidence which apply to all other witnesses, but there are some special rules which relate to him iu his profes- 732 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eustachian Tube. Evolution. under which information was acquired, and must be able to see that it is both within the language and the policy of the law." The report of the physician employed by an insur- ance company upon the health of a person applying for life insurance is not privileged. When the basis of the action is damages for an injury suffered by the patient it is of course competent for the physician to testify con- cerning the accident or ailment and give an opinion thereon. The statute in this case also is intended for the protection of the patient and not for his harm. In such actions, when it is desired to prove the bodily or mental feelings of the patient, his expressions indicating pain or suffering are competent evidence. The statements of a sick person relating to a condition prior to the existing illness are not proper evidence. Statements in writing, furnished by the patient to a physician describing the symptoms of his illness are not competent evidence. In Illinois it is said that the physician may testify as to what the patient told him in reference to his bodily condition, if said under such circumstances as would free the com- munication from all suspicion of being spoken with ref- erence to future litigation. In Massachusetts a different rule has been laid down. In an action in that State for personal injuries the physi- cian was not permitted to testify that the patient told him that she had received a blow in her stomach. In Tennessee, statements made by a man whose wounds were being examined that they had been inflicted by a particular instrument in the hands of a designated person were held to be inadmissible. The physician or surgeon usually keeps careful mem- oranda of cases which he is called upon to attend. Such memoranda are not in themselves proper evidence, but may be used to secure evidence. They may be shown to the witness, or used by him to refresh his memory. The witness must, however, be able to testify from his own recollection of the circumstances mentioned in the memoranda. If the record produces no recollection in the mind of the witness of the events mentioned in it other than that he knows he made the memoranda, it cannot be in- troduced as evidence. It is not necessary that the writing should have been made by the witness, nor that it should have been made at the time of the occurrences mentioned, but if not then made little value is usually attached to the recollection which it produces. A very important question in medical evidence relates to the admissibility of standard medical books as evi- dence. It seems to be the almost universal rule that such books cannot be read from or testified about, even when they are stated to be regarded as of high authority. This rule is accepted in England, and in most of the States of this country. In 1875 Justice Brett said of " Taylor's Medical Juris- prudence" that "it was no evidence in a court of jus- tice. It is a mere statement by a medical man of hear- say facts of cases at which he was, in all probability, not present. I cannot allow it to be read." The above rule is in force in Indiana, Maine, Maryland, Massachusetts, Michigan, New York, North Carolina, Rhode Island, and Wisconsin, and is supported by dicta in California and New Hampshire. In Iowa and Ala- bama medical books are allowed to be read. Upon the cross-examination of witnesses greater latitude is allowed than on the direct examination, and quotations from stan- dard medical works are usually permitted to be read to the witness, and he may be asked if he agrees with the quota- tions. The object of this is to test his knowledge and to dis- credit his testimony, if his statements and the authorities do not agree. For similar reasons scientific and medical works cannot be read to the jury as part of the argument of counsel. The rule as to the admissibility of medical books is well stated by Chief Justice Shaw in a Massachusetts case : " Where books are thus offered (to be read in argument) they are, in effect, used as evidence, and the substantial objection is, that they are statements wanting the sanction of an oath ; and the statement thus proposed is made by one not present, and not liable to cross-examination. If the same author were cross-examined and called to state the grounds of his opinions, he might himself alter or modify it, and it would be tested by a comparison with the opinions of others. Medical authors, like writers in other departments of science, have their various and con- flicting theories, and often defend and sustain them with ingenuity. But as the whole range of medical literature is not open to persons of common experience, a passage may be found in one book favorable to a particular opin- ion, when, perhaps, the same opinion may have been vigorously contested, and perhaps triumphantly over- thrown, by other medical authors whose works would not be likely to be known to counsel or client, or to court or jury." The rule excluding medical books from the argument of counsel is established in Massachusetts, North Carolina, Michigan, California, and New York. In Connecticut, Indiana, Texas, and Delaware it has been permitted to the counsel to read from medical works in their arguments to the jury, provided the extracts did not appear to be of the character of evidence. The read- ing from medical books is so likely to transcend the limits fixed that its control is in the discretion of the court. In arguments addressed to the court instead of to the jury medical books may usually be read. The dying declarations of persons can be stated by physicians when the cause of death is the subject of the declaration. Such statements are not admissible, how- ever, unless given when the person was in actual expecta- tion of speedy death. Still, it is not necessary that the patient should die at the time of making the declaration. The expectation of death is what gives admissibility to the declaration. In " Taylor's Medical Jurisprudence" are some excel- lent rules for the guidance of medical witnesses. Some of them are as follows : "In reference to facts, a medical witness must bear in mind that he should not allow his testimony to be influenced by the consequences that may follow from his statement of them, or their probable effect on any case which is under trial. In reference to opinions, their possible influence on the fate of a prisoner should inspire caution in forming them ; but when once formed, they should be honestly and candidly stated, without reference to consequences." " The questions put on either side should receive direct answers from the medical witness, and his manner should not be perceptibly different whether he is replying to a question put by the counsel for the prosecution or for the defence." " The replies should be concise, distinct, and audible, and, except where explanation may be necessary, they should be confined strictly to the terms of the ques- tion." " Answers to questions should be neither ambigu- ous, undecided, nor evasive." " The replies should be made in simple language, free from technicality." ' Henry A. Riley. EVOLUTION. The diverse uses of this word in dif- ferent provinces of philosophical thought, and in different ages, are very confusing to one who is not familiar with the history of science, and it is important to distinguish clearly, 1, the use of the term in philosophy ; 2, its use in biology as the name for a doctrine of the origin of the various species of living things ; and 3, its use in bi- ology as a name for a doctrine of the origin and develop- ment of the individual organism in the egg or seed. The distinction between the two latter uses of the word is much like the distinction between the general history of the human race and biography or the history of the in- dividual. We may therefore speak of philogenetic evo- lution, or the history of the changes by which each organism has acquired its present characteristics, and ontogenetic evolution, or the history of the formation of the individual organism in the egg. I. The Word Evolution in Philosophy.-A long discussion of the philosophy of evolution would be out of place here. Briefly stated, it is the doctrine that the visible universe has become what it now is by the action 733 Evolution. Evolution. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of forces which are contained in itself; and that it has attained to its present condition by a gradual process of change from unorganized homogeneity to organized complexity ; that all the complex bodies which now exist have originated from a simpler condition of things ; and that all the relations between the various parts of the universe have been gradually brought about by the ac- tion of causes which inhere in the material universe it- self ; and that its future history will be a direct resultant of its present condition. II. Evolution in Biology.-a. The Evolution of Species, or Philogenetic Evolution.-Two views as to the origin of species have prevailed among naturalists ; the view that each species is the result of a direct act of crea- tion, by an agency outside nature ; and the view that new organisms are produced, in the course of nature, by the modification of pre-existing organisms. The latter view is known as the theory of the evolution of life. Its independence of the philosophy of evolution is well shown by the fact that there are many thinkers who reject the latter while they believe in the evolution of life ; nor is such an attitude* at all illogical, for it is quite possible to believe that the origin of living things is no more super- natural than the origin of any other form of material existence, and, at the same time, to hold that all existence is evidence of creative intervention. We must also distinguish between the belief in the evo- lution of life and the acceptance of any particular ex- planation of the manner in which it has been brought about. Much of the evidence of evolution, such as the fact that such animals as the horse, the rat, and the cat are constructed on a common plan, or the fact that certain species, as the horse and the zebra, are much more closely related than others, as the horse and the cow, is so ob- vious that it cannot escape notice ; and the belief that re- lated animals may have been derived, the one from the other is as old as speculative thought ; but within the last two hundred years, the various relations between living things have been made the subject of thorough and exact scientific research, and proofs of evolution have been gathered from so many sources that the doctrine of the evolution of life is practically a product of modern thought. The chief sources of evidence in proof of the evolution of life may be grouped under the following headings : 1. The evidence from the geographical distribution of animals and plants. 2. The evidence from the geological succession of ani- mals and plants. 3. The evidence from homology, or fundamental simi- larity of plan. 4. The evidence from rudimentary organs. 5. The evidence from embryology. 6. The evidence from classification. 7. The evidence from variation. 8. The evidence of organisms which have been modi- fied under domestication. 1. The evidence from geographical distribution. It is well known that each species has a proper home, where it is most abundant, and beyond the boundaries of which it becomes rare, and gradually disappears. In some cases this home is bounded by geographical barriers, such as mountain ranges or large bodies of water; but more usually the range of an organism is restricted by ene- mies or competitors rather than by inorganic conditions. The range of a genus or a family is wider than that of each species; but, as a rule, the various species of a genus, or the genera of a family, inhabit the same prov- ince of the earth's surface, as we should expect them to do if they have been derived from a common ancestor. As certain animals and plants are adapted to life in a cold climate, others to life in warmer regions, some to life in the plains, some to life in the forests, and others to life among the mountains, we should expect to find a change in the fauna and flora as we pass from one region to another ; but a little thought will show that the presence or absence of a species depends on something else than the presence or absence of proper conditions of life. The European sparrow and the horse find in the United States a favorable climate, and the sparrow has multiplied in the Eastern States at such a rate as to almost exterminate many of our native birds. On our western plains and on the pampas of South America the descendants of the horses which were introduced by the early explorers still flourish and multiply, generation after generation. How is it, then, that these species, which are so perfectly adapted for life in our country, were not found here as natives ? It is clear that the distribution of a species is not determined by the external conditions of life. Europe and North America are much more alike in their climate and in other physical conditions than Europe and Africa, or North America and South America, while Africa and South America again are very similar. The animals and plants of Africa are totally different from those of South America, and very similar to those of Asia and Europe ; while the fauna of South America shows a similar resemblance to that of North America. On the one side we have baboons, lions, elephants, buffaloes, and giraffes; and on the other, spider-monkeys, pumas, tapirs, ant-eaters, and sloths; and among the birds, insects, and plants, the contrast is equally great. North America has its own species of humming-birds, rattlesnakes, and opossums ; while other species of each of these groups are found in South America, but in no other part of the world. Monkeys are found in the new world as well as the old ; but the species which are found in Europe, Asia, and Africa belong to a group which is not represented in America ; and the species which are found in South America and in the tropical parts of North America belong to a group which is not repre- sented in the old world. The physical features of Australia are as much like those of Africa and South America as those of the two latter are like each other ; but all the mammals of Aus- tralia, except man and the native dog, are marsupials or monotremata, and none of these mammals, except the opossum, are found anywhere except in Australia and the adjacent islands. As a rule, the inhabitants of widely-separated regions differ more than the inhabitants of those which are less remote, but this is not a universal rule. The marine in- habitants of the European and North American shores of the Atlantic are much more alike than those which are found on the two sides of the Isthmus of Panama, although this is only a few miles wide, and its two shores are almost exactly alike so far as their physical features are concerned. The present status of the theory of evolution, as applied to the origin of species, is chiefly due to the labors of Darwin and Wallace, and both these naturalists were led to their conclusions by the study of geographical distribu- tion, as exhibited by the inhabitants of oceanic islands. Wallace spent several years studying the zoology of the Malay Archipelago-a long chain of islands stretching from the north of Australia to the Malay Peninsula of Southern Asia, or more than four thousand miles. Some of these islands are larger than Great Britain, while some are very small; some of them are volcanic, while some are not; some of them are covered with dense forests, while others are almost bare of trees ; some are far from other land, while others are separated by narrow straits only a few miles wide. Wallace found that this group of islands is inhabited by two sets of animals, which differ from each other more than the inhabitants of Africa differ from those of America, and that the two faunas are not distributed according to any of the physical contrasts be- tween the islands, but are abruptly separated by a nar- row strait only fifteen miles wide, where it is possible to pass in two hours from one great division of the earth to another, differing as essentially in animal life as Europe does from America. To the west of this strait the islands are inhabited by animals which are essentially Asiatic in type, although most of the species are peculiar. In these islands apes, monkeys, cats, tigers, wolves, bears, deer, antelopes, sheep, oxen, elephants, tapirs, rhinoceroses, horses, squirrels, rabbits, and other familiar 734 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Evolution. Evolution. types, arc found, and the birds and insects belong to families which occur on the continent of Asia.. The islands at the eastern end of the group have a a fauna which is essentially Australian ; none of these familiar animals occur, and in their place we find kanga- roos, opossums, wombats, and the duck-billed platypus. The birds belong to no familiar group ; there are no woodpeckers or pheasants, but in their place the mound- making brush turkey, the honeysuckers, the cockatoos, and the brush-tongued lories, which are found nowhere else upon the globe. Wallace was led, by the study of geographical dis- tribution in the Malay Islands, to conclude that the in- habitants of the western end of the archipelago have been produced by the gradual modification of Asiatic forms, while those at the eastern end have been evolved in the same way, from Australian ancestors. Darwin was led to a similar conclusion through the study of the animals and plants of the Galipagos Islands, a small group of islands in the Pacific, five or six hun- dred miles from South America. He found that most of the species which inhabit these islands are peculiar, occur- ring nowhere else, although their nearest allies are all found upon the nearest land, the adjacent part of the continent of South America. He therefore concludes that animals from the conti- nent have some time found their way across, and that since that date the South American forms have become modi- fied along one line of evolution, while the descendants of the immigrants to the islands have become modified along another line. The facts of geographical distribution are inexplicable upon any view, except that allied animals owe their re- lationship to genetic descent; and this conclusion is strengthened by the study of the relation between the species which are now living upon the earth and the fossil remains of extinct species. 2. The evidence from geological distribution. The various fossiliferous rocks show a difference very similar to that which is afforded when geographical areas are compared. The species found as fossils in the formations of different periods in the earth's history are, as a rule, distinct, but the difference between them is slight when the formations are slightly separated, and great when they are far apart. The fossils of the period just preceding the present one show a similarity to the animals now in- habiting the same regions ; the species are different, but the prevailing types are the same. Thus fossil armadillos and ant-eaters and sloths abound in South America, the country which these animals still inhabit, and the post- tertiary mammals of Australia are marsupials, like the present inhabitants. The post-tertiary deposits of the old world yield an abundance of forms similar to those now existing there, such as the elephant, the rhinoceros, and the hippopotamus ; and the very strange birds of New Zealand had predecessors of similar strangeness. While the terrestrial animals show a close resemblance to those which now inhabit the same regions, belonging to the groups which are now prevalent, but, as a rule, to extinct species, the lower organisms exhibit even a closer relationship, and the marine animals which live under simple conditions, in an ocean which is not subject, like the land, to sudden changes, and which are of lower organization, as a rule, than terrestrial animals, and there- fore more able to resist vicissitudes of climate and other changes, are very generally of the same species which now live in the same areas. There is no reason why we should resist the natural con- clusion that the present inhabitants of each of the great provinces of the earth's surface are the descendants of those whose fossil remains are found in the same regions, and that the terrestrial and more highly organized species have undergone considerable modification because their conditions of life have changed ; while the lower forms of life have been subjected to little or no change, because they live under more simple and uniform conditions. Paleontology furnishes even more convincing evidence of evolution by the discovery of the fossil remains of ex- tinct organisms which unite in themselves the character- istics of groups which are now very widely separated; and the bird-like reptiles and reptile-like birds which are now known to have lived in past times leave little room to doubt that birds have actually been evolved from rep- tile-like ancestors by a gradual process of modification. The series of fossil species of Hipparion, Anchitherium, Eohippus, Miohippus and Neohippus, and Equus which have been discovered by American paleontologists, show all the stages in the evolution of the horse with a com- pleteness which leaves nothing to be desired, and the evi- dence for evolution could in this case hardly be more conclusive. Another proof of evolution is the fact that the order in which the representatives of the minor divisions of a great group have appeared in geological history is very similar to their relative rank in the system of classification. 3. The evidence from homology. The parts of the body of each animal are so perfectly fitted for their use that we find, as we should expect, that animals which have the same mode of life are very similarly constructed. More careful examination shows, however, that similarity in the plan of organization is often found where it is not due to similarity of use, but exists in spite of the greatest diversity of function. The leg of an insect is used like the leg of a bird, for walking or leaping or climbing, and the wing like the bird's wing, for flight, and the general mechanical construction is the same ; but there is no real fundamental similarity. The bird's wing is a limb, modi- fied for flight. The insect's wing is a fold of the integu- ment. The bird's leg has the muscles outside the bones, while the insect's leg has no bones, but has the muscles attached to the inside of a hard shell or case. There is no similarity in the use of a man's arm and that of his hand ; or that of a bird's wing, and that of a turtle's fin ; yet in each we have a shoulder-girdle, a humerus, a radius, and ulna, carpal and metacarpal bones, and phalanges, and the arrangement of the nerves and muscles is essentially alike, although their uses are so different. The theory that this fundamental similarity of plan, which is one of the most universal of the phenomena of nature, is due to community of descent gives us a clear, simple, and adequate explanation of a fact which is inex- plicable upon any other hypothesis. 4. The evidence from rudimentary organs. The fun- damental plan of structure of a group is often adhered to when there is, so far as we are able to discern, no use whatever for the parts which are thus developed, so that we have in one species rudiments of parts w7hich are of functional importance in another species. The human coccyx is a rudimentary tail, and it is furnished with ex- tensor muscles like those which are of functional impor- tance in the tailed mammalia. The extrinsic muscles of the human ear, and the superficial muscles of the scalp, are, so far as we can say, of no use whatever to man, and the only satisfactory explanation of the presence of these structures in man is that which regards them as inherited from a remote ancestor, in whose body they were useful and important. 5. The evidence from embryology. The embryos of the higher forms of life usually repeat more or less per- fectly, during their development, structural peculiarities which are characteristic of the adults of lower forms. Thus the human infant has, like adult apes, the arms longer than the legs, and the soles of the feet are turned inward in a position suited for grasping branches in climb- ing. In a young human foetus, the great toe is like a thumb, shorter than the other toes, and projecting at an angle as it does in adult apes. At a still earlier period the human embryo has a well-developed tail, a cloaca and Wolffian bodies, and gill arches, and branchial arteries, like the adults of the water-breathing vertebrates. In almost every animal which has been carefully studied similar facts have been observed, and they receive a sim- ple and satisfactory explanation on the hypothesis of evo- lution. According to this view the early stages in the de- velopment of the human embryo are like those in the development of a fish, because fishes and mammals are the descendants of a common remote ancestor from whom they inherit what they have in common. 735 Evolution. Evolution. DEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 6. The evidence from classification. It is a familiar fact that certain animals are more closely related than others, and the use of this word by all schools of natural- ists shows how natural is the conception that the bond of connection is genetic descent, or relationship in its strict sense. All naturalists recognize the existence of a natural classification of animals, and the attempt to discover this true or natural arrangement has resulted in the grouping of organisms into a system of larger and larger groups, precisely as would be the case if they were the actual de- scendants of ancestral forms, and the conclusion seems irresistible that the natural system of classification is natural simply because it is an expression of the actual genetic history of life. 7. The evidence from variation. All organisms tend to vary, and variations may appear in any organ or struct- ure whatever, and among the more common or dominant species of animals and plants naturalists find it quite im- possible to distinguish between true species and varieties, and there is every reason to believe that what are at one time mere slight varieties may become in time, by diver- gent modification, good species. 8. The evidence from domesticated animals and plants. The fact that the various forms of life are not fixed and unchangeable, but are capable of modification in any direction which may be advantageous, is conclu- sively proved by the fact that man has succeeded, within a few centuries, in producing, from a single ancestral form, organisms as different as the cabbage, cauliflower, broccoli, and Brussels sprouts ; or the peach and the nec- tarin ; or the fan-tail, pouter, tumbler, and carrier pigeons ; or the bulldog, the greyhound, and the terrier. The various breeds of domesticated organisms have been established by selective breeding, and Dr. Wells, of Charleston, S. C., was the first to point out that a similar result must be produced under nature, by the survival of the fittest. A belief in the evolution of life does not necessarily imply the acceptance of any particular explanation of the manner in which it has been brought about, but the dis- covery by Wells, Darwin, and Wallace, that we have in the survival of the fittest, through the natural selection and preservation of such favorable varieties as chance to appear, a means of explaining, at least partially, the evo- lution of life, has led most naturalists to acknowledge that the long series of facts which we have detailed are satisfactorily accounted for only by the theory of evolu- tion. b. Ontogenetic Evolution.-Embryologists in modern times frequently speak of the evolution of the embryo from the egg, using the word as if it were synonymous with development; but we must not forget that it had in the last century a precise technical significance, and that it still continues to be employed in this way occasionally, although most embryologists of modern times reject the evolution theory of the origin of the embryo, while they are evolutionists in the wider and more modern sense of the word. The development of a highly-complicated and perfect animal from a simple unorganized egg is one of the greatest wonders in nature, and it has always attracted the attention of thinkers ; and at the end of the last cen- tury Bonnet and Haller advanced their theory of evolution as an explanation of the phenomena of development. According to this theory the germ is supposed to contain, in a latent or dormant state, a minute but completely formed and perfect organism, and development is simply the unfolding or evolution of this fully formed and per- fect embryo into the mature animal or plant; and the pro- cess of development was regarded, not as production, but eduction. The advocates of this doctrine appealed to such facts as the presence of a minute plant inside the acorn, or the presence of a butterfly inside the skin of the pupa. It is obvious that this theory is logically incomplete, since it accounts for only a single generation, and its ad- vocates were therefore compelled to enlarge it and to as- sume that, as each organism thus exists in a perfect form in the egg, each germ must contain, on a still smaller scale, the perfect germs of all subsequent germs. They accordingly taught that all living things proceed from pre-existing germs, and that these contain, one enclosed within the other, the germs of all future living things : that nothing really new is produced in the living world, but that the germs which develop have existed since the beginning of things. This hypothesis was quickly overthrown by the first discoveries of modern microscopic embryology, and we now know that the embryo is not unfolded from, but built up out of, the egg ; and that the eggs of all animals, when they are not complicated by the presence of a supply of food, or of peculiar coverings for protection or other pur poses, are essentially alike in optical structure; and that they are not only like each other, but like the constituent cells of all parts of the body of the organism ; and that the development of the embryo is a process of cell-multi- plication. Modern embryologists have, therefore, rejected the hy pothesis of evolution, and have returned to the much older hypothesis of epigenesis of Harvey, who taught, in 1651, that every living thing is evolved from a germ in which no trace of the adult characteristics of the organ ism is discernible ; and most modern morphologists go even further, and state, without qualification, that the egg is simply an unspecialized cell which does not differ in any essential particular from the other cells of the body, and that the formation of the embryo is simply due to cell-multiplication. If this be the true view, how shall we explain the fact that the human ovum becomes a man, while the ovum of an oyster becomes an oyster ? This is not due in any way to the action of external circumstances, for among the lower animals the eggs are discharged from the body and thrown out into the water before development begins, and we may rear, in the same tumbler of sea-water, under exactly the same external conditions, from eggs which are almost identical so far as the microscope shows, animals as different as a star-fish, a crustacean, a mollusk, and a vertebrate. How shall we explain this if we reject the hypothesis of evolution ? The current explanation is this : We know, from many sources of evidence, that one of the higher animals, a horse, for instance, is a descendant, through a long series of generations, of a very remote ancestor, which was a unicellular organism. The unicellular egg is homologous with this ancestral unicellular organism, and it is only natural that it should recapitulate, in its own develop- ment, the series of changes by which the unicellular an- cestor was slowly evolved into a horse. At first sight this explanation seems plausible enough, but a little thought will show that it is in no sense satis- factory. The horse has been produced slowly, step by step, through the natural selection of successive slight variations, and there is nothing whatever to take the place of natural selection in the development of the egg. The modern hypothesis of epigenesis proves on analysis to be no explanation at all, and we are compelled to be- lieve that the germ is not an unspecialized cell, but that, in some shape or other, the mature organism is latent or dormant in it. While we cannot accept the hypothesis of evolution in the crude form in which it was first brought forward by Bonnet and Haller, there is, I believe, no escape from the belief that the egg is very highly specialized, except in the totally unscientific conclusion that each individual is the result of a new creation. As this conclusion is op posed to all the analogy of science, we must believe that the apparent simplicity of the egg is simply the result of our imperfect means of observation, and that some form of the evolution hypothesis is more probable than the hy pothesis of epigenesis. W. K. Brooks. EVOLUTION OF MAN. The debate upon the theory of evolution as applied to man is practically ended, so far as scientific biologists are concerned, since it is the all but unanimous conviction among biologists that the human species has been evolved from a lower form, not human, 736 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Evolution. Evolution. but distinctly an ape. The whole ancestral series may be thus given in abbreviated form : 1. Man. 2. Anthropoid. 3. Lemuroid (original primate). 4. Prototherium (original mammal). 5. Primitive reptile. 6. Icthyoid (early vertebrate). 7. Segmented worm. 8. Primitive worm (rotifer-like.) 9. Gastrula. 10. Protozoan. In this brief article it is impossible to give more than an aphoristic summary. We shall consider first the reasons for believing in the evolution of man ; second, the objec- tions to that belief ; third, the grounds for regarding the ancestral history as given above as approximately correct. Confusion should be carefully avoided between the two problems with which we shall deal, the first being the general problem whether man has arisen by evolution; the second being, what is the particular series of ances- tors of man. I. Arguments for the Evolution of Man.-These are general and special. The general reasons are those very numerous ones already alluded to in the general ar- ticle on evolution for believing in the evolution of the organic world. These fall into two natural classes, namely, direct and indirect arguments ; the former are those which afford immediate evidence of evolution, while the latter are in its favor by the inductive conclusions they support. The direct arguments are such as the ob- servations of the transformations of living forms, as in the case of pigeons, dogs, the axolotl, artemia, fruit-trees, polymorphous plants, etc. ; further, such as the ob- servations of actual genealogical succession, with many of which our present paleontology supplies us. In fact, we have now abundant evidence of the development of species within historic times, and even better and more abundant evidence of the development of species during pre-historic geological periods. The indirect arguments amount essentially to this : that the facts of biology amal- gamate with the theory of evolution, but with no other theory which attempts to explain the origin of living forms. In brief, evolution stands to biology as the theo- ry of the revolution of the earth around the sun stands to astronomy-both theories are proven by logical inference and their complete concordance with the facts concerned. No individual can ever confirm either theory by direct personal observation of the process which the theory affirms. Accepting, then, evolution, we necessarily reach the following syllogism :-All living species have been developed from pre-existing species, these from others, and so on back through an infinite past; man is a living species, therefore man has been evolved from another pre-existing species. The special arguments in favor of the evolution of man are: 1. The closeness of his resemblance in all respects to apes, so that the difference between man and anthropoids is less than the difference between anthropoids and mon- keys ; hence there is nothing to place the human species apart. 2. The many rudimentary organs which exist in man, and at once become explicable if we assume that they have been inherited from animal ancestors, in whom the organs existed to perform useful functions. Such ru- dimentary organs are the muscles of the ear, the platysma myoides, the organ of Jacobson, the thymus gland, the hairs on the body and arms, and the very fine hairs (lanugo) of the face, the appendix vermiformis, etc. 3. The embryology of man ; for it is found that the organs pass through the very stages, and in the very succession which, in accordance with the theory of evolution, they ought to pass through. Thus, the ear arises as an open pit and becomes a simple rounded otocyst, as in inverte- brates ; this otocyst then gradually assumes the form of the vertebrate membranous labyrinth ; the cochlea ap- pears as a simple outgrowth, like that of reptiles and the lowest mammalia, and then becomes coiled as in higher mammalia. In the development of the brain we trace in the embryo the same series of modifications as mark the steps in the evolution of the brain ; and with every part we examine the same holds true. The human foetus ex- hibits, in short, a progressing series of organizations which are temporary phases of its own history, but permanent phases in the structure of lower adult animals. This wonderful set of phenomena becomes comprehensible at once if we admit that man has descended from lower forms, and inherited their characteristics, but also added to them. It is sometimes called the first biogenetic law, that the development of the individual is to a certain ex- tent the synopsis of the evolution of the species. Man offers a striking verification of this law. We have not yet discovered the paleontological record of the origin of man. Certain reasons have led to the hypothesis that there was, within comparatively recent geological times, a large extent of land between Southern Asia and Africa to which the name of Lemuria has been given. Lemuria is supposed to have been a centre of dis- tribution for a good many species, including the ancestors of the anthropoids ; this would account for the presence of the orang-utan in Borneo, while his nearest congeners, the chimpanzee and gorilla, are in Africa, and the next nearest, the gibbons, in India. Now, the history of hu- man migrations indicates Southern Asia as the starting- point of the human race. We cannot, therefore, avoid the surmise that the so-called missing link, by which a biologist understands the common ancestor of man and anthropoids, lived in lost Lemuria, and that our best hopes of finding the " link " lie in the explorations, hardly yet begun, of the paleontological records of the islands of the Indian Ocean. Certainly, no biologist can regard the failure to find the immediate ancestor of man as a real objection to the belief in the actual past existence of that ancestor. II. The Objections to the Evolution of Man.- There are a few persons who, on account of theological dogmas and traditions which they cherish, believe that, though man may have been evolved from lower forms, his evolution was not effected by the action of merely the laws which govern the evolution of other animals, but wholly or in part by the direct intervention of the Deity. These views, although advocated by St. George Mivart, Alfred Russell Wallace, and others, are regarded by nearly all biologists as the outcome of d priori wishes, not as conclusions reached by impartial study. Indeed, the actual arguments are really weak, even puerile ; for instance, Wallace gravely argues that the disappearance of hair from the skin can be explained in no way he is able to think of, therefore some supernatural-that is, di- vine-power must have intervened. It is the old story again-the same spring of delusion reopened-man's ig- norance is God's providence ; what we cannot understand is explained, as of old among savages, by a supernatural anthropomorphic power. By a survival, as it were, of savage mental habit, Wallace assumes that the category of possibilities of his mind is complete and exhaustive, for if it is otherwise, if there are possibilities Wallace has not thought of-and there are hosts of them-his argument is worthless, and there is no proof whatever that divine interposition removed the hair from the back of man. By parity of reasoning, nearly all the other arguments against the evolution of man are easily obviated. There is, however, a modification of opinion to be no- ticed, according to which man consists of three parts, body, mind, and soul. The possibility of the evolution of the body is admitted, perhaps that of the mind also; but in the belief of a large number of persons the soul of man is a separate, new, and special creation, the exclusive gift to man. In this view, then, evolution is true of the ma- terial, but not of the spiritual man. This theory or faith takes us beyond the limits of science, because the exist- ence of the soul, as a distinct component of man, has never been found capable of scientific demonstration, and, of course, it is impossible for science to say whether animals have souls. If some animals-all animals ? If all animals, then, have not all plants souls ? We know no division line. Biologists usually feel the dilemma to be that a soul must be either denied or granted alike to all living things, including man; either alternative con- 737 ■h X <1 III 111 <1 LIU 11 UI lit" REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. forms to evolution, since in either case there is no funda- mental difference between man and organisms. Biology, then, cannot at present admit the opinion, in any form, that man originated in any respect by a special creative act. HI. The Ancestry of Man. - On comparing the young of anthropoids and men there is found to be a greater resemblance between them than between the adults. In accordance, then, with the first biogenetic law, it is probable that man, the gorilla, chimpanzee, orang-utan, and gibbons had a common ancestral form, which may have lived in Lemuria certainly not later than the tertiary epoch, unless possibly it survived after giving rise to other forms. This animal was presumably considerably smaller than a man, hairy, with a dark skin, long arms, short legs, a prehensile toe ; tailless ; with a round head, the facial region slightly protuberant, well- marked canines, a large, much convoluted brain, and with the cerebellum partly uncovered. The tracing out of the remoter history of human evolu- tion is a process of exceeding complexity, the essence of which is a judicious combination of the indications af- forded us by embryology and paleontology. Within the limits of this article it is impossible to enter into a de- tailed discussion of the balancing of the evidences pro and con each alternative. We must content ourselves with a brief resume of the conclusions which thus far have been reached. To proceed: There can be no doubt that the anthro- poids are descended from a lower primate or lemuroid animal which conformed more nearly to the early and simpler mammalian type, having long tails, being true quadrupeds, and not exhibiting those numerous modifica- tions of structure which have accompanied the acquisi- tion of the upright position of the body, and which reach their extreme in man. The lemuroidea, in their turn, must have arisen from a low and little specialized placen- tal mammal-a mammal of a generalized structure, one which probably was similar to the earliest and simplest of the insectivora and edentata, and was itself a near de- scendant of the first placental mammal, a creature which is, perhaps, most nearly represented to us by microlestes, a fossil of the lowest secondary rocks. It is the general opinion of anatomists that the placental mammals were derived from the monotremes, an order of which the liv- ing representatives are the Australian ornithorhynchus and echidna. We trace man, then, back by a compara- tively short series of steps to the lowest mammals, and a little consideration shows that, in fact, man is anatomically much more closely related to the lowest mammals than our pride in mankind has permitted us to acknowledge. The following saying of W. K. Parker is apt in this place : ' ' The proud conservative, who would isolate him- self upon his human throne, must not think that we are removing biological landmarks ; we are merely showing him that they never existed." The lowness of human or- ganization is shown in the embryonic characteristics of the face, the plantigrade pentadactyle foot, the archaic type of dentition, the minute structure of the stomach, etc. There are many other mammals which have been much more modified away from the archtype than has man, as for instance the ruminants. It seems to me impossible, upon anatomical grounds, to say which is the highest ani- mal, any more than we can pick out the highest plant. We can speak of man as "the highest animal" only by starting out with the agreement that the term shall bear no reference to the bodily specialization, and shall refer exclusively to the psychological powers. Much unneces- sary confusion has been caused by writers who have failed to make this indispensable discrimination. Until recently the theory has been generally taught that the mammalia arose from the amphibia, but this opinion cannot be sustained. The facts of embryology point, I believe, distinctly in favor of a very close relation- ship between mammals and reptiles, especially saurians. The common possessions-amnion, large allantois, and large yolk-sac-all of which are wanting in amphibia, are alone sufficient to show that mammals and reptiles must have had a common ancestor, which in its turn may have been, and presumably was, derived from the earlier uro- delous amphibian type. That the mammals are con- nected with the reptiles is indicated also by the discovery, by Professor Cope, of early remains of forms which he considers intermediate between the two classes, or as tran- sitional forms. To go back from the amphibia to their ichthyoid ances- tors, is difficult in the present state of knowledge. That the amphibia differ but little from fishes is pointed out with due care in all good text-books of comparative an- atomy, but beyond calling attention to their special re- semblances to ganoids, and making the general assertion that they are derived from fish-like forms, it is not safe to go. Still more puzzling and uncertain is the origin of fishes, or, in other words, of vertebrates. At onetime the attempt was made, but proved fruitless, to trace back the vertebrates through amphioxus to the tunicates or ascidians. This hypothesis was the outcome of the brilliant researches of Kowalevski. Since then Semper and Dohrn have argued for the evolution of vertebrates from segmented worms, and so many facts have appeared in support of this theory that it has now come into general favor. That the worms, or at least most of the so-called worms, arose from a rotifer-like animal (trochozoon), I consider to have been proved by the splendid studies of Hatschek. It is not difficult to get back in imagination from the rotifer to the larval form, planula, of the coelenterates, or, as this larva is now commonly called, the gastrula, a lit- tle thing consisting of a few cells forming two vesicles of epithelium, one inside the other. A little further, and we come to the unicellular animals. Such is the ancestry of man, given at least with some approach to accuracy ; we may accept the general out- line with much confidence, although the details of the genealogy may be in part erroneous. If we should con- sider the facts of human embryology one by one, it would only be to confirm in detail the general history, of which this article contains the headings of the chapters. Literature.-Darwin's Descent of Man ; Huxley's Man's Place in Nature ; Lyell's Antiquity of Man; Morse's Address on the Antiquity of Man ; the Paleon- tological Writings of Cope and Marsh ; Gaudry's En- chainements du Monde Animal ; Hartman's Anthropoid Apes ; Parker's Mammalian Descent; Minot, Is Man the Highest Animal ? Besides these a very large number of special articles. For criticism against evolution see Wal- lace's Natural Selection, and St. George Mivart's Essays. Haeckel's Evolution of Man is a sensational popular book, and has no scientific importance. Charles Sedgwick Minot. EXAMINATION OF RECRUITS. The Army of the United States is ordinarily recruited by voluntary enlist- ment ; in time of war enlistment is compulsory, under Enrollment Acts. The Recruiting Service is under the direction of the Adjutant-General of the Army, and is organized into two branches ; the general, for infantry and artillery, and the mounted, for cavalry ; each service having its own super- intendent, commandant of depot, and recruiting officers in charge of rendezvous. Medical officers are stationed at the depots, and occa- sionally at rendezvous, although, in time of peace, orig- inal examinations at the rendezvous may be made by the recruiting officers without a medical officer. The recruit, after examination at the rendezvous, is sent to a depot, where, the second day after arrival, he is critically examined by the medical officer ; if found free from physical defects, he passes into a probationary class, and is known as an "accepted recruit;" if any defect is discovered, he is brought before a board of in- spection, consisting of the commanding officer,the medical officer, and the three senior officers of the line present for duty at the depot; his disability is made known to the board by the surgeon, and his case carefully investigated by all the other members ; should they consider him as fit for ser- vice, notwithstanding the opinion of the surgeon, he is so held, and a note of the alleged defect made upon his de- 738 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Evolution. [emits. Examination of Re- scriptive list; should they agree with the surgeon, he is rejected, classed as an " unaccepted recruit," and a report of the case forwarded to the Adjutant-General of the Army, setting forth all the facts, together with the opinion of the board as to his unfitness, and whether the defect might or might not have been discovered by the recruiting officer " with proper care and examination ; " this report is accompanied by formal certificates of disability, with a view of discharge from service; final action in the case is taken by the Adjutant-General of the Army, who, ap- proving the findings of the board, discharges the recruit from the service, or disapproving, retains him, requiring a note of the existence of the defect to be entered on his descriptive list. Theoretically, the recruit is supposed to remain at the depot four months before being sent to his regiment, dur- ing which time he is instructed in the elements of his military duty, and is moreover under the observation of his company commander and the surgeon, whose duty it is, should any defect be discovered or developed, to recommend him for discharge. Before being sent to a regiment he is again examined (stripped) by the surgeon, and retained at the depot for treatment or final discharge, if any defect is discovered. It will be seen that every effort is thus made to weed out defective men, and send to regiments none but those who are physically able to perform all the duties of a soldier. The requirements for enlistment are, that the applicant shall be " above the age of sixteen, and under the age of thirty-five years, effective, able-bodied, sober, free from disease, of good character and habits, and with a compe- tent knowledge of the English language ; that he has the free use of all his limbs ; that his chest is ample ; that his hearing, vision, and speech are perfect; that he has no tumors, or ulcerated or extensively cicatrized legs ; no rupture or chronic cutaneous affection ; that he has not received any contusion, or wound of the head, that may impair his faculties ; that he is not a drunkard ; is not subject to convulsions, and has no infectious disorder, nor any other that may unfit him for the military ser- vice." 1 The position of a medical officer at a recruiting rendez- vous is an advisory one (as a medico-military expert) to the recruiting officer; unlike the medical examiner in life in- surance, he, in addition to his strictly professional inspec- tion of an applicant for enlistment, must express an opin- ion upon his aptitude, both mentally and physically, for the military service. In times past, this latter duty was restricted entirely to the recruiting officer, who was also the sole judge of height, weight, and chest measurements; but experience has demonstrated the importance of pro- fessional skill in the formation of an opinion as to the general efficiency of a man for the military service, and it is now quite as much the province of the medical officer to decide upon the military aptitude of a recruit, as upon his freedom from grosser physical defects. Of course, his decisions are conveyed as opinions to the recruiting officer, who alone is legally authorized to make an enlist- ment. In entering upon these duties, the medical officer should bear in mind the important fact that upon "the faith- fulness and thoroughness " with which they are per- formed depends in a great measure the health of the army, its mental and physical efficiency, and especially its mobility; carelessness or inattention on his part may permit the admission to its ranks of men who soon find their way into the hospital, whose undiscovered diseases may be transmitted to innocent comrades, or whose de- fects may furnish groundwork for the demoralizing prac- tice of malingering ; examinations made in a perfunctory manner will surely result in the unwitting acceptance of men whose mental and physical defects are only too clearly displayed in the company organization, and whose enforced discharge from the service will bring discredit upon the professional skill of the examiner, and unde- served censure upon the recruiting officer with whom he has been associated ; he should reflect that, in the sudden emergencies which our troops are so frequently required to meet on the frontier, able-bodied soldiers are indispensable to success, or to the saving of life and property from de- struction ; and that with an army so small as ours, in time of peace, every man enlisted must be relied upon to en- dure all the hardship of which a physically perfect human being is capable. Nor is this less a necessity in time of war with troops of the line, when celerity of movement, and ability to endure great privations, as lack of food and inclemency of weather, are imperatively demanded in the manipulation of armies under the modern science of war. " The experience of all nations has demonstrated the uselessness of attempting to conduct military operations to advantage unless the rigid scrutiny of the surgeon has been exerted to exclude such men as were subjects of, or predisposed to, disease, or were unfitted to sustain the con- tinued fatigue and exposure of the march."2 There are, however, conditions of the service in time of war which warrant a departure from this standard in some respects, and the acceptance of recruits with defects which, in time of peace, would be positive disqualifica- tions ; in future pages reference will be made, under the appropriate headings, to these deviations from the peace standard. In time of peace every enlisted man is presumed to be wholly efficient, and fit for duty at all times ; he who to- day is nursing the sick in hospital may to-morrow be in his place in a company, or a member of the garrison guard ; in time of war men may be enlisted who cannot be strictly classed as " fighting men," but who may be equally effective as soldiers in other departments ; a man with a hernia, which is kept in place by a truss that is well-fitting, is in every way able to cook for a company, although not fitted to wear a cartridge-belt and do active duty in the field; so, also, the loss of certain members -fingers or toes-would not necessarily disqualify a man from guarding a hospital, or driving a team, and thus taking the place of an able-bodied soldier whose services are more urgently needed at the front. For this reason it has been the custom in all armies to relax in certain par- ticulars their peace regulations, and diminish their list of disabilities in time of war, holding to service many men who in time of peace would have been rejected. To properly conduct his examinations the medical officer should have plenty of light, air, and time, and good floors. The room in which the examinations are made should be well lighted and ventilated, not less than forty feet long and twenty feet wide, with a well-laid, solid floor ; its furniture should consist of a fixed measuring-rod and slide, good platform scales, steel tape-measure, vision- test cards, and a set of test-wools for determining color- blindness ; in one corner there should be a bed arranged after the fashion of an operating-table, upon which ap- plicants can be placed for the examination of suspected strictures, and heights verified, if necessary, by horizontal measurement, etc. ; the instruments required are a set of steel sounds, a Cammann's stethoscope, an ophthalmo- scope, a set of Snellen's test-types, an astigmatic chart, the necessary apparatus for a rough analysis of the urine in cases of suspected lesions of the kidney, and the ap- pliances for immediate vaccination after acceptance of the recruit. There should also be, adjoining the examination-room, one fitted with bath tubs, and liberally supplied with soap and towels, where every applicant for enlistment (who must be carefully and thoroughly washed before exami- nation) can perform his ablutions under the supervision of the recruiting sergeant. The recruiting officer should always be present at the examinations,3 and for obvious reasons, all other persons excepting the recruiting sergeant should be excluded from the room. A very considerable and important part of the examina- tion can be made before the applicant is stripped, during which defects may be discovered that will render further procedure unnecessary ; he should be closely questioned as to his personal and family history, his previous service in military or naval life, his habits, his health in the past, and the receipt of injuries or wounds, or any surgical 739 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. operations which may have been performed upon him. The examiner, during this questioning, can form an opinion as to the knowledge of the English language pos- sessed by the applicant, his age, intelligence, and general fitness, both as to physique and morale, for the duties of a soldier. A thorough and satisfactory examination can only be made by pursuing a systematic course, without the adop tion of which the most expert examiner will omit im- portant points, and, probably, lose sight even of glaring defects. To accomplish this the War Department, upon the recommendation of the writer, adopted a "form" for the examination of recruits, which contains a series of questions, to be answered by the applicant, and recorded by the inspecting or examining officer. These forms are furnished by the adjutant-general of the army to all recruiting rendezvous. When the applicant is ready for the inspection of the surgeon, let him take the position of a soldier in the best lighted part of the room ; then examine him in the fol- lowing order after the methods elsewhere set forth . 1. Inspect his general physique, skin, scalp, and cra- nium, ears, eyes, nose, mouth, face, neck, and chest. 2. The arms should be extended above the head, the backs of the hands being together, and the applicant be required to cough vigorously ; any form of hernia may now be discovered by the eye and finger. 8. The man should be required to take a long step for- ward with the right foot, and bend the knee, the hands remaining extended above the head ; this exposes the genital organs, and varicocele or other defects in the scrotum may be recognized by the hand. 4. The arms should now be brought to the sides, and the man required to separate his buttocks with his hands, bending forward at the same time'; this exposes the anus. 5. Examine the heart. 6. The elbows should be brought firmly to the sides of the body, and the forearms extended to the front, palms of the hands uppermost. Extend and flex each finger sep- arately ; bring the points of the thumbs to the base of the little fingers ; extend and flex the hands upon the wrists ; rotate the hands so that the finger-nails will first be up and then down ; move the hands from side to side ; flex the forearms on the arms sharply, striking the shoulders with the fists ; extend the arms outwards, at right angles with the body, and flex the forearm upon the arm until the thumbs rest on the points of the shoulders ; while in this position raise and lower the arms, bringing them sharply to the sides at each motion; let the arms hang loosely by the side; swing the right arm in a circle rapidly from the shoulder, first to the front and then to the rear ; swing the left arm in the same manner ; extend the arms fully to the front, keeping the palms of the hands together ; observe carefully the elbows ; carry the arms quickly back as far as possible, keeping the thumbs up, and at the same time raise the body on the toes. 7. Extend the right leg, resting the heel upon the floor ; move all the toes ; raise the heel from the floor, moving the foot up and down, then from side to side ; present the sole of the foot for inspection; bend the knee and strike the shoulder with it, bending the body slightly for ward at the same time ; throw the leg out to the side as high as possible, keeping the body squarely to the front; take the military position "to kneel firing," first on one knee, then on the other ; get down on both knees ; squat sharply several times in succession , hop the length of the room on the toes, first of one foot and then the other; take a standing jump as far as possible; jump up and strike the buttocks with the heels. 8. Auscultate the lungs. 9. Test the hearing. 10. Test the vision, and for color-blindness. 11. Vaccinate the applicant, if accepted. Mr. Marshall, in his excellent treatise on the examina- tion of recruits, arranges the causes on account of which recruits are rejected under three headings First. " Diseases or deformities which a medical officer from his professional knowledge and acquaintance with the duties of soldiers considers are infirmities which dis- qualify men for service in the army." Second. "Slight blemishes which do not disqualify a man for the army, but which an unwilling soldier may exaggerate, and allege that he is thereby rendered unfit for military duty " Third. " Unimportant deviations from symmetry, or slight variations from the usual form or condition of the body; technical or nominal blemishes which do not in- capacitate a man for the army, or in the slightest degree impair his efficiency." Experienced surgeons will reject all recruits whose de- fects fall under the first two headings, from a conviction that they render the men unfit or ineligible for the army; but those under the third heading are frequently rejected from fear of responsibility-a dread of official correspond- ence if objected to, and an ultimate damage to professional character. In time of war cases coming under the first heading should be rigidly excluded, while those coming under the second and third headings should be as rigidly held to service. The General Examination.-Competent knoioledge of the English language is defined by the War Depart- ment as the ability of the applicant to "speak fluently, converse intelligently, and fully understand the orders and instructions given in that language." It would seem almost superfluous to refer to this mat- ter, the importance of which is self-evident, were it not for the fact that so large a number of foreigners have been enlisted, who were utterly ignorant of our language, whose blunders and mistakes have caused annoyances and impediments to the public service, and whose effi- ciency as soldiers has been thereby seriously impaired. It is of paramount importance that the soldier should be able clearly to understand the orders which are given to him, and to ascertain this fact beyond a doubt is one of the first duties required of the medical officer. Exception to this rule is made in the cases of skilled artisans, tailors and band musicians being especially mentioned. In time of rear familiarity with the language is not so necessary, as foreigners are more likely to be assigned to regiments made up of their own countrymen, with offi- cers who speak their language ; they can, also, be made useful in the administrative departments of the army, taking the places of men better fitted for field service. Age.-As has been already stated, the limits of age for enlistment in time of peace are, "not less than sixteen years, nor more than thirty-five years;" "minors under eighteen years will not be enlisted except for musicians, . . , and then only under authority from the superin- tendent." 4 The regulations of the army require that when minors present themselves for enlistment, they shall be treated with great candor ; the names and residences of their parents and guardians, if they have any, shall be ascer- tained, and notice sent to them of the minor's wish to enlist, that they may have an opportunity to make their objections or give their consent. When consent is given it must be in writing. All recruiting officers are enjoined to be very particular in ascertaining the true age of the recruit. If any doubt upon the point exists in the mind of the recruiting officer, he must not be satisfied with the oath of the applicant as the sole evidence of legal age, but if he cannot, in addition, furnish undoubted proof of the fact, he must be rejected.5 The maximum limit of age does not apply to soldiers who may re-enlist, or who have served honestly and faith fully a previous enlistment in the army;6 "previous enlistment," as defined by the War Department, refers to service in the regular army, and not in the volunteer army during the War of the Rebellion. In time of war the limitations of age in compulsory enlistment, under the Enrolment Acts, are twenty and forty-five years ; the question of minority between the twentieth and twenty-first years is not considered, except in voluntary enlistments, which are under the same re- strictions as in time of peace. The medical examiner must form his opinion of the 740 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Recruits. age of an applicant from his personal observation of men and upon physiological grounds. It is a point about which the greatest amount of deceit is practised ; concealment being attempted in voluntary enlistments with a view of getting into the service, and in compulsory enlistments with a view of exemption therefrom. He must, therefore, be always upon guard against imposition. Young men who would scorn to tell an untruth in other matters will lie about their age with the utmost effrontery, and old men will resort to every artifice to conceal theirs. While the divisions of life into periods, by years of ex- istence, are in a measure arbitrary, some men maturing at an earlier age than others, it is important to consider certain common evidences of maturity as fixing the period of legal majority, and furnishing a standard, indefinite though it may be, of eligibility for the military service. Among the most prominent of these evidences are the presence of the wisdom teeth, a plentiful supply of hair in the axillae, and over the pubes, well-formed testicles, and complete corrugation of the scrotal skin. While these conditions are liable to variation in individuals, they may be regarded as common to most youth at maturity, al- though no one can be considered as more frequently present than another. It has, however, been the experi- ence of the writer to find a peculiarly smooth condition of the skin of the scrotum in every case of minority ex- amined by him. This may be due to lack of development of the dartos. Men of mature age do not display it, but it is very noticeable in minors. The general appearance and bearing of a young man will, in conjunction with physical peculiarities, give the surgeon a very fair idea of his age, and there are few possessed with sufficient hardi- hood to deny a firm and decidedly expressed opinion by an observant surgeon upon the subject. In those whose age exceeds the maximum there will probably be found presbyopia, the arcus senilis in one or both eyes, a wrinkled skin, especially about the outer angles of the eyes and on the forehead, gray hair, and a peculiar hardness of the nails of the fingers and toes. Height and weight are subject to such modifications of standard "as the requirements of the service may dic- tate." At present a minimum of five feet four inches is fixed for the mounted and general service, although recruiting officers are permitted to exercise their discre- tion as to the enlistment of desirable recruits, such as band musicians,- school-teachers, tailors, etc., who may fall not more than one-quarter of an inch below this limit. The maximum height for the cavalry service is five feet ten inches-there is no limit in this particular for the general service. The weight of recruits for infantry and artillery is not less than one hundred and twenty pounds, nor more than one hundred and ninety pounds ; for cavalry and light artillery, not to exceed one hundred and sixty-five pounds. In the matter of height, deception is sometimes attempted for the purpose of avoiding ser- vice-the person increasing or lessening his stature, as may be necessary, to avoid the fixed standard. This may be exposed by laying the recruit upon a table, or the floor, and measuring him while in the horizontal position, the average excess of the horizontal length over the perpen- dicular height being about one-quarter of an inch. An opinion as to the proper degree of physical develop- ment of a recruit may be formed from the general pro- portions which should exist between his age, height, weight, and chest measurement. A man of twenty years of age should weigh not less than one hundred and twenty-five pounds, and for every inch of height above five feet five inches his weight should increase five pounds ; his chest mobility should not be less than two and one-half inches, and his chest measurement not less than thirty inches. the appearance of being hard drinkers will be rejected, " though they may not at the time be intoxicated."7 Some recruiting .officers go so far as to reject men on whom the smell of liquor can be detected at the time, and they are without doubt correct in their opinions and practice. It is a great mistake to " suspend a final decision . . . for a sufficient length of time to enable a man to recover from the effects of a mere temporary debauch," as is recommended by Tripier,8 as the man who will in- dulge in such debauchery before enlistment will be pretty sure to repeat it afterward ; and such men are not wanted in the army. If a man has to resort to the stimulation of alcohol to " brace himself up " for the ordeal of the ex- amination, it is a fair presumption that his habits as to the general use of stimulants will not bear much criticism. The evil wrought to the service by men having these habits is so great that it is far better to err, and run the risk of rejecting occasionally temperate men, than by relaxing any vigilance, to enlist those who may eventually prove themselves sots. While it is sometimes difficult to detect the habitual drunkard, and the medical examiner is forced to rely, to some extent, upon the man himself for such information as he may be willing to give, yet the long indulgence in habits of intemperance will almost surely be indicated by persistent redness of the eyes, tremulousness of the hands, attenuation of the muscles-particularly of the lower ex- tremities-sluggishness of the intellect, an eczematous eruption upon the face, and purple blotches upon the legs.9 Close and skilful questioning will often develop the facts connected with the antecedents of the applicant, and materially assist the examiner in forming his opinion of the case. Masturbators and Sodomites are also to be looked for and rigidly excluded. In addition to the well-known general signs of physical prostration due to indulgence in mas- turbation, Howe, in his little work on " Excessive Ven- ery," 10 says, "the local signs are sufficient for a diagnosis. . . . The penis is thinner and smaller than usual. It is often elongated, and cold to the touch at different points. The glans is much larger than the rest of the organ. . . . The veins of the integumental covering are dilated and varicose. In many patients the penis is bent laterally, and the inclination is generally toward the left side. . . . The scrotum is also relaxed and elongated, the testicles are small and soft; . . . sometimes they are extremely sen- sitive." The air of embarrassment which so often over- takes subjects of this vice, when closely questioned, will also lead to their detection. Sodomy may be suspected if the anus is much dilated, or is infundibuliform in shape: "The absence of the radiating folds is considered one of the best medico-legal proofs of the vice." 11 Tidy says,12 " a peculiar, funnel- like depression or hollow of the nates toward the anus, the anus gaping and the sphincter relaxed," are signs of the practice of this vice, to which greater or less impor- tance maybe attached as the circumstances of the case de- mand. Mental Disorders.-Insanity, idiocy, imbecility, and de- mentia are disorders which will call for the closest scru- tiny and observation by the medical examiner ; their nature is such that a careful diagnosis in the limited time allotted to the examination of a recruit is rarely possible. The necessity, therefore, of an acquaintance with their physiognomy is apparent. To one skilled in this means of diagnosis the detection of the less obscure grades is not a matter of great difficulty. The idiot, the imbecile, or the demented patient presents such well-marked character- istics that an error can hardly be made. It is in those un- fortunate persons who are on the border-land of mental deficiency, and the insane, that the greatest difficulties of diagnosis may be expected. Unless an insane person be- trays by action or speech some evidence of this disease, a correct diagnosis would be a matter of great difficulty, and no surgeon would be held responsible for accepting one who afterward manifested insanity. Should the ex- aminer have reason to suppose that the applicant is defi- cient in mental capacity, or has not the aptitude to ac- quire readily a knowledge of his duties as a soldier, he Habits.-Drunkenness, or habits of intemperance, is the cause of a very large number of the rejections made at rendezvous. It is the vice of the army, as well as of most walks in civil life, and the medical examiner cannot be too careful in scrutinizing every applicant for evi- dences of this demoralizing habit. The regulations of the army are very emphatic on the point, declaring that every man shall be sober when enlisted, and that men having 741 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. should be rejected. It is much safer to take even an ex- treme view of such cases, and run the risk of an errone- ous rejection, than to accept one about whom a suspicion of mental alienation can rest. Physique.-While a decision of cases under this head- ing does not always fall within the province of the medi- cal examiner, his opinion is entitled to great -weight with the recruiting officer. His knowledge of anatomy and the proper proportions of the human frame, as well as his familiarity with physiognomy, eminently qualify him to form a correct opinion as to the general appearance, both physical and moral, of the applicant, and his fitness for the duties of a soldier, in cases where no technical dis- ability exists or can be discovered by a non-professional man. His experience with the effects of disease, bad hab- its, food, and living upon the constitution will enable him to judge as to future efficiency, although there may be no direct evidence in the case before him that the ap- plicant has ever been subjected to such hardships. There is probably no one class of men which furnishes such large numbers to the hospitals, the guard-house, and the list of deserters as this, designated indifferently by military men as " poor physique," " feeble constitution," or " general unfitness." The leading characteristics of a good constitution may be briefly enumerated : "A tolerably just proportion be- tween the different parts of the trunk and members; a well-shaped head, thick hair, a countenance expressive of health, with a lively eye, skin not too white, lips red, teeth white and in good condition, voice strong, skin firm, chest well formed, belly lank, parts of generation well developed, limbs muscular, feet arched and of a moderate length, hands large.13 "The gait should be sprightly and springy, speech prompt and clear, and manner cheerful. The medical examiner should endeavor to judge from the eyes, from the whole expression of the countenance, from the conformation of the limbs, of those who are capable of making the best soldiers ; there are as certain and as well understood indications for judging of the soldierly qualities of men as there are for ascertaining the value of a horse or a hunting dog.14 All lank, slight, puny men, with contracted figures, whose development is, as it -were, arrested, should be set aside. The reverse of the characteristics of a good constitution, already enumerated, will indicate infirm health or a weakly habit of body ; loose, flabby, white skin ; long cylindrical neck; long, flat feet; very fair complexion, fine hair ; wan, sallow countenance, etc. Under our present system of recruiting in large cities a very objectionable description of men present them- selves for enlistment, whose health has suffered from de- bauchery of various kinds. They are tramps ; men who wander about over the face of the country, too lazy to work and too vicious to live in a well-regulated com- munity-a set of Ishmaelites who seek service in the army as the easiest method of getting food, clothing, and shel- ter, but without the slightest design of performing any more duty than they are compelled to. They generally appear as winter approaches, drivenby inclement weather to seek an asylum until the opening of spring. No more undesirable or unfit class of men come before a recruiting officer. They are seldom, after enlistment, out of the guard-house or hospital, and the company to which they belong is fortunate if, when they take their flight in the spring, they do not carry away with them all the available cash, or articles of value, upon which they can lay their hands. Another class of men, having neither ap- parent disease nor well-characterized physical or moral defect, are equally objectionable ; there is a ' • something " about them which satisfies an expert that they will make either indifferent or bad soldiers, for which reason they should be rejected. The power of recognizing these two classes of men is a talent which is greatly improved by practice, and which the medical examiner should culti- vate to the highest degree, persistently rejecting all about whose ultimate efficiency he has the slightest doubt. Even in time of war, when the urgency for men may be ever so great, there should be no deviation from the gen- eral rule as to men of this stamp and character, who, if once admitted will serve only to encumber the army either by their shiftlessness or viciousness. An army, in whatever strait it may be, is vastly better without than, with them. General Intelligence.-A higher degree of intelli- gence is now expected from the soldier than was the case in the earlier days of the republic. Promotion is open to him, and he is encouraged in every way to im- prove himself ; libraries are established to which he has ready access; reading-rooms, with liberal supplies of newspapers, are prepared for him, and schools are organ- ized in which he has opportunities for study. "It is worthy of notice that much of the advantage to be derived from modern improvements in the mode of edu- cating, training, dieting, and clothing the soldier depends upon his capability of appreciating the objects with which they have been introduced,"14 and while it is im- possible to formulate any specific standard of intelligence by which his eligibility is to be judged, such a direction can be given to the questions necessarily asked during the physical examination as will enable the medical officer to form a very good opinion of his general intelli- gence, and afford an opportunity to exclude men who, while they may not be exactly idiotic, are "a sort of demi-sim pieton. " The remarkable strides which have been made during the past quarter of a century in the science and art of war ; the superior mechanism of the rifle now in use ; the attention that is paid to target practice, and the efforts that are made to instruct the soldier in the management and care of his weapon and ammunition, tend to make his profession both instructive and interesting, and jus- tify the expectation that men of better tastes and habits than those obtained in the past will, in the future, be at- tracted to the profession of arms. It is well stated by Dr. Crawford, in the article from which quotation has been made, that the criminal and in- validing statistics of the army leave no doubt as to the frequent enlistment of the fatuous and imbecile, as well as the criminally vicious, and that if the development of the head, and the symmetry of its proportions were as carefully examined and as dogmatically insisted upon as is customary in determining the form, development, and symmetry of other organs and regions, a proportion, at least, of such men might be excluded from the service. Special Examinations.-The Cerebrospinal System. -Epilepsy, chorea, stuttering or stammering, all forms of paralysis, tabes dorsalis, neuralgia, disqualify. It is not to be expected that the medical examiner will make a diagnosis of all the different forms and phases of this class of diseases. It is sufficient for practical purposes that he should recognize such general symptoms as are indicative of grave lesions of the system, and should sat- isfy himself of the incapacity of the applicant for military duty ; in their later stages the manifestations are so well pronounced that it is hardly possible for errors of diagno- sis to occur ; but the earlier symptoms are in many in- stances obscure, requiring close observation for their de- tection. The personal appearance, facial expression, and gait will often betray the existence of many forms of nervous disorder, for which reason the medical examiner should require each applicant, after being stripped, to approach him from a distance, and if necessary, walk about the room, during which time he can thoroughly scan his person, observing particularly any deviations from the normal conditions. By this means the halting gait of paralysis of the lower extremities, or the shuffling unsteady step of tabes maybe detected. A careful exami- nation of the spine should be made by pressure upon the spinous processes from the cervical to the lumbar ver- tebrae, and any tenderness or pain manifested by flinch- ing made mental note of. Unsteadiness of the handsand arms should suggest a suspicion of tabes dorsalis, and the simple tests of standing or walking while blindfolded, the tendon reflex, and the tactile sense, be made with care. Stammering may be congenital, due to habits contracted, in childhood, to malformations of the vocal apparatus, or to organic lesions in the nervous system-from what- ever cause, if it is sufficient in degree to interfere materi- 742 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Recruits. ally with ordinary conversation the applicant should be rejected. Some care will be necessary in arriving at the degree of this affection, because the nervous excitement incident to the examination will of itself react upon the patient, whose embarrassment will increase his difficulty of speech. A little patience and kindliness of manner will, however, soon reassure him, and the true extent of the difficulty be appreciated. In time of war attempts will often be made to simulate disorders of this class for the purpose of securing exemption from military duty. The different forms of paralysis and tabes can, by the ex- ercise of some patience and care, be detected ; indeed, it would require a man to be possessed of great self-control, shrewdness, and a considerable knowledge of the symp- tomatology of disease to simulate, with any reasonable prospect of success, any form of paralysis. Ocular evi- dence, by the examiner, of a convulsion, is imperatively demanded in all cases claiming exemption on the ground of epilepsy. No statements, however well substantiated, should lead him to deviate from this rule. He should sat- isfy himself by the absolute loss of sensibility of the con- junctivae, the dilatation and immobility of the pupil, and the character of the convulsions, that the attack is one of true epilepsy before recommending,the case for exemp- tion. The pain of neuralgia may be simulated ; but true neuralgia of sufficient intensity to disqualify can hardly exist without producing such decided constitutional ef- fects as will be visible to the eye of the examiner. Constitutional syphilis disqualifies. The late forms of this disease as gummata, rupia, periostitis, ostitis, caries, etc., are rarely brought to the notice of the examining surgeon, or if such cases should be presented, the cachexia will be so well marked that there can be but little difficulty in making a diagnosis. It is the early manifestations of the disease which he is to watch for with great care, particularly as men are often the subjects of syphilitic infection without being aware of its existence, and therefore truthfully disclaim any knowledge of a disability for the service on that account. Careful examination should be made of the cervical, epitrochlear, and inguinal glands, as one of the earliest and most important manifestations of constitutional syph- ilis consists in their enlargement and induration. Otis, in his work on "Syphilis," states that this abnormal change extends, to a greater or less degree, throughout the entire lymphatic system. He describes the enlarged glands as varying in size from a small shot to a pigeon-egg; as being hard, movable, and painless: those in the epi- trochlear region being the most valuable in a diagnostic point of view, and rarely present before, or absent after, the tenth or twelfth week succeeding inoculation of syph- ilis, whether any roseola can be detected or not. Some- times only one gland is enlarged, which may be above the trochlea, along the inner border of the biceps, and therefore difficult to find. There is variation, also, as to locality in the different cervical and inguinal glands that are enlarged, a patient search for which will gener- ally be successful. The next evidence in order is the class- ical roseola, with its bright hue in the early stages, and its faucial inflammatory engorgement; the papular eruption with its crop of papules along the upper border of the forehead, hard to the touch, and painless (the corona veneris of Ricord); the circle of white scales arranged about the base of the papules on the body (the collarette of Biett); the coppery-colored stain left after the disap- pearance of this papular eruption ; alopecia, and mucous patches. These, either alone or taken together, should be sufficient evidence of the existence of the disease in its earlier stages to warrant the examiner in rejecting the applicant. As the cicatrices of buboes are not evidences of the existence of syphilis, they should not be made a cause for rejection, although their presence should lead to careful examination for signs of the disease, as hereto- fore mentioned. In time of war this disease is cause for rejection. Scrofula.-The active manifestations of scrofula are most often seen in children. In adults we find generally the evidences of earlier ulcerations, as cicatrices, more or less extensive, in various parts of the body, especially about the neck. If the disease is well marked, with en- largements of the joints, a pasty, dull, and lifeless com- plexion, the man should be rejected, both in time of peace and war ; if, however, the applicant presents the signs of early scrofula, from which he has entirely recovered, and is otherwise a desirable subject, he may be accepted, al- though it is more prudent to deny admission to the ser- vice of all cases which admit of doubt. Cancer, in whatever form or stage of development, is a cause for rejection. The " pipe-smoker's cancer," epi thelioma of the lip or tongue, and cancerous affections of the testicles, are the forms most likely to be seen among men desiring enlistment. As, however, the disease is one of middle or advanced age, it is very rarely met with at recruiting rendezvous, and is only mentioned in this place as one of a class of diseases which the surgeon may be called upon to reject. The Skin.-All chronic, contagious, and parasitic dis- eases of the skin ; naevi ; extensive, deep, and adherent cica- trices ; chronic ulcers ; vermin, and indecent tattooing, dis- qualify. Although vermid may be considered as only temporary annoyances, it will be found, as a rule, that the men upon whom they take up a residence are undesirable by reason of filthy habits. The fecundity of vermin is so great, so many opportunities are afforded for their migra- tion where numbers of men are associated together, and their presence is so disgusting, that, in time of peace, men infested with them should either be summarily rejected, or acceptance deferred until their persons are rid of the parasites. The most common form met with at recruit- ing stations is the crab louse (pediculus pubis'). Of para- sitic diseases scabies, favus, tinea tonsurans, and sycosis are most frequently met with, and should be causes for rejection, or action deferred until cures have been ef- fected. The tattooing of indecent devices upon the skin, on any part of the body, is cause for rejection, upon the ground that a man who will voluntarily submit to such defacement is morally unfit to be a soldier. The pres- ence of cicatrices from cupping should lead to a close ex- amination of the internal organs in their vicinity, which may have been seriously damaged by disease, or are liable to become again affected after exposure to the hardships of a winter campaign. When extensive adherent cicatrices impede the free motions of the limbs, they are absolute causes for rejection ; but when seated on other parts, as, for example, the head or trunk, they are not in them- selves objections in a recruit; as indications, however, of constitutional cachexia they are important.16 Cica- trices, non-adherent, white and smooth, resulting from an incised or lacerated wound, or a burn, and not involving much loss of substance or lesion of subjacent organs, are not causes for rejection. Chronic ulcers are not likely to be found, except in persons of broken-down constitution. Those resulting from abrasions or slight wounds, in per- sons who do not present any evidence of constitutional disorder, have probably been kept active from some local cause, upon the removal of which they will heal; but those involving much loss of substance, with atrophy of a limb, with a general constitutional disorder, or with varicose veins, especially when located on the lower ex- tremities, should disqualify ; even when healed they are apt to open again, so soon as the soldier is exposed to any cause of irritation, such as long marching or inclement weather. The skin of the negro seems especially prone to ichthyosis, and to keloid growths at the seat of even trivial injuries ; unless the affections are extensive, or the keloid growths so situated as to interfere with the motion of limbs, or otherwise impair the efficiency of an appli- cant, they should not be considered as causes for rejec- tion. In time of war exemption should be given only on account of long-standing or incurable diseases of the skin; the milder forms, as acne, herpes, urticaria, etc., as also some of the parasitic diseases, including scabies, may be treated with reasonable prospect of recovery in a short time, and the men accordingly should be held to service. Ulcers may be produced and purposely kept open with the view of evading service under conscription. Suspi- cion will naturally be aroused when an otherwise healthy 743 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. man claims exemption from service on account of an ul- cer of long standing, as this lesion is seldom seen except in persons of broken-down constitution, and generally in middle or advanced age. The appearance of the ulcer, and the tissues surrounding it, will furnish some evi- dence as to its age, active inflammation pointing to vol- untary irritation and a recent lesion, while an old ulcer presents characteristics the reverse of this. Such cases should be placed under close observation in hospital, and every means taken to prevent the patient from keeping up any irritation of the parts, bearing in mind the fact that an almost endless variety of foreign substances are used for this purpose, and that the finger-nails are espe- cially convenient for such use ; it may become necessary to put the patient into a strait-jacket before a correct diagnosis can be made. The Head.-Abnormally large head; considerable de- formities, the consequence of fractures; serious lesions of the skull, the consequence of complicated wounds or the operation of trephining; caries and exfoliation of the bone ; injuries of cranial nerves; tinea capitis; alopecia, disqualify. Any injury of the skull affords ground for suspicion of consequent injury to the brain, and the existence of epilepsy or some disorder, greater or less, of the mental faculties; hence all such injuries should be carefully examined as to their extent and seat. It is well known that the skull may receive extensive injury without any subsequent impairment of the faculties, and also that very slight injuries may be followed by serious consequences, more especially by epilepsy ; hence, although no positive disease may be detected, it is safe to reject any applicant who has evidence of considerable injury to the skull, if for no other reason than that its presence affords the man an opportunity for evasion of duty, and, if he choose to make it, a claim for discharge from the service on account of some alleged nervous affection, should military duty become distasteful to him after joining his command. With the evidence of an injury to the head before him, it would be difficult for a medical officer to disprove any assertion by a malingerer of the existence of disease. Wounds of the scalp, especially if non-adherent, should not reject; injuries of the cranial nerves, producing paral- ysis or impairment of function in the parts to which they are distributed, are causes for rejection ; tinea capitis is laid down in many works on recruiting as a disqualifi- cation. It is a disease almost exclusively confined to childhood, and is very rarely met with at a recruiting station. In the examination of several thousand men at the depot at Columbus Barracks, O., the writer did not see a case, nor has he ever seen one among the soldiers with whom he has served. The discovery of any disease of this genus in the hairy scalp would be cause for re- jection, not only on account of its contagiousness, but because it is both unsightly and offensive. The papu- lar eruption of syphilis is frequently situated in the hairy scalp, and may be easily felt by an examination of that part with the fingers. Alopecia is occasionally met with in recruits, and has given rise to much difference of opinion among army surgeons as to its being a disquali- fying cause ; if it is the result of a pre-existing disease, which will be manifest by the appearance of the scalp, if the loss of hair is total, or if but a few tufts remain about the back of the head, and the neighborhood of the ears, the man is unfitted for service ; the head-coverings issued to the soldier not being sufficient, in the absence of the natural covering, to protect him from accidents resulting from exposure to the heat of the sun or to the inclemency of the weather ; partial loss of the hair, either over the crown or above the forehead, is not cause for re- jection ; in time of war baldness is not cause for exemp- tion. The Spine.-Caries; spina bifida; lateral curvature of the cervical, dorsal, or lumbar regions; lumbar abscess; rickets; f racture and dislocation of the vertebra ; angu- lar curvatures, including gibbosity of the anterior and posterior parts of the thorax, disqualify. Lateral curvatures of the spine are often the result of some particular trade or occupation ; if the curvature is slight, and unaccompanied by signs of constitutional weakness, it should not disqualify. An appearance of lateral curvature frequently results from undue develop- ment of the muscles of one shoulder. This will be readily detected by making the recruit stoop forward from the attitude of attention, stretching out his hands over his head, and curving the back until his fingers reach the ground. A glance at the recruit's spine, when so bent, from before backward, will enable the surgeon to esti- mate the extent of lateral curvature, if it really exists.11 The following good rule for the determination of the de- gree of curvature which demands rejection has been suggested by Major Daingerfield Parker, U.S.A.-. The re- cruit standing erect, draw an imaginary line from the base of the skull to the end of the spine ; if the spinal prominences are curved one inch either side of the line, reject. Any pronounced angularity of the spine (gib- bosity) sufficient to impair the symmetry of a man's fig- ure, or distortion of the chest interfering with respira- tion, should reject. The fact that knapsacks and other heavy weights are no longer carried by soldiers upon their backs in modern campaigning removes the objec- tion formerly made to men having this defect in a moder- ate degree. In young men posterior curvature may be overcome by attention to drills and gymnastics, but in men beyond twenty-five years of age it is useless to at- tempt an improvement. In time of war slight curvatures, lateral or angular, should not exempt. The Ears.-Deafness of one or both ears ; all catarrhal and purulent forms of acute and chronic otitis media; polypi, and other growths or diseases of the tympanum, labyrinth, or mastoid cells ; perforation of the tympanum ; closure of the auditory canal, partial or complete, except from acute abscess or furuncle ; malformation or loss of the external ear, and all diseases thereof, except those which are slight and non-progressive, disqualify. Diseases of the ear inducing deafness are not often symmetrical, and affections of one ear are much more likely to be met with than those of both ; hence, the fact should be borne in mind that while an applicant for en- listment may apparently hear perfectly, a careful ex- amination of both ears will show that he may be deaf in one. To properly make a preliminary examination of hear- ing power for the voice, the examiner should stand at the side and in rear of the applicant, at least forty feet dis- tant, while the recruiting sergeant closes the external meatus of one ear by pressing the tragus gently back- ward and inward. A few words are then to be addressed to the applicant, distinctly, in a middle tone, and not too rapidly. If there is any defect in the hearing of the un- covered ear, it will at once be discovered by the failure to repeat what is said ; the same manoeuvre should be practised with the opposite side. The voice may be heard at least fifty feet distant in a closed room when both ears are normal; should there be deafness of either ear, the applicant must be rejected. It will be found that deafness is occasionally caused by the accumulation of cerumen in the ear; in which case, should the recruit be otherwise desirable, it would be proper to defer final action, and an opportunity given him to have the obstruction removed, when, if hearing is re- stored, he could be accepted. In time of war deafness is frequently simulated. Real deafness cannot be concealed, but the detection of simu- lated deafness is, at times, a somewhat difficult matter. Here every artifice which ingenuity may suggest will be employed to deceive the examiner, whose opinion of the case must be made up of negative evidence entirely, the only positive evidence available being the motive of the conscript, if this can be styled evidence. Besides the voice there are three methods to be em- ployed in testing the power of hearing, viz., the watch, the tuning-fork, and the double stethoscope of Cammann, although an opinion should not be formed from any single test, but from the results obtained by all. In using the first test, the applicant should be blind- folded, and while one ear is closed, the watch is to be held 744 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Recruits. in the air at various distances from his head : above, below, in front of, and behind the unclosed ear. The distance at which its ticking can be heard by the normal ear may be determined by the operator's sense of hearing Using this as a standard, the degree of hearing by the applicant can be approximately determined. Each ear should be carefully tested by this method, and the result noted. To use the second test, uniform sound can be obtained by striking the tuning-fork on the knee while the leg is flexed upon the thigh, or even extending the palm of the hand and striking upon its fleshy part. In the normal ear the tuning-fork, when placed on the central incisors, is heard equally well in both ears; the same is true if placed on the vertex or on the centre of the forehead ; if placed on the mastoid process, it is heard better in the ear of the same side: it is heard longer when placed in the air near the meatus, than on the teeth, etc. When there is some defect in the hearing dependent on disease located in the middle or external ear, the tuning-fork placed by its base upon the teeth, or on any of the central portions of the skull, will be heard better in the diseased ear. If placed in the air near the ear, it may not be heard as well as in the previous position. In doubtful cases, if the fork is laid a little to one side of the median line, it assists to confirm the diagnosis. For instance, the patient thinks he hears the fork best in the right ear, and it is then moved to the left side a little. If he still hears it as well as in the right ear, or even hears it equally well in both ears, there is no question of his hear- ing it better in the right.18 In diseases of the labyrinth having a nervous origin these conditions are reversed, and the tuning-fork will be heard better in the good ear-both ears being stopped. Hence the examiner must be on his guard, when investi- gating a case of suspected simulation, that he does not have a case of labyrinth disease before him. In such in- stances ocular inspection of the middle ear will be of value in completing a diagnosis. The third test, by the use of Cammann's binaural stetho- scope, is a very ingenious one, and is best described in the language of its originator, Dr. David Coggin.19 It is, however, only serviceable in simulated absolute deafness of one ear : " The patient affirmed that he was deaf of the left ear. I therefore inserted a tightly-fitting wooden plug into the right caoutchouc tube, and then put the two caoutchouc tubes into the metal ones. When I tried the instrument on myself, I found that words spoken could not be understood by the right ear. After the pa- tient had adjusted the stethoscope, he repeated without hesitation the words which I had whispered into the bell of the instrument, which served as a mouth-piece. The tube containing the plug was then taken out of the right car, which was firmly closed by pressure on the tragus. When I again spoke into the stethoscope, which was still in connection with the left ear, the patient positively as- sured me that he could no longer distinguish the words. He was, of course, aware that the tube through which he had before heard was no longer in connection with the right ear." It is more than probable, before the examiner has com- pleted these tests, that the simulator will have become so confused as to betray himself, when, of course, the ex- amination would cease. He must, however, be prepared to find men very obstinate, who have made up their minds to deceive, and may, therefore, be obliged to employ all the methods at his command in making a diagnosis. The preference of the writer is for the tuning-fork, about the use of which men are ordinarily ignorant, al- though the tests by the watch and stethoscope give excel- lent results. Careful inspection of the meatus should be made for evidence of inflammatory affections or for mor bid growths. In time of war cases of otitis may be placed in hospital for observation, to be exempted from service if subse- quent treatment develops the fact that organic changes have taken place, or permanent deafness resulted ; deaf- ness of one ear is not an objection, but when both ears are thus affected the man should be exempted. The Eyes.-Class 1 Loss of an eye ; total loss of sight of either eye ; conjunctival affections, including trachoma, entropion; opacities of the cornea, if covering part of a moderately-dilated pupil; pterygium, if extensive ; strabis- mus ; hydrophthalmia ; exophthalmia-, conical cornea; cataract; loss of crystalline lens; diseases of the lachry- mal apparatus ; ectropion ; ptosis; incessant spasmodic motion of the lids; adhesion of the lids ; large encysted tumors ; abscess of the orbits ; muscular asthenopia ; nys- tagmus. Class 2 : Any affection of the globe of the eye or its con- tents; defective vision, including anomalies of accommodation and refraction ; myopia; hypermetropia, if accompanied by asthenopia; presbyopia ; astigmatism; amblyopia ; glaucoma; diplopia; color-blindness {for the Signal Service only), disqualify. For convenience of examination the foregoing list of disqualifications has been separated into two classes: the first including those defects which may be discovered by the unaided eye ; the second requiring for their detection the use of special instruments. Loss of sight of the right eye, or loss of the entire globe, as well as other defects interfering with the vision, has been held by the War Department as cause for rejection. The writer is of the opinion that these disqualifications should apply to either eye, exceptions thereto being confined entirely to men de- siring to re-enlist. Aside from the disfigurement, there are certain manoeuvres in the drill and other exercises in military life which cannot be properly performed by re- cruits unless they have the perfect use of both eyes. Old soldiers are so well instructed in their duties and familiar with drills that nearly all military movements may be exercised by them without the use of both eyes, depend- ence being placed upon the word of command. The acceptance of one-eyed men has been advised, provided the sight of the remaining eye is perfect, and the fact asserted that some of our best rifle-shots among frontiersmen are thus mutilated. This may be true, and there could be no objection to such enlistments if the terms of the proviso could be made continuous ; but it is a well-known fact that when one eye has been perma- nently injured or diseased, the remaining organ is more or less liable to attacks of sympathetic ophthalmia, to avert which enucleation of the defective eye is often the sole resort. The slighter forms of injury or disease which may affect vision, if uncomplicated by an affection of the iris or ciliary body, are not followed by this result; but it is after the more severe injuries and diseases, partic- ularly when these bodies are involved, that sympathetic inflammation is to be anticipated. It is not always pos- sible for the surgeon to form an opinion as to the cause of blindness in these severe forms of injury without care- ful ophthalmoscopic investigation, to make which it is neither desirable nor proper for him to spend time. The fact that a disease affecting the integrity of the sound eye is likely to occur at any time would seem sufficient rea- son for objecting to the admission of such cases to the army. The writer is, therefore, of the opinion that loss of sight of either eye should in time of peace disqualify. Catarrhal affections of the conjunctiva, whether acute or chronic, are causes for rejection, as it is impossible to predict what their terminations may be ; a very mild conjunctivitis may develop into a most violent disor- der, attended with total loss of the eye ; or a chronic affection may linger for years, producing trachoma, af- fections of the lids, etc. Pterygium, if large and en- croaching upon the cornea to an extent that interferes in the slightest degree with vision, and strabismus, either convergent or divergent, if decided, reject. Any affec- tions of the globe of the eye, as keratitis, sclerotitis, retinitis, iritis, etc., whether acute or chronic, should reject. Careful examination should be made for the divergence of one or both eyes, when the applicant is re- quired to look steadily at an object (asthenopia), or their oscillation (nystagmus); both of which conditions are- likely to become more pronounced from the nervous ex- citement incident to the examination. Examination of the sight should be made with the utmost care, as perfectly clear vision is demanded for rifle-practice as conducted at the present day. The med- 745 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ical examiner should have a reliable sergeant to assist him. The applicant should stand facing the surgeon, and twenty feet from him, with his face to the light, as in this position the iris is moderately contracted, and opacities of the cornea, which may cover any part of the pupil, will be more readily discovered; the sergeant should cover one eye with a card, instead of the hand, as is directed ixj most instances ; if the hand is used, undue pressure is, unconsciously, liable to be made on the globe, the circulation is interfered with, and more or less dis- comfort and dimness of vision experienced when the eye is uncovered ; or a careless sergeant may, when covering the eye, so spread his fingers that the applicant can see the objects placed before him with the so-called covered eye, should the one uncovered be defective. The instructions given by the War Department for conducting this examination are contained in a general order, from which the following extract is made: "1. Range of vision necessary in recruits. Hereafter no re- cruit shall be enlisted who cannot see well, at six hun- dred yards, a black centre three feet in diameter on a white ground. This test will be made by means of cards, prepared under the direction of the Surgeon-Gen- eral of the Army. The black spots on the cards will be circular, four-tenths of an inch in diameter, and the re- cruit must be able to count them with facility at twenty feet distance."20 In compliance with that order the Sur- geon-General issued instructions from which the follow- ing extract is made : " These test-cards are ten in num- ber, with black spots arranged like those on playing- cards, and ranging from one to ten on each card ; . . . the surgeon . . . exposes successively the faces of two or three of the cards to the applicant, who must be able to state promptly the number of dots on each. This examination must be made with each eye separately, and may be varied by showing to the applicant one of the higher numbers, such as the nine or ten card, and cover- ing up a part of its face with another card so as to ex- pose one or more spots at a time. This test does not rep- resent absolutely perfect vision, but admits recruits with minor degrees of refractive anomalies. It has been thought best, however, that recruits with these minor anomalies should not be excluded on account of them, provided their eyes are healthy in other respects. " If there should be any doubt upon the subject with this simple test, the test-types of Snellen should be used. To determine the degree of errors of refraction, either the simple optometer or the test-glasses should be used. The writer is free to confess that he has failed to ob- tain any satisfactory results with the optometer, and has been compelled in all cases to resort to the trial-glasses for the desired information. Astigmatism may be deter- mined by the optometer, or by the use of the astigmatic charts furnished with the cases of trial-glasses. To de- tect color-blindness a set of test-wools is required, which should be used in accordance with the directions pub- lished by Holmgren, reprinted in Jeffries's work on " Color blindness," page 210 et seq. In time of war the following defects, which disqualify in time of peace, should not exempt drafted men from service : Loss of either eye; loss of sight of either eye; opacities of the cornea; strabismus, unless extreme; dis- eases of the lachrymal apparatus; ptosis, unless complete and indicative of serious brain lesion ; asthenopia and nys- tagmus, unless excessive; anomalies of refraction, unless extreme. The most common defect of vision among per- sons in this country is myopia, the degree of which to disqualify in time of peace, or exempt in time of war, has not been determined for the United States Army. Dr. Baxter, in his ' ' Report of the Medical Statistics of the Provost Marshal General's Office," states that "near- sightedness does not exempt; " Dr. Bartholow states, " Myopia ... is not a ground for exemption under the Enrolment Act, unless decided."21 Tripier says, " Myopia is an objection to a recruit."22 As has been stated, the range of vision for recruits, de- termined by the test dot-cards, admits them ' ' with minor degrees of refractive anomalies; " so far as myopia is concerned, these degrees are such as to admit men from whom efficiency as riflemen cannot possibly be expected. A man whose degree of myopia is as high as can, with each eye separately, count the dots at twenty feet, al- though he does it with difficulty ; but it is not possible for him to read the test-types of Snellen, that should be normally seen at that distance, nor to see the bull's eye on a target at any of the ordinary firing ranges, and if accepted as a soldier, he is therefore useless as a rifleman. Even with so low a degree of myopia as fs, the target is seen very indistinctly, and it is a question admitting of considerable doubt whether in such a case the soldier would ever become efficient as a marksman without the aid of spectacles; his vision would, however, be suffi- ciently acute for all ordinary purposes, and hence, if other- wise a desirable man, he might be accepted. The order promulgating the vision test is so worded that but few recruiting officers would feel themselves compelled to exact a literal compliance with its requirement for the re- cruit to "count with facility," and considering that he could "see well," if able to count the dots even with the difficulty encountered by a myope of degree, would accept him. In time of war, however, higher degrees of myopia may be admitted without serious detriment to the service, es- pecially if a system were adopted by which men so de- fective could be utilized in branches of the service other than the line, as is the case in foreign armies, where, for example, as in France, myopes of | and higher, and those of and higher in Italy, Austria, Switzerland, and Hol- land, are accepted; to do this, the use of spectacles would, of course, be necessary. In the English army recruits are admitted to the general service, and without being graded, with myopia; although Professor Longmore states it " to be very questionable whether any man with myopia = ought to be accepted as a recruit."23 When the facts are considered that the character of our service necessitates acuteness of vision in the use of the rifle, and that we have a vast population from which to recruit a small army, it seems proper that the highest standard for vision should be insisted upon, and that re- cruits should not be accepted in time of peace unless they have normal vision, as determined by test-types, or are myopic to a degree not exceeding when otherwise very desirable men. In time of war all degrees of myopia above should exempt, unless the use of spectacles is permitted, in which event, of course, most higher degrees, could be accepted. A very simple method for roughly determining the. higher degrees of myopia in cases which are free from astigmatism and other defects of vision is to ascertain the distance at which ordinary newspaper type can be read by the myope. With the normal eye this type is distinct at forty or forty-eight inches, and the dis- tance less than this at which vision is distinct in the myope will express the denominator of a fraction indicative of the degree of his myopia ; for instance, if the type can be read at fifteen or twenty inches, the person examined is about or -2l0- myopic, etc. As in the case of deafness, the surgeon must be pre- pared, in the examination of a conscript's vision, for the most artfully-laid schemes of deception ; but if he has patience, and works systematically, he will, in a large majority of instances, be able to ascertain the true state of the case, and expose deceit if it be attempted. Several excellent tests for the exposure of simulated defects of vision have been published, of which, doubt- less, the most convenient for use at a recruiting rendez- vous is that suggested by Dr. Howard Culbertson, U.S.A., and styled by him "the prismometer"; he describes it as follows : " The prismometer detects errors of refraction by means of the displacement of the false image seen through a prism. Its essentials are : a per- forated disk carrying a prism which covers one-half of the perforation, its truncated, thin edge dividing the per- foration into two equal parts, and a sharply-outlined, dead- white disk, about twenty-two millimetres in diameter, on a black, lustreless ground placed at a distance from the prism of 15' to 20'. This distance and the strength of the prism must be in such proportion that when an emme- tropic eye is placed back of the perforation and directed 746 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Recruits. to the white disk, a true and a false image will be formed, whose peripheries will be exactly tangent. In case the examined eye is hypermetropic the images will stand apart to a degree varying with the degree of hypermetropia ; in the case of myopia, on the other hand, they will overlap. The degree of ametropia in either case is measured by the lens, which, when held before the perforation, will render these disks tangent. By revolv- ing the disk bearing the prism through an angle of 180° the false image appears to revolve about the true end; in case of astigmatism the separation or overlapping is greatest in the meridian in which the astigmatism is greatest. Its axis may be determined by an index point- ing to a graduated arc in contact with the disk ; its de- gree by the spherical or cylindrical glass which renders the disks tangent in the meridian iu which they varied most from tangency." Professor Longmore54 describes the prism test of Graefe and the test by the stereoscope suggested by Mr. Lawrence. All of these tests depend for their success on the con- fused statements of the simulator, when compelled to look with his normal eyes through a prism, or to de- scribe objects especially prepared for view through a stereoscope. The stereoscopic objects require special prep- aration, and while a most excellent test upon men of more than ordinary intelligence, who may understand the effect of prism on vision, is not always practicable; any test by a prism is a good one, but that proposed by Dr. Cul- bertson is not only simple but effective, both against simulation and in the detection of refractive errors ; be- sides these are the Snellen test with colored glasses and test-types ; the use of various trial-glasses, the ruler test, etc., the description of which may be found in most works on diseases of the eye. Valuable information may be gained by a careful examination of the pupil in simulated blindness of one eye ; in an eye suffering from complete amaurosis the pupil is moderately dilated, and but feebly responds, or not at all, to the stimulus of light falling into it ; but does respond to the stimulus of light thrown into the other eye. In the simulator, of course, the pupil is normal. Other defects of the eye mentioned in the foregoing list should not exempt a conscript from duty, unless the vision is very materially interfered with, or, as in the case of disease of the lachrymal apparatus, the irri- tation produced by them keeps up a chronic inflammation. The Nose.-Loss of the whole or part of the nose ; defor- mities of the nose disfiguring the face, sensibly altering the voice, and impeding respiration ; stenosis and atresia of the nasal cavity ; chronic rhinitis (ozoena); polypus ; pur- ulent and foetid discharge from the nose, whether due to old and incurable ulcerations, or to any other lesion of the nasal mucous membrane, disqualify. Loss of the nose or parts thereof maybe congenital, ac- cidental, or the result of syphilitic or scrofulous ulcera- tions ; in the two former instances, unless the mutilation is of sufficient degree to make a noticeable disfigurement, or interfere with respiration, it is not cause for rejection ; in the latter instances it would, of course, disqualify. De- formities of the nose are generally produced by accident or by disease, congenital deformities being rare: the nasal bones may be so flattened, distorted, or destroyed by caries, as to interfere with respiration and speech. Syphilis creates great havoc in this location, hence these deformities should lead to suspicion of that disease, and careful investigation of the case. Stenosis and atresia are either congenital or due to alterations in the natural position of the septum, or to hypertrophies of the erectile tissue lining the cavity; in which latter condition the overgrown tissue covering the turbinated bones is forced against the septum, or projected in comb-like growths into the naso-pharyngeal space ; the breathing of persons laboring under this defect is entirely by the mouth, and their facial expression is often vacant and silly ; the irri- tation produced by the hypertrophied tissue keeps up an excessive mucous secretion, to relieve which there is an incessant hawking and spitting, and unless the cavities are cleared, decomposition takes place and is attended by its peculiar and nauseous odor. Deflection of the nasal septum is probably the most common cause of stenosis and atresia, the bone, in some instances, being forced against the side of the nostril, to which its mucous tissue may become adherent. Chronic rhinitis (ozoena) is readily detected by the horrible stench which patients carry about with them ; it is generally an evidence of a low grade of constitution, and aside from its disgusting local symptom would require rejection. Polypi, purulent discharges, etc., are all causes for rejection. In time of war, losses and deformities of the nose and ozoena, are the only defects which should exempt from military duty. The Face.-Navi; unsightly hairy spots; extensive cicatrices on the face, disqualify; "their presence would subject the man to the impertinent jests of his comrades, to his personal annoyance, and to the prejudice of good order iu his corps." The Mouth and Fauces.-Hare-lip, simple, double, or complicated ; loss of the whole or a considerable part of either lip ; unsightly mutilation of the lips from wounds, burns, or disease ; loss of the whole or part of either maxilla ; ununited fractures; ankylosis; deformities of either jaw, interfering with mastication or speech ;' loss of certain teeth ; cancerous or erectile tumors; hypertrophy or atrophy of the tongue; mutilation of the tongue; adhesion of the tongue to any parts, preventing its free motion ; malignant disease of the tongue; chronic ulcerations ; fissures or perforations of the hard palate; salivary or bucco-nasal fistula ; hypertrophy of the tonsils sufficient to interfere with respiration or phona- tion, disqualify. At the present day the army surgeon has to consider only the number and condition of teeth required for the proper mastication of food ; the question of bygone days as to their utility or necessity in biting cartridges having been settled by the introduction of breech-loading rifles, and the substitution of metallic for paper cartridges. It is probable that for many years to come the majority of our army will be stationed in the sparsely settled Terri- tories, and be compelled to make annual campaigns, as has been done in the past, for the protection of settlers from the lawless people and disaffected or vicious Indians among whom they have cast their lot. These campaigns, from a food standpoint, are as trying to the digestion of the men engaged in them as can be any campaigns in civilized countries in time of war : moving constantly from one camp to another, there is but little opportunity for the preparation of soft bread, and the hard biscuit must be used instead thereof ; if cattle are driven with the command, they soon become poor from constant travel, scanty food, etc., and their meat is so tough and stringy that the best of teeth can make but little impres- sion upon it, and the strongest stomachs have difficulty in digesting it. Since the abolition of the paper cartridge, the tendency among military writers on this subject has been to underestimate the necessity for sound teeth, ap- parently forgetting the fact that the soldier is often placed in circumstances where they are an absolute necessity for his health, and certainly indispensable for his comfort. The statement made by Dr. Baxter25 that, " as a matter of fact, there are not many days in which the soldier is not supplied with soft bread," is a grave mistake ; if he had plenty of soft bread the mastication of commissary beef in the field would still require the assistance of a goodly number of sound teeth ; hard biscuit can be softened by a variety of processes, but no amount of cooking will ever succeed in doing this for the beef referred to. It has been within the experience of the writer that men have been disabled through sheer debility, while on a protracted "scout," because of their inability to masticate the food on which the command was obliged to subsist. The molars and bicuspids, as the principal agents in mastica- tion, should therefore be in good condition ; it is not necessary that they should all be present, but the smallest number should be six, viz., two upper and lower molars, and one upper and lower bicuspid on the same side, all sound, and opposed to each other ; if the incisors and canines are perfect, but the molars and bicuspids gone, or extensively carious, rejection is demanded. Caries of a large number of the teeth, particularly if advanced, 747 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with destruction of considerable portions of the crowns, should reject, because it is probable that, before the ex- piration of an enlistment, they will be so far destroyed as seriously to interfere with mastication. The irritation of the gums caused by carious teeth is also frequently followed by abscess and troublesome swellings of the face and jaws. If artificial teeth are worn, the fact should be noted on the enlistment papers, but the artificial substi- tutes cannot be considered as taking the places of the natural teeth, nor as removing the disability for the mili- tary service arising from their loss. Lesions of the hard and soft palate must be carefully looked for, and the ton- sils thoroughly examined ; ulcerations and consequent perforations of the hard palate are often situated in the anterior part of the roof of the mouth, and unless the head is thrown well back, and the jaws widely separated, they may be overlooked. Ulcerations of the cheeks and gums, and especially on the sides and back of the tongue, must also be carefully searched for ; in the latter situa- tions they are often difficult to see, unless attention is called to them by the patient, as their location, either be- tween the papillae or following the course of the muscular fibres, conceals them from ordinary observation, especially if the tongue lies quiescent in the floor of the mouth, with its sides protected by the teeth. The subjects of excessive hypertrophy of the tonsils are undesirable as re- cruits, because of the likelihood that, at most inopportune times, they may be seized with an acute attack of inflam- mation of the parts, it being a well-established fact that previous attacks, of which the hypertrophy is the sequel, predispose to subsequent and more severe ones at any time; phonation, too, is materially interfered with, un- fitting the man for certain important duties, especially while detailed as a sentinel. In time of war, simple hare-lip, loss of teeth, cica- trices, hypertrophy of tonsils, should not exempt. Exemption on account of loss of teeth is frequently claimed by conscripts, and has been regarded as good cause ; men with such defects can, however, be made use- ful in the various administrative departments of the army, where the necessity for having sound teeth does not exist; therefore exemptions should not be granted for this cause; the wearing of artificial teeth may, under these circumstances, be favorably considered. The Neck.-Goitre ; ulcerations of the cervical glands; cicatrices of scrofulous ulcerations ; tracheal openings ; wry- neck ; chronic laryngitis, any or other disease of the larynx which would produce aphonia ; stricture of the cesophagus, disqualify. Goitre is not often met with among the class of men who are applicants for enlistment ; should it be recent and growing, or of sufficient size to interfere with respiration, or with the hooking of the coat-collar, or buttoning of the coat, it is cause for rejection. The cicatrices which are found in scrofulous subjects, who in childhood have had suppuration of the cervical glands, are both unsightly and liable to become irritated in hot weather by the coat- collar ; of course, as being indications of the presence of scrofula either in the past or present, a careful inspection should be made of the person for other signs of that dis- ease ; if none exist, and the cicatrices are healthy, the ap- plicant, if otherwise desirable, may be accepted ; but if they are numerous, purplish colored, or adherent, rejec- tion is demanded. Any ulceration about the neck, either of the lymphatics or in the tissues, is cause for rejection ; wry-neck, if permanent from any cause, should reject. Any chronic inflammation of the larynx, producing a huskiness of voice sufficient to render speech indistinct, or to induce actual aphonia, should reject. Of course the simple hoarseness of ordinary colds is not to be consid- ered, but any well-marked alteration of the voice should lead to an examination of the larynx, in which the ex- istence of organic changes would be cause for rejection. In time of war, only very extensive cicatrices, active ulcerations, or tracheal openings, should exempt; the presence of goitre, unless very large and unsightly, and wry-neck, if caused by rheumatism or any curable dis- ease, should not exempt. The Chest.-Malformation of the chest, or badly united fractures of ribs or sternum sufficient to interfere with respiration; caries or necrosis of ribs ; deficient expansive mobility ; evident predisposition to phthisis; phthisis pul- monalis ; chronic pneumonia ; emphysema ; chronic pleu- risy ; pleural effusions; chronic bronchitis; asthma ; or- ganic disease of the heart or large arteries; serious and protracted functional derangement of the heart ; dropsy de- pendent upon a disease of the heart, disqualify. The chest should measure not less than thirty inches in circumference, and have an expansive mobility of at least two inches. In obtaining these measurements the move- ments of inspiration and expiration should be confined entirely to the muscles of respiration; the applicant should be required to inflate the lungs to their fullest ex- tent by an easy, though complete, inspiration ; expira- tion should be made in the same quiet manner, and is most completely accomplished by requiring the applicant to count aloud until the necessity for a fresh supply of air compels him to inspire again. No contortions of the body should be permitted-such as throwing the chest forward and shoulders backward during inspiration, nor forcing the shoulders forward during expiration-as these movements can do nothing more than produce erroneous results. The measurements are to be taken when the man is stripped ; the arms are extended above the head, the tape brought around the chest in such a manner as to fall just below the points of the scapulae behind, and the nipples in front ; the arms are then to be brought down by the sides of the body, and while the tape is held tight enough to lay snugly against the skin, the man is directed to respire after the manner before related. The opinions expressed by various writers, especially Hutchinson, Balfour, and Brent, as to the fixed relations between the size, height, weight, etc., of parts of the body, and the capacity of the chest, have not been sustained by the results obtained by our surgeons in the examination of recruits during the civil war. That there are certain re- lations between these parts is doubtless true, but so many conditions are liable to present themselves which inter- fere with, or modify these relations, that no fixed rule can be laid down concerning the matter by which the surgeon should be guided ; experience, rather than mathe- matical calculation, has demonstrated that, as a general rule, men, in an ordinary state of health, should have an expansive chest mobility bearing an approximate rela- tion to their height, and that when this mobility falls be- low the relative standard, there is good reason to suspect the presence of pulmonary disease as a cause. It has been found that very tall men fail to reach this standard, and are more frequently rejected for insufficient chest mo- bility than any others. In making the measurements of the chest, attention must be paid to the proper proportion of its parts; the fact, however, being borne in mind, that certain occupa- tions have a tendency to change its shape without pro- ducing any lesion of the lung-tissue ; the lateral flattening of the chest-walls so often found in tall, slender men, or those of slight frame, with projection of the sternum- the " pigeon-breast "-is more likely to be associated with organic changes in the lungs than is the flat or hollow chest-the antero-posterior flattening. Malformations of the sternum and cartilages of the ribs are less likely to be present in the puny or phthisical subject, and have little or no significance in pulmonary disorders. It should be the object of the medical examiner to accept only men who have well-formed chests, or, as it is ex- pressed in the Army Regulations, " whose chests are ample; " any deviation from the typical healthy thorax being considered good ground for suspicion of changes in the normal character of its contents. It is entirely beyond the scope of this article to go into the details of a physical examination of the lungs ; hence it will be sufficient to say, that both auscultation and percussion should be performed before the examiner is satisfied to pronounce upon the availability of his patient for the military service ; with the exception of the ex- amination of the heart, there is none other which de- mands the exercise of so much care. Close questioning should be made into the family history of every applicant. 748 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Kecruits. as well as into his own life and habits, for any evidence of a predisposition to phthisis or the occurrence of attacks of pneumonia or pleurisy; a general susceptibility to changes of climate, weather, etc. ; the occurrence of asthmatic attacks, spitting of blood, etc. ; in fine, for anything which would bring out a clew to the previous existence of any affection connected with the pulmonary apparatus. Particular stress is laid upon this subject, be- cause it is no uncommon thing to find men seeking army life with a hope that its supposed freedom, regularity of habit, and their own location in particularly salubrious climates, might benefit an already existing lung trouble. Parents consent to the enlistment of their boys under the impression that the life of a soldier will "harden their lungs," and recruiting officers will often urge the accept- ance of applicants whose skin is suspiciously clear, upon the ground that the service will "bring them out;" "make new men of them," etc. ; the medical examiner must, therefore, be especially on his guard against the admission of such men to the service, and recollect that he is not required to diagnosticate any particular lesion of a lung in order to reject an applicant, but if he has reason to suspect a predisposition thereto-unhesitatingly to reject. Dr Tripier quotes very aptly from Bezin, as follows : " It is true we run the risk of rejecting men who may af- terward become very robust, and who, by a long and suc- cessful life, may contradict the prognosis we may have pronounced in their cases, but . . . you will be astonished at the number of young men who, received because no determinate lesion of the thorax was recog- nized when they were inspected, succumb afterward with phthisis, or whom it was necessary to send back to their friends and families with broken health, after their strength had been exhausted." (Aide-Memoire.) Of organic diseases of the heart, those affecting the valves are easily detected, and require no detailed notice here ; a cardiac murmur is, however, occasionally heard, which is not indicative of any disease of either heart or lungs, and about which the text-books on the general subject are silent. It has been described by Dr. Hamilton Osgood, in a paper read in March, 1883, before the Boston Society for Medical Improvement, and published in vol. cviii., No. 13, of the Boston Medical and Surgical Journal. Dr. Osgood gives to it the very appropriate name of a "misleading cardiac murmur;" it is heard during the respiratory act, with a portion of which it is synchronous (especially inspiration), and is located at the base of the heart. When respiration is temporarily suspended it may be heard, although not so distinctly as during the normal act; its true nature is to be discovered by auscultation during forced collapse of the lungs ; mere ordinary expira- tion will not uncover the heart, and the patient must be instructed to force out all the air possible, continuing his efforts until air can no longer be expelled from the lungs; after which the lungs must be kept immovable. By this procedure the heart is brought more closely in contact with the ear, and is freed from the presence of lung tis- sue, which, in the inflated lung, partially covers it; the " misleading murmur" will now be found to have disap- peared. Aside from its value in determining this point of doubt, forced expiration of the lungs is a valuable ad- junct in the examination of the heart under any circum- stances ; when that organ is uncovered, the natural as well as morbid sounds are more sharply accentuated, and deviations from the normal will be more easily discov- ered ; if the patient is required to put the anterior chest- wall on the stretch by standing with his back against a door or post, and his hands carried forcibly behind his back, the results will be much more satisfactory. In the diagnosis of cardiac hypertrophy, associated or not w ith dilatation, the inexperienced medical examiner may be easily misled. The movements of the heart are so largely under the influence of the sympathetic nervous sys- tem, that any cause acting directly through that system may produce such alterations of its rhythmical action as will lead to the opinion that they are the result of organic change. When the hand is placed upon the chest of an applicant who has just passed through the preliminary questioning, and been stripped for examination, the heart will probably be found in tumultuous action ; in some in- stances so violent as to produce a feeling of faintness. The excessive use of tobacco and coffee, or either, will also produce so much functional disturbance, irregularity of action, and palpitation, that organic changes may be suspected. The powerful, rhythmical action of the en- larged organ in true hypertrophy, taken in connection with the permanent change in the location of its apex beat, will supply the evidence mostly to be relied upon in forming a correct opinion of the case presented. It is not, however, always possible, in the short time allotted to the preliminary examination, to decide whether the abnormal action is functional or organic, and in all cases of doubt the applicant, if otherwise desirable, should be kept under observation for two or three days, in order that he may become accustomed to his surroundings, and recover somewhat control of his nervous system. Should it become apparent that even a functional disorder of the heart is persistent, or so serious as to interfere with the usefulness of the applicant, he should be rejected. The sequelae of cardiac lesions, dropsies, pulmonary engorge- ments, etc., will require close consideration, particularly in their earlier stages ; but it is a rare occurrence for men in a state of disease so far advanced as these symptoms would indicate to come to a rendezvous. In all cases of suspected cardiac lesions, the urine should be carefully examined. The directions given in the "mode of examination," on a previous page, to auscultate the heart before requiring the applicant to go through the violent exercise of run- ning, jumping, etc., were for the reason that the sounds of the heart are best heard when the patient is at rest. The lungs are best examined while rapid breathing is in- duced-hence the directions for their examination after the exercise mentioned. Should any lesion of the heart have been suspected, its rapid action after exercise will tend to bring out more prominently the abnormal sound. Advantage should be taken of this excessive action to ex- amine the course of the blood-vessels in the neck and other parts of the body, with a view to the detection of aneurisms. In time ofwar&W diseases of the heart and lungs should be cause for exemption, without exception. The Abdomen.-All chronic inflammations of the gastro- intestinal tract, including diarrhoea and dysentery ; dis- eases of the liver or spleen, including those caused by ma- larial poisoning ; ascites; obesity ; dyspepsia, if confirmed; haemorrhoids ; prolapsus ani; fistula in ano ; considerable fissures of the anus ; hernia in all situations, disqualify. Among the list of disqualifications mentioned by Trip- ier and Baxter are engorgement of the mesenteric glands, chronic peritonitis, stricture of the rectum, and taeniae. The first three of these diseases are exceedingly rare, and their diagnosis a matter of considerable difficulty at best. It is not very likely that the subjects of them will pre- sent themselves for enlistment, and they are accordingly omitted from the disqualifying list, because they fall within the list of general affections impairing the effi- ciency of men for military duty, the mere mention of which would extend an article into the limits of an elab- orate treatise, and the discovery of which would natu- rally be cause for rejection. The existence of any species of tape-worm is not considered a disqualification, their expulsion from the intestine being so easily accomplished, and their presence producing so little constitutional dis- turbance in the adult. To ascertain whether chronic in- flammation of the gastro-intestinal tract, or dyspepsia of an aggravated form, is present, the medical examiner will be compelled to rely largely upon the statements of the man himself. Accuracy of diagnosis cannot be expected except after observations conducted for a greater or less period of time ; many instances terminating only in nega- tive results. The grosser signs of these disorders may lead to suspicion of their existence, but in men anxious for enlistment, all evidence tending to establish the fact will be concealed, although the emaciation attendant upon long-standing and serious cases should put the ex- aminer on his guard. Fortunately, but very few of them 749 Examination of Recruits. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. are presented, and the mere mention of their names is enough to draw attention to the probabilities of their presence. Affections of the liver and spleen are of more practical moment, when one considers the fact that a large proportion of our recruits is drawn from sections of the country in which malaria is rife, and where men whose systems are broken down by the influence of this poison are forced to quit their ordinary employments, and seek a livelihood in some other and more healthful region ; the army offering the easiest means for accom- plishing the object. In these instances enlargements of the liver and spleen will be found, and associated with them the anaemia and generally debilitated condition characteristic of malarial poisoning. From some of the rendezvous subsidiary to the depot at Columbus, O., which were located in malarious regions, the men en- listed were feeble and anaemic, with enlarged spleens, dropsical legs, and a mental depression which was an apparent bar to improvement under their changed con- dition of life ; in many instances this change of climate, <etc., brought about a recurrence of the periodic fever, necessitating admission to, and protracted treatment in, hospital, and leaving the men utterly useless for future service. The evil became so great that orders were finally issued to discontinue the objectionable rendez- vous, and abandon the infected districts; attention, then, must be given to the condition of these organs, in all cases where the general appearance indicates malarial poisoning. Obesity, or pendulous abdomen, impairs the efficiency of men for military duty; they cannot take active exercise without loss of breath, or in warm weather without suffering from excoriations, prickly heat, etc. ; and moreover, in all such cases the presence of fatty de- generation of the heart and arteries is to be suspected. Haemorrhoids are so very common, and of so many de- grees of severity, that it is impossible to lay down any fixed rule by which all cases are to be decided ; each must be judged upon its own merits, and rather by the effects of the disease upon the individual, than by the size •of the tumors or their age. Internal haemorrhoids, ex- cept when protruding, cannot be discovered unless they are bleeding at, or just before, the time of examination, the evidences of which will appear upon the person or clothing of the applicant; they may possibly be ulcerated, in which event there will be a purulent discharge from the anus, which, however, may occur from other causes ; but its appearance should be the occasion for a careful inspection of the rectum, if the man denies being the sub- ject of piles. Their existence is an absolute cause for re- jection. External haemorrhoids, if multiple and large, ulcerated or inflamed, should reject. The small, accidental pile, commonly met with in men of constipated habits ; the pedunculations found in men of lax fibre, or old piles in which the former mucous lining has become trans- formed into a hard and insensitive covering similar to true skin, are not causes for rejection, if the man states that they have not given him trouble. These statements should however be taken with many doubts, as the de- sire to enlist will lead men to prevaricate about that point, and the medical examiner will be obliged to form his own opinion from the appearances presented by the tu- mors, and their effects upon the surrounding parts. Although fistula in ano may be discovered by means of the discharge from its track in most cases, a careful in- spection of the parts near the anus, for the external opening of the fistula, is necessary ; in very hairy men, the hair must be pushed aside and every point suggestive of the appearance of a fistula explored with a probe. There should be but little difficulty in discovering any well-developed forms of hernia ; it is those cases which are incomplete or partially developed about which the surgeon may be perplexed. The examination should al- ways be made while the man is standing, and with his hands extended above his head ; the surgeon should ex- amine the umbilicus, and afterward each inguinal canal, carrying his finger well up to the internal ring, and re- quiring the man to cough vigorously ; if the bowel pro- trudes to any degree from the abdominal cavity into the canal, it can easily be felt. There can be no doubt as to the unfitness for service, in time of peace, of an appli- cant who has a hernia, all varieties of which, whether com- plete or incomplete, are absolute causes for rejection; cases, however, in which the inguinal rings are relaxed, in which there is supposed to exist a "tendency to hernia," are not so easily disposed of ; the question as to the acceptance of men having this tendency being still an open one. In some foreign armies it is considered a sufficient cause for rejection,* but in our service the opinion of most medical officers is adverse to such a course. While it is true that the exertion incident to certain phases of military life may produce a hernia in men having relaxed inguinal rings, it is equally true that the accident may happen quite as often (relatively) to men who do not have this defect; indeed, there is no especial evidence to show that this is more fre- quently a cause, than is any other cause, predisposing to the disease. The experience of the writer fully confirms the statement made by Tripier,26 that "by far the greater number of herniae that have fallen under our observation have occurred in comparatively robust, thick-set men; just the men who rarely have relaxed external rings." The exclusion of this class of cases would, it is believed, result in the loss to the service of many excellent men, and until it is shown that they are more liable to the de- fect than others, rejection is not demanded. The exami- nation for a hernia should, however, be very carefully made, and the applicant required previously thereto to run, jump, or take other violent exercise ; care must be used in the examination of a scrotal hernia, that a mistake is not made in confounding it with other tumors con- nected with the cord or testicle-an error one might very easily fall into when examining any large number of men. The tissues covering an umbilical hernia are so very thin that there can be but little room for error in diagnosis ; indeed, the fact is, that any thinning of the abdominal walls in that vicinity amounts practically to a hernia ; but one must not confound with a hernia a not uncommon malformation of the umbilicus, in which, through some morbid process during the separation of the cord, a nipple-like tumor has been left that bears no small resemblance to an umbilical hernia. In time of war it would not be proper to reject men who had haemorrhoids, unless, if internal, they were very large, and the constitutional effects produced by the bleeding, or the irritation set up by their presence, was plainly visible ; in case of external haemorrhoids they should be very large, painful, and of long standing, to be cause for rejection. Herniae which are easily reducible, and retained in position by a well-fitting truss, or those which are incomplete, should not be cause for exemption. All other defects which disqualify in time of peace, do so equally in time of war. The Genito-Urinary Organs.-Any acute affection of the genital organs, including gonorrhoea and 'venereal sores ; loss of the penis ; phimosis ; stricture of the urethra; loss of both testicles ; permanent retraction of one or both testicles within the external ring ; any chronic disease of the testicle ; hydrocele of the tunic and cord; atrophy of the testicle ; varicocele ; malformations of the genitalia ; incontinence of urine ; urinary fistula ; enlargement of the prostate ; stone in the bladder; chronic cystitis ; all diseases of the kidney, disqualify. The existence of gonorrhoea, or a venereal sore upon the penis, should be cause for rejection ; aside from the fact that the subject of either of these affections is liable at any time to communicate it to his comrades, it is not possible for any one to foresee the complications which may arise during the course of either form, nor the sequelae it may leave behind. Venereal diseases are so very com- mon, and held in such light estimation by the laity, and indeed by many of the profession, that their existence is looked upon rather as an incident in the ordinary life of a soldier, than as a serious matter which may disable the victim for life. Men who have been inadvertently enlist- ed with any venereal disease should be placed in hospi- tal at once, both as a measure of cure, and for the pur- pose of isolation. It is to the interest of the service that such cases should receive prompt attention, as, even 750 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Recruits. if their progress toward a cure is not delayed by compli- cations, their terminations are liable to be marked by per - manent disabilities, demanding final discharge. Cases of gonorrhoea are frequently followed by stricture of the urethra, and venereal sores are almost as likely to prove syphilitic as innocent ; the instructions laid down in text-books for the differential diagnosis between chan- croids and chancres will prove but a poor defence, should a recruit who, at the time of enlistment is the subject of a chancroid be afterward discharged on account of con- stitutional syphilis ; the principle that the Government is justified in caring for such cases in its hospitals, for the purpose of securing the services of good men temporarily unfortunate, is entirely wrong, and the desired result is seldom attained ; the experience of the writer is to the effect that the large majority of such cases terminate by discharge, before the subject has been able to render any considerable portion of the service for which he was en- listed. The existence of any stricture of the urethra is cause for rejection ; its presence can be definitely determined only by the use of the sound, a procedure demanded in all cases giving ground for a suspicion of disease ; the condition of the stream passed in urinating must be care- fully inquired into, and all information relative to a his- tory of the case elicited by closely questioning the patient, before resorting to the use of an instrument. Simple nar- rowing of the meatus, which is congenital in many per- sons, should not be considered as cause for rejection. Phimosis, if complete, is liable to give a great deal of trouble to a soldier by repeated attacks of balanitis ; if there is adhesion between the prepuce and the glans, partial or complete, graver symptoms may present them- selves, and his efficiency may be impaired by reflex paral- yses, epilepsy, or other nervous affections, for the relief of which surgery is required ; for these reasons it is made a cause for rejection. When both testicles are absent from the scrotum, the inguinal canals must be carefully ex- amined for evidences of their retention therein ; loss by injury may be known by the scar remaining on the scro- tum ; should one or both testicles be found permanently resting in the inguinal canal, or absent from the scrotum from any cause, the applicant should be rejected. In affections of the testicle, discrimination must be made be- tween true diseases of this organ and morbid changes in the epididymis, the result of inflammatory action. The most common defect among the class of men who present themselves for enlistment is the enlargement from inter- stitial deposits following orchitis-sarcocele-which, when inconsiderable in size, is not a cause for rejection ; a diagnosis must however be made between it and other enlargements of the testicle, either syphilitic or malig- nant ; and should there be reason to believe that the en- largement is due to either of the latter causes, or should its size be such as to give annoyance to the patient, rejec- tion is demanded. A hydrocele may mislead one in cases of this nature, and the test by transmission of light should therefore not be omitted in any examination of the organs. It is exceedingly rare to find a varicocele of such size .as to become a real disability to a willing soldier in any branch of the service, excepting, perhaps, that requiring him to be mounted-under which circumstances he may injure it or the testicle-which in these cases hangs very low-against the saddle ; but as it is a defect which may be made to appear a disability, the soldier has an ever- present excuse for the evasion of duty, or a ground upon which to base an application for discharge. So long as he can demonstrate the existence of a disease or defect in any organ, so long will it be impracticable to insist upon a performance of his duty, and it is this circumstance rather than any well-grounded belief in the disqualifying nature of a varicocele, as well as the more general prin- ciple that no men should be enlisted who are the subjects of any recognizable physical defects, which leads to its being placed upon the list of rejections. The rule laid down by Tripier is an excellent one for the determination of the degree of varicocele which should reject: " If the testicle on that side is atrophied, whatever may be the volume of the circocele (varicocele), or if the volume of the latter exceed that of the former, the recruit should be rejected.27 Among malformations may be mentioned epi- and hypospadia, where the urethra terminates at a distance nearer the body than one-fourth the length of the penis. Incontinence of urine may be suspected by a urinous odor about the person of the applicant, or the appearance of his clothing, which may be stained ; of course there can be no evidence of the fact except after certain observa- tion, and, therefore, the statement of the man must be taken as to its absence before he can be accepted. If any disease of the kidney is suspected, a careful ex- amination of the urine should be made by chemical re- agents, extended if necessary to an examination by the microscope. It is, of course, presumed that the applicant will be closely questioned as to the existence of any symptom which would point to renal trouble ; the pres- ence of albumen, sugar, blood, or pus in the urine, al- though due to temporary ailments, is ground for absolute rejection, as would also be dropsical effusions into any of the tissues in the body. In time of war acute affections of the generative organs should not exempt; the subjects thereof can be placed in hospital until cured of the primary difficulty, and those who are free from constitutional taint, or very light strict- ures, sent to active duty ; phimosis, loss of testicles, hy- drocele of the tunics and cord, unless interfering with locomotion, and spermatorrhoea, are not causes for exemp- tion, as men suffering from these defects can be made useful in the administrative department, and in some cases in the line of the army. Affections Common to both Upper and Lower Extremities. -Chronic rheumatism ; chronic diseases of joints ; old or irreducible dislocations or false joints; severe sprains ; re- laxation of the ligaments or capsules of joints ; dislocations ; fistula connected with joints, or any part of bones ; dropsy of joints ; badly united fractures ; defective or excessive curva- ture of long bones; rickets ; caries; necrosis; exostosis; atrophy or paralysis of a limb ; extensive, deep, or adherent cicatrices ; contraction or permanent retraction of a limb or portion thereof; loss of a limb or portion thereof, disqualify. Nearly all defects in the extremities are apparent by some impairment of the natural shape or motion of the limb, and can hardly escape the notice of one who exam- ines attentively his cases ; indeed, in the inspection of large numbers of men one becomes so expert as to dis- cover departures from normal shape and motion as if by intuition ; diseases affecting the continuity of limbs which do not necessarily interfere with motion or alter shape, may occasionally require careful search for their detec- tion. It is more frequently the case that the surgeon is called upon to exercise his judgment in deciding how far an ex- isting blemish may impair the efficiency of an applicant, than he is to exercise his skill in searching for hidden or obscure disqualifications ; this is particularly the case in severe sprains, dislocations, large cicatrices, and chronic rheumatism. It should be remembered in the preliminary examination of the shoulder-joints, that it occasionally happens men cannot touch the point of the shoulder with their fingers, and a careful search fails to reveal any imper- fection of the joints of the extremity ; and that the elbow and wrist should receive especial inspection, as a defect is most likely located at these points; but rejection is not demanded unless a defect is clearly made out, as an ex- treme muscular development may be the cause, or a con- genital shortening of some of the bones exist without an interference with any other than this particular move- ment. Men desiring to enlist will seldom, if ever, admit the presence of chronic rheumatism, and it is only when, as a result of this disease that one or more joints are swollen or otherwise disabled, that the surgeon can be aware of its existence. The absence of any of these evidences will occasionally enable a man to enlist who has been previously discharged from the service on ac- count of alleged chronic rheumatism, in which event the medical examiner would be blameless of the charge of carelessness, as in all probability the discharge was pro- 751 Biaml"er?"[cruHX REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cured through fraud and malingering. Chronic rheuma- tism of sufficient severity to warrant a discharge from service should be followed by tangible evidence, in the shape of swollen or distorted limbs, deposits in the joints, or enlargements in the surrounding tissues, and these are not likely to disappear; close inspection must be made of all joints to discover any swelling or other evidence of sprain ; lameness of an inferior extremity, or stiffness of a superior one, should be an indication for careful ques- tioning as to the receipt of injury. It is not always wise to place too much confidence in the statements of men as to their freedom from pain, or ability to move joints which have been injured. It is well known that the remote effects of sprains, and other joint injuries, particularly of the ankle and wrist, are liable to manifest themselves, even at a late period, in swellings or pain after severe exertion ; and however honest one may be in the belief of his perfect cure from such an injury, and ability to perform all duty required of him, there may be an actual defect of which he is ig- norant. The medical examiner, therefore, must exercise his own judgment from the appearance of the parts, their sensitiveness, etc., as to whether this is the case or not, and reject in all instances which give room for doubt. Fractures which have been properly treated, and have united without deformity, are not of themselves causes for rejection, but when they are followed by neu- ralgic pains, or if there has been much displacement of fragments, so that the symmetry of the limb is destroyed, or if from excessive bony deposits there is impairment of motion, they are causes for rejection. Fractures of the bones of the forearm are very likely to give trouble by interference with the motions of pronation and supina- tion, both of which are necessary in handling the rifle during the exercises in the manual of arms. Malforma- tions of the limbs, as excessive curvature-bow-legs-are objections rather because of the awkward gait they in- duce than from any interference with the ability of the man to march; when the curvature is caused by a con- stitutional taint, as rickets, etc., there can be no question as to the propriety for rejection. Abnormal cartilagi- nous or bony formations in the muscles, or loose cartilages in the knee-joint, are objections when they impair the use of the joint. In time of war especial care is necessary, particularly in those affections which present but little external evi- dence of injury, to detect deception; chronic rheuma- tism, sprains, alleged dislocations and fractures, must not be made causes for exemption unless the evidences of im- paired strength and motion of the parts in which they are located are indisputable ; allegations of pain, loss of mo- tion, involuntary contractions, etc., will constantly be made, and if the surgeon has no other means of complet- ing his diagnosis in a case of suspicion, he should resort to the use of anaesthetics, under which simulation ceases, and the true state of an alleged disability ■will be made apparent; one must, however, bear in mind the fact, that in central lesions of the brain contractions disappear during chloroform narcosis ; it should be stated that au- thority for the use of anaesthetics is limited " to cases of professed rheumatic contraction of joints when unat- tended with perceptible alteration of form or structure,"28 although it is recommended in a wider range of cases by Tripier and Bartholow, both authorities recognized by the War Department. Au ingenious test for simulated contractions of limbs-flexures-has been suggested by a Russian military surgeon, and is published by Zuber.29 It consists in applying tightly to the affected limb an Es- march bandage, as if for amputation ; when the band- age is removed, the rubber cord remaining, the limb straightens itself involuntarily. The test has been tried in but few cases, and may not invariably succeed, but it is worthy of further trial. All officers of experience in the examination of ma- lingering soldiers agree upon the fact, that their most vulnerable point is in an exaggeration of the symptoms they endeavor to simulate ; when a man comes limping before a surgeon with every expression of pain upon his countenance, or assumes the most unnatural and con- strained positions of body or limb, he may, in nine instances out of ten, be set down as a malingerer, if he pre- sents no external physical signs of disease ; there is some- thing about a real sufferer or cripple which is very hard to describe, but which every surgeon will recognize ; and in a large number of instances the problem will be, not so much in recognizing the deception, as in compelling the subject to admit it. The Superior Extremities. - Fracture of the clavicle ; fracture of the radius and ulna; webbed fingers; perma- nentflexion or extension of one or more fingers, as well as ir- remediable loss of motion of these parts ; total loss of either thumb ; mutilation of right thumb ; total loss of the index- finger of the right hand; loss of the first and second pha- langes of all the fingers of either hand; total loss of any two fingers of the same hand, disqualify. Fractures of the clavicle, which are almost invariably followed by more or less deformity, are causes for rejec- tion in consequence of the painful pressure made at the seat of injury by the rifle, during certain movements in the manual of arms, and by the " sling straps " when carrying the knapsack or haversack. The mere fact that the clavicle has been fractured is not of itself cause for rejection, and even the presence of a slight deformity should not be objectionable, provided there is neither pain on pressure, nor interference with the free motion of the arm. The improved means of transporting the baggage of the soldier have in a great measure done away with the necessity for his knapsack ; the few articles of clothing he requires in the field are rolled in his blanket, which is slung over the shoulder and across the chest, and thus carried without inconvenience or pain to any injury the clavicle may have sustained. The haversack strap may, however, on long marches, or when the sack is well filled, produce painful pressure, or even excoriate the skin, and the gun is very liable to injure a prominent deformity on this bone ; therefore a tumor at the seat of fracture, from whatever cause, if considerable, would be a valid objec- tion to enlistment. Any fracture of the radius and ulna, particularly Colles', is liable to be followed by impair- ment of the motions of pronation and supination of the forearm-movements indispensably necessary in the drill of the manual of arms, the "set up" drill, and other military exercises. Should this be the case, rejection is demanded ; otherwise, union and motion being perfect, the injury is not a cause for rejection. The degree of mutilation of the hand which should disqualify, can only be determined by the facility with which a man so injured can handle a rifle ; in loading the Springfield (army) rifle, the breech-block is thrown open and the cartridge thrust home by pressure of the right thumb, the rifle is also cocked by the same member ; hence, it is very important that it should be intact; and any injury which materially interferes with its flexion or strength is a cause for re- jection. The common distortion of the extremity due to contusion or felon, need not disqualify ; the loss of the entire member would, of course, reject; loss or mutila- tion of the last phalanx of the left thumb need not dis- qualify. The first and second phalanges of the right in- dex-finger may be lost or mutilated without necessarily disqualifying an otherwise very desirable recruit, or a soldier who desired to re-enlist; it is ordinarily the finger used in pulling the trigger, but this can be done with facility by a stump, or by the middle-finger, as is the case with many marksmen whose fingers are perfect; it should, however, be the rule for recruits to have a perfect right fore-finger, departures from which should be made only in rare instances and for very good reasons. Permanent flexion or extension, or loss of motion of any fingers, so materially interferes -with a military use of the hand as to demand rejection. The congenital malformation of the little finger of one or both hands, which is so com- mon, is not considered a disqualification. In time of war, the loss of the right thumb ; loss of any two fingers of the same hand ; loss of the first and second phalanges of the fingers on the right hand ; permanent flexion or extension of two fingers of the right hand, or all the fingers united (webbed), are causes for exemption. The Lower Extremities. - Varicose veins ; knock-knees ; 752 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examination of Re- Exaniiner. [emits. club-feet; splay or flat feet; webbed toes ; the toes double or branching ; the great toe crossing the other toes ; bunions ; corns ; overriding or superposition of any of the toes to an extreme degree; loss of a great toe ; loss of any two toes of the same foot; permanent retraction of the last phalanx of any of the toes, or flexion at a right angle of the first pha- lanx of a toe upon the second, with ankylosis of the articula tion ; ingrowing of the nail of the great toe; stinking feet, disqualify. Dr. Baxter, in his "Report of the Provost Marshal General's Bureau," says that to be cause for rejection, varicose veins must be "voluminous and multiplied." There is no doubt of the fact, that the judgment of many surgeons is in error as to the degree of varicosity of the veins of the leg which should disqualify, and men have been discarded with veins so slightly enlarged that they could hardly be called varicose; the network of small veins so often seen in the popliteal space, and inside of the thigh, upon men of spare habit, or whose occupations have required them to stand a great deal, are not suf- ficient in degree to cause rejection ; nor, indeed, is such the case when a single vein may be more or less enlarged without the function of its valves being impaired. It is only when several veins are very large and tortuous, with failure of their valves, or when there is oedema, thicken- ing of the integument, or much ulceration, that they be- come disqualifications. An exception to this rule should be made in cases where haemorrhoids are present, when even slightly varicose veins are causes for rejection. One may see occasionally an instance in a very muscular man, where there has been a rupture of the. sheath of some muscles in the leg, which closely resembles a varix ; if the finger is placed over such a tumor during the contraction of the muscle, its true nature will be apparent. Knock- knees, if existing to such a degree as to interfere with the free use of the limbs, should disqualify ; as a general rule, if the inner borders of the feet, from the heel to the ball of the great toe, cannot be brought within one inch of each other without passing the inner condyles of the femur, respectively, in front of and behind each other, the applicant should be rejected. Flatness of the feet to a degree requiring rejection is very seldom met with among applicants for enlistment, notwithstanding the fact that it is supposed to be very common among the labor- ing population ; as a cause for rejection it has been very much exaggerated ; the ordinary flatness of foot so often seen, especially among negroes, is not more likely to be- come a cause of disability in marching than is the more shapely foot, unless an ill-fitting shoe is worn ; the ana- tomical peculiarity which disqualifies has been described by Gorcke, of the Prussian service, substantially as fol- lows : The inner ankle is very prominent, and is placed lower than usual ; a hollow exists below the outer ankle of a greater or less extent; the dorsum of the foot is not sufficiently arched ; the foot is broader at the ankle than near the toes ; the inner side is flat and sometimes convex, and when the foot is placed on the ground the sole pro- jects so much on the inside that the finger cannot be introduced below it; the body rests on the inner side of the sole, and the usual motion of the ankle-joint is im- peded. Bunions, if large and presenting evidences of old or recent inflammation, should always reject; they are a fruitful source of disability on long marches and in hot weather, the pain produced by the pressure of the shoe setting up an irritation which extends to the entire foot. The same may be said of corns when located on the sole of the foot; those under the head of the metatarsal bone of the great toe are the most painful, and produce lameness sooner than any others ; they are, moreover, very intract- able. Of the malpositions of the toes, that in which the first phalanx is flexed at right angles upon the second to such an extent that the man walks upon the end of the nail (hammer toe), is the most painful, and will disable more speedily than the others ; there is no shoe which can be made that will remedy the defect, and it is in conse- quence an absolute cause for rejection. Ingrowing of the nail of the great toe, if deep and accompanied with signs of irritation, inflammation, or suppuration, renders a man unfit for service ; if, however, he is very desirable otherwise, the simple operation of shaving away the re- dundant tissue on the border of the toe, in a majority of instances effectually cures the disease, after which he may be accepted. The fetid odor exhaled from the feet of some men is such as to make their presence in a squad-room unbearable to their comrades ; the excessive perspiration causing this odor keeps the toes and under surface of the feet soft and the skin macerated, for which reason very slight exercise produces painful ex- coriations and unfits the man for duty. When the feet show evidences of this condition the applicant should be rejected. In time of war very large varicose veins, club-feet, an excessive knock-knee, loss of great toe, and flexion of the phalanges of the other toes to an extreme degree, should exempt ; men having other defects of the feet, if unfit to join the active line can be made useful in the administrative departments and should be held to service. Charles 11. Greenleaf. 1 Army Regulations, 1881, paragraphs 757 and 785. 2 Statistics, Provost Marshal General's Bureau, 1875, p. viii. 3 Army Regulations, 1881, paragraph 784. 4 Ibid., paragraph 762. 6 Ibid., paragraphs 760, 761. 4 Ibid., paragraph 757. 7 Ibid., paragraph 757.. 8 Tripier's Manual for Examination of Recruits, p. 16. 9 Ibid., p. 16. 40 Op. cit., pp. 68, 69. 11 Kelsey : Diseases of the Rectum and Anus, p. 142. 12 Legal Medicine, vol. iii., p. 142. 13 Marshall: Hints to Young Medical Officers, p. 68. 14 Tripier's Manual, p. 12. 15 Crawford : Observations on the Examination of Recruits, British Army Medical Reports, 1862. 18 Tripier's Manual, p. 78. 17 Crawford; British Army Med. Reports, 1862, p. 534. 18 Pomeroy : Diseases of the Ear, pp. 33-36. 19 British Medical Journal, No. 1197, p. 1164. 20 General Order, No. 82, Adjutant-General's Office, 1879. 21 Bartholow : Manual for Examination of Recruits, p. 50. 22 Tripier's Manual, p. 46. 23 Longmore : Manual for Army Surgeons, p. 76. 24 Ibid., p. 84. 26 Provost Marshal General's Report, p. 167. 26 Tripier's Manual, p. 66. 27 Ibid., p. 70. 28 Statistics Provost Marshal General's Bureau, vol. 1., p. 5. 27 Des Maladies simulees dans i'armde moderne, par Dr. G. Zuber. 1882. EXAMINER, MEDICAL. The State of Massachusetts, in common with other States of the Union, employed the coroner's inquest as the official mode of inquiry in cases of deaths from sudden, violent, or suspicious causes, from the early history of the colony until 1877. In consequence of corrupt practices which had become of frequent occurrence, and also in consequence of the inefficiency of the existing system, and of the inherent incongruity of an office requiring expert knowledge both of law and of medicine, a persistent movement was made by the Massachusetts Medical Society,1 ably assisted by T. H. Tyndale, Esq., and other members of the legal profession, having as its prime object a radical change in the coroner system. This movement was heartily endorsed by the Massachusetts Legislature of 1877, and resulted in the enactment by that body of the following statutes, which constitute in the main the law now in force in Massachusetts: Acts of 1877.-[Chap. 200.] An Act to abolish the office of Coroner and to provide for Medical Examinations and Inquests in cases of Death by Violence. Be it enacted, etc., as follows : " Section 1. The offices of coroner and special coroner are hereby abolished. " Sec. 2. The governor shall nominate, and by and with the advice and consent of the council shall appoint, in the county of Suffolk not exceeding two, and in each other county not exceeding the number to be designated by the county commissioners as hereinafter provided, able and discreet men, learned in the science of medicine, to be medical examiners ; and every such nomination shall be made at least seven days prior to such appoint- ment. " Sec. 3. In the county of Suffolk each medical exam- iner shall receive, in full for all services performed by him, an annual salary of three thousand dollars, to be paid quarterly from the treasury of said county ; and in other counties they shall receive for a view without an 753 Examiner, Examiner. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. autopsy, four dollars ; for a view and autopsy, thirty dollars ; and travel at the rate of five cents per mile to and from the place of the view. " Sec. 4. Medical examiners shall hold their offices for the term of seven years from the time of appointment, but shall be liable to removal from office at any time by the governor and council for cause shown. " Sec. 5. Each medical examiner, before entering upon the duties of his office, shall be sworn and give bond, with sureties in the sum of five thousand dollars, to the treasurer of the county, conditioned for the faithful per- formance of the duties of his office. If a medical exam- iner neglects or refuses to give bond as herein required, for the period of thirty days after his appointment, the same shall be void and another shall be made instead thereof. "Sec, 6, The county commissioners in each county shall, as soon as may be after the passage of this act, divide their several counties into suitable districts for the ap- pointment of one medical examiner in each district under this act; and when such division is made, shall at once certify their action to the secretary of the Commonwealth, who shall lay such certificate before the governor and council ; but nothing herein shall prevent any medical examiner from acting as such in any part of his county. " Sec. 7. Medical examiners shall make examinations as hereinafter provided, upon the view of the dead bodies of such persons only as are supposed to have come to their death by violence. " Sec. 8. Whenever a medical examiner has notice that there has been found, or is lying within his county, the dead body of a person who is supposed to have come to his death by violence, he shall forthwith repair to the place where such body lies and take charge of the same ; and if on view thereof and personal inquiry into the cause and manner of the death he deems a further ex- amination necessary, he shall, upon being thereto author- ized in writing by the district attorney, mayor, or select- men of the district, city, or town where such body lies, in the presence of two or more discreet persons, whose at- tendance he may compel by subpoena, if necessary, make an autopsy, and then and there carefully reduce or cause to be reduced to writing every fact and circumstance tending to show the condition of the body, and the cause and manner of death, together with the names and ad- dresses of said witnesses, which record he shall subscribe. Before making such autopsy he shall call the attention of said witnesses to the position and appearance of the body. " Sec. 9. If upon such view, personal inquiry, or autopsy he shall be of opinion that the death was caused by vio- lence, he shall at once notify the district attorney and a jus- tice of the district, police or municipal court for the district or city in which the body lies, or a trial justice, and shall file a duly attested copy of the record of his autopsy in such court, or with such justice, and a like copy with such district attorney ; and shall in all cases certify to the clerk or registrar having the custody of the records of births, marriages, and deaths, in the city or town in which the person deceased came to his death, the name and residence of the person deceased, if known, or a de- scription of his person, as full as may be for identifica- tion, when the name and residence cannot be ascertained, together with the cause and manner in and by which the person deceased came to his death. " Sec. 10. The court or trial justice shall thereupon hold an inquest, which may be private, in which case any or all persons other than those required to be present by the provisions of this chapter may be excluded from the place where the same is held ; and said court or trial justice may also direct the witnesses to be kept separate, so that they cannot converse with each other until they have been examined. The district attorney, or some per- son designated by him, may attend the inquest and may examine all witnesses. An inquest shall be held in all cases of death by accident upon any railroad ; and the district attorney or the attorney-general may direct an in- quest to be held in the case of any other casualty from which the death of any person results, if in his opinion such inquest is necessary or expedient. "Sec. 11. The justice or district attorney may issue subpoenas for witnesses, returnable before such court or trial justice. The persons served with such process shall be allowed the same fees, and their attendance may be enforced in the same manner, and they shall be subject to the same penalties, as if served with a subpoena in be- half of the Commonwealth in a criminal prosecution pending in said court, or before said trial justice. " Sec. 12. The presiding justice or trial justice shall, after hearing the testimony, draw up and sign a report in which he shall find and certify when, where, and by what means the person deceased came to his death, his name if known, and all material circumstances attending his death ; and if it appears that his death resulted wholly or in part from the unlawful act of any other person, he shall further state, if known to him, the name of such person and of any person whose unlawful act contributed to such death, which report he shall file with the records of the superior court in the county wherein the inquest is held. " Sec. 13. If the justice finds that murder, manslaugh- ter, or an assault has been committed, he may bind over, as in criminal prosecutions, such witnesses as he deems necessary, or as the district attorney may designate, to appear and testify at the court in which an indictment for such offence may be found or presented. " Sec. 14. If a person charged by the report with the commission of any offence is not in custody, the justice shall forthwith issue process for his apprehension, and such process shall be made returnable before any court or magistrate having jurisdiction in the premises, who shall proceed therein in the manner required by law ; but nothing herein shall prevent any justice from issuing such process before the finding of such report, if it be otherwise lawful to issue the same. "Sec. 15. If the medical examiner reports that the death was not caused by violence, and the district attorney or the attorney-general shall be of a contrary opinion, either the district attorney or the attorney-general may direct an inquest to be held in accordance with the provisions of this act notwithstanding the report, at which inquest he, or some person designated by him, shall be present and examine all the witnesses. " Sec. 16. The medical examiner may, if he deems it necessary, call a chemist to aid in the examination of the body, or of substances supposed to have caused or con- tributed to the death, and such chemist shall be entitled to such compensation for his services as the medical ex- aminer certifies to be just and reasonable, the same being audited and allowed in the manner herein provided. The clerk or amanuensis, if any, employed to reduce to writ- ing the results of the medical examination or autopsy shall be allowed for his services two dollars per day. " Sec. 17. When a medical examiner views or makes an examination of the dead body of a stranger, he shall cause the body to be decently buried ; and if he certifies that he has made careful inquiry, and that to the best of his knowledge and belief the person found dead is a stranger, having no settlement in any city or town of this Commonwealth, his fees, with the actual ex- pense of burial, shall be paid from the treasury of the Commonwealth. In all other cases the expense of the burial shall be paid by the city or town, and all other ex- penses by the county, wherein the body is found. " Sec. 18. When services are rendered in bringing to land the dead body of a person found in any of the har- bors, rivers, or waters of the Commonwealth, the medical examiner may allow such compensation for said services as he deems reasonable, but this provision shall not enti- tle any person to compensation for services rendered in searching for such dead body. " Sec. 19. In all cases arising under the provisions of this act, the medical examiner shall take charge of any money or other personal property of the deceased found upon or near the body, and deliver the same to the person or persons entitled to its custody or possession ; but if not claimed by such person within sixty days, then to a public administrator, to be administered upon according to law. 754 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examiner. Examiner. ' ' Sec. 20. Any medical examiner who shall fraudulently neglect or refuse to deliver such property to such per- son within three days after due demand upon him there- for shall be punished by imprisonment in the jail or house of correction not exceeding two years, or by fine not ex- ceeding five hundred dollars. " Sec. 21. The medical examiner shall return an account of the expenses of each view or autopsy, including his fees, to the county commissioners having jurisdiction over the place where the examination or view is held, or in the county of Suffolk to the auditor of the city of Bos- ton, and shall annex thereto the written authority under which the autopsy was made. Such commissioners or auditor shall audit such accounts and certify to the treasurer of the Commonwealth, or the treasury of the county, as the case may be, what items therein are deemed just and reasonable, which shall be paid by such treasurer to the person entitled to receive the same. the old law, there were held in three counties in Massa • chusetts one hundred and twenty-four inquests. In three years, under the new law, with a larger population, the number of inquests held in the same counties was but seventy-five. Under the old law the ratio of inquests to cases of all sorts examined throughout the whole State was about forty per cent. Under the medical examiner law the ratio has not been more than twenty-two per cent. " The reasons for this change may be found in the appoint- ment, to fill the offices formerly held by coroners, of men whose education necessarily fits them for the work which they are expected to perform. Under the old law a man found dead, even without the least suspicion of violence, as in simple cases of heart disease or apoplexy, would in all probability be reported to the village cor- oner, provided the most common hypostatic marks of post-mortem discoloration were observed by a bystander, and interpreted by him as significant of a violent death. Hence the coroner sets in motion the cumbrous machin- ery of his office. In the first place he sends for a con- stable. The constable summons a jury. The witnesses come next; and last of all, the nearest physician is sum- moned, whose evidence finally shows that the man died a natural death. Under the working of the present law the order of procedure is reversed. The medical officer first views the body, and in a case like that just cited he simply reports it as a view. If, however, he believes there is reasonable suspicion of violence, as revealed by the evidence shown him from an external examination of the body, and a personal inquiry of the witnesses, and also by an autopsy, if that be requisite, the case is then reported to the proper authorities for inquest." 3 After the medical examiner law had been in operation for a period of seven years and a half, the Legislature of 1885 carefully considered certain measures which were proposed for the further improvement of the existing law. These were : the reporting of cases to some central authority who should be entrusted with the compilation, classification, and publication of the returns of the med- ical examiners ; the proper remuneration of medical wit- nesses at autopsies; and a provision for more definite au- thority for making autopsies on the bodies of persons found dead. The first of these duties had been performed very ef- ficiently for seven years by the Massachusetts Medico- Legal Society, an association having as its object "to elevate the official character of the medical examiner, and to assist him in the discharge of his duties ; to collect and utilize such facts as have a medico-legal value ; and to excite a general interest in the subject of forensic medicine, and to promote its successful cultivation."4 The transactions of this society form a valuable contri- bution to the literature of forensic medicine. It was de- sirable, however, that the State should have the super- vision of the reports of its medical officers, since it could by statutory enactment require a complete report from each examiner, a measure which was clearly impossible in a voluntary association. The following are the amend- ments enacted in 1885 : [Chap. 379.] An Act relating to Medical Examiners.- Be it enacted, etc., as follows : " Sec. 1. Section nine of chapter twenty-six of the Pub- lic Statutes is amended to read as follows; Section 9. In the county of Suffolk each medical examiner shall re- ceive from the treasurer of the county, in full for all ser- vices performed by him, a salary of three thousand dol- lars a year, and the associate medical examiner a salary of five hundred dollars ; but if the said associate medical examiner serves in any year more than two months, at the request of either medical examiner, he shall, for such service in excess of two months, be paid at the same rate as such medical examiner, and such compensation shall be deducted from the salary of the medical examiner in whose stead he serves. The medical examiners in other counties shall receive fees as follows • For a view with- out an autopsy, five dollars ; for a view and autopsy, thirty dollars ; and for travel, at the rate of ten cents a mile to and from the place of view. "Sec. 25. For the purposes of the appointment and qualification of medical examiners and the action of the county commissioners herein provided for, this act shall take effect upon its passage, and shall take full effect on the first day of July next." [Approved May 9, 1877.] (Sections 22, 23, and 24, pertaining to the vicarious functions of the coroner, when acting as a sheriff, and also to certain verbal corrections in other statutes, are omitted.) The principal features in the foregoing act, which con- stitute the chief difference between the medical examiner system of Massachusetts and the coroner system, are the following: 1. The separation of the medical from the legal duties involved in the investigation of the cause of death, the former being intrusted to medical officers ("able and discreet men, learned in the science of medicine ") (Sec- tions 2-9, 16-21, Acts of 1877, Chapter 200 ; and the latter to properly qualified legal magistrates, Sections 10-14). 2. The abolition of the coroner's office, and also of the jury (Section 1 et seq.}. 3. The limitation of the number of medical officers (Sections 2, 6). This law is the result of a successful attempt to intro- duce into a New England commonwealth, imbued with a traditional adherence to old and firmly established customs, the plan of Continental Europe modified and adapted to a republican form of government. As may be seen by an examination of Section 8 of the present law of Massachusetts, the medical officer takes the initiative steps in the investigation of each case re- quiring the exercise of his duties. This method of pro- cedure rests upon the assumption of a natural sequence in the investigation of all cases of death by violence. ' ' The inquest is held by the court, and is the inquiry into the facts outside the body ; the examination is made by the (medical) examiner, and it leads the way to the inquest." " The purpose of the law is the detection of crime; its method, the division of functions among those prop- erly qualified to perform them." 2 The operation of this law has been thoroughly tested in Massachusetts since its enactment in 1877, during which time the examination of at least twelve thousand cases has been carefully conducted, and the advantage gained by the change has been successfully demonstrated. Financially, the medical examiner system has also proved successful. Comparing the cost of coroner's in- quests and views in Massachusetts for three years under the old law (1874, 1875, and 1876) with the cost of simi- lar inquiries under the new law for a like period (1878, 1879, and 1880), as nearly as could be ascertained, the re- sult was for the former period, $63,712.04; and for the latter, $54,509.31 ; leaving a difference of $9,202.73 in favor of the medical examiner system, notwithstanding an increase of population between the two periods of at least one hundred thousand, and a consequent increase in the amount of work done.3 The chief causes of this diminution in expense are the abolition of the coroner's jury, and the decrease in the number of inquests. In the three years specified under 755 Examiner. Exercise. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. " Sec. 2. When a medical examiner deems it necessary to have a physician present at an autopsy as one of the witnesses, as provided in section eleven of chapter twenty- six of the Public Statutes, such physician shall be al- lowed five dollars for his services. Other witnesses re- quired by law to be present at an autopsy, shall be allowed two dollars each. " Sec. 3. Every medical examiner shall, annually, on or before the first day of March, transmit to the secretary of the Commonwealth certified copies of the records of all deaths which have occurred during the year ending on the last day of the preceding December, the cause and manner of which he has investigated, in accordance with the requirements of chapter twenty-six of the Public Statutes ; provided, however, if the term of office of any medical examiner shall end before the said last day of December, he shall send to the secretary of the Common- wealth, within the sixty days next ensuing upon the expiration of his commission as a medical examiner, cer- tified copies of the records of all deaths officially investi- gated by him during that part of the then current calen- dar year in which he continued in office. " Sec. 4. Each medical examiner shall be entitled to receive from the treasury of the Commonwealth, for re- cording and returning the facts relating to deaths as herein provided, twenty cents for each of the first twenty entries, and ten cents for each subsequent entry in any year, as certified by the secretary of the Commonwealth, and such allowance and payment shall be made to the medical examiners in Suffolk County for record and re- turns pursuant to this section, notwithstanding the limi- tation to the salary fixed by section nine of chapter twenty-six of the Public Statutes as amended by this act. Any medical examiner shall forfeit not less than ten nor more than fifty dollars for each refusal or neglect to ful- fil the requirements of section three of this act. "Sec. 5. The secretary shall, at the expense of the Com- monwealth, prepare and furnish to the several medical examiners, blank books of suitable quality and size, to be used as books of record under this act, and blank forms for returns, on paper of uniform size. " Sec. 6. The secretary shall cause the returns received by him for each year, in accordance with this act, to be bound together in one volume, with indexes thereto ; he shall prepare or cause to be prepared from the said re- turns such tabular results as will render them of practical utility, and shall make report thereof annually to the gen- eral court in connection with the report of the registry and return of births, marriages, and deaths required by section fifteen of chapter thirty-two of the Public Stat- utes. " Sec. 7. Every medical examiner shall forthwith file with the district attorney of his district, a report of each autopsy made by him, and of his view and personal in- quiry in such case under the provisions of chapter twenty- six of the Public Statutes; and shall certify in such re- port that, in his judgment, the cause and manner of death could not be ascertained by view and inquiry, and that an autopsy was necessary for that purpose. The district attorney shall examine such report, and if of the opinion that such autopsy was necessary shall, except in the county of Suffolk, so certify to the county commis- sioners having jurisdiction over the place where the au- topsy is held, and no fee for any autopsy shall be certified by the commissioners for payment until such certificate by the district attorney shall have been filed with said commissioners. " Sec. 8. This act shall take effect upon its passage. (Approved June 19, 1885.)" Further improvements have been suggested, having reference chiefly to the method of appointment of med- ical officers, the requirement of special qualifications, and also the consequent reduction of their number. The present number of medical examiners is seventy- three, being about one to each twenty-six thousand of the population. Boston has two, with an associate who acts in the absence of either of the others. Each one of the larger cities has also one medical examiner, who also acts in the neighboring towns. The remainder are dis- tributed with a fair degree of uniformity throughout the State. Samuel W. Abbott. 1 Transactions of the Massachusetts Medical Society. Proceedings of the Councillors, vol. xii. October 4. 1876, p. 77. 2 Concerning Coroners and the Theory and Practice of Inquests. By T. H. Tyndale, Esq. Transactions of Massachusetts Medico-Legal So- ciety, 1878, vol. i., No. 1, p. 38. 3 Financial Aspects of the Medical Examiner System. Transactions of the Massachusetts Medico-Legal Society, 1881, No. 4, pp. 206, 207. 4 Constitution of the Massachusetts Medico-Legal Society, Article 2. References. EXCELSIOR SPRINGS. Location and Post-office: Ex celsior Springs, Clay County, Mo. Access.-By the St. Joseph Division of the Wabash, St. Louis & Pacific Railroad to Vibbard, thence five miles by carriage. Therapeutic Properties.-The qualitative analysis shows the presence of the carbonate of iron, alumina, silica, and the chlorides of sodium, magnesium, and lime. Although the property is as yet unimproved, the reputa- tion of the springs as a valuable chalybeate appears to be growing very fast. The town, which began with the discovery of the springs in 1880, now contains two thousand inhabitants. G. B. F. EXCORIATIONS, NEUROTIC. Under this title the late Sir Erasmus Wilson described a peculiar affection of the skin characterized as follows : " Hypersemia, with indura- tion, in small oval or quadrangular spots of about a quarter of an inch in diameter ; a sense of fulness, burning, tin- gling, pricking, and itching; sometimes a vesication cor- responding with the diameter of the congested spot and very slightly raised ; sometimes an excoriation produced by rubbing or scratching ; more or less haemorrhage, fol- lowed by a black crust; on healing, a pigmentary stain ; usually pigmentation of the entire skin to a greater or less extent; and accompanying these symptoms a state of general nerve-disorder sometimes assuming the charac- ters of hysteria." In one case a lady, aged forty-seven, had the face spotted with small abrasions, oval or poly- hedral in contour, for the most part square or oblong, and sometimes pointed toward the inferior margin. They were about one-fourth of an inch in diameter, and were fifteen or twenty in number, in various stages of advance and decline, scattered over the forehead and face. The patient's attention was first directed to their existence by a sensation of fulness, burning, and tingling, continuing for some hours, until relief was sought by rubbing or scratching. The effort of a very slight rub was to detach the cuticle, -which seemed to slide off the spot, leaving an excoriated patch, which sometimes bled to a greater or less degree. The pathological history of the affection was that of a hyperaemia giving rise to a flat, circumscribed induration, accompanied by slight redness, and with the sensation of fulness, burning, and tingling, and then a slight serous exudation appeared beneath the horny epidermis, suffi- cient to loosen the cuticle, but rarely sufficient to develop a blister ; these several processes occupying only a few hours in their progress. Pigmentation is the final result. In the case above given the process had been going on for nearly two years. In another case given by Wilson, that of a young lady, aged twenty, of markedly neurotic character and in a de- bilitated condition, a somewhat similar eruption broke out about the mouth after eating ice. She then, by acci- dent, bruised her nose, and a second attack of the disor- der showed itself on and around the injured organ ; a third attack became developed on the forehead, as the conse- quence of a draught of cold air. The skin became swarthy and pigmented. With reference to the spots, the patient observed that they developed with a feeling of ful- ness, burning, tingling, pricking, and itching ; if left to themselves they frequently gave rise to a small blister, but the excessive pruritus usually caused her to rub or scratch them until the blood flowed, when relief would be obtained. The face, in Wilson's experience, is the part most usually attacked, but it appears occasionally as a general affec- 756 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Examiner. Exercise. tion. Wilson has seen a well-marked example restricted to the forearm, and especially to the district supplied by the ulnar nerve. When it occurs as a general affection it is apt to be mistaken for prurigo (pruritus ?). Wilson likewise considers some cases of the affection to approxi- mate to haematidrosis. Since the affection usually occurs in highly nervous, anaemic, and sometimes hysterical females, the question as to their being factitious comes up for consideration. Wilson himself has little or no doubt as to the natu- ral character of the lesions presented, but some other dermatologists consider them as artificially produced. It is certain that eruptions so closely analogous as to render their distinctive points difficult to bring out in a written description have been shown to be factitious (see Feigned Eruptions). Again, some of the cases described by Wilson re- semble in various points dermatitis herpetiformis. The stress which he lays upon the severe itching as a constant symptom, and the herpetiform character of the lesions in some cases, suggest this view. At present, however, Wilson's description and name are best preserved. Arthur Van Harlingen. But hand-to-hand fighting, and with it the athletics of chivalry, vanished at the first puff of gunpowder. Later Mercurialis, Luther, Melancthon, and Zwingli urged a return to the Hellenic games; and later still Locke, Rousseau and others, wrote to similar purpose. In 1799 Nachtigal opened a gymnasium in Denmark, and in 1813' Ling introduced into Sweden his system of curative bodily movements. At Schwefental (1806) a gymnasium was erected by Saltzmann, who put Guts-Muths at its head. In Prussia (1811) Jahn established the first Turnplatz, being actuated by a patriotic impulse to train there sol- diers who should expel the hated Napoleon. This ac- complished, the government, fearing that gymnasia might become rallying-places for men of liberal politics, closed them (1817), and imprisoned Jahn. In 1815 Clias started a similar popular movement in Switzerland, and after- ward did much to awaken interest in France and Eng- land. Gymnastics were imported into America from Germany,* Dr. Beck, a pupil of Jahn, opening a gym- nasium in Massachusetts in 1825.f Physiological and Therapeutical Effects of Ex- ercise. |-On Respiration.-Under exercise respiration is hurried and the pulmonary circulation swifter. A man walking one mile an hour breathes twice as much air as when he lies down ; if he walk four miles an hour, he breathes four times as much air ; and if six miles an hour, seven times as much. And he takes out of this inspired air an increased ration of oxygen. During a work day a laborer appropriates 8.61 ounces of oxygen more than he does on an idle day. The carbonic dioxide of expiration is also increased. This gas, most of which is formed in the muscles, is during their activity washed away in aug- mented quantities by the blood, which rushes blue and surcharged to the lungs for purification. The exhalation of watery vapor is likewise increased under exercise. Hence follow certain hygienic rules (Parkes) : 1. Dur- ing exercise the action of the lungs should be perfectly free ; respiration should be watched, and if laboring, the exertion should stop. 2. A working man's food should contain an extra supply of carbon which is best furnished in fat. 3. Because it lessens the excretion of carbonic dioxide, alcohol is harmful to a man of bodily activity. 4. The air should be pure ; ventilate gymna- sia and workshops. Certain therapeutic uses of exercise may also be noted. Taken in connection with out-door life and rigid hygiene, exercises which expand and strengthen the chest possess a prophylactic value to persons predisposed to chronic lung disease, and are useful even to those already in the clutch of the hereditary enemy ; since, if properly ordered, they hasten the disappearance of morbid products, directly, by insuring an energetic pulmonary circulation, and indi- rectly, by the general vigor attending their use. For the correction of thoracic deformities, whether congenital (pigeon-breast, etc.) or acquired (as a sequel of pleuritic effusion, etc.), suitable gymnastics are the sole trustwor- thy resource. On Circulation.-The heart beats faster. If the work be oppressive the pulse becomes very rapid, small, and irregular. After exercise its rapidity is often sub-normal, sixty, or even forty, and it may intermit. " Loss of wind " EXERCISE, PHYSICAL. History.-The Spartans were the first systematically to cultivate physical excel- lence. Even girls were taught to leap, run, and throw the lance, and women made exhibition of their skill be- fore they could marry. Lacedaemonia developed such formidable warriors, that other states were forced to adopt a similar system. In Athens, however, gymnasia became schools for mental as well as bodily education, and their hygienic as well as their military importance was recognized. Youths and men exercised nude (yv^vos, hence gym- nast).* Before exercising the gymnast oiled and dusted sand over his skin, which afterward was scraped clean and oiled again. This is splendidly recalled by Lysip- pus' statue of the Apoxyomenos, a youth who draws a strigil along his outstretched arm. Races and wrestling were favorite exercises, and with leaping, throwing discus and spear, made up the Pen- tathia. In the Pancratium, a combination of boxing and wrestling, every form of violence, except biting, -was per- mitted. It terminated only with the submission or death of one combatant. Boxers used the chopping blow, the fist being weighted to make it heavier. The ears were thus so often injured that a damaged auricle became the mark of the pugilist in statuary. This exercise was rather oddly recommended for headache and vertigo. With the increase of strength and skill required, a class of professionals gradually arose, and amateurs (ayatviardi) dropped out. Interest was kept alive by liter- ary contests and the stimulus to exercise afforded by the statues adorning the gymnasia, yet with the rise of pro- fessionalism the games lost prestige, and the downfall of the system ensued. Though having small sympathy with the hygienic and aesthetic purposes of the Greeks, the Romans adopted their gymnastic ritual, employing it solely to fit soldiers for war. Running, wrestling, swimming, lance-throw- ing, bearing burdens, sword exercise, and horsemanship were practised by officers and men alike. Marius never missed a day on the Campus Martius, and Pompey could vie with any soldier of his army. With the increase of luxury, athletics were, however, again abandoned to a professional class, and ended in the combats of hired gladiators. Recalling the immoralities of Greece and the barbari- ties of Rome, the early Christians abandoned athleticism for asceticism, till doubtless many had reason to feel, like Plotinus, ashamed of being in the flesh. Mediaeval athletics were mainly military. Peasants were compelled to use the bow, and jousts and tourna- ments gave the nobles a prodigious amount of exercise. ♦ A very complete athletic training was, however, pursued by the North American Indians. Boys were taught to use weapons, to wrestle, and run, and practised a mimic warfare, recalling the Greek Anup ale. Some became so swift as to overtake the buffalo, and so strong as to shoot their arrows through and through his huge bulk. Catlin's pictures attest the superb physique attained by them, of which another artist, Geo. de F. Brush (Century, May, 1885), remarks: " Their constant iight exercise and freedom from overwork develop the body in a manner equalled, I must believe, only by the Greek." + But they were not rapidly popularized. A writer, in 1855 (North American Review, July), thus bewails the physical degeneracy of that day: •* What a pale, cadaverous, and prematurely aged set of youths as- semble as graduating classes in our most venerated universities ! Oh, for a touch of the Olympic games, rather than the pallid cheeks, fleshless limbs, and throbbing brains of our first scholars in Harvard, Yale, or Princeton I " Could our reviewer witness the athletic contests for which these very colleges have in one generation become so famous, his lamen- tations would be hushed, and joy replace the spirit of heaviness. $ For an interesting resume of the therapeutics of exercise the reader is referred to a paper by Dr. D. A. Robinson, of Bangor. Me., printed in the Report of the American Social Science Association for 1885. ♦ To this is usually ascribed the suggestion of that vice which strangely infatuated the noblest as well as the most depraved minds; though how a wickedness old as Sodom, and commonly enough spontaneous, can be justly charged to a gymnastic usage, is not plain. 757 Exercise. Exercise. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is due to cardiac embarrassment and to fatigue of the re- spiratory muscles. To over-exertion, as in forced marches, is ascribed the condition known as " irritable heart." Hypertrophy and dilatation are not rare consequences of prolonged over- exertion ; and sudden efforts have been known to rupture a valve or even a weakened heart-wall, and are the most active agents in the production of aneurism. On the other hand, a life of enervating idleness leads to fatty de- generation of the cardiac muscle. Rules: Train the circulatory powers most carefully before testing them. During exertion watch the pulse; if it rise to 140 or 160, or become small or irregular, stop. Rest after exercising. On the Skin.-During exercise the skin flushes and sweat starts from the pores. Much of the water expelled as urine during repose now evaporates through the lungs and distils through the skin. Instead of the proportion reading as during rest: Loss by kidneys is to loss by skin and lungs as one to one-half, it now reads, as one to two. By an hour's sharp exercise several pounds, avoir- dupois, may thus be taken out of a man, a drain which, if Nature has her way, is rapidly made good by drinking. The evaporation of this surface moisture keeps the bodily temperature equable, notwithstanding that heat is rapidly evolved. After exercise the temperature may become subnormal. Rules : Keep the skin clean. When in training, satisfy thirst by drinking cautiously. If the temperature rise, sunstroke may be apprehended. After exercise, bundle with flannels. On the Muscles.-The temperature of the muscle first falls, then rises, and continues to rise after the cessation of contraction ; it rises higher when this is resisted. This rise results from ' ' the explosive decomposition of a com- plex substance, part of the energy developed producing movement and part heat." Bodily heat is produced by the general metabolism, but by far the greatest amount is generated in the muscular tissues. Under contraction the muscular reaction becomes acid, from the development of sarcolactic acid, and its venous blood grows darker, owing to an increased production of carbonic dioxide. Muscular exhaustion depends on the accumulation of sarcolactic acid, and the exhaustion of the supply of oxygen and of the nervous influence. When contracting, a muscle makes a sound distinctly audible by the stethoscope. This susurrus has the same note as the vibrating instrument determining the shocks ; when caused by the will, it has always one note, viz., 19.5 vibrations per second. Under exercise against resistance, muscle increases in its nitrogenous constituents, growing by hypertrophy and hyperplasia, and becoming stronger. Trained muscles are harder than untrained ; a gymnast's arm, when under tension, is as unyielding as a wire cable. This is doubtless due to the increased power of full, simultaneous contrac- tion acquired by the muscular fibres. But over-use may lead to muscular disease. It is a de- termining cause of progressive muscular atrophy, of pro- fessional paralyses and spasms, and of that rare condition, true muscular hypertrophy, characterized by an enor- mous increase in the breadth of the muscular cylinders, which, while sometimes possessing increased strength, are incapable of enduring effort. Sudden effort, as in throw- ing a ball, occasionally ruptures a muscle, tendon, or even one of the bones of attachment. Rules: Exercise all the muscles, not single groups. To prevent exhaustion, allow intervals of rest. On the Urine.-The amount of water is lessened. The relation of the excretion of urea to the amount of work cannot yet be considered as settled ; but the unmistakable tendency is to refer variations of urea-excretion to in- crease or diminution of albuminates in the food rather than to any amount of preceding exercise. Excessive exertion has been known to produce glyco- suria and diabetes insipidus. On the Nervous System.-Bodily exercise does not inter- fere with mental activity, and other nerve functions are improved in tone. In the treatment of neurasthenia, spinal nervous weakness, poliomyelitis anterior acuta,, myelitis, the decline of chorea, and pareses from vari- ous causes, appropriate gymnastics are potent allies. Over-exertion, especially when combined with exposure- to cold, is, however, a fruitful cause of nervous disease. During winter campaigns spinal nervous weakness, mye- litis, and tabes are common maladies of soldiers. Sexuality is lessened, and physical exercise fulfils a use- ful indication in cases of abnormal seminal losses, sexual irritability, etc. On Digestion, Nutrition, etc.-Appetite is improved, digestion gains in vigor, and nutrition is perfected. In gastric, intestinal, and hepatic disturbance, or resulting states of perverted nutrition, bodily exercise achieves its clearest therapeutic triumphs. As the circulation through the hepatic veins depends largely upon the aspiration force of the expanding thorax, it is plain that quickened, deepened respiration may relieve congestions of the liver and organs whose blood returns via the portal vein. The varying pressure exerted by the muscles of the abdomen upon its contents, tends to the same result. Hence con- stipation, dyspepsia, and "biliousness," find enduring re- lief in habits of physical activity. The benefits of exer- cise in anaemia, chlorosis, and scrofulosis are partly explained by its stimulating effect upon appetite and di- gestion. Gout and obesity, results of imperfect oxida- tion processes, are distinctly ameliorable by exercise, and in the latter case this is preferable to any dieting system. That the corpulent should consume their fat in activities which leave them firmer in fibre and more vig- orous, is every way better than for them to starve it away under a depleting and debilitating regimen. Kinds of Exercise.-Three varieties of exercise are distinguishable practically.* A person may by out-door sports win constitutional strength, yet be poorly devel- oped. By running he may acquire respiratory power, without becoming muscular. Or he may by indoor work develop fine muscles, and yet be delicate and short of wind. Hence, while most exercises are more or less com- posite, these special aims suggest the following classifica- tion : Exercises Constitutional. Muscular Voluntary muscles. Involuntary muscles (of heart and respiration). 1. Constitutional exercises include all out-door sports,, walking, climbing, riding, bicycling, hunting, swimming, etc. These invigorate the general health, but develop almost exclusively the lower limbs. Professional pedes- trians and ball-players often have superb thighs and legs, but puny chests and arms. Open-air exercises are much the best for children until adolescence, when they should- have in addition some developmental training. 2. Exercises for the Voluntary Muscles.-Only those in- volving muscular effort in overcoming resistance are in- cluded here. Mere movements, even calisthenics, do not. develop frame or muscles. At Amherst College it is be- lieved that "the main object should be not to secure feats of agility and strength, or even powerful musclesr but to keep in good health the whole body." 1 Accord- ingly the students engage in light gymnastics timed by music. This system, while redounding to health (sick- ness among seniors being about one-half that among fresh- men), secures little developmental gain. Statistics for twenty years show that 2,106 students had, at the end of their four years' course, by half an hour's work four times a week, obtained an average increase of 0.61 inch height, 9 pounds weight, 1.21 inch chest, 0.54 inch up- per arm, and 0.41 inch forearm.1 Compare these gains, scarcely greater than might be expected from natural growth between the ages of nineteen and twenty-two, with the results obtained by a system of strong exercise at Bowdoin College. Here 200 students by the same daily expenditure of time, gained in six months an aver- * Maclaren (Physical Education) classifies exercises as recreative and educational. All should, however, be recreative in the usual sense. Un- less it gives pleasure and relaxes mental tension while it occupies the- limbs, exercise becomes labor, an added strain, not a diversion. The doctor who in vacation walks with ease his ten miles among the hills, finds five too many when traversed between patients' houses. 758 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Exercise. Exercise. age of 0.25 inch height, 2 pounds weight, 1.75 inch chest, 1 inch upper arm, 0.75 inch forearm, 1.50 inch thigh, and 0.75 inch calf.2 Maclaren3 suggests the following system of gymnastics as fitted to afford harmonious development: First, an in- troductory course of posturing and light exercises with dumb-bells and bar-bells ; second, leaping, the horizontal beam, vaulting (bar and horse); third, parallel bars, trapeze, swinging rings, ladders, horizontal bar, the plank, escalading ; fourth, climbing the pole (fixed, slanting, and turning), the pair of poles, the rope, rosary, and mast. By one hour's daily exercise for eight months, twelve men from nineteen to twenty-eight years of age gained under this system an average of f of an inch height, 10 pounds weight, 2| inches chest, 4 inch forearm, and If inch upper arm ; and fifteen students of Woolwich Mili- tary Academy, averaging eighteen years of age, in four and a half months, gained on an average 0.82 inch height, 2.47 pounds weight, 2.48 inches chest, 0.06 inch forearm, and 1.08 inch upper arm. Although a well-appointed gymnasium is the best place for these exercises, yet their main advantages may be ob- tained in one's bedroom by ingenious adaptations of chairs, tables, etc., to the purposes of apparatus, or by a trifling outlay in dumb-bells, Indian clubs, and carpenter work.4 Were we to select any of the above points of improve- ment as supreme in importance it must be the chest. This is the keystone of a fine physique. Its development includes that of other parts. No one can perfect the ca- pacity, bony frame, and muscles of his thorax without also developing back, loins, and limbs. A writer5 de- clares : "If the outline of the biceps when contracted be clearly defined, the chest is sure to be capacious." The very reverse holds true ; a good chest means good arms, and like enough good legs. Therefore this is a safe gymnastic precept : Take care of your chest, and your limbs will take care of themselves. It may, perhaps, be asked, If one is well without them, what need of a capacious chest and powerful limbs ? While it is true that many undeveloped persons enjoy fair organic health, greater respiratory and muscular power would unquestionably make such lives more ef- fective and longer. A roomy thorax and strong heart are no mean allies in resisting the assaults of disease. A few extra cubic inches of respiratory capacity, or a small reserve of disciplined cardiac power may suffice to deter- mine a favorable issue in pneumonia, pleurisy, or typhoid. Every inch which a man adds to his chest measure adds to the measure of his days. These advantages to the in- dividual are, moreover, shared by those who inherit his physical traits. Athletic parents beget robust children ; while round shoulders and feeble limbs betoken a neglect antedating that of their possessors. Physical develop- ment can, perhaps, be excessive, yet resulting injury is limited and personal; whereas neglect of bodily improve- ment sins against posterity. 3. Respiratory Exercises.-Rapidity of performance adds to any exercise the element of respiratory effort. A light dumb-bell may be lifted and grounded so slowly as scarcely to quicken respiration, or so rapidly as severely to test the wind. The voluntary muscles do no more work in one case than in the other, but the involuntary muscles of circulation and respiration may do twice as much. Hence, such efforts should be preceded by scien- tific training. Haste tests the heart as lifting tests the loins; to endure it that organ must acquire increased power by gradually augmented tasks. Only less impor- tant, because implied, is a similar education of the respi- ratory muscles. Realizing that the thoracic organs are to bear the strain, the racer's need of a capacious chest seems vital. The bounding heart, surcharged vessels, and expanding lungs must have room. No youth whose thorax is small of calibre, or worked by undeveloped muscles, should enter any contest of speed. Few spectacles are more inexcus- able or painful than that presented by some half-grown, pigeon-breasted boy staggering, perhaps fainting, under the distress of a long race. As respiratory exercises must be classed all track ath- letics, walking, running, etc. Under proper direction these afford excellent training for the wind, and are usu- ally employed as auxiliaries by those preparing for any contest of speed or endurance. They should be begun slowly, and cease if the breathing becomes labored. When they are followed for their own sake, the athlete should make diligent use of other exercises enlarging the thora- cic cavity, and strengthening its musculature. Training.-To train is to lead the most healthful life possible, wdiile by appropriate exercise the body is pre- pared for some supreme effort. At least eight hours' sleep is prescribed. Alcoholics and tobacco are forbid- den, though not in so bigoted a spirit as never to be allowable, even if their withdrawal creates more disturb- ance than does occasional temperate indulgence. Diet is plain, but otherwise unrestricted. In olden times diet was fetich to which comfort and health were often sacri- ficed. Men were tortured with thirst, because water was supposed to be bad, and were sickened by uncooked meat imagined to be good. What wonder that diarrhoea and boils were usual concomitants of training ? Exercise must be begun and increased with modera- tion, and ought not to continue when great fatigue is mani- fest. Heart and muscles are gradually to be made anew to meet the new demands. This is a slow process, but none should seek to shorten it. Without adequate prepara- tion the strongest man is unfit for severe exertion, and a weaker may suffer great harm. Inexcusably faulty must have been the selection or training of any man who faints after a race ; he was either unsound or unprepared. It should be widely known that athletic contests are unsafe for such men. The exercise will vary in character with the purpose in view, but should never be exclusively of one kind, as all rowing, or all running. Those affording general develop- ment, as well as those educating the special strength needed, are to be employed. " Sameness of exercise gives precision and dexterity, but variety is essential to vigor and power.6 Neither is exercise to be discontinued abruptly. Upon suddenly abandoning an athletic for a sedentary life, some have suffered the very worst consequences ;7 such cases are often quoted as warnings against athleticism. Milder effects of this error are common. Many a man deprived of his customary strong exercise experiences much discomfort while heart, muscles, and stomach are adapting themselves to the new life of inactivity. " The tranquil mind must be preserved with little or no interruption. Physical strength cannot coexist with an unhappy, discontented temper." 8 Worry is the enemy of bodily and mental well-being, and takes out of a man more than work does. Partly to avoid unnecessary anx- iety, athletes put themselves in the hands of trainers who look after details and prescribe the work, thus lightening the task. Under training ordinary men gain in weight, train up, and not down. Dr. Morgan found that those rdwing for two successive years gained on an average 2.25 pounds ; those rowing three times, 3.8 pounds ; those rowing four times, 3.1 pounds.9 When one becomes fatigued with the monotony of too protracted and too strict training, he is said to be over- trained. Like all other people, athletes need variety and change. A week of relaxation and amusement usually restores the man who has " gone stale." Athletic Sports.-The athletic sports figuring most prominently nowadays combine to a greater or less de- gree the three types of exercise ; they are carried on in the open air, and they demand muscular and respiratory power. Rowing.-Though by many regarded as the perfection of exercise, rowing is nevertheless open to the following objections : * Respiration is unnaturally performed. Be- ing regulated by the stroke, it is intermittent. During * For these criticisms, as for many other hints and suggestions, the writer, in common with most authors dealing with these subjects, is indebted to Archibald Maclaren's excellent work, Training, in Theory and Practice, 759 Exercise. Exercise. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the pull the breath is held, while expiration and inspira- tion occur during the recover. The racing stroke there- fore necessitates thirty-five or forty-five breaths a min- ute, thus imposing upon circulatory and respiratory apparatus a strain whose severity is augmented by the unnatural manner in which their functions are performed. At the same time the chest is not being developed ; if a good one, it even retrogrades under exclusive rowing. The parts receiving most employment are the legs, thighs, hips, loins, back, abdomen, and forearm ; but even these do not have sufficient exercise to secure their full develop- ment. The amount of work actually done by each oars- man in a racing shell has been calculated to be 18.56 foot- tons. In walking one mile he would do 18.62 foot-tons. When it is remembered that one hundred and fifty foot- tons represent a moderate amount of daily exercise for a healthy man,* we can comprehend how, without other ex- ercise than rowing, a well-developed man falls off. It is therefore asserted that improvements in boats (sliding- seats, outriggers, etc.), while advancing rowing as an art, detract from its value as a muscular exercise, or rather have made of it almost entirely a respiratory exercise. The enthusiastic oarsman should clearly understand that rowing a shell is insufficient for the purposes of fine de- velopment, and especially that to fashion the spacious and powerful chest indispensable for all respiratory effort, other special exercises are needful. Base-ball.-While requiring skill and wind-power, this game affords little opportunity for muscularity, and bestows little development except upon the lower limbs. It is mainly a constitutional and respiratory exercise. Accidents to fingers are common ; but since the intro- duction of the catcher's mask and body-protector the graver injuries once received behind the bat (fractures of the nose, concussion of the brain, etc.), have become rare. Foot-ball.-From early times this has been the favor- ite winter game of Great Britain, and now holds a similar place in many American colleges. Play has of late be- come very scientific, and preparation for the champion- ship matches very careful. At Yale, Princeton, and Harvard strict training begins with the Fall term. The teams daily practise an hour and a half, and run a half mile or mile afterward. Between seasons they work in the gymnasium. More than any other athletic sport, perhaps, foot-ball educates courage, coolness, quick perception, obedience ; while it affords scope for every physical excellence, whether of strength, speed, endurance, or address. Nev- ertheless serious risk attends the game, and the old-fash- ioned opinion of James I., that it is " meeter for laming than making able the users thereof," still finds support in the following facts. During the past seven years f there have been received, on the Yale grounds, one fracture of the tibia, one fracture of the clavicle, one serious patellar injury, and an indefinite number of sprains and bruises. At Princeton, during the past ten years, there have oc- curred one fracture of the fibula, one fracture of the clavicle, one dislocation of the elbow, one dislocation of the clavicle, several sprains of the knee, arm, and leg, and lesser strains and bruises not enumerated. At Har- vard, in the last three seasons, one case of severe cerebral concussion (from a kick); one man knocked senseless, los- ing two teeth, but sustaining no other permanent injury ; one severe strain of the back, one badly sprained arm, four sprains of the knee (two being renewed the ensuing season), one case of " water on the knee," one broken nose, one sprain of wrist, two sprains of ankle (both in same man), while such accidents as "small cuts and bruises, and slightly strained muscles are expected, and not considered of any account." j: Most players declare the game to be less rough than appears to spectators : yet during the season of 1883 a majority of the Harvard team became hors de combat. Though it may be, as one writer avers, " no danger for a healthy young man to be laid up a few weeks," yet in view of the above list of really formidable casualties, the timidity of parents who prefer for their sons some safer recreation, merits indulgent forbearance ; for, as now played, foot-ball is incomparably the most dangerous form of amateur athletics.* Horsemanship ranks high as a " constitutional." Un- fortunately in the Eastern States it has fallen into com- parative desuetude, but in the South and West it is still a usual out-door exercise. Interest in equestrianism has been faintly revived in the East by the rise of the game of Polo. As is generally known, this is essentially " shin- ney" on horseback. The players ride ponies not exceed- ing fourteen hands one inch in height, and each carries a long-handled mallet, wherewith to drive the ball toward or through the enemy's goal. Polo requires a perfect un- derstanding between man and mount, and gives oppor- tunity for adroit and dashing horsemanship. It is much affected by English army officers as a means of acquiring a skilful manege. But hitherto it has found few follow- ers among us. Our cavalrymen are kept in training by the sports and campaigns of the frontier; gentlemen players number not much over one hundred. Nor is it likely that they will ever be very numerous in the United States. The expense attending the maintenance of relays of horses puts Polo beyond the reach of any but the wealthy ; and only the strong and bold would engage in so risky a sport. It is admitted that during the past eight seasons Polo has caused one death, one serious head injury (from a blow), one fracture of the leg, several fractures of the clavicle, numerous sprains of the wrist and ankle, and many other accidents naturally attending the collisions and falls of horsemen and the misstrokes of their mal- lets. f Effects upon the Health.-Momentous questions for physicians are: What influence do athletics exert upon the health, what is the frequency of accident, what the effect upon the expectation of life ? Careful life-insurance companies refuse professional athletes ; and that the lives of trapeze performers, circus riders, pugilists, and the like, are subject to constant hazard goes without saying. Nevertheless, accident-in- surance companies can afford to accept ordinary exhib- itors as medium risks. Aside, however, from traumatic dangers, it is supposed that the profession undermines the constitution. Dr. B. W. Richardson10 ventures to affirm that " there is not in England a trained profes- sional athlete of the age of thirty-five, who has been ten years at his calling, who is not disabled." An all-impor- tant consideration, however, in the case of professionals is irregularity of life. Their habits, aside from their business, would forbid their acceptance as insurance risks ; indeed, it might fairly be urged that intervals of sober living and exercise make good in some degree the damages of dissipation. Certain it is that Dr. Richard- son's assertion does not meet universal acceptance. Mr. P. T. Barnum j: declares as the result of life-long obser- vation of professional athletes, that " their strength is in- creased, their health improved, and their lives length- ened." Dr. S. E. Post11 studied for several weeks the health of five female circus actors, of whom three were riders, aged respectively twenty-four, thirty-two, and thirty-five years, in the business seventeen, fifteen, and eighteen years ; and two were gymnasts, aged twenty-five and twenty-seven, and in the business nine and nineteen years. All were, or had been, married; and all, save one, who had a congenital uterine defect, were mothers. Remarkable to relate, the riders were accustomed to con- tinue their work to the seventh month of pregnancy. Miscarriages from falls were naturally common, but * Mr. E. L. Richards, Jr., in Outing, April, 1885, defends foot-ball as " not extremely dangerous or even dangerous." He regards it as yet in process of evolution, so that this statement may refer to the ideal of the near future. The accidents above cited justify the position herein taken respecting the game up to the present time. + I have to acknowledge the kindness of Dr. Charles Carey, of the Buffalo Polo Club, and of Mr. T. H. Howard, of the Knickerbocker Club, New York, who have furnished me the information above given. t In a letter to the writer. * A day-laborer does between 300 and 500 foot-tons. + My information dates backward from 1884. f For these facts I am indebted to the kindness of Mr. Eugene L. Richards, Jr., Captain Y'ale Foot-ball Team; Mr. M. M. Kimball, Captain Harvard Foot-ball Team ; and Mr. L. Rodman Wanamaker, member of Princeton Foot-ball Team. 760 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Exercise. Exercise. otherwise the health was excellent, and it was their com- mon opinion that women performers do not break down, save as the result of surgical injury. But it is concerning amateur rather than professional athleticism that medical opinion is oftenest asked.* Per- haps the earliest statistical statement was that of Guts- Muths who claimed that at his institution during 32 years, in which 334 pupils were educated, not one death had occurred. The most elaborate investigation hitherto published is that of Dr. John Edward Morgan.12 He found that of 294 rowers in the Oxford-Cambridge races, from 1829 to 1869, 39 had died ; 9 of pulmonary and 3 of heart affections, and the others by acute disease, acci- dent, etc. Seventeen (six per cent.) claimed to have been injured. One had pneumonia a year after his race, two complained of heart troubles, one had suppurative ar- thritis of the elbow, five died of phthisis (hereditary), one was found dead in bed, two were thought to be harmed yet lived eleven and eighteen years after the race, one died of decline, one claimed to have over-rowed himself, and three thought the sudden cessation of training injured them. Dr. Morgan justly declines to charge all these in- juries to rowing. Still, granting they were so caused, it was nevertheless found that the expectation of life of each oarsman after his race exceeded that of ordinary men by 2.2 years. Dr. E. A. Bradford 13 pursued a similar inquiry con- cerning the members of the Harvard university crews. Of 101 men who rowed against Yale from 1852 to 1870, one died of Bright's disease, five of phthisis (three hereditary, and two cases of irregular lives), one from " intense neu- ralgia " (!), one by suicide, two by accident, and one from unknown cause. The excess in expectation of life of these 101 over that of ordinary men is calculated to be 63 years, or 0.62 year for each man. While it is conceded that these numbers are too small to warrant implicit trust, and that the predicted gain in longevity, even if ultimately verified, may fairly be as- cribed to the fact that these were picked men ; yet this in ■ quiry shows that injuries charged to rowing do not hurry their recipients into early graves. It may be said that such statistics prove simply that rowing is safe for selected men,* but take no account of many weaker ones, who, engaging in athletics, are per- chance hurt by accident or in constitution. To obtain information as to the frequency of injuries, traumatic and constitutional, received in athletic exercises of all sorts, the writer (in 1884) sent a series of questions to per- sons f connected with twenty-one American colleges prominent in such pursuits. Replies were received from all but three, and may be tabulated as follows ; j: * Good oarsmen in English universities occur, Galton says, in the pro- portion of one man in a hundred. + In every instance the gentleman addressed had immediate personal knowledge of the subject. Opinions concerning athleticism formed by exoteric persons, however learned or distinguished, have little value. The reader may, for illustration, refer to the discussion on athletics in the New York Independent, April 10,1884. Experto (not ex parte} crede. + For the information embodied in the table I am indebted.to the cour- tesy of the following gentlemen : Dr. Dudley A. Sargent, Harvard ; Pro- fessors Geo. Goldie and Henry' F. Osborne, Princeton; Mr. Walter Chauncey Camp and Prof. E. L. Richards, Yale; Mr. Jasper T. Goodwin and Prof. A. L. Beebe, Columbia ; Dr. E. Hitchcock, Amherst; Mr. H. B. Hulbert, Dartmouth ; Mr. Randolph Faries, University of Pennsyl- vania ; Mr. A. C. Campbell, Lafayette; Mr. C. M. Clark. Williams; Mr. R. J. Thompson, Bowdoin ; Mr. Chas. A. Schultz, Racine ; Mr. Jno. M. Brainard, Trinity ; Mr. Fred. S. Barnjum, McGill; Mr. Wm. A. Tateum, Wesleyan ; Mr. J. W. Graves, University of Virginia ; Mr. Wm. S. Dil- worth, Stevens Institute. * The press holds sombre and sensational views upon this topic. Not long ago the death of a college student was referred by the dailies to over-exertion on rowing-machines. I am credibly informed that the young man died from the consequences of imprudent exposure while heated after exercise. When another gymnast was found dead in bed, the newspapers diagnosed heart disease consequent upon over-exertion, and lamented the frequent physical wreckage of athletes. A physician conversant with the facts states that this person, an epileptic from child- hood, had a habit of sleeping on his face. As the autopsy revealed asphyxia to be the cause of death, it may be concluded that he suffo- cated during a seizure while thus sleeping. College. Number of stu- dents engaged each year in athletics. Character of traumatic injuries received. Number of con- stitutional in- juries. Number- developing injury after leaving college. Remarks. «-i ao o <x> f S 44 . 0 o' .S * ? U QQ o> In gymnasium. In field sports. num ;ic nds. ime ov brmant ■dge ex early raumat >f all ki - Harvard Not stated. Athletics .. . 120 Gymnasium. 950 1,070 Fracture in 4 years. 1 Sprains each year.. 2 Yearly 2.25 Fracture each year... 1 Dislocation each year. 1 Rupture each year.... 1 Sprains 12 15 (in foot-ball principally). 17.25, allow 18.00 None, because of prelimin- ary physical examination. Formerly 6 yearly, 3 by over-training. Heard of, but none known. Trained offi- cersuperin- tends exer- cises. Pre- liminary physical ex- amination. Princeton.... 15 years. Gymnasium. 350 Fracture of forearm... 1 Sprains 5 Injury to finger 1 Dislocation of great too 1 8 Base-ball. Injuries to head by blow of ball 2 Sprain 1 Foot-ball. Injury to skull by kick. 1 Fracture of fibula.... 1 Fracture of clavicle.. 1 Dislocation of clav icle. 1 Dislocation of elbow.. 1 Sprains . fl Serious bruises 3 Track Athletics. Sprains 3 Injury by fall 1 21 2.00 Pulmonary haemorrhage (hereditary) on ball-field.. 1 Fainting dur- ing race 2 3 Ball - play- ers died of phthisis after lea v- ing col- lege 2 Trained offi- cer in gym- n a s i u m. Profession- al trainer for crews, etc. Yale 6 years. Base-ball... 50 Foot-ball ... 50 Boating .... 50 Lacrosse.... 20 Track athlet- ics 20 Tennis 50 Gymnasium. 50 290 Fatal " traumatic apo- plexy" while boxing. Real nature of case uncertain. Suggested to have been one of aortic malformation.. 1 Serious injury, nature not stated 1 2 Base-ball. Fracture of leg by col- lision with post 1 Fracture and disloca- tion of fingers 1 Foot-ball. Sprains, number not stated, allow 6 Fracture of clavicle... 1 Fracture of tibia 1 10 2.00 None known. None known. No special officer in charge of athletics. 761 Exercise. [tre. hjXo p 11 til al nue <m<)1" REFERENCE HANDBOOK OF THE MEDICAL SCIENCES College. Amherst Williams Wesleyan Lafayette .... University of Virginia Bowdoin McGill Univer- sity Columbia Trinity Brown Racine Dartmouth.... Stevens Insti- tute University of Pennsylvania Totals.... - £ o > S 3 o g CD C o T3 24 years. 4 years. 4 years. 4 years. 4 years. 4 years. 20 years. 10 years. 4 years. 4 years. 6 years. 4 years. Not stated. 4 years. Number of stu- dents engaged each year in athletics. Compulsory gymnastics, of whom 40 are excused to engage in other athletics... 310 50 100 75 100 65 Gymnasium, 50 to 60 Foot-ball ... 35 Field sports. 30 120 150 30 30 100 100 75 35 3,050 Character of traumatic injuries received. 17 C tn a *3 E 5 aj as * 0.50, allow 1.00 2.00 3.00 Allow 2.00 Allow 1.00 Allow 1.00 Allow 1.00 0.30, allow 1.00 5.00 Allow 1.00 1.00 15.00 56.00 Number of con- stitutional in- juries. - Claimedby friends to have been in- jured in " tug of war." Died of phthisis af- ter leaving college 1 None. None. Pul m on ary haemorrhage after base- ball game.... 1 Faint in boat. 1 None. None. None. Unable to an- swer. None. None. Not described. 1 None. be be c .9 © 5 •a 5 , 'S . g.BJ G G O None. None. None. None. None. None. None. None. None. 2 Remarks. Officer in g y m n a - sium. Two i n- s tructors selected from senior class. Trainer for boating men. N o special officer. Ex- ercise not systematic- a 11 y pur- sued. No officer. Trainer for crews. Trained offi- cer in gym- nasium. Instructor in gymna- sium. Instructor in gymna- sium. Instructor in gymna- sium. Pro- fessional trainer for ball nine. N o special officer. Instructor in gymna- sium. No gymna- sium. In gymnasium. Fracture of wrist 1 Sprain of wrist 1 Not one serious acci- dent a year. One fatal fall from bar some years ago. None. Sprained ankle 1 None. None. None. Annually, character not stated. 2.50 Slight accident 1 Injuries trifling, though some have required medical attendance, 2 to 4 per cent. No severe injury. Injuries very slight. In field sports. Injuries of fingers, bruises, etc., in base- ball, number not stated, allow 11 Base-ball. Finger injuries, allow 5 Foot-ball. Sprain of knee with " partial dislocation" 1 Fracture of clavicle.. 1 7 Accidents a year, " sprains or fract- ures," 2 or 3 Foot-ball. Fracture of clavicle.. 1 Patellar injury 1 Fracture of nose 1 Sprained ankles 4 " Two or three." Only injuries re- ceived have been at foot-ball, and none of these have been seri- ous." Foot-ball. Fracture of sternum.. 1 Fracture of clavicle.. 1 Dislocation of thumb. 1 3 Annually, character not stated. 2.50 Occasional finger in- jury in base-ball. In ju riestrifling, though some have re- quired medical at- tendance, 2 to 4 per cent. No severe Injury. Annually 15 Injuries very slight. Thus it appears that, of 3,050 students engaging each year in athletics, 56 (not quite two per cent.) * receive traumatic injuries. Of these about one-half are encoun- tered at foot-ball. So that, unless he plays this hazard- ous game, the student-athlete adds less than one per cent, to the dangers attending the scholarly life. This incre- ment is insufficient to prevent his being classed among "preferred" risks (such as clergymen, physicians, law- yers, bookkeepers, etc.). His total liability to accident does not equal that of " ordinary " pursuits (surveyors, architects, hotel-keepers, etc.). Accident insurance com- panies therefore permit their preferred classes to engage in athletic exercises without prejudice to their insurance. In but eight colleges were gymnastics supervised by a special college officer (1884), and in only one was a pre- liminary medical examination made ; yet only nine cases of constitutional affection can, by the most liberal allow- ance, be ascribed to athletics, and for some of these we must go back many years. But, of course, it is impossible to keep track of college graduates, and thus some may have developed harm whose cases do not appear. The fact that the reports came not from individual athletes or their relatives (as in Morgan's and Bradford's statistics), * And this cannot be considered an under-statement. My informants' reports are unquestionably candid, and have been interpreted liberally. A broken finger counts for as much as a broken arm ; and when trifling injuries are mentioned, but not enumerated, a generous estimate of their number is added to that of serious casualties. When the yearly quota of accidents (obtained by dividing the whole number by the number of years in the second column) is fractional, the fraction is raised to unity; though in some cases the accident list is thus doubled. It is true that in many reports general terms, difficult to interpret numerically, are used ; but that this has not led to an under-estimate is evident from the fact that the most minutely careful reports (from Harvard, Yale, and Princeton), when considered separately, still give the number injured at less than two per cent. (1.012 per cent.). 762 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, ^ophthalmic Gol- but from disinterested parties, has also tended to keep down the number of constitutional injuries. Men use calmer judgment concerning the etiology of disease in others than in themselves or their own families. Could we hear personally from each man, many ailments devel- oping since graduation (rheumatism, dyspepsia, neuras- thenia, phthisis) would doubtless be referred to athleti- cism. Probably, therefore, the number who might claim constitutional injury is under-estimated, though, consider- ing the incapacity of the laity to reach sound opinions on any medical subject, it is questionable whether all such claims are just. Still, taking these reports for what they are worth, it may fairly be declared that popular notions respecting the danger of athletics are grossly exaggerated. But the inference must not be drawn that athletic exer- cises are safe for all indiscriminately. Notably in cases of heart-disease, much danger attends them. Hence, a physical examination by an expert should precede every form of bodily training. Its importance has been repeat- edly urged, yet in only one American university was it required in 1884. In view of this negligence of the au- thorities, college athletic organizations would secure wider popular confidence were a physician's certificate of sound physique made an indispensable preliminary to membership. Such an examination should take account of the applicant's family history (with special reference to phthisis or the haemorrhagic diathesis); of his personal history (as to shortness of breath, syncope, epilepsy, etc.); of his general appearance, age, height, weight, chest, and limb measurements ; if an oarsman, of his ability to swim ; of the presence of hernia ; and especially of the condition of his lungs, heart, and great vessels. Those who are unfit being thus excluded, and the deli- cate placed upon their guard, the preceding discussion justifies the assertion that all others are in duty bound to develop their bodies. By taking thought one may add to his stature. The responsibility of parents and teach- ers extends to bodily as well as to mental education. It is not necessarily by contests in strength, endurance, or acrobatism that symmetrical development is to be won, though these are usually harmless, and even beneficial. The safer and simpler exercises suffice. Physique and not feats should be the aim, and one, at least, of many college gymnasium prizes should reward progress in bodily improvement, rather than exhibitions of sensa- tional gymnastics.* Muscularity is not incompatible with intellectuality. As to honors gained, rowing men at Oxford have been shown to be on a par with the rest of the university, while at Cambridge they excel the non-rowing men.14 Another writer 15 states that the average of " classmen " in the universities at large is thirty per cent. ; while among cricketers it is forty per cent., and among rowers forty- five per cent. Galton 16 emphasizes the fact that men of genius usually possess a fine physique. Neither do athletics brutalize manners or morals, those of pugilists to the contrary notwithstanding. Training necessitates abstinence, educates the will, and subdues while it fortifies the physical nature. Since the rise of athleticism, college disorders have become less and less common. They who once made up the mischievous, dis- solute set, now find on ball-field or river an outlet for their youthful spirits more innocent than the carousals of the good old times.11 But after all has been said concerning the safety, bene- fit, and duty of physical education, the practical difficulty presents itself that many are by circumstances debarred from its acquisition. The overworked business or pro- fessional man declares it impossible for him to take any great amount of exercise. His vocation leaves neither time nor energy for such pursuits. After the day's labor he craves rest: he cannot burn his candle at both ends. It needs nice management to enable him to hold his own physically ; improvement is out of the question. Therefore it is to the young that the gospel of develop- ment must be preached. While time and vigor fail not, let them see to it that the thorax is made ample, and the limbs strong. A fine physique once attained is never wholly lost. He who has satisfied his physical obliga- tions, whose credit with Nature is good, is not visited by her heavy penalties for subsequent shortcomings. He retains through life the chest gained in his young man- hood, and though his muscles lose some of their fulness, they may be kept in healthy tone by moderate outdoor rec- reation, which few lives are too busy to permit. Hence, the following seems a practicable scheme of physical development and exercise; In childhood the con- stitutionals ; in youth the developmental, and after them, perhaps the respiratory exercises ; in adult life the con- tinuance and perfection of development, or, if this be im- possible, some form of constitutional again. W. S. Cheesman. 1 A Report of Twenty Years' Experience in the Department of Physical Education and Hygiene in Amherst College, June, 1881. By Dr. Edward Hitchcock. 2 Quoted by Blakie : How to Get Strong and How to Stay So. 3 Physical Education. 4 Blakie : op. cit. 5 Dr. Morgan : University Oars. c Maclaren : Training in Theory and Practice. 7 See editorial N. Y. Medical Record, March 18, 1882, on the death of John J. Dwyer, the pugilist. 8 Dr. Winship, in Atlantic Monthly, January, 1862. 8 University Oars. 10 Diseases of Modern Life. 11 N. Y. Medical Record, May 17. 1884, 12 University Oars. 13 The Sanitarian, December, 1877. 14 Morgan, op. cit. 15 R. F. Clarke : Intellectual Influence of Athleticism, 1869. 16 Hereditary Genius. 17 For a full and statistical treatment of this subject, see " College Ath- letics," by Prof. E. L. Richards: Popular Science Monthly, February and March, 1884. EXOPHTHALMIC GOITRE.- Synonyms: Basedow's Disease. Graves' Disease. Exophthalmic Cachectique. Cardiogmus Strumosus. Definition.-A disease of the sympathetic nervous system, manifested hy various circulatory disturbances, enlargement of the thyroid gland, protrusion of one or both eyeballs ; certain cutaneous changes, and mental de- rangement. Symptoms.-The development of the disease is ex- tremely slow and insidious. The patient for a long time suffers from vague attacks of depression, irritability, palpitation, shortness of breath, and fatigue after slight exertion. There is next a slight increase in the contour of the neck, and, within a period varying from a few months to several years, a certain prominence of the eye- balls, which increases so that a conspicuous protrusion is presented. This condition of affairs produces errors in accommodation and dimness of vision. There is a pecul- iar redness and suffusion of the face which is sometimes suggestive of hard drinking, a fulness and duskiness of the lips, and throbbing of the temporal vessels. About this time or later, certain trophic changes take place. The hair becomes thin and perhaps falls out, the eyelashes may entirely disappear, and upon careful examination it is not uncommon to find spots of bronzing upon the fore- head and chest, and sometimes in other situations. Her- petic patches may make their appearance from time to time, and in three of my cases I have seen unilateral sweating It is common, in advanced stages of the disease, to find night-sweats which are very exhausting and an- noying. The appetite fails and the digestive functions generally become deranged. Several cases have been re- ported in which glycosuria complicated the disease. I regard this as anything but an unusual symptom, and in no less than six of my cases was it present at some time or other. The changes in the circulation are worthy of the closest study. It is not unusual to find aortic mur- murs usually with the first sound, throbbing carotids, an increase in arterial tension, and certain local peculiarities, particularly over the enlarged thyroid, and the exoph- thalmos. If the hand be placed upon the tumor, a pe- culiar undulatory, purring sensation will be transmitted. If the fingers be pressed over the closed eyes, a distinct * These conclusions apply equally to both sexes, and it is pleasant to know that after so many years of sociological and gynecological invective against the physical degeneracy of woman something is at last being done. The leading female colleges are taking elaborate measurements, and are recording the physical advances made by their pupils under courses of suitable gymnastic exercise; while tennis, walking, riding, etc., are beginning in some degree to compensate for the damages once done by social dissipations. 763 fJ™' REFERENCE handbook of the medical sciences. thrill will be felt, and it will appear as if the balls might be pressed into a cushion at the back of the orbits, which in reality is a mass of distended blood-vessels embedded in the fatty tissue in this locality, Great muscular feeble- ness and exhaustion mark the latter stages of the disease, which lasts any time from two to ten or fifteen years, or even longer. Various digestive disturbances occur during the course of the malady, and attacks of vomiting, loss of appetite, nausea, and diarrhoea are frequent. The men- strual functions are very commonly deranged, and ex- cessive uterine haemorrhage enters into the history. In some cases the catamenia entirely disappear. The action of the heart is exceedingly irregular, and the radial pulsa- tions may range from 120 to 140 per minute, while the temperature is nearly always elevated. In some cases there is associated epilepsy (Ballet) or neuralgia (Banham). The latter author reports a case in which pain affected the left side of the face, and was more severe over the supra- and infra-orbital regions. Choreiform twitchings are occasional complications, the muscles of the face being generally involved, and these are fully considered by Gueneau de Mussy. Very great mental depression is nearly always present. Among other occasional symptoms may be mentioned tinnitus, palpitation, great thirst, subjective feelings of great heat, perverted sense of taste, occipital headache, muscae volitantes, diplopia, dry cough, and mus- cular weakness. The appended cut represents the appearance of one of my patients, in whom the disease had existed for five years. It will be observed, like Yeo's case, that the exophthalmos was crossed, and was more marked on the right side, while the tumor was on the left, a point not as fully shown as it might have been in the photograph. This woman suffered from very decided circulatory distur- bances ; a rapid, full pulse ; a turgid, puffed appearance of the face ; blue and swollen lips ; and at times she became quite dusky. Distinct and universal pulsation could be detected when pressure was made over the goitre or the eyeball; her hair was very thin (as it is very often in other cases), and her forehead and chest were the seat of bronze discolora- tion. She has suffered from frequent attacks of labial herpes ; the secretion of saliva is quite excessive ; her di- gestion is poor, and there is a tendency to diarrhoea. Her mental condition is one of great depression ; at times this almost amounts to insanity, and for a period of a few weeks she entertained delusions. Etiology.-The causes which lead to the development of the disease are very peculiar, and at best but im- perfectly understood. Mental worry or shock may be mentioned as the most definite, and sometimes the disease develops very rapidly after such agitation. Story speaks of a young girl in whom the disease followed a shock caused by the receipt of a letter announcing the death of her brother. Traumatic causes are mentioned, and See- ligmiiller reports the case of a blacksmith who, eight days after the receipt of a severe blow above the clavicle, pre- sented a train of symptoms consisting of pupillary dila- tation, exophthalmos, pallor, etc. Certain cases follow cardiac disease, while others appear in anaemic subjects whose condition is due to haemorrhoidal bleeding or metrorrhagia. The subjects of this disease are almost without exception women; in fact, my own cases were all females between the ages of thirty and fifty, and in all, except two, the disease affected both sides uniformly ; and this, I believe, is the experience of most observers. Pathology and Morbid Anatomy.-The burden of proof shows that exophthalmic goitre is a disease of the sympathetic nervous system. There is abundant evi- dence of this, as furnished by the cases and observations of Eulenburg,' Guttmann,2 Gueneau de Mussy,* Woods,3 Long Fox, and others. All of these observers have found lesions of the cervical portion of the sympathetic, and es- pecially the inferior cervical ganglia. This consisted usu- ally of thickening, which may be bi- or uni-lateral. Fox refers to a case where the lower cervical ganglia on the right side were "thicker and redder than usual. The connective tissue was increased, as well as the nuclei and spindle-shaped cells. The ganglion cells were few in number." Smith reports " shrinkage of the cells of the inferior cervical ganglia." Many writers believe in the complex nature of the morbid process, and it would appear that the medulla must be affected to account for some of the symptoms, especially those of an ocular character. Mobius holds to this theory. Gueneau de Mussy refers to a case in which pigmentation of the face figured, and he is inclined to ascribe this to the influence of the thoracic glands about the bronchi and trachea, in the production of an irritation of the vagus. Panas and Webber incline to the bulbar origin of the disease. The circulatory troubles are undoubtedly due to disturb- ance of the functions of the vagus as well as of the sym- pathetic. Jones believes the palpitation to be due to im- paired innervation by the vagus. The hypertrophy of the thyroid and the exophthalmos, the latter being secondary to orbital changes, are depend- ent upon the acceleration of the heart and the vascular dilatation. This latter I am inclined to ascribe to a sym- pathetic lesion, which is of early origin. There are so many symptoms which, grouped under other names, are so un- mistakably sympathetic neuroses, that I am inclined to believe that when the medulla is affected it is simply an extension. In connection with exophthalmic goitre we should study its first-cousin, myxodema. I have had an hybrid case of the latter, in which exophthalmos was present, and in others there were the mental, pigmentary, and circula- tory changes, and either thyroidal enlargement or atrophy. Besides the changes referred to, Begbie, Mackenzie, and others have found cardiac and vascular lesions, softening of the corpora quadrigemina, medulla, and other parts. Diagnosis.-A distinction must be made between that form of thyroidal enlargement of endemic origin which is so often found as a chronic and slowly developing af- fection, and the form under consideration, known as ex- ophthalmic goitre, which is essentially an affection of the sympathetic system, and in which the thyroidal tumor is but a prominent symptom. This latter malady is one in which circulatory disturbances are dominant, and the trophic changes, the ocular protrusion, and the violent expressions of cardiac excitement evince a radical altera- tion in the tonicity of the organs of circulation. Prognosis.-Cures of the disease have been reported by Cheadle, Mackenzie, Bartholow, Hammond, Charcot, Trousseau, and others. The fatal cases are numerous. Thomas reports one and Hammond another, and several cases in which autopsies were made are recorded by Eu lenburg and Guttmann. Fox reports a case where the goitre lasted for five years and then disappeared. I have seen several cases of six or eight years' standing. Treatment.-A variety of remedial agents have been used, and those which have promised the greatest meas- ure of success are ergot, quinine and iron, and galvanism. Bartholow recommends the external application of the ointment of the red iodide of mercury, and the use of iodine. He believes that galvanism is of service only in the cases of "simple hypertrophy and cystic state of Fig. 1055. * Referred to by Fox. 764 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Exophthalmic Gol- Expectorants. [tre. the latter case it is commonly the ungual phalanx which is involved. In rare instances such outgrowths have been observed upon the teeth. These have been called by Virchow "odontomata." Teeth more or less perfectly formed have been found in ovarian and dermoid cysts, and in the antrum of Highmore. Bony tumors of much magnitude within the skull are very uncommon. The largest observed by me was one springing from the petrous portion of the temporal bone, on the left side, in a lady about seventy years of age. It was somewhat sessile, about the size and shape of a hen's egg, and deeply indented the brain in that region. The case was seen in consultation with Dr. Austin Flint, Sr. ; and the presence of the tumor was unsuspected before the autopsy. The mental faculties of the patient had been entirely unimpaired throughout life, and the hear- ing was rather better on this side. There was no differ- ence in muscular power on the two sides. Death oc- curred in a suddenly appearing coma, without other symptoms, and proved to have been caused by haemor rhage into the left ventricle, produced by rupture of the choroid plexus, the vessels of which were here consider- ably sacculated and dilated, somewhat resembling a min- ute bunch of grapes. The blood tilled both lateral ven- tricles, the third, the iter, and the fourth ventricle. The cancellous variety of exostoses is found almost ex- clusively on the epiphyses of long bones, and is covered, as a rule, with a thin layer of hyaline cartilage. Accord- ing to the table of statistics given by Bryant,4 the femur, tibia, and humerus are those most commonly involved. Exostoses of periosteal origin are more apt to be dense. When bony tumors start from the interior, growing into the medullary cavity, they are called by Green enostoses. Treatment.-Exostoses can be treated by operative measures alone, and these are demanded only when the mass becomes of annoying bulk, or threatens by encroach ment some important structure. In such cases it should be removed, if possible, by the chisel, drill, or saw. Proximity to joints may render the excision undesirable, and particularly where a superimposed mucous bursa is found. Such bursae are usually joint-connected, and should not be cut away. The treatment by denudation, recommended by Astley Cooper, can rarely be indicated. In this procedure the endeavor is to check the growth, and perhaps induce ne- crosis of the tumor, by stripping off the periosteum cover- ing it. Concerning cauterization, Nelaton5 says that it may be done when the situation of the tumor renders excision or denudation impossible. In extreme cases involving the limbs, amputation of the affected member must be practised. 'Robert II. M. Dawbarn. 1 Surgical Pathology, p. 408. 2 Pathology and Morbid Anatomy, p. 118. 3 Surgical Pathology, p 530. 4 Practice of Surgery, p. 964. s Pathologic Chirurgicale, tome ii., p. 21. gland " Chvostek, Meyer, Leube, and Benedikt have found that galvanization of the cervical sympathetic some- times resulted in cure. The former used an ascending gal vanic current, the positive pole being placed on the dorsal vertebra, the negative at the back of the neck. Weak cur- rents were used, and the application rarely exceeded two minutes. I have used galvanism with good effect, but rely almost entirely upon a little-known remedy, hydroiodic acid, with which I have cured three cases of advanced and serious goitre. This is given in aqueous solution (Gar diner) in increasing doses. The equalization of blood pressure should be aimed at, hygienic measures instituted which will favor normal cutaneous circulation, and mental excitement prevented, if possible. Allan McLane Hamilton. 1 Archiv fur Psychiatrie und Nervenkrankheit, 1, 1868, p. 430. 2 British Medical Journal, 1882, 1, 351. 3 The Influence of the Sympathetic on Disease. London, 1885. EXOSTOSES. Under this title are usually included all tumors composed of osseous tissue-all osteomata. The term osteophytes is employed by some authors to de- signate bony excrescences the result of chronic inflamma- tory action, such as those resulting from ossification of tendon, fascia, or muscle, or accompanying chronic osti- tis and periostitis (simple or specific), or arthritis, as in the so-called arthrite seche. For example, Billroth 1 says ; ' ' Osteophytes are the products of an inflammatory irrita- tion of the periosteum and surface of the bone ; they are precisely what we call callus in fractures, and they are formed in the same way." Other writers on pathology, as Green,2 describe osteo- phytes as heterologous bony tumors, considering only those of bony origin-homologous-as exostoses. To Green, a bony tumor in the lungs or brain is an osteophyte. Strictly speaking, from the derivation of the word, exostosis is only one variety of osteoma ; but, as already stated, the terms are by many used interchangeably. It seems proper to draw a line of distinction between true bony tumors-that is, abnormal growths not pro- duced by inflammatory action-and other osseous deposits. Regarding this point Faget3 writes : " That may be reck- oned as an osseous tumor, or outgrowth of the nature of a tumor, whose base of attachment to the original bone is defined, and grows, if at all, at a less rate than its out- standing mass." Whereas, in inflammatory bony forma- tions there is a less sharply defined base, and the mass grows rather by addition to the circumference of the base than to the height of the swelling. Certain new-growths-notably chondroma and the oste- oid variety of sarcoma-sometimes undergo partial or almost complete ossification ; these tumors are not classed as exostoses. Neither should deposits of merely calcare- ous matter, unorganized, receive this name. Exostoses are almost always of very slow growth, be- ginning most commonly in early adult life, and being checked in their advance by old age. They are benign in their nature, and according to Green (op. cit., p. 119) are often hereditary and multiple. For the most part, except they press upon sensitive structures, they are un- accompanied by pain. Upon section and microscopical examination they will be found composed of true bony tissue-Haversian canals and lamellar systems-but these are more irregular in their arrangement than in normal bone. From their differences in relative density these tumors have been divided into three varieties : 1, The ivory or eburnated ; 2, the compact ; 3, the cancellous. Most au- thorities, however, describe only the first and last, consid- ering the second as belonging either to one or to the other. Referring to the eburnated exostoses, Paget (op. cit., p. 536) says ; " These hard osseous tumors are very rarely found in connection with any bone but those of the skull." It will be noted that exostoses are apt to resem- ble the type of bone from which they spring. Upon the skull the orbit is a favorite seat of the growth. Next to the skull these exostoses are perhaps most fre- quently found upon the pelvis, scapula, or great toe. In EXPECTORANTS are medicines which are used in ca- tarrhal affections of the larynx, trachea, and bronchi, to modify secretion and facilitate the removal of morbid products. Until recently our knowledge of their .use was founded entirely on careful clinical observations. It had been ob- served that certain remedies ameliorate cough and in- crease expectoration in the early stage of acute inflamma- tions of the air-passages. Most of them, when given in large doses, produce nausea and vomiting, and a notable depression of the general circulation. They were, there- fore, called depressant or nauseant expectorants. Other remedies had been found to ameliorate cough and dimin- ish expectoration in the latter stage of acute catarrhs, and in chronic catarrhs attended by copious secretion. In large doses many of them cause local irritation, with more or less excitement of the general circulation. Hence they were called stimulant expectorants. The recent experiments of Rossbach 1 have confirmed the theory, founded on clinical observation, that some expectorants increase and others diminish secretion. They have ren- 765 Expectorants. Expectorants. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dered our knowledge more precise, and besides, have es- tablished the important fact that some expectorants cause a diminution of the vascularity of the respiratory mucous membrane. Depressant Ex'pectorants.-Apomorphina Ilydro- chloras.-Soon after apomorphine came into vogue, clin- icians observed that it exerts a very decided influence in catarrhal inflammations of the air-passages. In a short time after its administration is begun expectoration is effected more easily, and the sputa become more copious and less viscid. Usually these effects occur without any noteworthy nausea, or this is observed only after the first dose. According to the experiments of Rossbach, the expec- torant action of apomorphine is due to augmented activ- ity of the mucous follicles ; for it caused a very decided increase of the quantity of mucus of the exposed trach- eal mucous membrane, wflien the nerves passing to the trachea had been divided, and all the large blood-vessels supplying this organ had been ligated. In expectorant doses, apomorphine does not diminish the appetite, nor cause diarrhoea. Apomorphine is indicated in catarrhal affections of the larynx, trachea, and bronchi, when only small quanti- ties of viscid mucus are secreted. Hence, especially in the early stage of bronchitis, when dry, sibilant rales are heard, and when coughing occurs frequently, and is at- tended by little or no expectoration. Trustworthy observers state that they have obtained more speedy and more decided success with apomorphine than by all other means in bronchitis, tracheitis, laryngitis, phthisis, and the stage of resolution of pneumonia. Ross- bach employed it in pseudo-membranous croup with ex- cellent results, the membranous exudation becoming de- tached and expelled.2 Apomorphine is contra-indicated in the above-named affections when moist rales are heard and expectoration is copious. It should never be given when the bronchial tubes are overloaded with secretions which are not ex- pectorated from want of strength. When a cough is frequent and very severe, and little mucus is secreted, as showm by the scanty, viscid spu- tum, morphine may be combined with the apomorphine, if the latter do not speedily ameliorate the cough. Mor- phine does not prevent the" action of apomorphine. The combination simultaneously increases secretion and low- ers the excitability of the respiratory centre. No fixed rules can be given as to the dose of apomor- phine, on account of the differences in susceptibility to its action, and the great variations in extent and intensity of the catarrhal inflammations of the air-passages. For adults, from one-half to one grain in twenty-four hours is usually sufficient; but sometimes from one and a half to two grains are required. * Doses of one-sixteenth to one- sixth of a grain may be given every two or three hours. To children apomorphine may be given in doses of one- sixtieth to one-tenth of a grain, according to their age. At the age of one year the single dose may be one-sixtieth of a grain, and this may be increased by the one one-hun- dred-and-twentieth grain for each additional year, so that at the age of two years the dose will be one-fortieth, at three years one-thirtieth, and so on. It may be prescribed as follows : R. Apomorph, hydrochlor., gr. ss.-j. ; acid, hydrochlor, dil., gtt. x.; aq. destill., $ jss. M. Sig.: One teaspoonful every two or three hours. The acid is addpd to prevent the change of color, which rapidly takes place if no acid is added, and the medicine is not dis- pensed in a dark bottle. A syrup may be added, or, if de- sirable, each dose may be taken in sweetened water. Mor- phine may be added to the apomorphine, as in the following formula: B. Apomorph, hydrochlor., gr. ss-j.; morph, hydrochlor., gr. ss.; acid hydrochlor, dil., gtt. x.; aq. destill., § jss. M. Sig.: One teaspoon- ful every two or three hours. Ipecacuanha.-This medicine is frequently employed in catarrhal affections of the air-passages, especially in the early stages, when cough is severe and expectoration scanty. It acts most rapidly when given in such doses as produce nausea. As the activity of the mucous glands becomes increased during nausea, it has generally been held that ipecacuanha acts by increasing secretion, but that this takes place only when nauseating doses are used. But it is frequently observed that the symptoms of bron- cho-tracheal catarrh become ameliorated by doses which do not produce notable sickness. The action of ipecacuanha is due to the alkaloid eme- tine, which it contains in small and variable quantities. Rossbach found that emetine causes a decided increase of the mucus of the trachea, without augmenting the quantity of blood in the mucous membrane. The increase of secretion also took place when the nerves going to the trachea had been divided, showing that it results from a direct action on the mucous glands or oh the secretory nerves. Ipecacuanha is indicated in acute and chronic catarrhs of the air-passages attended with scanty and viscid ex- pectoration. It is the expectorant generally employed in the bronchial inflammations of very young, very old, and feeble patients, and is especially applicable when these affections present more or less fever, a dry skin, soreness of the chest, oppressed breathing, painful cough, viscid sputum, and dry niles. The dose of ipecacuanha varies from half a grain to two grains, on account of the variable quantity of eme- tine which it contains, and the differences in intensity and extent of the catarrhal inflammations. If small doses do not speedily cause a decided change in the expectora- tion, larger ones should be given, so as to induce slight nausea. The syrup and wine of ipecacuanha are given in doses of ten to forty minims. Antimonii et Potasii Tartras.-Tartar emetic is a very depressing expectorant. When administered in small doses, one-sixteenth to one-sixth of a grain, at intervals of several hours, it usually produces no immediate effects ; but after several doses have been taken, a decided action on the heart and secretions becomes manifest, the heart's action becoming slower and feebler, and the secretions of the mucous membranes and skin decidedly augmented. After several days, if the medicine is continued, very marked debility ensues. Tartar emetic is held to be serviceable in severe forms of bronchitis occurring in robust individuals. It is es- pecially indicated w hen there are present dyspnoea, flushed face, full and strong pulse, soreness of the chest, with little or no secretion, as shown by the dry, sibilant rales heard on auscultation. On account of its depressing ac- tion, which is most evident in weakly persons, it is not a suitable remedy for debilitated, very young, or very old patients. It is contra-indicated in catarrhs of the air-pas- sages complicated with severe disorders of the alimentary canal. Tartar emetic is usually administered in doses of one- twelfth of a grain every two or three hours. B. Antim. et potass, tart., gr. j. ; syr. althaeae, § ss. ; aq. destill., 3 j. M. Sig.: One teaspoonful every two hours. Some- times minute doses are given at very short intervals, as by dissolving one grain in five or six ounces of water, and directing a teaspoonful of the solution to be taken every ten minutes until nausea ensues. As soon as this takes place, a marked increase of secretion and expecto- ration occurs, with decided relief of the soreness of the chest and dyspnoea. The wine of antimony, containing 1 part in 250 parts, is given in doses of 10 to 40 minims. It is one of the ingredients of the compound mixture of glycyrrhiza, which is given in doses of a tablespoonfid. Lobelia is used as an expectorant when bronchial ca- tarrh is complicated with spasmodic contraction of the bronchial tubes, or when a severe cough is attended with difficult breathing, abundant sibilant rales, and viscid sputum. From its utility in such cases it has been in- ferred that it increases secretion, and at the same time re- laxes the bronchial muscles. In spasmodic asthma it is frequently employed with much benefit. But it usually fails to produce any marked effect, unless given so as to cause nausea. The dose varies from one to five grains, as an expectorant. Of the tincture (1 to 5) the dose is 5 to 25 minims, and of the vinegar (1 to 10) double these quantities. 766 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Expectorants. Expectorants. Pilocarpine.-This alkaloid was found, in the experi- ments of Rossbach, to cause a very profuse secretion of watery, transparent mucus from the trachea and bronchia, so that moist rales could be heard over all parts of the thorax. Trials of the remedy in cases of bronchitis were attempted, but the action on the salivary and sweat glands, and on the heart, was so disagreeable to the pa- tients that they refused to persevere in its use. The or- dinary therapeutic use of this medicine has occasionally been followed by pulmonary oedema. Alkalies.-It has been frequently observed that bron- chial catarrhs improve during the internal use of alkalies. Usually, expectoration takes place more readily, and the sputum is less adhesive. Hence, it has been inferred that alkalies increase the bronchial secretion, and render it more fluid. The results of Rossbach's experiments are at variance with this view. After exposing the tracheal mucous membrane of cats, he injected into a vein two grammes of carbonate of sodium. The mucous membrane rapidly became pale, presenting a peculiar grayish-white color, and the secretion of mucus gradually diminished, and soon ceased completely. As this result was unexpected, the experiment was often repeated, but the same phenom- ena uniformly took place. Rossbach was unable to de- termine the cause of the arrest of secretion. That it was not due to the anaemia "was evident from the fact that even more decided anaemia, produced by irritating the nerves distributed to the trachea, did not diminish the secretion of mucus. The local application of solutions of carbonate of sodium, containing from one to two per cent., caused no obvious change in the appearance of the mucous membrane. The experiments of Rossbach confirm the clinical ob- servation that increased alkalinity of the blood modifies the secretion of mucus, although they contradict the theory that it becomes increased. Perhaps it will be found hereafter, as suggested by Brunton, that the modi- fication of secretion depends upon the quantity of alkali administered, small doses increasing and large ones di- minishing the secretion. If further observation should show that the action of al- kalies is the same in man as in Rossbach's experiments, it would follow that alkalies might be used in all stages of bronchial inflammation, and that they would be service- able not merely to modify secretion, but to diminish the hyperaemia, the chief morbid phenomenon of the disease. Stimulant Expectorants.-Ammonii Chloridum.- No medicine is more frequently employed in bronchial catarrhs than this salt. It is held to be suitable wThen no fever is present, and expectoration is difficult on account of viscidity of the secretion, and to be useless when the sputum is abundant and easily coughed up. In observations on himself, Wibmer found a very de- cided increase of the bronchial mucus after doses of eight to fifteen grains, taken hourly. Other careful observers also noticed an augmentation of the bronchial secretion from its use. The experiments of Rossbach seem to show a different mode of action. Under the influence of the salt the tracheal mucous membrane became anaemic, and the secretion of mucus gradually ceased. The utility of chloride of ammonium in catarrhs of the air-passages may therefore depend upon a favorable modification of the vascularity of the mucous membrane, not merely upon a change of the quantity of the secretion. Chloride of ammonium is indicated in bronchitis after the fever has subsided. When secretion is very viscid, it is frequently combined with ipecacuanha, or with minute doses of tartar emetic. To adults it is given in doses of five to ten grains every two or three hours. B. Ammon, chlor., 9ij to 9iv.; ex. glycyrrh., 3 ss. to 3 i.; aq. des- till. , § iv. M. Sig.: One table'spoonful every three hours. The extract of liquorice of this prescription renders the taste of the salt less disagreeable. If slight elevation of temperature exist, or if dry rales be heard, ipecacuanha maybe added, or, in robust subjects, tartar emetic as fol- lows : R. Ammon, chlor., 9iv.; ex. glycyrrh., 3 ss.; syr. ipecac., 3 ij. to 3 iv.; aq. destill, ad | iv. M. Sig.: One tablespoonful every three hours. B- Ammon, chlor.. 9iv.; antim. et potass, tart., gr. ss. to j.; ex. glycyrrh., 3 ss.; aq. destill., § iv. M. Sig.: One tablespoonful every three hours. Ammonii Carbonas.-This salt is employed in bron- chitis, catarrhal pneumonia, and croupous pneumonia, when the fever has subsided or abated, and the general condition of the patient requires the use of stimulant remedies. It is held to act on the mucous glands of the air-passages, thus increasing the quantity of mucus and rendering it more fluid. At the same time it stimulates the respiratory centre when given in tolerably large doses, and thus augments the efficiency of the expulsive efforts. The recent researches on the physiological action of this salt have fully confirmed the theory held in the early part of this century that it possesses great utility in pul- monary affections, because it stimulates the nervous sys- tem, and hence enables debilitated patients more readily to cough up accumulated masses of mucus. Usually it is given to adults in doses of five to ten grains every two or three hours. On account of its pun- gency it is combined in prescriptions with gum arabic and sugar or liquorice. 3. Ammon, carb., 9ij. to iv.; pulv. acacise, sacch. albi, aa 3 ij.; aq. menth. pip. ad § iv. M. Sig.: One tablespoonful every three hours. Aqua ammonias, and Spiritus ammonia aromaticus, in appropriate doses, may be used as stimulant expectorants, to increase secretion and excite the respiratory centre. Scilla.-Squill is perhaps more frequently used than any other expectorant in the advanced stage of acute bronchitis and in chronic bronchitis, especially when se- cretion, though not scanty, is tenacious, and hence expec- torated with difficulty. The investigations on the phys- iological action of squill have not fully explained its expectorant action, no special modification of secretion of mucus having been observed. But they have conclu- sively established that squill modifies the action of the heart in the same manner as digitalis, rendering its con- tractions slower but more forcible. The general blood- pressure, therefore, becomes increased, and the circulation in the respiratory mucous membrane accelerated. It is hence quite probable that catarrhal symptoms subside as the result of the improved pulmonary circulation. The fact frequently observed that squill is most effectual in bronchial catarrhs with obstructive heart-disease, strongly supports this view. Squill is usually administered in the form of the syrup, in doses of 20 to 40 minims every two or three hours. It is often combined with ipecacuanha and camphorated tincture of opium when secretion is scanty and the cough severe. B- Syr. scillae, syr. ipecac., tinct. opii camph., aa 3 j. M. Sig. : One teaspoonful every three hours. Senega.-The use of senega as an expectorant is based upon careful clinical observation, although it has been found to cause cough and expectoration of mucus in healthy persons. Experience has shown that it is most useful in the second stage of acute bronchitis, in chronic bronchial catarrh, and in pneumonia in the stage of reso- lution, when the symptoms indicate that the bronchial tubes contain large quantities of secretion. It is held to be especially serviceable when the sputa are muco-pur- ulent and the power to expectorate is small. The use of senega in bronchitis and pneumonia is in- dicated by the presence of numerous moist rales, pur- ulent or muco-purulent expectoration, and oppression of the chest. It should not be administered as long as the temperature is much above the normal. It is, ho,wever, doubtful whether senega tends to increase fever, as it has been found experimentally that saponin, which appears to be identical with the active principle of senega, lowers the temperature. The preparations of senega most frequently used are the fluid extract and the syrup, in doses of 10 to 20 min- ims and 1 or 2 drachms, respectively. Oleum Terebinthina.-It has frequently been observed that oil of turpentine diminishes the sputum in various forms of bronchitis with profuse secretion, and lessens the offensive odor of the expectoration in fetid bronchitis and pulmonary gangrene. That it really lessens the amount of secretion in bronchial catarrhs was conclusively 767 Expectorants. Expectoration. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. shown by Juergensen (Ziemssen's " Handbuch," Bd. v., p. 182), who in numerous cases carefully measured the quantity of sputum, and constantly found a diminution. The clinical observations have been fully confirmed, and the mode of action of oil of turpentine plausibly explained by the investigations of Rossbach. In carefully con- ducted experiments he found that the oil exerts a very decided influence on the mucous membrane of the air- passages. When a current of air which had passed through oil of turpentine, so as to become loaded with it, was applied to a part of the mucous membrane, the secre- tion of mucus gradually diminished, and finally ceased, and the membrane became very dry. A watery solution containing from one to two per cent., dropped upon the mucous membrane, caused an immediate increase of secre- tion and notable anaemia. Oil of turpentine, when taken internally, is partly eliminated by the respiratory mucous membrane. In passing through the membrane it doubtless exerts an irritant or stimulant action on the blood-vessels, in con- sequence of which they contract. This contraction of the vessels is soon followed by absorption of exudation and lessened activity of the mucous glands. The decided improvement observed in the odor of the sputum in fetid bronchitis and pulmonary gangrene is doubtless attrib- utable to the antiseptic power of oil of turpentine, by which it arrests the process of decomposition in the secre- tions. Rossbach supposes that its antipyretic action, its property of slowing respiration, and its depressing effect on sensory nerves, may contribute to its therapeutic utility. Oil of turpentine is indicated in all forms of bronchitis with free secretion, but especially when the expectora- tion is profuse, muco-purulent, and fetid. It is usually given in doses of 5 to 20 drops every two or three hours. Frequently it is administered in emul- sion, as follows: B- Olei terebinth., 3 j.; vitellum ovi unius; syr. aurant., § ss. ; aq. cinnam. ad § iv. M. Sig. : One tablespoonful every three hours. Juergensen administers the oil in doses of about 12 drops six times daily in several ounces of milk. If the oil is taken in capsules, a small quantity of milk may be drunk after each one, in order to prevent irritation of the stomach. Copaiba.-Although the action of this agent on the mucous membrane of the air-passages has not been in- vestigated experimentally, it seems highly probable that it is analogous to that of oil of turpentine. Numerous careful observers have found it useful in chronic and in fetid bronchitis, and some of them state that it is equalled by no other medicine in catarrhs attended with profuse expectoration. It is usually given in emulsion in doses of 10 to 20 minims from three to six times daily. Pic Liquida.-Tar seems to be useful in chronic ca- tarrh of the bronchi and in phthisis, when copious secre- tion is taking place. It often lessens the expectoration, eases the cough, and diminishes the oppression of the chest. Usually it is administered in the form of the officinal syrup, of which the dose is 1 to 4 drachms. The following formula was recommended by Adrian : B. Picis liq., vitell. ovor., aa 25.0 ; glycerini, 50.0. M. Sig. : One or two teaspoonfuls from three to six times daily. Eucalyptol.-This volatile oil has recently gained some repute in bronchorrhoea and fetid bronchitis. " It is a pow- erful antiseptic. Taken internally, it is eliminated by the kidneys and the lungs, and seems to act upon the respir- atory mucous membrane in the same manner as oil of tur- pentine. It is administered in doses of 5 to 15 drops in capsules or emulsion. Grindelia has lately been strongly recommended in spasmodic and catarrhal affections of the bronchial tubes, and in whooping-cough. According to some of the pub- lished reports, in some instances "it acts like a charm, instantly controlling the cough, and relieving the tickling in the throat and bronchial tubes." The fluid extract is given in doses of 10 to 60 minims. Ammoniacum, benzoic acid, myrrh, balsam of Peru, bal- sam of Tolu, garlic, and sanguirMria have been employed in bronchial catarrhs with good effects. They are, how- ever, at the present time, rarely prescribed. Morphine and Atropine.-These alkaloids are so useful in diseases of the air-passages, and so frequently administered simultaneously with some of the expecto- rants, that a very brief consideration of their mode of action is here appropriate. Atropine is in constant use in phthisis to arrest night- sweats. Many observers have noticed, during its admin- istration, a decided lessening of expectoration and cough. This effect was usually ascribed to an action on the vagi in the lungs, and on the mucous glands, which were supposed to become affected in the same manner as the sweat-glands. In experiments, Rossbach observed that atropine acts very strongly upon the tracheal mucous membrane. He invariably found that the membrane, which had been secreting normally and was very moist, became absolutely dry. Gradually very decided hyper- femia supervened ; yet no secretion occurred for an hour or longer, and afterward returned very slowly and feebly. The persistence of the dryness, notwithstanding the hy- peraemia, proved that atropine acts on the mucous glands or secreting nerves. It is, therefore, an appropriate rem- edy in bronchial and pulmonary diseases, when the cough depends upon copious secretion in the trachea and bron- chial tubes. Morphine lessens cough in two ways-by diminishing secretion, and by lowering the excitability of the respir- atory centre. Rossbach observed that, normally, after removal of the mucus from the tracheal mucous membrane, about twenty seconds passed before the membrane was again completely moist. But after subcutaneous injections of morphine, the membrane did not become equally moist before the lapse of eighty to one hundred seconds. Cough may be very readily produced by slightly irri- tating the normal mucous membrane of the larynx and trachea, especially near the bifurcation of the bronchi. An hour after injecting morphine, Rossbach found that only very severe irritation produced cough, while gentle irritation had no effect. When used simultaneously, both alkaloids act, lower- ing the excitability of the respiratory centre, and notably lessening secretion. In chronic catarrhs, emphysema, and phthisis, with copious expectoration, they have been found of great utility. In phthisis, when the expectora- tion comes from cavities, no very marked diminution can be produced. As a rule, the two alkaloids should be prescribed sepa- rately-atropine to be taken only in the evening, between six and ten o'clock ; and morphine, in very small doses, during the day. Samuel Nickles. 1 Berliner klinische Wochenschrift, 1882, Nos. 19, 20, and 27. 2 Ibid., No. 27, p. 411. EXPECTORATION. Every sputum contains, as its es- sential basis, water and mucus. Their proportions vary. In the frothy fluid of pulmonary oedema water predomi- nates, but is scanty in the thickened sputum of late ca- tarrhs. Mucus is secreted by the lining membrane of the respiratory tract, and is demonstrable by adding acetic acid which precipitates the mucin. Albumen is an occa- sional ingredient, notably in croupous pneumonia. Mingled with this ropy, tenacious menstruum are vari- ous particulate elements, some having no clinical impor- tance, while to others a pathognomonic significance at- taches. The latter will be considered with the diseases which they characterize. Among the former are : Pus, present in nearly all sputa, and constituting the bulk of the yellow product of bronchitis; and mucus-cor- puscles. With these are shrunken or fatty cells, large cells containing pigment (commonly degenerated alveolar epithelium), cell nuclei, and granular matter. Blood-corpuscles retain their normal shape, or are cre- nated, or swollen. Epithelial Cells.-The pavement variety are the com- monest form ; the columnar being rarely found, owing to the firmness of its attachments. In the secretions of an acute rhinitis, ciliated epithelia may sometimes be de- tected stripped of their vibratile cilia. Only occasionally is the ciliary fringe still attached and in motion. 768 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Expectorants. Expectoration. Fungi.-Micrococci and the spores and thallus of lep- tothrix and oidium albicans occur sparsely in healthy sputum, but in fetid expectoration are present in large numbers, together with masses of vibrios. Sarcime ven triculi are occasionally seen, and have been observed in phthisis when the stomach was free from them. In whooping-cough the sputum is crowded with spores and filaments of vegetable fungi, by Letzerich regarded as the cause of the disease. His views have not, however, found general acceptance. Foreign Substances.-Sputum which has stood in the crachoir is liable to invasion by extraneous particles of cotton, linen, silk, feather, lycopodium, starch, bacteria, etc. In passing the fauces and mouth it may attach par- ticles of food having lodgment there. Sputa are classified according to their predominant con- stituents. The mucous is observed in health and in the early stages of catarrhs. It is clear, viscid, slightly min gled with pus. The muco-purulent contains mucus and pus, and accompanies the later stages and chronic forms of nasal or bronchial inflammations. After standing twelve or twenty-four hours, it separates into three layers, the upper mucous and frothy, the middle clear and trans- lucent, the lower purulent and opaque. It is the com- monest variety. The purulent is composed chiefly of pus from some suppurating cavity communicating with the bronchi-a phthisical or bronchiectatic vomica, an empy- ema emptying through the lung, abscesses of the media- stina, suppurating bronchial glands, etc. Sanguineous sputa consist of blood mingled with mu- cus. The thoroughness of this admixture varies. When long retained and churned with mucus, as in pulmonary infarction, or when effused into the alveoli with other in- flammatory products, as in pneumonia, blood is evenly diffused. But when coughed up immediately upon escap- ing, it spots or streaks the expectoration, or occurs in unmixed clots. Its source is a question of moment, and examination of nose, mouth, pharynx, and larynx should first exclude these as its possible origin. We must then determine whether it come from the lungs or the stomach. In pulmonary haemorrhage the patient is sensible of a warm fluid welling up behind the sternum, cough is ex- cited, and bright red, frothy, alkaline blood expelled. Toward the end of the attack coagula may be raised, and for some time thereafter bloody mucus is expectorated. Often a phthisical predisposition is evident, and physical examination detects rales limited to a portion of one lung. Blood from the stomach is commonly vomited, is free from air, acid, dark like coffee-grounds, and perhaps mingled with food. A history of gastric disease is ob- tained, and the haematemesis, if copious, is followed by tarry stools. Dogmatism, however, easily leads to error, for cough excites vomiting, and vomiting cough. Blood from the lung may be swallowed, and afterward ejected with the characters of gastric haemorrhage; and blood from the stomach, if promptly expelled, may possess the bright hue and alkaline reaction of haemoptysis. But in the absence of pathognomonic signs, careful examination and weighing of the circumstances will usually guide aright. Owing to progressive oxygenation of its haemoglobin, sputum containing blood may change color, becoming reddish-brown, yellow, or green. Fungi, if in sufficient numbers, impart a yellow tint like that of biliary pigment. Coal-heavers expectorate a sputum black with carbon, while workers in dyed stuffs observe that their expecto- ration is colored similarly to the fabrics of their looms. In physical characters sputa differ widely. The spe- cific gravity depends on the amount of air mingling with the mucus. When long retained in a cavity, sputum be- comes fetid. Its quantity varies, and is no index of the gravity of the case. Exacerbations of pneumonia are characterized by scant expectoration; in the severest cases it may be entirely absent; while resolution is at- tended by profuse exspuition. If, however, while pul- monary disease is advancing, and the bronchi are full, the sputa diminish in amount, we may infer that the sensibility of the vagus is lowered, and death by ex- haustion threatens. Special Sputa of Disease.-Catarrhal Laryngitis.- In this, as in all catarrhs, the earlier sputum is mucous, frothy, viscid, and contains but few epithelia, the "spu- tum crudum " of the ancients. Later it becomes abun- dant, muco-purulent, and richly endowed with cells- ' ' sputa cocta. " Pure pus is never seen. Croupous and Diphtheritic Laryngitis.-Whether these diseases be identical or not, we cannot distinguish their morbid products. In both there is expelled a fibrinous false membrane in layers of varying thickness and tough- ness, and containing pus, blood, and colonies of bacteria. Decomposition may render these shreds offensive. Catarrhal Bronchitis.-The sputum conforms to the types characteristic of the stages of catarrhs in general. In dry bronchitis it is scanty and tough, in bronchorrhoea copious and watery, amounting to a pound or more daily. When bronchitis is due to inspired particles of coal, metal, etc., these are found in the crachat. Fetid bron- chitis is characterized by profuse greenish expectoration, wherein float plugs or cores containing pus, detritus, crystals of sebic acid, leucine and tyrosin, and giving off valeric and hydrosulphurous acids, ammonia, and other volatile products of decomposition. Croupous Bronchitis is marked by the expectoration of casts of the bronchial tubes. They consist of coagulated fibrin holding pus, and rarely fat or blood, in its meshes. Though usually milk-white in color, they may have a yellowish-white or a bloody tinge. Their surface is fre- quently knotty, and the thicker stems may be flattened -irregularities due to variations in the coagulation and contraction of the fibrin. Their length, usually from three to six centimetres, may reach ten or twelve centi- metres. Their thickness rarely equals that of a lead-pen- cil. Excepting the largest and smallest stems, which are solid, these casts are hollow, containing mucus and air. On section we recognize concentric layers, the formation having occurred not all at once, but intermittently. Be- tween these layers air may be imprisoned by the rapid production of new coagulating material. Sometimes the casts turn spirally on their axes, but ordinarily they pre- sent a faithful reproduction of the dichotomous ramifi- cations of the bronchi even to the infundibula, this being best exhibited by floating them in water. From the conformation of the cast we can, in fact, sometimes de- termine whether it came from the short-branched divis- ions of the upper bronchi, or from the longer tubes of the lower lobes. They do not form in the trachea. When implicating large pulmonary areas, they may cause death by suffocation. Asthma.-During paroxysms the expectoration is scant, but afterward more abundant. Throughout and just af- ter the attack there are found in the sputa peculiar crys- tals having the form of long colorless octahedra. They are soluble in water, acids, and alkalies, insoluble in ether, and swell in glycerine. Their real nature is un- known, but appears to be a substance analogous to mucin. Leyden supposed that by irritating the terminal filaments of the vagus these crystals might cause the asthmatic paroxysms. But asthma occurs in the absence of such crystals-which, on the other hand, are occasionally found in the sputa of diseases unaccompanied by asthma -bronchitis, pulmonary emphysema, and in the casts of croupous bronchitis. Pleurisy.-The expectoration is mucous, or muco-pur- ulent. An empyema rupturing into the lung gives rise to an immense evacuation of clear pus, followed for an indefinite period by purulent expectoration, usually fetid. Croupous Pneumonia. The early sputum is mucous, frothy, transparent ; but soon becomes slightly purulent and more and more bloody. Typical pneumonic sputum is red or rusty in color, gluey, sticking obstinately to the lips and edges of the receptacle. In cases likely to end fatally, it may exactly resemble prune-juice. It consists of mucus, and, because of its deficiency in alkaline phos- phates, is often acid. It contains, besides an excess of chlorides and some sugar, pus, epithelia, granular cells, oil globules, blood, and dichotomous fibrinous casts of the bronchioles. With these products the concussions of severe cough mingle air in considerable quantities. The 769 Expectoration. Expert Evidence. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. proportion of blood varies, sometimes scarcely staining the crachement, at others becoming its principal ingre- dient. The number of blood-disks is not necessarily great- er in the dreaded prune-juice expectoration, as this is stained by coloring matter set free by their destruction. Remak's bronchial casts are best observed on shaking the sputum with water, and separating the little white masses observable in it. When present (they are wanting in from ten to twenty per cent, of the cases) they constitute a valuable diagnostic sign, since, like those of croupous bronchitis, they unequivocally indicate a fibrinous in- flammation of the air-tubes. In some cases, notably those of one or other apex, ex- pectoration may be absent, the alveolar croup extending little beyond the infundibula. In the cachectic and drunk- ard sputa are frequently wanting. Children swallow the product of their cough, and in the aged this is apt to be catarrhal and useless for diagnosis. At the approach of death, whatever the patient's age, expectoration is sup- pressed. With resolution the rusty color fades, the sputa be- come yellow, owing to changes in the haemoglobin; casts disappear, pus increases, and finally the muco-purulent type is declared. When abscess results, we observe, in connection with the physical signs of a cavity, profuse, greenish, purulent expectoration containing shreds of pulmonary tissue, crystals of fatty acids, haematoidin, cholesterin pigment, micrococci, etc. When pneumonia ends in gangrene, and the gangrenous focus communicates with a bronchus, the sputum be- comes horribly offensive, and is loaded with shreds of necrosed tissue, acicular crystals of the fatty acids, etc. Friedlander claims to have observed in pneumonic sputa a coccus peculiar to this disease ; but Sternberg de- clares it identical with the ordinary salivary coccus caus- ing septicaemia in rabbits. Embolic Pneumonia causes a scanty red or black spu- tum composed of mucus and blood, and lasting eight or ten days. Emphysema.-The sputum is that of bronchitis. Pulmonary Congestion and (Edema.-We sometimes observe a plentiful frothy, liquid sputum more or less bloody ; but usually expectoration is slight or absent. Phthisis.-While the disease is extra-bronchial, expec- toration may be wanting, though ordinarily, even in the earliest stages, a catarrhal sputum is expelled. Later it becomes nummular, opaque, yellowish-green, contains little air, and sinks in water. When disorganization has occurred, the sputa may contain fragments of lung-tissue and elastic fibres from the alveolar partitions. These, first observed by Van der Kolk, are found in the expec- toration of most diseases involving lung-destruction. They may be detected in the sediment deposited after mixing the sputum with water. Fenwick's method con- sisted in boiling the sputa with an equal quantity of a so- lution of caustic soda ; three or four times its bulk of cold distilled water is then added, and the mixture cov- ered, and allowed to stand several hours ; after which the precipitate is searched for elastic fibres. These occur singly, or in a net-work. Large fragments are rare, small ones common. They must be distinguished from the fibres of meat, flax, cotton, leptothrix, etc. The test which now possesses highest authority as an indication of pulmonary tuberculosis is the discovery in the sputa of the bacillus described by Koch. For infor- mation as to this organism, and the technique necessary to its demonstration, the reader is referred to the article on Tuberculosis. Besides these diagnostic marks, there may be hard masses of phosphate and carbonate of lime, which, since they must have been freed from incapsulation, are a pretty sure indication of progressive pulmonary softening. They might, however, come from obsolete inflammatory foci in bronchial glands opened by ulceration. Phthisical sputum from cavities is often offensive, and may be stained gray or even black by the pigmented cic- atricial tissue surrounding them. Haemorrhage is not rare, and when often repeated, in connection with high bodily temperature, indicates a rapidly extending morbid process. Interstitial Pneumonia.-Unless bronchiectasis exists, the sputum is that of catarrh. If bronchial dilatation has occurred, the expectoration is quite characteristic. There are intervals during which it accumulates and none is raised. Finally the cavity overflows, cough ensues, and the whole mass is evacuated. Whereupon follows another interval of quietude. The patients are thus aware of two sorts of cough -one dry, the other accom- panied by an expectoration more profuse than that of any other pulmonary disease. The expectorated matters separate into three layers- the upper frothy, with lumps of mucus here and there ; the middle, a whitish-gray liquid, translucent, and shot through by floating mucous shreds ; the lower, a green- ish sediment containing caseous plugs or cores. In these latter are found pus, acicular crystals of fatty acids, of ammonio-magnesian phosphate, leucin and tyrosin, fungi, and blood. Elastic fibres are rare, being destroyed, it is supposed, by a ferment present in the putrefactive mate- rial. Sulphuretted hydrogen, ammonia, and volatile fatty acids render the mass highly offensive, though after standing this odor may disappear. Pulmonary Gangrene.-The sputum is blackish, and contains all the elements just described, but its produc- tion is more uniform. Cancer of the Lung.-Expectoration may be absent or abundant. In the lower layer, deposited on standing cancer-masses, single cancer-cells, blood, and often elas- tic fibres may be found. Aortic Aneurism.-A bloody expectoration may pre- cede death for two or three days. Echinococcus.-The source of expectorated hydatid vesicles, booklets, etc., maybe the lung; but ordinarily these come from a cyst of the liver, rupturing upward into the pleura, and thence into the bronchi. W. S. Cheesman. EXPERT EVIDENCE, LAW OF. When questions of fact come before a judge or jury for decision, which can- not be intelligently decided because they are beyond the knowledge of the ordinary judge or jury, then, and then only, are witnesses permitted to give opinions upon these questions, and explain the relation to each other of the facts testified to by other witnesses. Such witnesses who testify to opinions are called experts. It is very often that matters relating to science, art, natural history, me- chanics, chemistry, special trades, physiology, insanity, and kindred matters, are involved in a legal decision, and no intelligent or just verdict can be arrived at with- out the aid of some one specially skilled in these branches of knowledge. The necessity of the case is the basis for the introduc- tion of such witnesses, although their testimony makes an exception to the general rule that witnesses, to be com- petent, must have a personal knowledge of the facts at issue. The need of expert witnesses was felt very early in legal history, and they are frequently mentioned in the Roman Law. The agrimensores of that system of law were experts in the modern sense, and the titles of divisions of the Pan- dects would show that skilled medical experts were in use to elucidate the truth and apply it to particular cases. Some of these titles are : De Inferendo Mortuo, De Inspi- ciendo Ventre, De Hermaphroditis, De Impotentia. The common law early recognized the need of experts, and in a case tried about the year 1400, it would appear that their proper functions were well settled. In this in- stance the prisoner was charged with mayhem, and, as he demanded an examination of the extent of the injury, a writ was issued to the sheriff to summon Medicos, chirur- gicos de melioribus London., ad informandum Dominum Regem et Curiam de his quae eis exparte Domini Regis in- jungerentur. The right to introduce expert evidence is now firmly established, and it is always used when any advantage to either side of a controversy is thought possible. There is, however, a great difference of opinion as to 770 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Expectoration. Expert Evidence. its value expressed both by the courts and by text writers. Best, in his work on Evidence, says : " It would not be ■easy to overrate the value of the evidence given in many difficult and delicate inquiries, not only by medical men and physiologists, but by learned and experienced per- sons in various branches of science, art, and trade." On the other hand, the courts have frequently stated their disbelief in the value of such evidence. " Justice Davis, of the Maine Supreme Court, says : "If there is any kind of testimony that is not only of no value, but even worse than that, it is, in my judgment, that of medi- cal experts. They may be able to state the diagnosis of the disease more learnedly, but upon the question whether it had, ata given time, reached such a stage that the subject of it was incapable of making a contract, or irresponsible for his acts, the opinion of his neighbors was, if men of good common sense, would be worth more than that of all the experts in the country." Chief Justice Chapman, of Massachusetts, in 1869, said: " I think the opinions of experts are not so highly re- garded as they formerly were ; for, while they often afford great aid in determining facts, it often happens that ex- perts can be found to testify to any theory, however ab- surd." Justice Grier, of the United States Supreme Court, de- clares that, "Experience has shown that opposite opin- ions, of persons professing to be experts, may be obtained to any amount, and it often occurs that not only many days, but even weeks, are consumed in cross-examina- tions to test the skill or knowledge of such witnesses, and the correctness of their opinions, wasting the time and wearying the patience of both the court and the jury, and perplexing, instead of elucidating, the questions in- volved in the issue." The rules governing medical expert testimony are the same as those relating to other kinds of scientific expert evidence, but the illustrations given in this article 5x^11 be taken from the domain of medical investigation. The first point to be .settled is in reference to the per- sons who can properly be called experts. It has been de- cided in some cases that any person who is a physician can be sworn as an expert. The courts recognize no dif- ference between conflicting schools of medicine, and no objection can be made to the testimony of an expert based upon a dislike of his theory of medicine. It has been stated that, where there is no statutory requirement, nothing is necessary to entitle a person to give evidence more than that he has been educated in the science of medicine ; and this he may be by study without practice, or by practice without study ; it is not necessary that he should be a physician, or have studied for one, nor be a graduate, nor licensed to practise, nor need he have been a practitioner. One may be competent to testify as an expert, although his special knowledge of the particular subject of inquiry has been derived from the reading and study of standard authorities, and not from experience or actual observation. But one cannot qualify himself as an expert in a particular case merely by devoting himself to the study of authorities for the purposes of that case. While this is a correct statement of the general condi- tion of the law, it has its exceptions. In Vermont it has been held that mere education as a physician, without some practice, is insufficient to qualify a person as an ex- pert. In Arkansas the courts have held that competency must be shown both by study and experience. In New York a physician or surgeon may give testi- mony, although not in practice ; but this fact will affect the credit given to the evidence. The law does not require the branch of knowledge un- der review to have been a specialty of the physician, but it has been held that a person who has given himself ex- clusively to one department cannot be allowed to testify in regard to another specialty. It must appear, however, in every case, that the witness has some peculiar knowl- edge not possessed by the majority of men. The judge presiding over the trial is the only person who can decide as to the qualifications of the expert, and when he is satisfied the matter is settled. The decision of the judge, admitting or excluding an expert from the witness-stand, will not be set aside upon appeal except in a very clear case of mistake. The judge may examine the witness as to the extent of his knowl- edge before he will be permitted to testify. The competency of the witness having been settled by the court, the jury is then to decide as to the weight to be given to his testimony. The testimony of an expert is to be weighed and tested like any other kind of evidence, and is to receive just such credit as the jury think it entitled to. The jury is not bound by the opinions of medical experts ; they may act against the greater number of opinions, it is said, and in favor of the fewer ; for the opinion of one expert may, on account of his greater knowledge and experience, be of greater value than the opposite opinions of several. The expert, upon his examination in chief, may give his opinion, and also the grounds and reasons for it. In one case it was held that it was his duty to do so, in order that the jury could tell whether there was sufficient basis for his opinion. Hypothetical questions covering the facts already brought out are usually used in American courts in the examination of experts. It is considered proper for an expert to give his opinion upon an entirely new case, provided he can swear to the formation of an opinion by reasoning from other well-known cases. Medical witnesses may say what in their opinion would be the result of certain facts submitted to them, but can- not give an opinion as to the general merits of the case on trial, as this would usurp the province of the jury. Experts cannot state inferences or conclusions which any person might be competent to form. For instance, in a murder trial, an expert, it is said, cannot testify as to the probable position of the body when the blows were received, the judge saying that surgeons were not ex- perts in giving blows or knowing how the body could be placed most conveniently to receive them. In another murder trial, where the body was found partially burned, but with some parts untouched by the flames and covered with loose clothes, it was held not to be proper for the medical witnesses to state their opinion that death had occurred before the fire broke out. This was on the ground that any unlearned person of good common sense might come to the same conclusion, from the fact that the convulsive movements of a living body touched by flames would cause clothes to be displaced. On the other hand, it has been held proper to ask a wit- ness his opinion whether a woman was pregnant, on a trial for attempted abortion; whether a blow was suffi- cient to cause death ; whether a fracture of the skull was caused by a fall ; whether a gunshot-wound caused death, etc. When the issue to be tried is the alleged in- sane condition of the prisoner at the time of committing the act, the witness can be asked whether such and such appearances, proved by other witnesses, are symptoms of insanity. He cannot be asked broadly if in his opinion the act is an insane one. A witness who has heard all the evidence introduced can be asked the following question: " Assuming the facts stated in the evidence to be true, what state or condition does it indicate ? " In regard to his professional brethren, an expert is al- lowed to give his opinions under certain restrictions. For instance, in actions for malpractice a witness may be asked whether the practice pursued was good practice ; whether the fatal result of an illness was the effect of neglect or want of skill on the part of the attending phy- sician ; but an expert cannot be asked his opinion as to the general skill or reputation of the physician on trial. An expert cannot be contradicted by the testimony of an unskilled person. The evidence of experts should not be given in techni- cal language where it is possible to use terms in ordinary use. An extreme case of this kind is given in ' ' Taylor's Medical Jurisprudence," and other instances of the kind have perhaps helped largely to create a dislike for expert evidence in general. A surgeon informed the court " that on examining the prosecutor he found him suffering from a severe contusion of the integument under the left orbit, with great extravasation of blood, and ecchymosis in the surrounding cellular tissue, which was in a tumefied 771 Expert Evidence. Extension. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. state; and there was also considerable abrasion of the cuticle." The judge said, " You mean, I suppose, that the man had a bad black eye ? " "Yes." " Then why not say so at once ? " Ordronaux, in his " Jurisprudence of Medicine," says on this point: " Much of the wrang- ling over the taking of skilled testimony before courts, which constitutes the opprobrium of so many trials, may be attributed to a want of precision and candor in putting questions, and the consequent inability of witnesses to answer them clearly. "When a witness cannot so in- terpret the gist of a question to himself as to comprehend the pivotal point of the inquiry, he cannot answer it lucidly. He may give a constructive answer in very nearly the same words addressed to him. But this is answering the letter only of the inquiry, or following the lead of his interrogator, not expressing his own ideas, which, when a skilled witness, it is plain he was specially called to unfold." The proper function of the expert witness is quite clear in theory, though this is often lost sight of in the interest and excitement of the trial. It is frequently forgotten that the expert is not called upon to express any opinion upon the merits of a controversy, but only upon questions of science raised upon facts proved or assumed to be true. It is also forgotten in many instances that the ex- pert should have no personal concern in the ultimate issue of the case, and that he is not specially a witness for the side which calls him. His function is really an adviser of the court, an ami- cus curiae, rather than a party to the suit. Balbus, in his Commentaries, says, "Medici proprie non sunt testes sed est magis judicium quam testimonium." This was written, however, when the praetor had practically unlimited con- trol over actions, and the separate functions of judge, juror, and witness were not fully recognized. There is a seemingly general opinion in the community that expert evidence is of doubtful value, and there have been a variety of expedients suggested for increasing its influence with courts and juries, and for securing the respect of the public. It has been argued, with considerable force, that there should be a trained body of public experts regularly ap- pointed, with salaries paid by the State, whose services shall always be at the command of the judges in criminal cases. It has, also, been suggested that experts should only be examined by the court, and to the extent that the judge in his discretion considers demanded by the exigen- cies of the case. Another suggestion is that in civil cases the compensa- tion of experts should be determined by the court, and ordered to be paid by one side or the other. The compensation of experts is an important matter, and it has been somewhat debated whether they should not be confined to the same fees allowed other witnesses. It is the theory of ordinary trials that a person cognizant of facts important to the just decision of a case can be brought to court to testify whether willing or unwilling. This procedure is based upon the common dependence of one citizen upon another, and the necessity in a compli- cated civilization of being able to settle controversies by securing all proper evidence. This is one of the condi- tions of public order, and every person is presumed to yield something for the general good. These considerations do not apply to experts, who are not summoned because of their personal knowledge of the facts of a case, but because of their superior technical knowledge. It would be an unbearable burden if the greater knowl- edge a person possessed, the more likelihood he had of being compelled to testify in court, unless suitable com- pensation were made him. It has been fully settled, therefore, that expert witnesses are not obliged to give testimony against their will in cases where they are sub- poenaed. They would probably be guilty of contempt of court if they did not obey the subpoena, but they cannot be compelled to testify as to their opinions upon assumed facts if they do not desire to. The payment of a proper fee may be made a condition precedent to testifying. If, however, an expert witness begins to give testimony without raising the point of a failure to compensate him, he cannot stop of his own motion. He is obliged to con tinue his testimony until his examination is concluded. In a very recent case a witness went through his exami- nation in chief without objection, but would not submit to cross-examination until he had been paid. He de- clined to answer even when directed to do so by the trial- judge, and upon being punished for contempt of court in so refusing, this action was held proper on appeal. John D. Lawson, a well-known legal writer, gives some very concise rules governing expert evidence as applicable to physicians. They cover in substance many of the principles and cases already stated, and are as fol- lows : 1. The opinion of a medical man upon the condition of the human system, the cause of death, or the cause or effect of an injury, the effect of a particular treatment, the likelihood of recovery, the mental condition of a per- son, and the like, is admissible. 2. A medical man cannot testify as an expert as to matters not of skill in his profession, or conclusions or inferences which it is the duty of the jury to draw for themselves. 3. A medical man is an expert on the value of medical services, but not as to the measure of damages. 4. The law does not recognize, to the exclusion of others, any particular school of medicine or class of prac- titioners. 5. To give an opinion on medical questions, one may be qualified by study without practice, or by practice without study. Nor is it absolutely necessary that he should be a physician or have studied for one. 6. The opinion of a medical man is competent as to matters which he has not made a specialty in his study or practice. 7. A medical man is not disqualified to give an opinion because he is not a graduate of a college, and does not possess a license to practise, or is not at the time in prac- tice, or because a case exactly like the one in question has never been seen or read of by him before. 8. One not an expert may give an opinion founded upon observation that a certain person is sane or insane. Henry A. Riley. EXTENSION, Principle of, as Employed in Sur- gery. The term extension, as here employed, signifies merely the stretching of a portion of the body, usually a limb or a group of muscles, by means of two opposing forces, extension and counter-extension, applied to the extremities of the part to be acted upon. The w'ord is an awkward one, since, when employed in connection with a segment of a limb, it may mean either the stretching of this segment or its motion in a direction opposed to flexion. This double meaning not infrequently leads to confusion, and a far better term is traction ; but it has, nevertheless, seemed best to retain extension in the title of the present article, as a term sanctioned by usage, and the one most commonly employed to designate this thera- peutic principle. It is not proposed to describe here in detail the appli- cation of extension to all the diseases and injuries in the treatment of which it is employed, but merely to point out briefly the principle of this method, and the general indications for its use in surgical therapeutics. The spe- cial modifications required in particular cases will be found described in the several articles upon fractures, joint-disease, club-foot, paralytic deformities, and the like. The application of extension may be temporary or per- manent, and may be accomplished by means of the hand, of mechanical appliances, or simply of the weight of the body or limb. Mechanical extension is made by means of a weight and pulley, springs, screws, and other devices. This therapeutic principle is used in surgery in the reduc- tion of dislocations, in the treatment of fractures, joint- disease, fibrous anchylosis, lateral curvature, club-foot, and other deformities, and to elongate shortened muscles. Dislocations.-The principle of extension is of limited 772 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Expert Evidence. Extension. application in the reduction of dislocations, and must usually be conjoined with manipulation of the luxated limb in order to be effective. In case the head of the bone has passed through the capsular ligament, in luxa- tion of the femur, for example, direct extension would de- feat the object aimed at by narrowing the slit, and thus preventing the replacement of the head of the bone. In old luxations continuous traction may be of service, but it is especially in congenital dislocation of the hip that permanent extension is of value. Here there is usually no capsule to resist the reduction of the femur, and tlie object desired is to keep the femur and the innominate bone as near as possible in their normal relations, in the hope that in time adhesions may form to retain the bone in place. In this case extension, to be of any service, must be absolutely continuous, as it is ob- vious that any relaxation, for however short a time it may be, will have the effect of undoing much, if not all, that has previously been accomplished. Elastic traction by means of adhesive plaster and some form of apparatus is here indicated. Fractures.-In most cases of broken bones the ac- tion of the muscles is such as to cause the fractured ex- tremities to ride past each other, and thus to defeat the efforts made to retain the fragments in apposition. The result of this is that either the ends of the tone are so widely separated that no union takes place, or, as most commonly happens, sufficient callus is thrown out to effect a union while the fragments overlap, and the con- sequence is a shortened limb. This is more particularly the case in fractures of the femur, and it is here that the principle of extension finds its most perfect application. This method of treating fracture of the femur is not of very recent invention, although it is only within the last quarter of a century that it has come into very general use, mainly through the teachings of the late Dr. Gurdon Buck. It is mentioned by Guido di Cauliaco, or Guy de Chauliac, in his " Seven Tracts," said to have been com- piled in 1363, in which he stated that he employed a leaden weight attached to the foot in order to make traction on the leg. Mr. James, of Exeter, urged the adoption of the method in a paper read before the British Provincial Medical Association in 1839. In America, cases so treated were reported by Dr. Luke Howe, of Jaffrey, N. H., in 1824 ; by Dr. Wm. C. Daniell, of Savannah, in 1829 ; and by Dr. A. L. Dugas in 1854. Dr. Swift, of Eas- ton, Pa., also used this method, and it is claimed that he was the first to employ adhesive plaster instead of gaiters to at- tach the extending bands to the limb. Dr. II. G. Davis, formerly of New York, in a paper published in the year 1856, advocated the principle of extension as applied not only to the treat- ment of fractures, but especially to that of disease of the hip-joint and other articulations. But it is to the late Dr. Gurdon Buck, of New York, that the credit belongs of perfecting the method, and firmly establishing it as a recognized therapeutic measure. During the past twenty-five years there have been nu- merous modifications of detail, but the principle of appli- cation remains substantially the same as it was when first formulated by Dr. Buck. The following is his description, as read before the New York Academy of Medicine, and published in the " Transactions " for 1861: "A roller ban- dage, commenced at the toes in the usual way, is continued to the ankles, where it is temporarily arrested. A band of adhesive plaster, two and one-half to three inches broad, and long enough to allow the middle of it to form a loop below the sole of the foot (the ends extending above the condyles of the femur), is then applied on either side, in immediate contact with the limb, from the ankles up- ward. Over this the bandage is continued as high up as the plaster. A thin block of wood (Fig. 1056) of the width of the plaster, and long enough to prevent pressure over the ankle, is inserted into the loop, and serves to attach the extending cord, and this cord is fastened to an elastic rubber band (such as is used for door-springs) which passes round the block. By this arrangement elasticity is combined with extension. " The limb is now prepared to be extended. The arrangement of the pulley is very simple. A strip of inch board, three inches wide, is fastened upright to the foot of the bedstead, and perforated at the height of four or five inches above the level of the mattress. Through this hole the extending cord is passed; and on the further side of the strip a screw pulley is inserted at the proper level; and over the pulley the cord, with a weight attached, is to play. The footboard of the bedstead, if there is one, may be perforated, and the screw pulley inserted on the out- side of it, so as to answer the purpose. To allow the application of lotions to the thigh during the first few days of treatment, the ends of the adhesive bands should stop short at the con- dyles of the femur, and be turned down. Afterward they may be re- placed upon the thigh, the bandage continuing over them preparatory to the application of the coaptation splints, which should be added at this stage of the treatment. The coapta- tion splints of the ordinary sort should be secured by three elastic bands made of suspender webbing, fitted with buckles (see Fig. 1057). These have the advantage of keeping up uniform concentric pressure as the swelling of the limb diminishes. Counter-extension may be maintained by the usual perineum band lengthened out and fastened to the head of the bedstead. India-rubber tubing, of one inch calibre, stuffed with bran, or with a skein of cotton lamp- wick drawn through it, makes an excellent perineum strap. A piece two feet in length, with a ring fastened at each end, answers an admirable purpose. A strip of canton flannel wound spirally round the perineal band protects the skin, and is to be renewed as often as soiled. " A thin, wedge-shaped hair cush- ion, to raise the heel above the mat- tress, and' a bag filled with bran or sand, to place on the outside of the foot to prevent rotation outward, com- plete the appliances requisite to carry out this method of treatment. The amount of weight to be employed must be determined by the resistance to be overcome and the tolerance of each patient. More than five or six pounds will rarely be required for children under eight years of age. For older patients eight to fifteen pounds will ordinarily be sufficient, though as much as twenty-five pounds were used in one case reported in this article. As the treatment advances, and the tendency to shortening di- minishes, the weight may be re- duced." Instead of being fastened to the footboard of the bed the pulley may be attached to a separate stand, as shown in Fig. 1058. This is useful, more especially in hospitals where cots or iron bedsteads are used. Dr. Buck subsequently modi- fied the arrangement of his plasters, using two strips, to Fig. 1056.-Block used to widen the Loop of Plaster, preventing Pressure upon the Malleoli. Fig. 1058.-Stand Pul- ley and Weight. Fig. 1057.-Coaptation Splints used in the Treatment of Fracture of the Thigh by Buck's Extension. Fig. 1059. - Plaster Strips, with Buckle and Webbing-strap attached. 773 X 11 «1" 11 IC j 1II C JI I CJ^ - reference handbook of the medical sciences. which were attached a buckle and webbing-strap, seen in Fig. 1059. Fig. 1060 shows the apparatus in use in the treatment of fracture of the thigh. Dr. Buck subse- quently simplified his method somewhat by dispensing with the p^ineum strap, and raising the foot of the bed on blocks, thus utilizing the weight of the patient to ob- that the best results are obtained by traction combined with motion. It is certainly the belief of most Ameri- can authorities that immobilization alone is insufficient, and therefore the employment of traction, in some form or other, is almost universal in this country. It is be- lieved by others, again, that the curative influence of traction is due to the separation of the inflamed joint-surfaces and the lower- ing of intra articular pressure. But although by the employment of great force it may be possible to cause a separation of the articular surfaces in certain joints, as the knee for example, in others, as the hip, this does not oc- cur.* And furthermore, the experi- ments of Hueter and Reyher have shown that the effect of traction is to increase intra-articular pressure rather than to diminish it. Hueter maintains that the advantages of traction are to be ascribed to immobilization, a slight shifting of the points of contact of the opposed joint-surfaces, and to an in- crease of intra-articular pressure. Volk- mann and others lay much stress on the alleged anti- phlogistic effect of extension, but a direct antiphlogistic action may well be doubted. In chronic articular osteitis the muscles controlling the joint are in a state of tonic spasm during the waking hours, while during sleep they relax somewhat, and'then from time to time contract again, suddenly, causing the joint to start, and the patient. Fig. 1060.-Buck's Extension, as applied to the Treatment of Fracture of the Thigh. lain a counter-extending force. This method is employed not only in fractures, but also in the treatment of joint disease-especially of hip-joint disease-to overcome tonic muscular contraction, and to prevent retraction of the flaps after amputations. Fig. 1061 represents the mode of its application for the latter purpose. In this case the wooden block is dispensed with, as the convergence of the strips of plaster is an advantage in retaining the flaps in position. An- other mode of employing extension in the treatment of fracture of the femur is that shown in Fig. 1062. The plas- ter strips are attached to the leg in the usual way, and then a side splint ex- tending from the crest of the ilium to a distance below the sole of the foot is applied. Extension is made by means of a spiral spring, so fashioned that it can be strengthened or weakened to any desired extent by turning a screw, and counter-extension is obtained by a perineal strap attached to the upper extremity of the splint. An ordinary Davis' hip-splint may also be employed in certain cases for the same purpose, but it is usually less convenient than the weight and pulley, although there is not so much danger of relaxation of the extending force. Chronic Joint Disease.-The principle of traction is employed very extensively in the treatment of chronic osteitis of the articulations, and is undoubtedly the most effective therapeutic measure which we possess for the management of these tedious and rebellious affections. But although the beneficial results of traction in joint disease are not to be denied, the exact way in which these Fig. 1061.-The Application of Buck's Extension to the After-treatment of Amputation of the Thigh. although asleep, to utter a piercing cry as of agony. One of the most noticeable effects of strong traction, firmly and constantly maintained, is the overcoming of these muscular contractions. It is undoubtedly, in great meas- ure, by antagonizing the muscular spasm, and thus pro- tecting the inflamed joint-surfaces from constant trauma- tism, that traction is useful. The action of the muscles is to press the articular ends of the bones more firmly together, and traction will overcome this, even though it may not effect an actual separation. The immobiliza- tion of a diseased joint, which is ob- tained by traction, is also an undoubt- ed advantage; for many joints, in which the inflammatory process is not far advanced, and in which muscular spasm is not excessive, seem to do equally well when simple immobiliza- tion is secured as when it is combined with traction. Extension in the treatment of joint disease may be obtained by the weight and pulley as de- Fig. 1062.-Extension by Means of a Spiral Spring. (From Wolzendorff's " Handbuch der kleinen Chirurgie.") results are obtained is not so clear. It is asserted by some that simple fixation of the diseased articulation is all that is obtained by traction, and that equally good results may be secured by immobilization of the joint by means of plaster-of-Paris or by the splint devised by Thomas, of Liverpool. But, on the other hand, there are those who maintain that fixation of the joint is to be avoided, and * M. Lannelongue stated at a meeting of the Surgical Society of Paris, held on January 13th, 18S6, that he had found a separation of the articu- lar surfaces of the hip in a child which had died from convulsions while under treatment, by extension, for morbus coxarius. The body was frozen while traction was still maintained, and a section then made of the articulation. 774 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. EjAlI 111C > I t lA™ scribed abpve, but since the course of the disease is usu- ally so long, some form of portative apparatus is com- monly employed, thus enabling the patient to move about, and obviating the evil effects which might follow upon prolonged confinement to the bed. In applying adhesive plasters for extension in joint disease it is usual to cut one or two strips on each side, which are wound spirally around the limb, the main strip passing up the centre in the ordinary way (Fig. 1063). By this arrangement a more firm hold is obtained upon the limb, and the liabil- ity to slipping of the plaster is in great measure avoided. When adhesive plaster is applied for a long period to the skin it is apt to cause excoriations, or even an eczematous inflammation, and to avoid this difficulty various other means of securing the limb have been tried. Small ad- vocated the use of a wicker-work sheath, similar to the toy known as " Indian finger," the action of which is to grasp the limb more firmly in proportion as the extend- ing force is increased. It has been shown, however, that forcible compression, even tight bandaging, of a limb will induce a rapid atrophy of the mus- cles, and this would seem to be a sufficient objection to Small's method. A moderate amount of traction may be obtained by sewing the buckles to a piece of bandage of the proper length, pinning these strips to a roller bandage previously applied, and then applying another roller over this. It is impossible, however, to obtain very firm exten- sion by this method, and it presents the same objections, furthermore, as does Small's sheath, that it con- stricts the limb, since, to hold at all, the bandage must be very firmly applied. The best adhesive plaster for use in maintaining traction is that knowm as "fnoleskin" or "swan's-down," although with children the plaster spread on twilled muslin is strong enough for most purposes. The weight of the limb is some- times employed to make traction, as in the method advocated by Hutchinson, of Brooklyn, in the treatment of hip-joint disease. The patient wears a shoe with a cork sole on the sound side, while the weight of the limb, sometimes as- sisted by a leaden sole, makes trac- tion on the diseased articulation. The child walks on crutches. The chief disadvantage of this method is that the traction-force is com- pletely under the control of the pa- tient, and when he hobbles about without his crutches, as he often does, when there is no special joint-tenderness, unless constantly watched, the trauma- tism caused by stepping down from the sound side, raised by a high sole, is even greater than it -would be were no attempt made at treatment. For a descrip- tion of the different forms of apparatus employed in the extension-treatment of joint disease, the reader is referred to the article on that subject. Another form of extension is that employed to stretch single muscles, or groups of muscles, in the treatment of torticollis, club-foot, and other deformities. This is sometimes effected by inter- mittent manual traction, but more commonly by the use of specially constructed instruments, the description of which will be found under the different articles devoted to these affections. In Sayre's method of treatment of lateral curvature of the spine, the patient is suspended and the weight of the body utilized in securing extension during the application of a plaster-of-Paris corset, the object of which is to maintain permanent traction. Davis, H. G.: Deformities and their Remedy, American Medical Monthly, March, May, and June, 1856. Hartshorne, Edward : Notes in Regard to the Question of Priority in the Use of Weight Extension and of Extending Adhesive Bands, Ameri- can Journal of the Medical Sciences, April and July, 1869. Legros et Auger: Destractions continues, etc., Archives Generales de Medicine. Paris, 1868. Bonju : Des indications de 1'extension continue par la methode ameri- caine. Paris, 1879. Buck, Gurdon: An Improved Method of Treating Fractures of the Thigh, Transactions of the New York Academy of Medicine, vol. ii. Volkmann : Ueber d. Behandlung d. Gelenkentziindung mit Gewichten, Berliner klinische Wochenschrift, 1868. Czerny : Gewichtsextension, Wiener medizinische Wochenschrift, 1869. Steinberger: Ueber d. Small'sche Extensionsgeflecht, Wiener medi- cinische Wochenschrift, 1872. Hueter: Klinik der Gelenkkrankheiten. Leipzig, 1877. Further references will be found in the articles on Extensionsverbande in Eulenburg's Real-Encyclopadie, and on Allgemeine Verbandlehre in Von Pitha und Billroth's Chirurgie, and in the Index Catalogue of the Library of the Surgeon-General's Office, U. S. Army. Thomas L. Stedman. Litebatube. EXTRA-UTERINE PREGNANCY. Nature and Varieties.-When the fructified ovum does not reach the uterine cavity, but undergoes development elsewhere, the pregnancy is called extra-uterine. This general term includes a number of varieties. First, and probably the most frequent, is tubal or Fal- lopian pregnancy. The ovum may find lodgement in any portion of the tube, from the fimbriated extremity to its uterine termination. Very few cases of Fallopian gesta- tion are completed in the full development of the foetus, but almost uniformly the ovum escapes from the tube. During the growth of the embryo the tube is lacerated, and in most cases fatal haemorrhage results ; but in rare instances the attachment of the placenta remains, and the foetus in its membranes grows to maturity in the cavity of the abdomen. Hence the second, or tubo-abdominal, pregnancy. In the third variety, or ovarian pregnancy, the ovum becomes fructified in, and does not emerge from, the Graafian follicle until considerably advanced in its growth, when it is developed in the abdominal cavity. The existence of this form of gestation is not credited by all obstetricians. Fourth, the ovum may commence its development in the follicle while the fimbriated extremity of the tube embraces it, and continues to cover it to a greater or less extent, thus giving rise to what is called tubo-ovarian, or ovario-tubal pregnancy. Fifth, abdominal. The ovum in this sort of a case falls from the ovisac into the peritoneal cavity, then forms attachments, and undergoes development. In this variety the ovum generally grows to maturity. Sixth, in inguinal pregnancy the ovum is lodged in the inguinal canal, at the external ring. This variety may result in complete gestation. It becomes possible by rea- son of displacement of the ovary and Fallopian tube, as in ovarian hernia. Authors speak of vaginal pregnancy as having occurred. While such a thing is doubtful, it ought not to be consid- ered impossible. There are classed, under the head of extra-uterine preg- nancy, cases in which the placenta is adherent to the in- side of the Fallopian tube, while the foetus occupies the cavity of the uterus ; and others in which the placenta is developed within the cavity of the uterus, while the em- bryo is in the abdominal cavity. In both of these varie- ties the foetus may grow to maturity, and be apparently strong and healthy to the end of the natural term. Seventh, obstetricians include two varieties under the general term extra-uterine pregnancy, which might with great propriety be called ectopic uterine gestation, viz., cervical and mural pregnancy. The former is very rare and of little importance comparatively, while the latter is very important, and probably not so infrequent as is gen- erally supposed. The author has met with two cases which he believes ought to be classified in this variety of pregnancy. They had both advanced to the end of nine months, when one of the patients died, exhausted, after four days of ineffectual labor, while the other survived Fig. 1063.-Adhesive Plas- ters used in making Traction in Hip-joint Disease. 775 Extra-uterlne Pregnancy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the completion of gestation three years, and eventually lost her life from the effects of laparotomy for the re- moval of the dead foetus. Development and Effects.-When ectopic preg- nancy occurs its effects upon the uterus are quite uni- form, and resemble to a great degree the changes in the early months of normal pregnancy. The uterine walls undergo trophic enlargement, which involves the muscu- lar, vascular, and nervous systems, while internally nida- tion is probably complete when the formation of a de- ciduous membrane has taken place, and the utricular glands have become developed. The enlargement of the uterus continues until it arrives at the size which it usu- ally attains at the end of the third month of ordinary ges- tation, which it maintains until after term. Generally, during the third, fourth, or fifth month, the decidua becomes disintegrated and passes off as a whole, or in shreds, attended with haemorrhage and pain, causing symptoms somewhat closely simulating those of abortion. If the ovum is lodged in the tube between the expanded end near the ovary and its uterine extremity, the tube is lacerated by distention some time between the end of the second and the termination of the fourth month. This is so uniformly the case that but very few cases are on record in which the foetus attained to com- plete development. Dr. Parry quotes Spiegelberg's de- scription of a case in which a woman reached the end of the ninth month of gestation, at which time were found, on post-mortem examination, all the appearances of tubal gestation. When the tube bursts and the ovum escapes into the abdominal cavity, a fatal haemorrhage generally oc- curs and the patient dies, either in collapse suddenly, or in a few days, of septicaemia or peritonitis. If the haem- orrhage is inconsiderable, the placental attachment in the tube may be preserved, the ovum grow to normal size in the abdomen, and the case be converted into the tubo-ab- dominal variety. In this form the ovum may be entire, i.e., the foetus is surrounded with the amnion and chorion containing their normal fluids, or, in very rare instances, the membranes may be destroyed and the naked embryo still live and grow to foetal maturity in the peritoneal cavity. When the fecundated ovum retains its position in the ovisac and forms its placental attachment there, in its de- velopment it is apt to be embraced, as before stated, by the fimbriated extremity of the Fallopian tube, and carry with it an imperfect fibrous covering. In the true abdominal variety full development is the rule, and the placental attachment may be to the perito- neal surface in the cut de sac of Douglas, to the intestines, or to the omentum. The development, so far as the ovum is concerned, is usually normal. The membranes retain their integrity, and contain the usual quantity of fluid up to the time of the ineffectual labor. After the period of maturity, in cases in which the foetus is surrounded by a more or less perfect muscular layer, the liquor amnii is retained, while the sac is more or less changed by amorphous deposits, often cartilaginous in some places, in others cretaceous. It often becomes ad- herent to surrounding parts, indurated and thickened, re- maining in that condition for an indefinite time, or it gradually diminishes in size on account of the disappear- ance of the amniotic fluid. The induration and retro- grade changes sometimes invade the structures of the foetus, and convert it into a mass so solid as to entitle it to the epithet lithopedion. These changes are not likely to involve the ovum, which is covered by the membranes alone, as in pure abdominal pregnancy. In these latter cases the liquor amnii is gradually absorbed, the mem- branes collapse and embrace the head, neck, and extrem- ities, so as to form a closely adherent, filmy envelope, which imparts to the spaces between the fingers and toes the appearance of a web. This condition may be found years after the termination of gestation. The author once had the opportunity of removing a foetus which was in exactly this condition three years after the end of gesta- tion, it having perfectly retained its organization up to that time. When inflammatory attacks have invaded the sur- rounding structures, modifications of the ordinary condi- tions may result which render a description of them impossible, on account of the blending and confusion in the maternal and foetal tissues. The position of the foetus in these varieties is generally above the pelvic cavity, and may be directed in any di- versity of manner. In that class of ectopic pregnancies in which the em- bryonic development takes place more or less completely in the substance of the uterus-the tubo-uterine, the utero- tubal, and the mural (interstitial) varieties-the ovum is more or less surrounded by muscular fibres derived from the uterus and tubes. In the mural variety this is so in a remarkable degree, and, as before stated, the fibrous in- volucrum may form a complete muscular cyst, having many of the properties of the uterine walls. In it the foetus and membranes may be fixed with either the head or the breech crowded deep into the pelvis, making an oval tumor resembling the shape of the impregnated uterus. Such pregnancies often pursue a course similar to that of normal pregnancy, and attain the stage of complete de- velopment. In some cases, however, a rupture of the cyst occurs during the process of gestation, and causes fatal haemorrhage, or the foetus may escape into the peri- toneal cavity and grow to term. In the cases in which the foetus is in the uterine cavity, and the placenta in the tube, the foetus may be developed as in ordinary preg- nancy and be expelled at term, the placenta remaining in its tubal site, or, entering the uterine cavity, be also ex- pelled. After term the products of gestation undergo similar changes to those above described. Every variety of ectopic gestalion may give rise to in- flammatory processes, causing the ovum to be surrounded by exudation in which suppurative infiltration occurs, and converts the whole mass into a great abscess which may be evacuated through the abdominal, vaginal, or in- testinal walls. If the patient survives the terrible ordeal thus inaugurated, the whole of this material may be elim- inated and she may recover. Causes.-A large number of the conditions giving rise to misplaced gestation affect the Fallopian tube-con- genital malformations, as deficiencies or absence of the tubes, lack of fimbrife, etc. Peritonitis and cellulitis may occur, involving the tubes in suppuration and erosions, rendering them deficient in extent, or by exudation con- tract or twist them. There may also be displacement of the tubes and ovaries, as in hernia. All these conditions im- pair the conducting power of the tubes, and thus prevent the entrance of the ovum into them, or divert its progress as it passes toward the uterus. Those causes in which the uterus is concerned are in- flammations that prevent the entrance of the ovum. Tu- mors of that organ are said sometimes to give rise to ectopic pregnancy. To these may be added the mutila- tions of the uterus by the various surgical operations, in which fistula) or openings in its walls may remain, per- forations from abscesses, etc. Aside from these local unfavorable conditions, some writers believe that violent emotions succeeding or accompanying the act of coition, such as fright, great apprehension, and fear of discovery, are occasional causes. Unquestionably, a large number of cases cannot be traced to any definite cause. Symptoms.-It is not probable that all the varieties of extra-uterine pregnancy are accompanied with the same array of symptoms. One would naturally expect more violent symptoms in cases in which the ovum is sur- rounded by muscular tissue, as in the Fallopian tubes, uterine wall, etc., and that when the embryo is lodged in the cavity of the peritoneum and not surrounded by resisting fibres, the symptoms would be less marked, and sometimes would give rise to but few unusual phe- nomena. And while sufficient observation has not estab- lished rules by which the symptoms in different varieties may be judged, the observant student will be convinced that facts, so far as known and interpreted, favor such ex- pectation. In the beginning of our studies, we are therefore pre- pared to expect that many caseswill not present abnormal 776 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Extra-ute rine Pregnancy. symptoms of sufficient prominence to attract attention during the course of gestation, and this, I am sure, is ac- tually the case. Often it has been observed that these ectopic pregnancies are not suspected, until revealed by the failure of labor at the end of gestation. It may be, however, that these are exceptional cases, and rare, and it is quite likely that they would be detected without great difficulty, if brought to the attention of a competent ob- server. " In the great majority of cases there are quite obvious symptoms, which will generally attract the atten- tion of the intelligent practitioner. As the symptoms differ very materially during the progress of the pregnancy, it will be convenient, after Parry, to consider them as occurring in the times: 1, from the end of the first to the end of the fifth month ; 2, from this latter period to the end of gestation, and 3, thenceforward while the ovum remains in its unnatural surroundings. This division into periods is also justified by the nature of the changes going on in the ovum and the surrounding tissues and organs. The first period may be said to represent the time when the containing involu- crum is most resisting, when the growth of the foetus and membranes is overcoming their narrow confinement, and gaining a more roomy cavity, either by rupture of the sac, as in some cases of Fallopian pregnancy, or by press- ure upon the pelvic organs in the abdominal variety, until it is large enough to rise into the abdominal cavity. The symptoms, to a certain extent, indicate these changes. It is during this period that the main changes in the uterus take place-the formation and expulsion of the decidua. In addition to the ordinary symptoms of pregnancy, and common to normal and abnormal gestation, viz., changes in the mammae, nausea, abdominal enlargement, etc., there are two which seem to be, if not characteristic, at least quite constantly present in ectopic pregnancy. They are pain and metrorrhagia. While these symptoms are not necessarily co-existent, they are usually so, inas- much as they commence and cease at the beginning and expiration of the first period. Pain.-The pain generally begins first, and is usually, although not invariably, cramping in character, indicating spasmodic action. The patient is seized suddenly with severe pain that gives the idea of colic, causing the patient to double up and assume the position characteristic of cramps. These pains continue for an indefinite time, sometimes for a few moments only, at other times for several hours, and then subside, leaving comparative com- fort or a distressing sense of soreness. Paroxysms of this kind return at varying intervals, sometimes of a few hours, several days, or even weeks apart. Sometimes the first paroxysm-but usi^lly not until it has been repeated a number of times-is succeeded by symptoms of collapse, and the patient dies in a few hours or days from profound anaemia, caused by internal haemorrhage. This latter con- dition indicates the laceration of the enveloping tissues and rupture of blood-vessels, from which a large quantity of blood escapes into the peritoneal cavity. This acci- dent is, however, not invariably followed by death, for when the effusion is not so great as to bring about synco- pal dissolution, the patient may rally, gradually emerge from the collapse, and slowly recover, or fall a victim to inflammatory or septic conditions after many days, and sometimes weeks, of suffering. These pains do not always terminate in symptoms of collapse, but gradually cease as pregnancy advances. It must be confessed, however, that these last are rare cases. The cramping cases are attended with an over- whelming mortality. There is no definite time for the beginning of these pains, but they may first show them- selves during the second, third, fourth, or even the fifth month, and possibly later. In the large majority of cases they first show themselves during the second or third month, less frequently in the fourth, and still less fre- quently in the fifth month. By the commencement of the sixth month the cramping pains cease. However, it is generally conceded, I believe, that the patient suffers un- usually all through her pregnancy. There is apt to be much tenderness of the abdomen, lameness and aching of the back, etc. Metrorrhagia.-This symptom is sometimes so moder- ate as to be considered by the patient as a return of her menses, but carefully observed, it will be found that it lacks several of the characteristic conditions of that flow. It does not occur at the regular time, nor does it con- tinue to flow during the ordinary number of days and then subside. The time of the occurrence is irregular and duration indefinite. Occasionally the haemorrhage is a spurt for a few moments or hours. At other times it is a mere show, and then again it may be very copious. In fact, the remarkable feature is its dissimilarity in many essential particulars to the menses. One important ac- companiment may generally be observed, viz., the dis charge of membrane in some form, often in shreds so small as to escape notice without careful investigation ; at other times the pieces maybe large and easily detected, and rarely there may be a complete decidual cast of the uterus. This metrorrhagia is not confined to any definite time. It generally begins to make its appearance at the end of the second month, and may continue at irregular intervals until the fifth month. It may occur, and perhaps more frequently, simultaneously with the attacks of pain. When the pain, metrorrhagia, and discharge of membrane take place at the same time, the cases strongly resemble, and may be mistaken for, miscarriage. Metrorrhagia does not occur in all cases of extra-uterine pregnancy, yet it is observed so frequently that its absence must be regarded as the exception to the rule. Probably the ex- foliation of the deciduous membrane is the cause of the haemorrhage in by far the greater number of cases, but the great vascularity of the uterus must be regarded as an important element in its causation. The hypertrophy of the uterus is the same in kind, al- though less in degree, as in normal pregnancy, but the subsidence of the haemorrhagic tendency as gestation ad- vances must be accepted as sufficient proof that it is not the only cause. The fact that the deciduous membrane is not generally noticed in the uterine cavity at term would seem to indicate pretty plainly that the haemor- rhage subsides with the complete expulsion of that mem- brane. We must enumerate, as another one of the common symptoms of the early months of this form of pregnancy, an enlargement of the lower part of the abdomen. Diagnosis.-In the early months, before the fcefal movements can be discovered, the diagnosis is attended with many difficulties ; and yet, in most cases it may be definitely and correctly made. One of the difficulties is to arrive at, and convince the patient and friends of, the necessity for as thorough an examination as is required ; another is the great sensitiveness of the pelvic organs; and perhaps not the least is to attain completeness in our ex- ploration of the pelvic organs. The first, so far as the physician is concerned, should give way to a careful con sideration of the important symptoms above described ; while a forcible expression of his convictions as to the gravity of the case will usually influence the patient and friends as to the propriety of the procedure; complete anaesthesia will overcome the second ; and the third will yield to skilful manipulation and sound judgment. The physical examination should be well considered, and every arrangement should be made before it is com- menced. It should be remembered that in a great many cases the ovum will occupy the cul de sac behind the uterus, while in others, it will be higher up and to one side. The former may be expected to be movable, while the latter will generally be fixed. In both, if pregnancy is as much as three months advanced, the uterus will be displaced, either forward or to one side. In the retro- uterine cases the examination should be both vaginal and rectal, and the hand which is not used for this part of the examination should b^ applied above the pubis. In the cases in which the ovum lies on one side of the uterus, the ex- amination should be made by way of both these cavities, and through the bladder, as first suggested by Noeggerath. With two, three, or even four fingers in the rectum, we can easily reach and explore the whole of the retro-uterine space, and with the downward pressure of the hand ap- 777 Extra-uterine Pregnancy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plied above the pubis, the tumor, if any exist, may be fixed. If the tumor thus embraced contain an embryo, it will be globular, elastic, and fluctuating. Sometimes the foetus may be felt through the membranes, and by re- percussion be made to move in the liquor amnii. As a part of the exploration, we should ascertain that the uterus is empty by the use of the sound or the fingers. If we can assure ourselves that that organ is displaced forward, empty and hypertrophied, and that the tumor has the position and qualities above described, the diag- nosis will be complete. The only thing that might render it doubtful would be the possibility of the presence of an ovarian tumor or a cyst of the broad ligament ; but the marked symptoms which influenced us to make the ex- ploration are so seldom caused by either of these growths, that we might exclude them. On the other hand, if the symptoms were produced by miscarriage, there would be no retro-uterine tumor. The possibility of a miscarriage being attended by haematocele should be considered ; but the examination would enable us to discriminate between that condition and an extra-uterine pregnancy. If the embryonic tumor should be situated higher up and to one side, I should regard the examination through the ure- thra, by the introduction of the finger, the best means of making a satisfactory exploration. Reached in this way, the tumor, if representing a tubal pregnancy, can be dis- tinguished from hydrosalpinx or pyosalpinx by its globu- lar shape, greater size, and the character of the symptoms and history. While I would recommend, as a valuable method of examination, such an exploration through the urethra, the diagnosis may perhaps often be made with accuracy by means of the rectal and suprapubic method. Symptoms in the Second Period.-From the time of quickening to the end of gestation. The exceptional sensitiveness and tenderness continue throughout this period. The motions of the foetus ap- pear exaggerated, and often cause intense suffering in most of the cases. At term they may become tumultuous, being caused apparently by the death-struggle of the foe- tus, and then they cease entirely. These convulsive attacks in the foetus may recur several times ; sometimes there is but one such attack. While this is a common mode of termination of foetal life, it does not always take place in this manner, as death may occur without any unusual manifestation. The irregular haemorrhages may continue. They frequently are not noticed before the commence- ment of the spurious labor. The same may be said of the cramping or colicky pains. At the end of gestation, pains not unlike those of the first stage of natural labor, and probably caused by uter- ine contractions, are almost invariably noticed. They are often mistaken for labor, and the anxious expectations usual at such times are terminated by their cessation. Sometimes these vain efforts at expulsion are reproduced for several days or weeks, and finally subside in the be- ginning of the third period. During the continuance of the second period, the usual general symptoms of pregnancy, as the enlargement of the breasts, discoloration of the nipples and linea alba, appear at the proper time. The abdomen becomes en- larged, but there is apt to be an irregularity of outline in the tumor which it contains. It is not often a regular pear-shaped enlargement as in natural pregnancy, but too broad or elongated, and situated too much to one side. The disproportion may be such that the broadest part of the tumor is near the pelvis instead of at the upper part. Rarely it is kidney-shaped, the convexity being above, or the contrary. It is not usually movable, although in some instances it is more than naturally so. The foetal outline is more easily determined in consequence of its proximity to the abdominal walls, the placental murmur and the foetal heart are more audible, etc. It must be re- membered, however, that occasional exceptions to these conditions make the diagnosis mon? difficult. Physical Examination.-In consequence of the sensi- tiveness of the patient, a thorough examination should best be made under the influence of ether. The object of the vaginal examination is the establishment of the relations of the uterus to the tumor. It is taken for granted, as a preliminary measure, that the existence of pregnancy is demonstrated by the usual signs. The exact position of the uterus should first be sought out. For this purpose the bimanual method is indispensable. With one or more fingers of one hand in the vagina or rectum and the other hand above the pubis, we may quite accurately trace the figure of that organ. It will generally be found on the an- terior portion of the tumor, greatly elevated during the whole time, and closely applied to the anterior wall of the abdomen where it appears to be fixed. The cervix is high up and very near the pubis. With the finger in the va- gina, a depressed and generally marked line along the side of the uterus may be traced, showing its attachment to the larger tumor. The hand above may also distinguish the same relations of the uterus. Sometimes the latter may be attached to the side or even to the under surface of the tumor. The sound will afford corroborative evi- dence of the relations of the uterus. The propriety of using the sound must be judged of by the other indications in each case. It is true that the proofs deduced from these means of research may be fallacious, but they are seldom so. Of course, the tumor will in most cases be behind the uterus, and often, though not always, may be reached by the fin- ger in the pelvis. If it can be established that the relations of the uterus to the tumor are such as have been described above, the extra-uterine nature of the pregnancy will be demon- strated. Sometimes an examination through the urethra will enable us to appreciate the shape and connections of the uterus more easily and perfectly. When the tumor can be reached through the vagina or rectum, the head, shoulders, and other parts of the foetus may often be dis- tinguished, and even ballottement has been found practi- cable. After the growth of the ovum has carried it to a point above the level of the uterus, appropriate manipulation will show the continuity of the tumor behind the uterus and its identity with that in the abdomen above it. Ex- amined through the abdominal walls by palpation, the tu- mor of abdominal pregnancy will appear more impressible and fluctuating, then that of uterine pregnancy, the dif- ferent points in the foetal body will be more easily de- tected, and the usual alternation of contraction and relax- ation of the impregnated uterus will be absent. This kind of examination will be as available and ac- curate at the end of term, when the spurious labor is to be diagnosticated from real parturient phenomena. Symptoms of the Third Period.-Some patients do not long survive the struggle made to expel the foetus, but die from conditions due to the effects of this last effort. Exhaustion from the long-contihued suffering is one of these conditions, the symptoms of which are not peculiar to this form of pregnancy, Septicaemia, and general pelvic and abdominal inflammation, may also occur. When no immediately fatal consequences arise, symp- toms indicating the changes going on in the tumor are soon observed, one of which is a more or less rapid dim- inution of its size from the absorption of the liquor amnii. In the true abdominal variety the tumor not only becomes smaller, but the outlines of the foetus closely wrapped in the clinging membranes become very marked. Sometimes, however, the tumor becomes fixed in the lower part of the abdomen. This fixation is, no doubt, the result of bands of fibrin thrown across it by a process of inflammation, with more or less notable febrile excite- ment and local tenderness. At other times the foetal mass forms no adhesions and is very movable for years, and can be felt through the abdominal walls as it lies " floating about among the intestines." In cases in which the ovum has a more or less complete fibrous envelopment, the tumor becomes more dense as well as smaller in size, and the shape of the foetus less distinguishable, and often there are no special signs by which it may be diagnosticated from abdominal growths. One important symptom in this state of things is the stationary dimensions of the foetal mass during the long time it may remain in the abdomen ; while in a morbid growth there is usually a somewhat steady increase in size. 778 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Extra-uterine Pregnancy. While these ordinary changes are going on, all the symptoms of pregnancy subside. Perhaps immediately after labor the breasts secrete milk. This secretion, how- ever, may soon cease, and the breasts become empty and flaccid ; the lochial discharge at first observed also ceases, and the uterus gradually assumes its normal dimensions and functions. In this dormant state the tumor, always sensitive, is liable to accidents that give rise to distinctive symptoms, as inflammation and suppuration, with the dis- tressing conditions attending the prolonged efforts to elim- inate the contents of the tumor. Prognosis.-The mortality in all varieties, according to Parry, is about sixty-seven per cent. Recent German writers give a more favorable prognosis. It will require further observation to arrive at a correct estimate of the prognosis, as well as in regard to some other points of great practical importance in connection with extra-uter- ine pregnancy. It would seem that the greatest danger arises from rupture of the foetal sac, and that the fatality is due to the effusion of blood into the peritoneal cavity in suf- ficient quantities to cause death by exhaustion, or by its subsequent decomposition causing septic or aseptic peri- tonitis, or by shock. The cases in which these disastrous results are sup- posed usually to follow belong to the tubal variety in some of its forms, and the time the earlier months of pregnancy. It is believed by many gynaecologists of great repute that very few, if any, cases of tubal pregnancy con- tinue to term ; that nearly, or quite, all terminate in rupt- ure, and are succeeded by death in one of the modes above mentioned. This extreme view of the dangers of tubal pregnancy is not entertained by the German and French authors. In a paper read before the Chicago Medi- cal Society, and published in the Journal of the American Medical Association, on "Palliative Measures in Extra- uterine Pregnancy," by W. W. Jaggard, M.D., Adjunct Professor of Obstetrics in the Chicago Medical College, Gallard is represented as making the statement that haema- toceles arising independently of trauma are almost al- ways due to the rupture of the cyst of extra-uterine preg- nancies ; and Schroeder is reported as saying, " this etiology of retro-uterine haematocele is decidedly of fre- quent occurrence, even if the tubal pregnancy is seldom diagnosticated." Schroeder says further, that J. Veit has recently collected 146 cases of haematocele, of which 40, or twenty-eight per cent., are referred to this mode of origin. If these conclusions are true, it would seem that all but the gravest cases have escaped the attention of most American and English authors, and that in retro-uterine haematocele are quite often hidden the products of tubal pregnancy. As before stated, further observation is nec- essary to determine these important points in the progno- sis. If in the disappearance by absorption of the contents of an ordinary haematocele. women are frequently relieved of the consequences of an error in the process of generation hitherto regarded as almost invariably fatal, we shall be able to put aside much of the anxiety attaching to such cases. According to this last view, the danger lies in the quantity of the extravasation, and that it more frequently falls short of a disastrous amount than it reaches that point. Both the pessimistic and optimistic views above no- ticed leave us to infer that very few tubal pregnancies, as such, extend beyond the fifth month, and that those which outlast this time belong to one of the other varieties; and while one of them takes away much of the terror that attaches to this variety of pregnancy, the other leaves a large margin for the gravest apprehension of serious dis- aster connected with it. However this may be, we do know that a great many cases succumb to the overwhelm- ing loss of blood. The mortality of the second period, as compared to that of the first, is very small. When the ovum has sur- vived the fifth month, it generally lives until the ordinary term of gestation. In some instances, however, disastrous rupture supervenes, and produces effects similar to those of the earlier period, viz., exhaustion, peritonitis, and septicaemia. At term the struggle to get rid of the products of the ectopic pregnancy not infrequently ends in exhaustion, or causes rupture which may be followed by fatal haemor- rhage, peritoneal inflammation, or septicaemia. The prognosis, after the termination of gestation, de- pends upon conditions that are likely to supervene in consequence of the presence of what has really become a foreign substance. After the dead foetus has become en- cysted, it may remain without causing any considerable mischief for a great number of years-indeed, during the whole subsequent lifetime of the patient; but much more frequently it is the cause of greater or less suffering, and is a constant menace to the life and health of the patient. When the conservative effects of encapsulation fail to protect the parts which surround it, nature frequently makes an effort to remove it by suppurative inflamma- tion, and the patient is subjected to protracted suffering, and even death, as the result. The enveloping tissues are converted into a pyogenic cavity ; the pus permeates the tissues of the ovum, softening and, to a great extent, liquefying them, and the whole becomes a large abscess. As in abscesses from other causes, the contents gradually find their way to the surface, either through the abdomi- nal walls or into some of the hollow viscera. When the pus and foetal debris make their way through the abdominal walls direct, the case is more likely to terminate favorably than when they pass through the vis- cera, probably because, in this mode of discharge, the vis- cus is involved in the inflammation, in addition to the fact that the process of elimination is less perfect and much prolonged. The comparative hazard of this termi- nation depends to some extent upon what one of the hollow organs is the medium through which the products of the pregnancy find their way out. One of the worst direc- tions these can take is through the bladder, as the urethra is too small to permit of the passage of the harder sub- stances. Similar difficulties attend the discharge through the uterus. The difficulties of the discharge through the alimentary canal are greater the higher up in that cavity the perforation occurs, as the whole of the alimentary tract below that point is kept in a state of inflammation, and nutrition is more disturbed. Nothwithstanding the great and protracted suffering thus produced, these cases may, and not infrequently do, terminate favorably. When the abscess punctures the vagina, other things being equal, we may reasonably hope for a successful issue. At any stage of the process of elimination by suppura- tion absorption of pus may cause pyaemia, or the absorp- tion of the putrescent material caused by decomposition of the foetus may give rise to a rapidly fatal septicaemia. Another cause of danger occasionally noticed is pressure upon the abdominal or pelvic organs. Treatment.-In devising treatment for extra-uterine pregnancy we should bear in mind that, even if we do not interfere, the child's life will probably be sacrificed ; that the fatality to the mother is very great; that the danger to the mother is greater before than after the end of the fourth month, and that the danger mainly consists in the frequency with which the rupture of the ovum occurs during that time. The treatment in this early period will greatly depend upon whether the discovery of the condition is made be- fore or after the rupture ; for, although, of course, there are cases in which rupture does not occur, we should treat every instance as though we expected it to take place. It is now, I think, universally conceded that our main object, before the bursting of the sac, should be to arrest the progress of pregnancy by depriving the embryo of life. There are several methods of doing this which have proven successful. The first which I shall mention is by as- piration, by which a part or the whole of the liquor amnii is drawn off. This is followed quite promptly by the cessation of life in the embryo, and, in favorable instances, by the contraction of the tumor with its final disappear- ance. Probably a hypodermic syringe is the safest instru- ment to employ, and the abstraction of a single syringeful ■will be sufficient. A fine needle of the ordinary aspirator 779 Extra-uterine Preg- y c • [ 11«111 c y . REFEREyCE HANDBOOK OF THE MEDICAL SCIENCES, would be more appropriate, when the sac is somewfliat distant. In most instances aspiration through the vagina will be practicable. This method of arresting the growth of the embryo may be followed by septic inflammation of the sac that may prove fatal, and the operation should be practised with such precautions as will place the patient in the most favorable condition. The embryo has also been poisoned by the introduction of narcotics by means of the hypodermic syringe. Dr. Tanner recommends the injection into the sac of half a grain of morphia. Several cases are recorded as having been cured by this means. The dangers attending this procedure are somewhat greater than those which charac- terize the former method. It sometimes requires more than one operation to effect the object. Galvanism and electricity, from recent reports of cases by Drs. Thomas and Munde in the " Transactions of the American Gynaecological Society for 1885," seem to be more generally successful than any other means. Dr. J. G. Allen, of Philadelphia, and others also report success- ful cases. For the performance of galvanization the pa- tient should be etherized to insensibility ; one electrode, isolated to its extremity, should then be introduced into the rectum opposite the tumor, and the other, covered by a sponge, placed over the abdominal walls against the sac. Dr. Thomas employed as many as twenty cells, and in- terrupted the current in some instances and in others not. The application may be made for two or three minutes, then there should be a rest of two or three minutes, and so the procedure should be repeated until the duration of the operation is twenty minutes or more. This operation may be repeated every two or three days until the death of the embryo is effected. A very appropriate way of in- ducing the effect of the current would be, first to apply twelve or fourteen cups, and gradually add one after an- other until twenty are employed. Dr. Munde, who witnessed severe shock from the use of the galvanic current, would seem to prefer the faradic. Either current would doubtless answer the purpose. Whichever may be employed, it will be necessary to re- peat the application every second or third day until the motion of the foetus ceases, or the symptoms of pregnancy subside. Killing the embryo in this way is usually followed by shrinking and condensation of the tumor, and its ultimate disappearance. While galvanism is generally successful, it is not always so, as Hicks, of London, failed in his case. And it should not be held as certain that it is always a perfectly safe process. Possibly the sac may be ruptured, and the con- sequences of this accident will then be incurred. It is also possible that the changes induced by galvanism may not be innocuous, and septicaemia may result from de- composition of the ovum. It doubtless has advantages over any process that perforates the sac. It is not necessary to more than allude to the excision of the cyst, either through the vaginal or through the ab- dominal walls. The brilliant success of Dr. Thomas in opening the sac through the posterior wall of the vagina with the galvano- cautery knife, and extracting the embryo, will be remem- bered, but it should also be known that he met with dif- ficulties that deter him from a repetition of the operation. Excision through the abdominal walls is far more haz- ardous than the destruction of the embryo by electricity, or, for that matter, by the other methods mentioned. Treatment after the Rupture of the Cyst.-If the direful prognosis so confidently promulgated by Dr. Stephen Rogers, in his excellent paper read before the American Medical Association in 1849, and so generally accepted by American physicians, be true, there can be but one means of successfully treating these cases, viz., securing the bleeding vessels by laparotomy. Many facts, however, some of which have been mentioned above, would seem to justify us in giving more credit to the powers of nat- ure in helping the patient out of her difficulties. The author has witnessed recovery from what was diagnosticated by three other capable and experienced physicians-in which opinion he himself concurred-as rupture of the foetal sac of a three months' pregnancy. The symptoms of the progress of the pregnancy and those of the rupture were well marked and intelligently observed. The condition of the patient was one of pro- found collapse, but upon the arrival of the author pre- pared to perform laparotomy, reaction had begun, and it was decided to wait a short time; and, as the patient con- tinued to improve, the operation was not performed, and the patient recovered as above stated. In cases, therefore, in which shock or collapse is followed by symptoms of re- action, however feeble, we may reasonably delay laparot- omy and resort to haemostatics, such as ice in the vagina ami over the hypogastric region and vulva, and digitalis administered internally to sustain the action of the heart. Should the symptoms of internal haemorrhage continue, the pulse becoming more frequent and feeble each hour, marking increased loss, we must operate. It seldom hap- pens that these patients bleed to death in less than from fifteen to twenty hours, so that often we may have suffi- cient time to act considerately. The profession is greatly indebted to Dr. Rogers for his earnest and energetic advocacy of laparotomy in these desperate cases. But we should not forget that even in this desperate strait there is room for discrimination. In one case the author's hands were tied by the over- powering influence of counsel against laparotomy, al- though he yet believes there was a reasonable chance of success. • The patient lived from the time the proposition to operate was made fully twelve hours. Lawson Tait has recorded five successful cases. Dr. Charles K. Briddon's patient lived forty-eight hours after this operation. With proper discrimination, laparotomy is *to be com- mended as a remedy-in fact, the only one for the des- perate conditions involved in rupture of the fcetal cyst. In the present improved state of abdominal surgery, the operation does not present insurmountable difficulties. The collapse, short of the moribund state, ought not to be a contra-indication, because under the influence of ether the shock would not be sufficient to add materially to the dangers of the patient, and the loss of blood would be so slight as to have very little influence. In the early months there have usually been no complicating inflammations to mask the appearances in the abdominal organs, apd in this way to confuse the operator, and he consequently will be able definitely to trace the anatomy of his case. The difficulty of securing bleeding vessels or surfaces should not be very great. In many cases the tube or other medium of attachment may be lifted into view, and a ligature passed around or through it and tied. If this cannot be done, the to-and-fro subsurface (or darning) stitch will secure bleeding surfaces of any size or shape. This mode of securing bleeding surfaces is fully de- scribed in the chapter on ovariotomy in the author's work on Diseases of Women. After the removal of the products of pregnancy the toilet of the peritoneal cavity may be made by sponges, towels, or a running stream of water from an elevated fountain. This fountain may be improvised by plac- ing hose in an elevated bucket so that it will act like a siphon. The author believes that the technique of this opera- tion is quite as simple as that of oophorectomy. That laparotomy, for the removal of the products of an ectopic pregnancy after rupture, and in the circumstances under which it will generally be performed, is not of the most promising character, is fairly admitted, but it does promise more than the futile administration of opium, as- tringents, and the use of cold. In fact, any other method in which collapse is permitted to constantly increase is a tame submission to emergencies that ought not to be thought of. That practitioners who have no experience in abdominal surgery are not capable of performing lapa- rotomy for this purpose, is no reason why those who are should not do it. Treatment from the Fifth to the Ninth Month.-Practi- cally, the treatment during this time must depend upon indications as they arise, and not on fixed rules of prac- 780 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Extra-uterine Preg- Eye. [nancy. tice. The condition of the patient, in all cases, is of course a subject of great solicitude. The general health should be maintained by appropri- ate attention, and all accidents be guarded against. All causes likely to produce rupture of the cyst, or give rise to peritoneal or cystic inflammation, should be avoided. We should also be prepared for any emergency that may occur. Treatment during the Ninth Month and at the End of Gestation.-During the ninth month, or after the child has become viable, the question of gastrotoiny for the safety of the child assumes a prominence that renders its consideration necessary. Another question of still greater importance, however, is how the welfare of the mother may be affected by that operation. Is the danger to the mother rendered greater, or the contrary, by the opera- tion ? These two considerations will generally enter into the discussion together. In a discussion following the read- ing of his paper at the meeting of the American Gynaeco- logical Society, at Chicago, in 1884, Dr. Thomas gives the weight of his great authority in favor of the operation in the interest of the child in this language : "If there is a living child in the abdomen, remove it at the end of the ninth month. ... If the child is dead, I wait for the shrinking of the placenta, unless unfavorable symptoms develop demanding interference." This statement would seem to commit him to advocat- ing the removal of the child at the end of gestation, after the shrinking of the placenta had taken place, in the in- terest of the mother. I am not authorized in making the statement, yet I believe that he would wait even then for symptoms demanding interference. Notwithstanding the emphatic declaration of Dr. Thomas, I think the question is yet open to discussion. The arguments in favor of, or against, the practice must depend upon the collection of facts derived from the observations of those who repre- sent abdominal surgery in jts advanced state. We cannot admit the testimony of surgeons who lived and operated before the revelations consequent upon the general prac- tice of ovariotomy as worthy of such consideration as would enable us to formulate rules for our guidance upon this subject. We look to modern gynaecological surgeons for the solution of questions pertaining to the perform- ance of gastrotomy for the safety of the child at term, as their superior methods are such as may possibly secure to the mother better chances of life than if left to nature. The question as it now stands permits the practitioner to arrange himself upon either side, or to be governed by circumstances in individual cases. In doing thus he will be in company with eminent authority, whichever way he may decide to act. The main difficulty in gastrotomy, in the presence of a living foetus, is the disposition of the placenta. It cannot be removed wuthout the almost posi- tive certainty of meeting with fatal haemorrhage. To leave it in the abdomen, even with the best methods of drainage and most efficient disinfectants, we incur very great danger of its decomposition causing death from septicaemia. The latter, however, is the lesser danger, and is the one chosen by the best surgeons. I know of no authority for the immediate removal of the placenta. Treatment after the Death of the Child at Term.-The amount of suffering, under these circumstances, is some- times so slight as to require no treatment. At other times the reflex symptoms or local sufferings are sometimes so severe as to require general treatment for palliation. In such instances the kind of treatment required will be in- dicated by the character of the suffering. But in some cases the gravity of the conditions present will demand the removal of the dead foetus and its appendages. Laparotomy undertaken for this purpose must be per- formed according to advanced methods, viz., with anti- septic precautions in full detail. The especial steps of the operation for this purpose will depend wholly upon the particular features of each case. In many instances it will be impossible to remove the whole of the sac, and the only rule by which we can be governed is to extirpate as much as we can without al- lowing the passage of any of its contents into the peri- toneal cavity, and also to establish an external fistula through which the remaining contents may be discharged and perfect drainage effected. To this latter end the drainage-tube will contribute in a valuable manner. In most, if not all, cases the attachments of the placenta should not be disturbed. Sometimes it will, however, be found to be absent, or so attenuated and amalgamated with the surrounding tissues as to be almost, if not quite, an innocuous substance, around which reparative processes have already been established in such manner as to permit its inclusion in the general efforts made by nature to fill up the cavity. Sometimes, however, its attachments will be insecure, and we must trust to its elimination through the external wound. The septicaemic consequences of this process must be guarded against by antiseptic injections and the early re- moval of presenting portions as they are separated from the general mass, and by the employment of the most effi- cient means for the support of the system under these try- ing circumstances. Not infrequently nature makes an effort to get rid of the irritating foetal mass by surrounding it with the prod- ucts of inflammation, and disintegrating it by purulent infiltration. Thus converted into a large abscess, the pus finds its way to the surface and points at some particular place. In such cases the operation for evacuating the pus is indicated, and consists in dilating any opening made, or in making one, at the most prominent place, large enough to permit the escape of the foetal debris, or to enable the operator to extract them by means of forceps, blunt hooks, etc. If the pus, however, takes the direction to- ward the intestinal canal, we can do nothing to aid the discharge, and our efforts will be directed toward sustain- ing the system by general treatment. An exception to this rule may occur in consequence of the point of elimination being in the rectum, when that cavity may be dilated and the extraction of the foetal mass more or less completely effected. When the vagina is invaded by the pus and debris, we can often dilate the opening and extract them by the fin- gers or with instruments. The treatment of cervical and inguinal pregnancy is much simplified, because they are both outside the peri- toneal cavity. Excision and drainage would be the radi- cal measures to pursue at any stage of the pregnancy, or after gestation is complete. That operation, in the early period of pregnancy, would be scarcely, if at all, more dangerous than the use of electricity to destroy the life of the foetus, and should be preferred because it removes the foetus and membranes, and thus secures the patient against the possibility of sepsis from their decomposition. William H. Byford. EYE, DEVELOPMENT OF THE. The brain and spinal cord are developed by an invagination of the external, dorsal, layer of the embryo, or ectoderm (epiblast), in the axis of the body. It commences by the formation of a groove which gradually deepens. The edges of this groove finally unite so as to form a tube (medullary tube) lying directly beneath the ectoderm, which has just closed over it. The cavity thus left in the centre of the medul- lary tube forms, in the adult, the central canal of the spinal cord and the ventricles of the brain. The anterior portion of the medullary tube soon be- comes more or less segmented, that is, constrictions form transversely to its axis, dividing this portion into what is known as the fore brain (proencephalon), Fig. 1064, Fb, the mid brain (mesencephalon), Fig. 1064, Mb, and the hind brain (metencephalon), Fig. 1064, Hb. This anterior portion of the medullary tube, destined to form the brain of the adult, soon becomes strongly flexed upon that por- tion which later forms the spinal cord. Very early in the development of all vertebrate embryos there form two lateral evaginations, or hollow out- growths, from the lower sides of the fore brain toward the ectoderm, which forms the external covering of the head. These outgrowths are known as the primitive optic vesicles, and their cavity communicates with the cavity of the me- dullary tube. In mammalia these evaginations begin be- 781 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fore the anterior portion of the medullary groove (fore brain) is entirely closed ; while, in the chick, these hol- low outgrowths do not begin to form until after the clos- ure of the medullary tube is complete. A constriction in the direction of the axis of the body soon forms in these outgrowths, separating the distal por- tion of the primitive optic vesicles from the fore brain. This constriction forms a pedicle and gives rise later to the optic nerve. The portion be- yond the pedicle, the primitive optic vesicle, gives rise to the nervous por- tions of the eye. Fig. 1064 repre- sents the forward half of a chick em- bryo. The primi- tive optic vesicles (Opr) are seen pro- jecting laterally from the sides of the fore brain (Fb), and have reached the sides of the head. The con- striction which separates them par- tially from fore brain is just begin- ning to appear. In the chick the primitive optic vesicles proceed outward to the ex- tern al ectoderm, and finally come in contact with it, so closely, in fact, that there is no meso- dermal tissue what- ever, in which the primitive optic vesicle is embed- ded, lying between its distal surface and the inner surface of the external ec- toderm. All the authorities agree on this point. In mammalia, however, authorities, with the exception of Kessler, agrde that the primitive optic vesicle is sepa- rated from the external ectoderm by a thin layer of meso- dermal (mesoblastic) cells. These mesodermal cells, with others that are later included, form the vitreous humor of the adult eye. These cells are shown, in a somewhat later stage how- ever, in Fig. 1067, which represents a section of a part of contact. At first a thickening of the external ectoderm at this point is seen. This portion of the ectoderm then begins to invaginate. This invagination coming in con- tact with the distal portion of the primitive optic vesicle causes this portion of the latter to become flattened, and then to bend inward. This is represented in Fig. 1065 A. At I is the thickened ectoderm (Ec), which has begun to invaginate; r and u represent the primitive optic vesicle, the distal wall of which (r) has commenced to retreat in- ward. This invagination of the ectoderm proceeds until a deep cup is formed, the lips of which coalesce and the in- vaginated portion, now a closed vesicle, is cut off from the overlying ectoderm, which has become continuous again. This stage is seen in Fig. 1065 B ; I (lens) is the vesicle which has just been formed from the ectoderm (Ec); the distal portion of the primitive optic vesicle (r) has become more indented. This distal wall (r) continues to grow inward until the walls nearly touch, and we have formed a secondary optic vesicle with double walls (Fig. 1065 C, r and u). The cavity of the primitive optic vesicle is now only represented by a narrow space separating the two walls of what is now to be called secondary optic ves- icle. The invaginated vesicle of the ectoderm forms the lens of the adult eye. The external ectoderm covering it forms the epithelial layer of the cornea. The distal wall of the secondary optic vesicle forms the retina, and the prox- imal wall forms the pigmented epithelial layer of the choroid. This description of the formation of the lens and the secondary optic vesicle is in reality more or less diagram- matic ; it is essentially the manner in which these two formations are produced. If the de- veloping animal be ob- served only from its dor- sal aspect, the changes would be seen as de- scribed. But if studied from the side of the head, or from the ven- tral aspect of the head, a complication is found, present in all verte- brates, and which is ex- ceedingly important in the phylogenetic de- velopment of the eye, into a discussion of which space will not allow me to enter. This complication is rather difficult to describe. The primitive optic vesicle, instead of forming a regular cup as described, grows ir- regularly, so that the superior portion reaches the ecto- derm first. When the invagination of the external ecto- derm begins to form the lens, the walls of the primitive optic vesicle have, to a greater or less extent, coalesced to form the secondary optic vesicle ; the sides of this for- mation then begin to grow downward and cover the lens on its anterior and posterior surfaces, so that we sooy have the secondary optic vesicle taking the form of a hood, the distal edge of which encloses the lens now on the top, front, and back, leaving a space or fissure at the bottom (ventral aspect) open. This stage is seen in Fig. 1066, which represents the appearance of the eye seen from the side of the head of the embryo; the lens, I, being enclosed by the hood-shaped secondary optic ves- icle, which here (seen on end) looks like a horseshoe. This fissure, which runs along the bottom of the eye at this period, is known as the choroid fissure, and it not in- frequently happens that we find, in the adult, an incom- plete closure of this fissure of the secondary optic vesicle, and when this is the case we have the abnormal condition of the eye known to physicians as coloboma. This may re- main open only in the iris {coloboma iridis), or be confined to the retina {coloboma retinae); in the latter case, on ex- Fig. 1064.-Anterior Portion of a Chick Em- bryo at the End of the Second Day of Incu- bation. Seen from above. (After Kolliker.) Fb, Fore brain (proencephalon) ; Opv, primi- tive optic vesicles; Mb, mid brain (mesen- cephalon) ; Hb, hind brain (metencephalon) ; Hl, heart; M, medullary tube; bi, mesoblas- tic somites (primitive vertebra?). Fig. 1066.-View of External Surface of Eye. (After Remak.) I, The thick walls of the still open lens ; x, cavity of lens; o, external opening of the lens ; r, external layer of secondary optic vesi- cle (retina); u, external layer of same (uvea). Fig. 1065.-Diagrammatic Representation of the Development of the Lens and Secondary Optic Vesicle. Looking from above. (After Remak.) Ec, external ectoderm ; I, lens; r, future retina ; u, future choroid (uvea); v, cavity of vitreous humor; x, thickening of the ectoderm ; o, cavity of the still open lens. the head of an embryo mouse. The cells are seen, the nuclei being represented by black points between the thickened ectoderm, I, and the optic vesicle, Opv. When the primitive optic vesicle reaches the external ectoderm, a change begins to take place at the point of 782 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. amining the eye-ground with an ophthalmoscope, we can see a white, wedge-shaped patch, the base of which is di- rected downward, at the inferior part of the background. The white is the sclera shining through. This is merely a reversion to primitive state-a failure in the union of the two lateral walls of the secondary optic vesicle, and somewhat similar to the non-union of one of the visceral arches which gives rise to the abnormal condi- tion known as "hare- lip." Fig. 1067 represents a section of the stage shown in Fig. 1066, made in a plane perpen- dicular to the paper, and through the middle of its greatest diame- ter. By this folding down and around the lens a portion of the surround- ing mesoderm is in- cluded, and this en- closed mass gives rise (together with the small layer, in mammals, which is pushed in by the invagination of the lens) to the vitreous hu- mor of the adult eye; and the portion of mes- odermal tissue that is included in the folding of the pedicle (optic nerve) gives rise to the arteria centralis retina of the adult optic nerve. Now, to follow more iq detail the development of the lens, we find, when it has become detached from the external ectoderm and is still a vesicle, that the walls of this vesicle are of about equal thickness throughout. As de- velopment proceeds we find that the inner or proximal wall begins to thicken, the cells in it becoming long and spindle-shaped, and later even fibrous in structure. The outer or distal wall remains thin, and does not consist of This growth and proliferation of the cells of the proxi- mal wall soon fills up the cavity of the lens. The lens at this stage is so large as to nearly fill up the cavity of the secondary optic vesicle (Fig. 1068, r, p) in mammals, while the lens is, proportionally, much smaller in birds. The changes in the later development of the lens consist in the further elongation of the cells of the proximal wall into fibres, and the disappearance of the nuclei in them. During this change they become arranged as are the fibres of the adult lens. The structureless lens capsule arises, according to Kblli- ker and Kessler, as a cuticular formation from the epi- thelial cells of the lens ; while Lieberkuhn, Arnold, Lowe, and Sernoff hold that it is derived from mesodermal cells. Inasmuch as there are no mesoblastic cells In front of the lens, nor between it and the distal wall of the primi- tive optic vesicle, i.e., behind it, in birds, as showm above, and that there seems to be a fine hyaline mem- brane surrounding the lens shortly after its separation from the external ectoderm, would seem to indicate that the views of Kolliker and Kessler are correct; and further, from the fact that from its origin it is structureless, and not cellular, which would be the case if it were derived from mesodermal cells. The vitreous humor (corpus vitreum) is developed from the mesodermal tissue that is included into the secondary optic vesicle by the folding of its walls downward, to- gether with that portion (in mammals) which is pressed in by the invagination of the lens. This layer is seen in Fig. 1067 and in Fig. 1068, v. Kolliker considers this vit- reous humor a true embryonic connective tissue. Development of the Cornea.-After the lens has been separated from the external ectoderm from which it has been developed, it remains for some time in contact with it. The cells of this overlying external ectoderm form later the epithelial layer of the cornea. Soon there ap- pears a layer of mesodermal tissue, which creeps in be- tween the lens and the ectoderm. It first only surrounds the edges of the lens, and is consequently in the form of a ring open at its centre. This ring begins to form about the time the cavity of the lens begins to close up, and is thickest at its periphery, and thins out to a fine edge at its centre. Later, it forms the body of the cor- nea and coalesces with the ectoderm, the corneal epithe- lium. This ring becomes thicker and the open space in its centre closes up, so that a complete layer now lies be- tween the ectoderm and the lens. This is shown in Fig. 1068. The ectoderm e has been removed, except at the bot- tom of the figure ; the thin layer of mesoderm m" is seen covering the distal face of the lens. After the comple- tion of this layer, a layer of flattened cells (mesodermic) grows in between it and the lens. This layer of flattened cells forms the membrana Descemeti of the adult eye. A split soon takes place in the mesodermal layer, at the edge of the cornea. The inner layer covering the edges of the secondary optic vesicle forms later the meso- dermal portion of the iris, while the outer forms the cor- neal corpuscles. These corpuscles wander into the meso- dermal layer of the cornea. The space in the distal portion of the eye-ball, which in the adult eye is filled with aqueous humor, is developed after the completion of the membrana Descemeti. The space which exists after the formation of the lens is filled up with the mesodermal tissue and goes to form the cornea, but after the membrana Descemeti is fully formed, this space is seen which enlarges and becomes filled with a liquid, the aqueous humor. The cavity continues to en- large, but is not complete until the iris has reached its full development. The iris is formed from two tissue groups, viz., the ectoderm and mesoderm. In an early stage the lens is placed at the mouth of the secondary optic vesicle (Fig. 1065, c, I), and it entirely closes up its orifice, being in contact or nearly so all the way round after the coalescence of the walls which bound the choroid fissure. The lips of the secondary optic vesicle now begin to grow over the distal edge of the lens, and by this growth the Fig. 1067.-Transverse Section of Mouse Embryo. Ec, ectoderm; M, mesoderm; Opv, optic vesicle ; I, invaginating lens (still open) ; E, cavity of brain. Fig. 1068.-Horizontal Section through the Eye of a Rabbit Embryo of Fourteen Days. X62. (After Kolliker.) o, Optic nerve; p, choroid (pigmentum nigrum); r, retina; v, vitreous body; I, lens; le, epi- thelium of the lens capsule ; e, ectoderm ; m, mesoderm around second- ary optic vesicle; m', mesoderm between the lips of the secondary optic vesicle and the lens ; m", mesodern in front of the lens. more than a single layer of cells. This stage is shown in Fig. 1068, I (lens) representing the point where the dis- tal wall joins the proximal and the immense enlargement of the cells of the latter. 783 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lens is forced into its cavity. This edge, which extends over the lens, forms one of the layers of the future iris ; the uvea and its margins, which never coalesce, form the edges of the pupil. Over the distal surface of this edge of the secondary optic vesicle there forms a layer of mesodermal tissue, spoken of above, from which are developed the muscles and vessels of the future organ. We will now return to the early stages of the secondary optic vesicle, in order to study the development of the ret- ina, which is developed from its distal wall. When first formed, the walls of the secondary optic vesicle, as was the case in the lens, are of equal thick- ness. However, as development proceeds the distal wall becomes quickly much thicker, while the proximal does not only not increase, but diminishes, in thickness. This diminution of the wall is probably due partly to the fact of its increase of surface, in order to keep pace with the rapidly increasing inner wall. This marked difference in thickness of the two walls is shown in Fig. 1068, r (ret- ina) and p (pigmented epithelial layer of the choroid). The thickness of the retinal (distal or inner) wall is not only due to increase in the size, but also in increase in the number of cells. This thickening is uniform, and continues up to the time when the first appearance of the fibres of the optic nerve becomes evident. It then begins to thin at its edge, that is, in the vicinity of the mouth of the cup, and this thinning continues during the formation of the iris, the limit being reached at the formation of the ciliary process. From this thin portion of the secondary optic vesicle there forms: 1, the pars ciliaris retina, or the colorless part (corona ciliaris) of the ora serrata; 2, the deep layer of the iris pigment. The macula lutea is not present in the embryo, nor is it present in the newly born foetus. Its development at present is not clearly understood. Histological Development of the Retina.-As soon as the retina, as such, can be distinguished, that is, on the for- mation of the secondary optic vesicle, we find the cells composing it very similar in form throughout its whole extent, and also closely resembling those which at this time are found in the substance of the whole central nervous system, viz., of spindle or fusiform cells, with tolerably large and distinct nuclei. Internally we have, according to Kblliker, the retina lined with a fine hyaline membrane, the membrana limitans interna, and ex- ternally, that is, facing the proximal wall of the sec- ondary optic vesicle, with a similar membrane, the mem- brana limitans externa. According to Koganei, when the eye has advanced no farther than the primitive optic vesicle stage, two layers in its distal part can be distinguished: (1) a peripheral layer, composed of spindle-shaped cells, called by Wurz- burg and Lowe the primitive cells (Uranlagezellen), and (2) an internal layer of cells more vesicular, the nuclei of which show the ' ' Karyokenetic " figures, and which he called the " proliferating layer." The first marked differentiation of cells takes place (1) in the innermost layers (two or three) of cells. They be- come larger, together with their nuclei. (2) External to this forms a clear, thin layer which contains a very few cells. (3) Internal to^the first (1) forms a layer of fine fibres. We now have, commencing at the inside: 1, the mem- brana limitans interna; 2, a layer of fibres (of the optic nerve); 3, a layer of large cells (ganglion cells); 4, a thin molecular layer ; 5, a thick layer of the remaining, non-differentiated, cells of the inner wall of the secondary optic vesicle ; 6, the membrana limitans externa. (The fifth layer is the layer of primitive cells of Wurzburg and Lowe, and, according to Koganei, who is later than Kolliker, from which the above is taken, there exists a layer between this (5) and the membrana limitans externa, his " proliferating cells." He also does not recognize the molecular layer at this stage, nor the membrana limitans externa. Kolliker's investigations are based on the mam- mal, while Koganei's are based on the chick.) This condition of the retina remains for some time, the only change being an increase in thickness. The layers of the adult retina, including the layer of the rods and cones which lies between the molecular and the membrana limitans externa, are formed from the fifth layer, the thick external layer of the retina at this stage. On the ninth day of incubation in the chick (Koganei) the retina does not increase any more in thickness, and the following layers are found (all except that of the rods and cones): 1, membrana limitans interna ; 2, fibrous layer of the optic nerve ; 3, ganglion layer ; 4, molecular layer; 5, internal granular layer; 6, middle granular layer; 7, beginning of the external granular layer; 8, membrana limitans externa. By the end of the seven- teenth day of incubation in the chick, we have added the layer of the rods and cones and the pigmented layer. The external or proximal wall of the secondary optic vesicle gives rise to the pigmented epithelial layer of the choroid ; it coalesces with the retina, and its cells receive a deposit of pigment in a manner similar to other pigment- containing cells. The optic nerve is formed from the pedicle of the optic vesicle. It takes part in the folding of the secondary optic vesicle, already spoken of. In the folding a por- tion of mesodermal tissue is included, which later forms the arteria centralis retina. In the case of the chick, this folding is only present in the immediate vicinity of the optic vesicle, and in this form (birds) we do not have any trace of the arteria cen- tralis retina. According to Balfour, the optic nerve does not fold over, but the original cavity, that which is in communi- cation with the cavity of the brain, gradually becomes obliterated, the process of obliteration beginning at the retinal end of the nerve. This view, however, is not sup- ported by any of the later writers. While there still exists a cavity in the optic nerves, the optic chiasm begins to form from fibres at the roots of the stalks; the fibres of one going over to those of an- other. The sclera and tunica vasculosa oculi are formed from the mesodermal tissue in which the eye is enveloped. The former (sclera) forms very slowly, and for some time it cannot be distinguished from the surrounding meso- dermal cells. The general layer surrounding the eye (optic vesicle) splits into two layers, the inner forming the vascular tissue, and the outer the sclerotic coat. Accessory Organs.-The eyelids form after the cor- nea is fully developed. They commence by folds form- ing in the ectoderm, which pass gradually downward (the upper) and upward (the under). The whole fold is at first ectodermal, but gradually mesodermal tissue is pushed in between them, and this layer gives rise to the vascular parts and the muscles. The eyelashes form as do the hairs of other parts. The lachrymal glands are formed by solid proliferations of the conjunctiva, commencing in the human embryo about the third month of gestation. They soon become hollow, and open outward. Summary.-The lens is formed from an invagination of the ectoderm. The vitreous humor, from enclosed mesoderm. The aqueous humor formed from the epithelial cells that line its cavity. The cornea, (1) epithelium, from ectoderm; (2) body, from a mesodermal layer. The iris, formed from (1) lips of the secondary optic vesicle (ectoderm); (2) from an overlying layer of meso- derm. The retina, formed from the distal wall of the sec- ondary optic vesicle (ectoderm). The optic nerve, from the pedicle of optic vesicle (ecto- derm). The choroid, (1) epithelium, from the proximal layer of the secondary optic vesicle (ectoderm); (2) vascular por- tion, from the overlying mesoderm. The sclera, entirely from mesodermal tissues. No entoderm (hypoblast) enters into the formation of the eye. Benjamin Sharp. 784 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye, Eye. EYE : DISEASES OF THE LIDS. The skin of the face is reflected over the entire outer surfaces of both lids, and although its character is somewhat changed in this region, the lids are, nevertheless, subject to all the diseases of the skin in general, in addition to several oth- ers which depend upon the nature of the various anatom- ical structures peculiar to the eyelids themselves. One of the great peculiarities of the eyelids is the very loose connection of the skin with the subcutaneous tis- sue ; and in this condition we find an explanation of the fact that extensive oedema or ecchymosis of the lids may follow upon injuries or diseases which in themselves are comparatively slight. And these conditions are prone to follow any inflammatory process in any tissue, either of the orbit itself or of the orbital viscera. (Edema of the eyelids may follow secondarily any of the numerous diseases which we meet within the con- junctiva, cornea, sclera, and orbital cellular tissue ; and also diseases of the iris, ciliary body, choroid, and various lymphatic tissues around the eye. It also certainly follows all penetrating wounds of the eyeball, including operations, if these wounds are to be followed by a reaction ending in suppuration of the tis- sues within the eyeball. Who has been so fortunate, in operation for cataract, as not to have seen the upper lid puffy and cedematous on removing the dressing for the first time, say two days af- ter the operation ? And when we do see it we know full well that things are not going right inside of the eye. And we are also reminded very forcibly of the ease and rapidity with which the lids can become cedematous in all such troubles. Besides these local causes, oedema may be produced by constitutional troubles, as in diseases of the heart and kidneys ; and so much stress should be laid on this fact that an oedema of the eyelids, with no apparent local cause, should always be considered as pointing toward an affection of the heart or the kidneys, demanding a thor- ough examination of those organs on our part. There is this, however, to be said about the difference of eyelid oedema from local, and that from constitutional, causes. Where it is the result of disease of the eye or or- bit it is more pronounced in the upper lids, and may be very great. On the other hand, if it is the result of heart or kidney disease, it is usually in the lower lids, and is not, generally, so intense. If it is the result of albumin- uria, we may see only a slight oedema of the under lid, quite removed from the free margin; and its extent and amount may bear no definite ratio to the severity or length of duration of the causal disease. It may make its appear- ance quite early, or may be first noticed after a general anasarca has set in. In its anatomical causation it does not differ from dropsy of any other part of the body, and we may also add that its treatment is the same as other localized or even general dropsies. If it has been caused by an eye disease or an injury to the lid itself, we may neglect the oedema and treat the cause, resting perfectly assured that the swelling of the eyelid will subside when the exciting influence has been overcome. We may, however, apply a compress bandage to the eye, and cold or warm applications, according to the indications. Simple oedema is not accompanied by any active in- flammation of itself, and will leave the eyelid in normal condition after it has passed away. But we must not confound this with those forms in which the swelling is due to accumulation of pus in the subcutaneous tissue or other palpebral structures ; but the latter condition will be best treated of under the heads of the various diseases in which it occurs. Inflammation of the Eyelids in General.-As the structure of the palpebrae is very similar to that of the skin, and their tissue is in intimate connection with that of almost every part of the eye and orbit in their vicinity, we can readily understand that two kinds of inflamma- tory processes are to be met with in the lids: one in which the lids are primarily inflamed, or primary blephar- itis, and one in which the blepharitis is entirely secondary. In the great majority of the cases of secondary ble- pharitis the lids are implicated by what has been termed ■inflammatory oedema, without any actual hypertrophy of the elements of the palpebral tissues. In this condition we generally have a great swelling of the lids, due to an excessive infiltration of the loose tissue of those organs, which will quickly subside on the removal of the pre- existing cause, leaving the lids themselves in a compara- tively normal condition. Should the infiltration, how- ever, become so great as to destroy any of the integral parts of the lid-tissue by mechanical pressure, we may have, first, a general maceration or diffused blepharitis ; or, if the destruction has been circumscribed, a lid ab- scess may be formed, which, if it break on the outer sur- face, gives us an ulcer differing but little from those conditions which have been brought about by actual pri- mary disease of the lids themselves, and which will have to be treated in the same way. The primary inflammations of the lids, not including those from general dermic affection, are usually brought about by wounds, burns, or the action of chemical re- agents ; but whatever be the cause, should there be any extensive destruction of the tissues, they should be treated by rest, cold, etc. If a large cicatrix remains there is apt to be either a turning-in of the eyelashes (entropium), or an eversion of the lid (ectropium), both of which can be cured by an appropriate operation. In speaking of traumata of the lids in general, there is one form of accident which is very peculiar, and which deserves special mention ; that is, the bite of poisonous insects, such as spiders, etc. I have seen but little mention of this misfortune in oph- thalmological literature, but in the cases which have come under my personal observation, in every instance the w'hole eyelid has become completely atrophied in a manner which is by no means easy of explanation. The result is especially unfortunate, since while we may re- store portions of the lids by plastic operation, when the whole lid is missing we are helpless. I have never had the fortune of seeing one of these cases in the beginning, but only after the damage of complete atrophy had been ac- complished ; therefore I can say nothing of the process of the disease. As another instance of a peculiar affection of the eye- lids which does not deserve being treated of under a spe- cial heading, we have the primary indurated chancre. It happens not infrequently, but does not differ in its characteristics from those of other localities ; nor does its treatment require any special consideration. The same may be said of lupus, ulcus rodens, ephidro- sis, etc., with the possible exception of the latter, in which the augmented secretion of sweat between the folds of the lids, where the skin is very loose, may become acrid and produce excoriations of the skin. This is, how- ever, easily avoided by oily applications and cleanliness. It is considered preferable to treat of the various dis- eases of the lids, which deserve special treatment, under special heads, and we therefore pass to them in the fol- lowing order : Abscess of the Lid.-The symptoms of this are just what we would expect to find in an abscess of any other part of the skin and subcutaneous tissue-evidences of a more or less circumscribed inflammatory process in the subcutaneous tissue, which is at first hard, then soft and filled with pus. So far as the process is concerned, it has many peculiarities in the lids which it will be well to men- tion. It often commences in a very energetic manner, with great swelling, and fever approximating a phlegmo- nous character. Under such conditions the whole lid is red and greatly swollen, hot, and almost semi-translucent, with a smooth, shining aspect. This condition of the disease is very painful indeed, the pain being almost equal to that of diphtheritic conjunctivitis, in which condition it is exquisite. Again, we may have a condition approaching what is known as a cold abscess, in which the acute inflammatory symptoms are by no means to be compared with the above phlegmonous condition. For anatomical reasons abscesses occur most frequently 785 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in the upper eyelids, and near the margin of the orbit they are by no means rare. They occur but seldom in the under lids. The region of the superciliary ridge is a favorite seat for "hot abscess," as it is also for gummata, and it some- times becomes a nice point to make a differential diagno- sis between primary abscess of the lid in this region, and primary abscess of the lachrymal gland. However, as far as the treatment is concerned, there is but little dif- ference between them. In the energetic forms of lid abscess the tumefaction sometimes reaches the size of the fist, rendering the eye- lid completely helpless, and closing the eye entirely. Be- tween this and the merest pimple all conditions occur. Causal Influences and Course.-These abscesses are often due to traumata, such as penetrating wounds, burns, chemical agents, etc. Again, we may have the abscess arising spontaneously, in a very obscure manner. They are also a frequent accompaniment of facial erysip- elas, or they may be the result of thrombosis of any one of the vessels of the lids, as I myself have had occasion to observe. The course of the disease may vary, according to the nature of the abscess, anywhere from a very acute devel- opment to one of extreme slowness, as we find in so-called cold abscesses. However, it is very rare that we find no formation of pus, and in every case in which distinct fluctuation is manifest the treatment is obvious. It is not necessary to wait until the abscess " comes to a head," but we may incise it at any time when fluctuation is present. When the pus has been evacuated the cavity will always heal kindly, and we need have no anxiety on account of it, unless it has been situated at or very near the margins of the lid. In this case we may have a turning-in of the eyelashes, which will require a small operation for its cor- rection (see section relating to Entropium). There is no occasion for the inflammatory process to spread very far, since we can always control its limits to a certain extent; but if the patient comes to us at a later stage to be relieved from the effects of the disease, rather than from the disease itself, we may find that a very consider- able part of the palpebral tissue has been destroyed and replaced by connective tissue. Such conditions may lead to ptosis and require appropriate treatment (see section relating to Ptosis). If the abscess is left to itself, it may and will break spontaneously ; but this sometimes occurs on the inner surface, and the pus will then be emptied into the con- junctival sac. This must never be allowed to occur in the case of abscesses of the upper lid, since the healing- will result in a cicatrix which will rub against the cornea in every motion of the lid, causing great irritation. For this same reason we should never open an abscess of the upper lid on the under surface ; but we may do so in the case of the lower lid. Treatment.-In the treatment of lid abscesses we must, of course, stop the process as quickly as possible, since destruction of tissue in the lids, as elsewhere, means formation of cicatricial elements, which, in an organ so nicely fitting the eyeball as do the lids, may become a very serious matter, requiring extensive and delicate after-oper- ations. Therefore, if pus is present let it out, by all means, as quickly as possible. If there is no pus, we should strive to prevent its occurrence by active antiphlogistic meas- ures. If the appearances are stormy, we should put the patient in bed, and make ice applications to the lid-or lids continually. In this manner we may be able to procure an abortion of the process. If, however, we have been unsuccessful in this, and pus is beginning to form in spite of us, it will be well to change our treatment to warm ap- plications-not hot but warm-to bring about a rapid ' * head- ing," which we must then open immediately. Warm applications are best applied by taking thick pieces of felt, and cutting them sufficiently small to cover just so much of the lid as we deem proper. Let them lie for some time in warm water, and then apply them to the lid. It is sometimes necessary to hold them in place by a compress band, especially in the case of very young children and nervous individuals, One word about the manner of opening an abscess of the lid. The incision must be large and deep, so as to allow a free exit for the pus, since it is not always proper to exert a great amount of pressure on the inflamed parts to force pus through an aperture which has been made too small by the surgeon's knife. The cut must be made parallel to the free margin of the lid, since when the wound has healed the cicatrix will then correspond to the wrin- . kies of the eyelid, and will not be seen. And furthermore, if an extensive cicatrix should remain, it will pull in the proper direction in its future contraction, and will not re- sult in any malposition of the eyelashes. This is not always the case when the cut has been made either perpendicular, or even in an oblique direction, to the free lid-margin. If the swelling be large in comparison to the amount of pus which has been evacuated, we may put on a tight compress ; but, as a general rule, nothing more will be necessary beyond a free opening of the abscess. A piece of goldbeater's skin, or English plaster, will not be out of place if we do not anticipate any further formation of pus. If such has been applied and pus should form, we must, of course, remove all covering and let the pus out. If the cut has been made very large we may put in a few sutures ; but, as above stated, in the majority of cases no treatment after the opening of the abscess is necessary, except cleanliness. If the abscess has already broken and the opening is not large enough, it will be well to enlarge it with the knife ; or if the rupture is not in the most advantageous location, we may pay no attention to it but cut freely in the proper place. Also, if the abscess has broken on the in- side of the lid, we should open it from the outside, so as to avoid a slow and continued voiding of the pus into the conjunctival sac. Ulcers oe the Eyelid.-Ulcers of the eyelids do not differ to any great extent from ulcers of the same char- acter on any other location of the skin ; therefore a sep- arate description of them as a class will not be necessary, and we need consider only the characteristics of the pecu- liar forms and their treatment. There are several varie- ties which deserve mention. 1. The ordinary ulcer, which has been produced either by the breaking of an abscess or by traumatic influences. It may be that a superficial wound has cut away the ex- ternal layers of the skin or of the lid, and in course of time this will produce a simple ulcer, which, however, will heal kindly by the observance of cleanliness and pro- tection from the atmosphere, or by dusting iodoform powder over it. Burns, whether from heat, or from chemical reagents, produce ulcers of the lids and are treated in the usual way. 2. Syphilitic ulcers may either be the result of primary infection, and, therefore, be true chancres, or may occur as one of the manifestations of tertiary syphilis. A differ- ential diagnosis between these two varieties is of course easy, as is also the treatment, since it must be the usual regime for constitutional syphilis. These ulcers must not be confounded with those from lupus, or with that of ulcus rodens, or epithelioma. The syphilitic ulcer is more rapid in its course, and is devoid of the great hardness of the indurated edges of an epithelioma, and is accompanied by a greater inflamma- tion of its surrounding tissue than is the latter. Ulcus rodens, or epithelioma, is by far the most frequent form of ulcer met with on the eyelids. It generally comes on in advanced life. It is very sluggish in its course, and often commences as a mere pimple or wart, which the patient will describe as having " been there" for several years, when a short time ago it was trans- formed into a running sore. We find it, on examination, to be a superficial ulcer, usually implicating the free mar- gin of the lid, and it may be covered by a thin scab. If we pinch up the skin, so as to hold the ulcer between the forefinger and thumb, it will feel hard like a button from its indurated edges. The patient does not complain of any great pain on pressure, nor is there any great amount of inflammation in the surrounding tissue. However, when the wart or pimple has once assumed the form of 786 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. an ulcer, the ulcer goes slowly but surely on to destroy the surrounding tissue of both the skin and the parenchyma of the lid, until it has eaten away the whole lid, destroyed the eyeball, entered the nose-implicated, in fact, all the orbital and circumorbital tissues. It is not prone to attack the lymphatic glands in the vicinity, but, when it does so, the chances of cure, even by extensive operation, are very much reduced. Like all malignant tumors of the body, ulcus rodens is, in the be- ginning, a purely local affair, and if we have an oppor- tunity of operating at an early period, so as to completely eradicate it, the patient's life is safe. The treatment of epithelioma reduces itself simply to that of removal with the knife, and, although its course is not a rapid one, it is not considered best to attempt to destroy it by zinc paste, etc. We say this for several rea- sons ; among others, the cure is much more rapid, and, furthermore, when we cut we know just what we are doing, and can make the defect in the lid of any shape we please, so that, should it be necessary to cover it by a plastic operation, we can have things all our own way. Not so if we resort to chloride-of-zinc paste or to the actual cautery, since the tissues will go on sloughing to some extent, and in the end, even if we cure the disease, we must have a healing by granulations, and conse- quently a very ugly cicatrix. This latter will be apt to induce a malposition of the lid and necessitate a plastic operation in the end. But if we operate at once, the whole treatment is much more simple, is quicker, and very much more certain of a permanent cure. If, however, the lesion is so extensive that it cannot readily be removed with the knife, and we have reason to believe that some of the epitheliomatous induration re- mains, then the zinc paste is to be recommended. If the disease should return-as it certainly will do if our operation has not been a perfect one-we should operate again and again, because we may be able to re- move all at the second operation, even when we have failed in the first. And aside from this chance of radical cure by a second, third, or fourth operation, each time we remove all the affected parts that we can, we add greatly to the comfort of the patient, and certainly prolong his life, though, of course, only for a limited time. If the patient should absolutely refuse to allow the use of the knife, it would be better to refuse treatment al- together than to apply astringents, etc., since they are very apt to hasten the progress of the disease and its fatal termination. However, should the disease have pro- gressed so far that a removal with the knife is not to be attained, we may use chloride of zinc paste. Keep the ulcer clean and attend to concomitant symptoms, more with a view to the comfort of the patient than to any idea of a permanent cure. And this should be stated, if not to the patient, at least to his or her friends, so that they do not lay the ultimate death of the patient at our door. As to the prognosis of epitheliomatous ulcers, we are never safe in making a prediction, no matter how small the ulcer may be, if we find the lymph-glands in the neighborhood implicated; but this goes almost without saying. One thing should, however, be insisted on, and the advice given even without the asking, that all warts and long-standing pimples on the eyelids should be at once removed, since at the time at which they exist as such they are easy of radical extirpation ; and no one knows when the innocent-looking little things are going to alter their character in such a manner as to put all of our surgical. knowledge and skill to the test, and the pa- tient's life in danger. If we find that the defect from the operation, or de- struction by the ulcer, cannot be covered by a plastic operation, we may wait until healthy granulations have sprung up, and then graft skin on to them in the usual manner. 3. Lupus Ulcers.-These sometimes approximate the character of ulcus rodens, but they usually occur at an earlier age than that at which we would expect the lat- ter disease. They implicate the surrounding tissue of the lid to a much greater extent, and are accompanied by more inflammation. Nor are tlie edges of the ulcer nearly so much indurated as are those of rodent ulcers. Besides, we generally have several lupus nodules in the skin in the immediate vicinity of the ulcer, and also other lupus patches elsewhere in the skin or mucous mem- branes. If we remove a lid, in a case of this nature, and put it under the microscope, we shall almost certainly find tu- bercles, when the diagnosis is certain. According to some authors (Stellwagen and others), the favorite seat of lupus on the eyelid is at the free margin, and it implicates the whole thickness of the lid. We have the forms of lupus known as lupus maculosus, lupus hypertrophicus, lupus exfoliations, lupus ulcerans. We also have all these varieties at the same time, since they are more probably different stages of several ulcers, than different forms of the disease. As far as the diagnosis of lupus is concerned we may rely upon the following symptoms without a microscopic detection of tubercles in the skin : There will be deep- seated, radiating cicatrices where a neighboring ulcer has healed. Lupus ulcers are not so hard around their edges as rodent ulcers, and they are apt to have lupus nodules in their vicinity. They are not painful, and give the pa- tient no unpleasant symptoms. They occur in young people almost exclusively, and the disease yields readily to the well-known methods of internal and external treat- ment. Blepharitis Ciliaris.-The characteristics of this dis- ease are a redness of the free margin of the lid, or lids, and considerable hypertrophy, with small pustules appearing at the roots of the eyelashes. The latter cause the eyelashes to be agglutinated together into small pencils. When the disease is circumscribed, appearing only as a few isolated pustules along the lid-margin, some authors denominate it acne ciliaris, reserving the term blepharitis ciliaris to designate the condition in which the disease is more or less general over the whole margin covered by the eye- lashes. However, since the etiology and treatment are the same, we will include them both under the term ble- pharitis ciliaris. There are several phases of the disease which it would be well to mention, since the appearances presented at one stage differ from those at another, and an error in diagnosis might therefore be made. In the beginning we have simply a redness of the margin of the lids, with but little swelling. At this stage there is an increase in the secretion of the glands of the hair-follicles, and the parts appear to be very red and translucent, and very small beads of secretion may be seen collected around the roots of the lashes. Later this secretion appears thicker, and, it may be, forms small scabs consisting of detached epithelial cells mixed with fat granules. These scabs adhere firmly to the skin, and also to the eyelashes, causing the latter to be gath- ered into small pencils of hairs. When this has occurred, the mouths of the glands on the lid-margins become closed, and the secretion inside degenerated, so as to add very greatly to the energy of the disease, since this pent- up old secretion soon becomes very irritating. Therefore there is an increased vascularity of the soft connective tissue surrounding the glands, with a corresponding hy- pertrophy along the whole free margin of the lids. If the little glands have all undergone the same amount of inflammation, the result is an even redness and swell- ing along the whole line of the diseased part; but one or several of the glands may have suffered more than the rest from some accidental cause, and we then find an uneven condition of the lid-margin, the swollen glands presenting the appearance of small nodules. The tissue around the mouths of the glands and around points of exit of the hairs may be entirely broken down (possibly by mechanical pressure), when small abscesses or ulcers will appear, the free surfaces of which are covered with a scab. If we detach these scabs we notice a little cone of pus attached to each one, leaving a corre- sponding conical cavity in the lid-tissue. To this condition of affairs the term blepharitis ciliaris ulcerativa has been applied, but I hardly think we should 787 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dignify it with a special term, since it is one of the acci- dents which may happen at any stage of the disease. It will be noticed in all cases that there is a consider- able increase in vascularity of the lid-margins, and these newly formed vessels not only surround the hair-follicles, but also ramify in the corium and subcutaneous tissue of the lid-margins. Therefore, when the small scabs are de- tached, there is always found more or less blood mixed with the pus along the lid-margin. There may also be active granulations, either around the hair-follicles and glands or within them, and these, too, will bleed when disturbed. As a complication which not infrequently accompanies an acute or even chronic condition of blepharitis ciliaris, we may mention excessive oedema of the lid-margin, or of the whole lid. This may be so extensive and so strik- ing as to monopolize the attention of a superficial ob- server, and lead him into error in diagnosis. Etiology.-The disease may be caused by a primary inflammation of the hair-follicles and glands of the eye- lashes. It may be induced by an abnormal secretion which is irritating. It may also be caused by want of cleanliness, smoke, dust, bad ventilation, or poor food, or even severe straining of the eyes, especially if a condition of hyperopia be present, The presence of lice at the roots of the eyelashes may cause an inflammation, but in this case the little parasite is easily recognized. In many cases a chronic conjunctivitis is the exciting, cause. We must remember that this particular part of the lids is prone to inflammation, since its circulation is a terminal one, and, therefore, very liable to stasis and con- gestion from slight causes. Then, again, it is just at this point that the skin merges into the mucous membrane which lines the inner side of the lid. Remembering this, we can easily imagine how a chronic inflammation of the conjunctiva could be continued on to the mouths of the hair-follicles and glands of the free lid-margin, and cause mischief. Even if there should be a closing of the mouths of these structures by secretions from the conjunctiva, the necessary result would be a damming in of the folli- cular and glandular secretion. This would decompose and result in a blepharitis ciliaris. Also any acute exanthematous disease may produce it, or it may be only a local demonstration of a disease com- mon to other hairy parts. Any one of these conditions may result in a blepharitis, which, when once inaugu- rated, cannot be distinguished from the primary disease originating in the glands and follicles of the lashes. The disease is essentially chronic in its character, and in some instances, when not treated properly, may con- tinue uninterruptedly through life. In other instances the slightest cause may bring on a fresh attack, or the affection may recur periodically without any apparent cause. In women it may return at each monthly period, or it may recur each year at a certain season. The Prognosis of the disease will depend entirely upon the severity of the attack. In the milder forms, and in some of those in which the secretion has a tendency to form crusts over the openings of the follicles, healing may occur spontaneously, or as the result simply of cleanliness. There may be a permanent destruction of a few of the hair-roots, leaving the lid-margin " bald " in places, and the ciliary border may also remain red, but with no other disagreeable symptom. This condition is known as lippitudo. It may be, however, that a certain part of the free margin of the lid has suffered more than its share, and if this be near one of the puncta lacryma- lia, a partial eversion, known as ectropium, will cause the lachrymal point to stand away from the eyeball, so that the tears will not enter its mouth. If this be the case in the lower lid, the tears will run over the face and be very troublesome. The cause of the running over, or the eversion of the lachrymal point (mouth of duct), is known as epiphora, whereas the running over is termed stillici- dium lacrymarum. If there have been a greater activity of the inflammation at one point, as, for instance, be- tween the follicles and the inner surface of the lid, the subsequent cicatricial contraction of the newly formed tissue may pull the eyelashes inward at that point, result- ing in a partial entropium. I have such a patient under my care at present, but a small operation for this will do away with the condition entirely. It has, however, caused him extreme annoyance, and his eyes have been treated for all sorts of troubles, the exciting cause, the rubbing of four or five lashes against the cornea, having been entirely overlooked. It often happens that all the eyelashes are destroyed at their roots and drop out, leaving the whole lid-margin bald, a condition termed madarosis totalis ; or it may be that one or several places are robbed of those protective hairs, when we style the condition madarosis partialis. In some cases the eyelashes along a great extent of the lid- margin are everted, then we call the condition trichiasis. In rarer instances, instead of a destruction of the hair-fol- licles we may have an increase in their number, so as to have a double row of them more or less complete, with the inner row resting against the cornea ; this is known as distichiasis. All of these unpleasant complications are more fre- quently caused by the form of the disease which we may call blepharitis ciliaris suppurativa, much less frequently by that known as blepharitis ciliaris hypertrophica. Treatment.-In the mildest forms the treatment may be restricted to cleansing the eyes frequently, or, in chil- dren, causing them to wash their hands and face several times a day, and insisting on their keeping their clothes clean. The latter, of course, will have no direct bearing on the disease, but nevertheless is of great importance, since it will cultivate a habit of cleanliness in the child, which will be of the greatest benefit. We should also insist on abundant exercise in the fresh air, and good, nutritious diet. If the inflammation is great, we may pull out the eye- lashes where it is necessary. Indeed, this is to be recom- mended for several reasons ; among others, it often has a very beneficial influence upon the course of the disease, many cases being cured by this means alone. We need have no fear in such epilations, since the lashes are sure to come back if their follicles are not already de- stroyed, and in the latter case they will ultimately drop out of themselves. Also, in pulling them out we very ma- terially assist in the process of keeping the lid-margin clean, and render more easy the direct medication of the inflamed parts. If crusts have formed they must be entirely removed before any astringent is used, for if this be not done the treatment will be of no avail. Should the crusts adhere very firmly it would be well to use a mild solution of tannin, applied warm with a soft sponge. As soon as we have cleansed the lid-margins we may use a mild ointment of hydrarg. oxyd. flav., 0.10, with vaseline, 10.00, to be rubbed over the lid-margin with the finger until we are sure that the ointment has come in contact with the inflamed parts. This is to be done whether we have pulled out the eyelashes or not. If there are large crusts which are not easily removed with the eyelashes in situ, and if epilation is very painful, we may cut the lashes olf close to the crusts and then pro- ceed to cleanse. The best time at which to apply the salve is at night, just prior to going to bed, or it may be also used in the morning if deemed necessary; but it is not good prac- tice to use it more than twice daily under any circum- stances. If there be any conjunctival catarrh, we may also brush in a small bit of the same salve into the conjunctival sac. This will suflice in the majority of cases ; but if the dis- ease do not yield it would be well to paint the inflamed lid-margin with a solution of argent, nitric., 0.10, in aquae dest., 20.00, immediately after having removed the crusts, and just before applying the ointment. The same solu- tion of silver will do for use on the conjunctiva. Care must be taken not to dip the brush with which we apply the silver into the bottle, since any organic matter which remains on the brush will reduce the silver and render the solution worthless. Light is not nearly so potent an agent in destroying a silver solution as the presence of organic matter. We should, therefore, previously pour a small quantity of the solution out into another vessel, a 788 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. " salt-cellar " for instance, and dip the brush into this, but never into the bottle. The disease is essentially one of childhood, and almost always is the result of some bad condition of the system, and may be the after-effect of such diseases as measles, etc. The little ones are frequently anaemic and often scrofulous, and should be attended to accordingly; other- wise the local treatment will be much less efficacious. Occasionally we meet with a case which does not im- prove under this treatment, but continues without much change for months. In these we should insist on the es- tablishment of the best hygienic conditions. Make the patient avoid all smoke, dust, badly ventilated rooms, etc., and it may even be necessary to send him to some moun- tainous region, where he should remain until he is well. If the disease returns, we must begin again, as if every relapse were the first attack. So much for the treatment of the disease itself. If there should remain any after-effects, such as turning-in of the eyelashes so as to rub against the cornea, we must operate. A temporary relief may be secured by pulling the offending eyelashes out, but they will surely return and result in the same corneal trouble. Therefore, to put an end to all future anxiety, operate for entropium, and end it. If the lachrymal point should stand away from the globe so that the tears cannot reach it, slit up the canal in such a manner that the opening will lie in contact with the eyeball, but slit it freely. Should we find that our silver solution is too weak, we may increase its strength to one, or even two, per cent. ; and some authors even recommend as high as ten per cent, in rare cases. And further, if there seems to be a tendency to form ulcers which penetrate deeply into the substance of the lid, we may even use the lapis mitigatus. However, in all forms of such powerful agents we must be very careful to close the lids so that the solution does not come in contact with thb cornea. In fact, it would be well to neutralize it almost immediately by washing with a strong solution of sodium chloride. In using the miti- gated stick we must make it very sharp-pointed, and after having thoroughly cleansed the lid-margin, touch only those places where the ulcers are. We may pass the end of the stick into the ulcerous cavity as far up as we can, but great care must be used lest the patient, by some unhappy movement, bring the stick into contact with the cornea, and thereby produce an ulcer of this part as a new complication. If there are many such small ulcers, it will be more prudent to treat only a few of them at each visit; otherwise we may excite more active inflam- mation, with great oedema, etc., and the patient may re- fuse to to be treated further. As is the general rule in ophthalmic, as well as general, surgery, we should be very careful in using even mild astringents in acute cases of blepharitis. It will be found far better to treat the lids with cold applications (even ice) for a little while, and with nothing else, merely en- forcing cleanliness. After the active inflammation has been overcome and the disease is in what we might call a subacute or chronic stage, then the salve and nitrate of silver are to be used. We must never overlook the condition of the conjunc- tiva, since if this be the seat of even a catarrhal inflam- mation, it must be first cured before treatment of the blepharitis can produce any good results. Baldness of the lid, madarosis, is beyond our help. The eye should be protected by glasses, etc. As a hint to those who are not familiar with oph- thalmic surgery, but nevertheless are sometimes obliged to make cold applications to the eye, we would suggest the following method : Procure a large piece of old cloth-linen, if possible- and cut it into strips six inches long and four inches wide, and fold these so as to make ^ads one and a half inch long and one inch wide. If wb wish to treat only one eye, about ten of these will be sufficient. Procure a large piece of ice, and place all of the wads on it at the same time, until they are cold. Then place one at a time on the eye, until it has become somewhat less cold, never letting it get warm ; then remove it to the ice, and take a second piece. If we change them every half- minute or every minute, the eye will soon become cold. If the patient be a child, he will object to them only for a minute or so, and afterward become very fond or them, since they give great relief, especially if much heat and pain be present in the eyelid. Hokdeolum, Chalazion.-The characteristic picture presented by a hordeolum (stye) is a circumscribetl tume- faction, which is generally capped by a whitish point, produced by an excessive inflammation of one of the glands of the free margin of the lid. It is attached to the so-called tarsal cartilage, and the skin of the eye- lid is freely movable over it. Such tumefactions vary in size from a mere point to the dimensions of a large bean, and are hard to the touch, especially if the finger be passed backward and forward over them. They are usu- ally single, but may be found multiple. There are twTo kinds of styes, which we distinguish clinically not so much on account of their nature as from the manner in which they are to be treated. These are the outer stye and the inner stye. If the gland which has caused the stye lie toward the outer side of the tarsal cartilage (or, as we should say, "tarsus," since there is no cartilage in the eyelid), the stye will protrude outward, or toward the outer surface of the lid. If the gland lie on the inner side, the swell- ing will press against the conjunctiva. These little tumors generally grow very rapidly, and from the fact that the gland runs into the firm tissue of the tarsus, the pain and swelling accompanying them are almost always out of all proportion to their size. They may be accompanied by seemingly grave symptoms, such as high fever and great constitutional disturbance, but this is not generally the case. The process may be at times so active that the whole lid will become red, greatly swollen, and cedematous, accompanied by photophobia, ciliary neuralgia, and lachrymation ; but generally we have a more or less rapid formation of pus. This being evacuated, the whole train of symptoms disappear as rapidly as they came, leaving no trace behind them. In some cases we may have certain products of the in- flammation remaining after the pus has been voided and become organized. We then have a chalazion, as we shall see later. Hordeola sometimes " point" at the natural mouth of the gland, viz., on the free margin of the eyelid ; but if one of the long Meibomian glands has been the seat of the trouble, extending, as it does, far up into the palpebral tissue, the pointing may take place either on the outer or on the inner side of the lid. Etiology. Course, and Prognosis.-The cause of a stye may be, of course, an active inflammation which has its seat primarily in the walls of the gland or the circum glandular tissue, or it may be secondary to a contamina- tion of these glands from blepharitis ciliaris, or even from acute or chronic conjunctivitis, either trachomatous or otherwise. As before remarked, they are more often very rapid in their formation, but sometimes they are slow', and even take weeks before they reach their maximum, and then they may slowfly or rapidly pass away. It sometimes even happens that they never come to a head, but are, as it were, "aborted." Again, they may not come to a head, but the walls of the glandular abscess and its con- tents may form a more or less solid new formation and pass into a chalazion. They are almost alw'ays the result of some derange- ment of health, and are more frequent in anaemic and scrofulous individuals. They may also be caused by overwork of the eyes in a bad light, or in rooms with bad ventilation, much dust, etc., and especially when the eye is hyperopic. If any of these conditions are present the stye is apt to be recurrent, so that several will come, one after the other, in about the same place. When the stye is evacuated, its contents are generally found to be pus mixed with epithelial cells from the glandular walls, but sometimes we find lumps of a pecu- 789 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. liar nature, made up of embryonic connective tissue with neoplasmatic blood-vessels. Thus, it is not difficult to understand how it is that, even when the contents are par- tially emptied, we still have a further formation of con- nective tissue with hypertrophy of the epithelial elements of the walls of the gland, producing a structure which we term chalazion, and which is not easily removed except by the knife. A chalazion may therefore be termed a hordeolum in which the active symptoms of irritation have subsided, leaving remnants of the gland and its contents in a more or less organized condition. Both have their origin in the same manner, viz., an inflammation, either primary or secondary, in the Meibomian glands. When the gland is in a state of active inflammation, it constitutes hordeo- lum, but when the inflammatory process has subsided and left an organized residue, it is chalazion. It is there- fore almost unnecessary to say that we may have both ex- ternal and internal chalazia. When we examine a chalazion under the microscope we find that not only the contents of the glands have been changed in character, but also the glandular walls. The chalazion is always smaller at first than the inducing hor- deolum, since the hypersemia is very much reduced, and also a part of its contents has been either evacuated or ab- sorbed. It will be found to be much more compact by shrinking of the newly-formed connective tissue, and may look as if it were almost identical in structure with the tissue of the tarsus. It is attached to the tarsus, and seems as if it were a detached or rather a prolonged por- tion of it. When seen with the naked eye, it presents a shining surface on the inside, with a more or less rough exterior. It is essentially connective tissue, the product of inflammation, as can easily be seen with even low magnifying powers. The ultimate result of a chalazion may be an increase in size of the little tumor, until it results in a deformity which the patient insists on having removed before it has attained its maximum growth. It sometimes, however, attains the dimensions of a large bean. In other cases these tumors shrink, and become so small that we have to hunt for them carefully before finding them. In some, however, we have the lumen remaining filled with pus and detached epithelial cells from the walls of the gland. Or the pus may be wholly absorbed and replaced by a serous fluid, containing chalky deposits, fat granules, cholesterin crystals, etc. Oftentimes the cavity of the chala- zion is divided into compartments by bands of connective tissue, the spaces between which are filled by the above- mentioned compound. In those instances in which the tumor has increased in size, we may find that it is by virtue of an increase in development of connective tissue ; but more frequently the walls of the gland are at fault, in that by proliferat- ing they form cystoid cavities, etc. Treatment.-Of course, the main object in treating a hordeolum or stye is to get rid of it as soon as possible. If there have been no formation of pus, it would be well to try and prevent such formation by active antiphlogistic measures. And for this ice applications will be found to act very well in some cases. This is to be especially rec- ommended in those cases in which the disease com- mences actively, with great swelling of the lid and severe pain. The ice-wads should be applied constantly in the severest forms, but when the process seems to be less en- ergetic we may restrict the applications to a few hours a day. When the abscess seems to be formed but not well defined, we must apply warm, not hot, applications, for the purpose of making it come to "a head." As soon as there is pus it must be let out immediately. In fact, a hordeolum is simply an abscess, and we treat it as we do ordinary abscess of the lid (see section relating to Abscess of Lid). In rare instances, when the mouth of the gland isopen, we may evacuate the pus by pressure, but as a general rule the use of the knife is to be preferred. The rule is not to wait too long before cutting, since in all cases a deep incision will certainly do good in relieving the pain and in preventing swelling ; better cut too early than too late. If we have made a small incision and find that but little pus comes out, or there is an admixture of lumpy embryonic connective tissue, it would be well to enlarge the opening and make warm applications so as to bring about free suppuration, with the view of obviating the formation of a chalazion which will have to be removed with the knife at some future time. While making the warm applications care should be taken to pass a probe into the cavity of the abscess often enough to keep it from closing up. In some cases, when the cavity is al- ready filled with connective tissue difficult of removal, we may pass a stick of lapis infernalis mitigatus deep into the hole to destroy such tissue. After all the new products of inflammation have been removed from the hordeolum we may let it alone, for in the great majority of cases a cure is the immediate result. If we have to deal with a chalazion I think there is but one way to proceed. Many authors recommend ap- plications of strong astringents over the tumor. Many insist on cutting the sac open by a deep and long inci- sion, pressing the contents out, and treating the inside of the sac with strong caustics. Against all of these the ob- jection may be brought that such a course of treatment is very long, and the very best result will be the leaving within the eyelid of the hypertrophied wall of the gland, which is liable at any time to proliferate and bring on the same, if not a worse, trouble, in the shape of glanduloma. Therefore, it is to be recommended to remove these lit- tle tumors with the knife, but in a very careful and pre- cise manner. The most elegant way of doing this is to use Knapp's modification of Desmarre's lid-clamp. Adjust the instrument so that the whole tumor is free in the en- closure, and carefully dissect the entire sac out at once. Not the slightest portion of the sac should remain, since it will be liable to grow and bring about a relapse. We can be perfectly certain that we have removed the whole affair if we do not cut the sac, and this is the only assur- ance we have. It is easy to avoid cutting it if we go slowly, since the clamp will render the operation blood- less, and also cause the whole tumor to stand out dis- tinctly, enabling us to see just what we are doing, and to know the effect of each and every cut. One more suggestion may be made, viz.: when the chala- zion is on the upper lid it must be removed from the outer side of the lid, since if we cut from the inner side we may produce a cicatrix, which will constantly rub against the cornea and produce constant trouble. If the under lid is affected we may remove the tumor from the inner side by everting the lid with the clamp, since this lid does not come in contact with the cornea in the ordinary motions of the eyeball. The inner sur- face of the lid is to be preferred because the wound will be cut off from the atmosphere when the lid falls back into position, and the healing will be much more smooth, rapid, and complete. The clamp will generally render the lid so anaesthetic that the operation will not be accompanied with any great amount of pain ; but to be sure of a bloodless and painless operation, we may inject a few drops of cocaine around the tumor before applying the lid-clamp. Ptosis Palpebr^e Superioris.-As the name implies, this disease is a paralysis of the levator muscle of the up- per lid. The diagnosis is easy, since the lid always hangs down, and covers the eyeball, the patient being unable to raise it without external assistance. It may be total or only partial, and either congenital or acquired. When the disease is congenital the rule is that it gener- ally improves with age, and often very markedly during the first few years of life. Therefore, we should not be in too great a hurry to operate on such eyelids in children. The cause of the disease in children is very obscure, especially when we remember the almost invariable im- provement which takes place as the child grows older. In acquired ptosis the great majority of cases are the result of syphilis, and, therefore, the patient has a good chance of recovery by simple medicinal treatment of his disease. The probable cause in these cases also is not very evi- dent, unless it be a very circumscribed gumma or other syphilitic product near the floor of the fourth ventricle 790 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. of the brain, since, in many cases, we simply have that part of the third nerve which controls the levator palpe- brae superioris involved, those branches which control the other muscles of the eyeball remaining in a normal condi- tion. And the disease is usually situated on one side only, as are indeed the vast majority of syphilitic eye troubles. Sometimes, however, we see the whole nerve paralyzed, and then the seat of the disease is evident. In other cases we have ptosis without any syphilitic contamination, resulting from a cold, or from some cause which is very obscure. These last are the cases which seem to be more troublesome than any other kind, some of them remaining unchanged throughout life, unless treated in the manner to be described below. Many authors state that they obtain good results from treating such paralyses with electricity, but it must be acknowledged that it is very unsatisfactory. However, many cases do well under treatment with iodide of potas- sium combined with mercury in some form, whether sy- philis be the cause of the disease or not. Electricity may be used in conjunction with this. In those cases which have remained stationary for a long period, it is hardly worth while to try this treatment for any length of time, but resort should be had to an operation-one which should be done at leisure, since it is one of the most delicate in all ophthalmic surgery. For instance, if the effect of the operation be not sufficient we have lost our first chance of success, since the lid will still droop too much and cover the pupil, rendering the eye useless. On the other hand, if the lid have been shortened too much, so that the eyeball cannot be covered by the action of the sphincter muscle, corneal ulceration, or at least an incurable chronic conjunctivitis, will certain- ly result. In this operation, therefore, superior knowledge and skill on the part of the operator are absolutely neces- sary. It is sometimes marvellous what an eye will stand and recover from, in the shape of clumsy work in other operative procedures ; bht the bungling operator will cer- tainly meet with disaster when he attempts to correct a ptosis. In the case of complete ptosis, a new operation has been introduced which is ingenious in its conception and comparatively easy of execution. It consists in removing so much of the skin, subcutaneous tissue, and even muscle, that the patient can still close the lid with ease with his sphincter or orbicular muscle. The wound is left to cic- atrize so as to form a band of connective tissue along the lid parallel to the free lid-margin. Then several large needles with thick thread (doubled is better) are passed from below the cicatricial band through the band, and along the middle of the eyelid over the supra-orbital ridge and into the tissue of the supra-orbital muscle. Three or four of such threads should be put into the appropriate positions, and the threads allowed to remain in the tissue oi the lid until they produce tracts of suppuration. They are then removed, and after free suppuration has gone on for a time, the tracts are allowed to heal. In this way four connective-tissue cords will be produced, ex- tending from the band parallel to the lid-margin to the supra-orbicular muscle. It is easy to see that the patient will be able to raise his lid by means of the supra-orbicu- laris, and it is really astonishing to notice the ease and rapidity with which he trains this muscle to take the place of his lame levator palpebrae superioris. A convenient way of determining just how much tissue can be removed from the eyelid and still allow the lid sphincter to close the eye easily, is to take a broad pair of forceps and pinch up the tissue, requesting the patient to close his eye. By taking up a little more tissue at each trial a limit will soon be reached beyond which the eye cannot be closed. Beyond this we dare not cut. In fact, it is not desirable to cut up to this limit, since we must allow for the subsequent cicatricial contraction. A convenient pair of T-shaped forceps, very much like a pair of oyster-tongs without the teeth, has been ar- ranged for taking up the tissue of the lids all along the lid-margin at once. This instrument is doubly conven- ient. from the fact that we can at once proceed to snip off the tissue held in the forceps by a few cuts with the scissors, thus leaving the exact area over which we must cut away the subcutaneous tissue, provided this tissue have not already been removed by the first cutting. The operation may be performed with great exactness and beauty by a surgeon of experience, but it must be acknowledged that in comparatively inexperienced hands it is oftentimes unsatisfactory. If there be only a partial paralysis of the elevator mus- cle of the upper lid, it becomes a very delicate matter to adjust our operation to the requirements of each case. Tiie T-shaped forceps should be carefully used until we arrive at the best possible adjustment. The included tis- sue is then removed, and a sufficient number of sutures put in. Ankyloblepharon, Blepharophimosis.-This is a condition in which the two eyelids, from some cause or other, have grown together, closing the palpebral fissure either totally or in part. It may be congenital or ac- quired. As to the etiology of congenital ankyloblepharon, its oc- currence is easy to explain if we remember the method of development of the eyelids. In the beginning the lids are simple folds of the ectoderm, or, rather, just behind the equator of the embryonic eyeball a nodule is formed on each side, above and below which there is an outgrowth from the general surface of the head. These elevations increase in size and bend over to be closely applied to the young globe, advancing continually until they meet each other over the front part of the cornea, and completely coalesce, pressing tightly on the developing cornea. At a certain stage, if all goes well, this membrane is divided along the line which marks the future palpebral fissure, and the two lids are thus formed. It sometimes happens, however, that this separation does not take place, and we then find the lids adhering together after birth, produc- ing the condition known as congenital ankyloblepharon. If there have been a failure of the separation along the whole line of the palpebral fissure, the ankyloblepharon is complete or total. If the separation have taken place in part, it may be at one or more places only, the anky- loblepharon is partial. The character of the tissue holding the lids together will vary from a simple continuation of the conjunctiva from one lid to the other, to a total agglutination of the whole thickness of the two lids. In the majority of cases the attachment is confined to the outer or inner end of the palpebral fissure, and this is easily explained by the fact that the original separation of embryonic lids com- mences in the middle of the fissure and progresses toward the sides. If, therefore, the progress of separation should cease at any time, the result would be a union of the lids at the sides only, leaving the palpebral fissure open in the middle ; but the fissure will be too short. This condition we call congenital blepharophimosis. The two conditions are, therefore, caused in the same way. And one or the other degree may also exist in the acquired affection following upon an extra-uterine inflammation. The fusion is much more frequently seen at the outer limit of the palpebral fissure than at the inner, from the fact that in the young animal there is another formation going on rapidly at the inner angle, which has a tendency to separate the lids at this point. This formation is the membrana nictitans, or that part of the lids and conjunc- tiva which forms the caruncula lachrymalis in man. Both of the conditions of ankyloblepharon and ble- phoraphimosis are disagreeable, since they shut off a cer- tain area of the field of vision, and are also liable to produce pressure on the eye. They should, therefore, always be corrected as soon as possible. In acquired forms they are always the result of inflam- mation, either of blepharitis ciliaris, or of excoriations of the lid-margins by acrid secretions, burns, or wounds, or they may result from long-standing chronic conjunc- tivitis, especially from the trachomatous variety. Treatment.-The treatment of ankyloblepharon con- sists, of course, in division of the tissue which binds the two lids together, which can only be accomplished by cutting. The extra tissue should be cut off close to the free margin of the lid by means of a pair of scissors, one 791 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. blade of which is passed between the tissue and the cornea, care being taken to remove all of it. The whole ques- tion of success of the operation will then lie in the pre- vention of new adhesions between the cut surfaces; a bandage is, therefore, hardly to be recommended. We may paint the cut surfaces with collodion, or place a piece of gold-beater's skin over them, taking care that the lids should be held open as much as possible. There is not nearly so much danger of the union taking place at the inner angle of the palpebral fissure as at the outer, and if the tissue has extended to the outer canthus it would be well, and in some cases necessary, to supple- ment the cutting away of the new tissue by transplanting the conjunctiva, so as to bring it between the lids at this point, an operation known as canthoplasty. Blepharophimosis in general is restricted to a grow- ing together of the eyelids at the outer canthus. It causes a narrowing and shortening of the palpebral fissure and a pressure on the eyeball. The operation of cantho- plasty is resorted to for its relief. In dividing the tissue with the scissors, care must be taken that the incision be made in a line which is the exact continuation of the pal- pebral fissure. After division is accomplished the con- junctiva is seized at the outer angle and dissected away from the globe, with as much sub-conjunctival tissue as possible. If the lids are stretched apart the cut surface be- tween them will be in the shape of an isoscelese triangle. A suture is passed through that part of the detached con- junctiva which lies just beneath the angle of the palpe- bral tissue, and this is then brought into the angle between the two equal sides of the triangle. The con- junctiva is also attached to the two angles at the base of the triangle, and in this way the whole cut surface will be covered by the conjunctiva, thus preventing reunion of the separated lids. In very rare cases it is found that the outer angle of the triangle above mentioned is so far from the conjunctiva that the latter cannot be brought fully up to the end of the cut surface. In such cases we must sew it as far out as we can bring it without tearing it, but in no case should we fail to put in the other two sutures. The operation is then not a typical one, but it often proves quite suc- cessful. Symblepharon.-As the name implies, this affection consists in an attachment of one or both of the eyelids to the globe of the eye. Like ankyloblepharon, it may be either congenital or acquired. When congenital it may be of any extent, from a condition in which there is attachment of the whole lid to the eyeball to one in which adhesion exists at only a small part of the surface. We distinguish two kinds of symblepharon, viz., symblepharon anterius, and symble- pharon posticum. The former consists in an actual grow- ing together of the lid to the eyeball near the lid-margin and the cornea ; in the latter, the conjunctiva is shortened at the fornix, or there may be strings of connective tissue extending from the lid to the region of the sclera. In the former case the connecting tissue is generally a more or less solid neoplastic structure, which in the congenital forms includes the whole tissue of the lid, and in the ac- quired variety consists of connective tissue which has resulted from an organization of active granulations. This tissue usually springs from near the middle of the lid, and near the free lid-margin, or it may be a solid band of new growth extending the whole depth of the conjunctival sac. Its extent will depend on the extent of the injury producing it, in acquired cases, or upon the stage of development at which the defect has occurred in congenital symblephara. The connecting band has, generally, the form of a fan or double fan, one spreading out over the sclera and cor- nea, the other into the tissue of the lid. These fans con- sist of bands of connective tissue, which can be followed with the microscope for some distance into the respec- tive tissues. In the posterior varieties the bands of connective tissue, ■which are covered by conjunctiva as long as they are pass- ing in the region of the fornix conjunctivae, are imbedded in the submucosa both of the bulbar and of the palpebral conjunctiva. They seldom pass deep into the tissue of the lids or into that of the sclera, and when they do, only a few isolated bands of connective tissue can be followed into these structures. If the symblepharon occurs at the outer canthus or outer angle of the palpebral fissure, it is usually of a solid nature, composed of dense fibrous connective tissue ; and when at the inner canthus, the whole caruncula lachrymal- lis and semilunar fold (plica semilunaris conjunctivae) will be found included in it. In such cases the connective- tissue bands extend not only from the tarsi of the lids to the sclera, but also deep in behind the eye, where they become attached to the capsule of Tenon and even to the periosteum of the orbit. Now and then we meet with a variety of symblepharon which consists of isolated bands of connective tissue, cov- ered by conjunctiva, extending from the tarsus of the lid to the scleral or corneal tissue ; these are always congen- ital, and their production is easily explained. Again, there is a variety which consists of a membranous band, extending across and dividing the conjunctival sac into two distinct compartments. This I have never seen my- self, but have found it several times described in ophthal- mic literature. Those cases in which the connecting tissue is of solid structure, rich in blood and lymph-vessels, have received the name of symblepharon carnosum; those in which it is in the form of a membrane, symblepharon membrano- sum; and when there are but a few isolated bands ex- tending from the lid to the eyeball the condition is called symblepharon trabeculare. So long as the symblepharon is confined to the region of the fornix conjunctivae (where the conjunctiva is re- flected from the lid on to the eyeball), and does not im- pede the motions of the eye too much, it will do but little harm, and we may pay no attention to it. In those cases in which the attachment is nearer the margin of the lid and the cornea, we are often called upon to operate, since the pupil is often covered to a greater or less ex- tent, or, where it is not, the bands of attachment pull on the eye and the lid with each motion of either of these organs, and are thus a constant source of irritation. Again, they may be so attached that the lid margin will be pulled out of place, producing an ectropium when- ever the visual axis is turned in a certain direction, or the ectropium may be permanent as long as the symblepharon exists. Etiology.-In order to understand the mode of forma- tion of a congenital symblepharon we must remember the manner of development of the embryonic eyelid. We have many varieties of intra-uterine inflammation of the eyes, but if the symblepharon have been caused by such in- flammations it does not differ in its etiology from the same condition acquired in after-life. Although it is true that these forms exist at the birth of the child, we do not re- gard them as real congenital conditions, since the latter term is more properly restricted to a malformation which is the result of some fault in development. Therefore, under the head of congenital symblephara we will include only the latter group of cases. In the earliest stages of palpebral development the lids extend over the whole eye and are firmly attached to each other, there being no palpebral fissure. They are also very firmly pressed against the cornea in many cases, pushing the corneal tissue out of shape, the latter some- times being raised into an irregular protuberance along the weak line of junction of the lids. I have seen such cases while studying the development of the eye ; they presented a condition in which the epithelial suture which binds the young lids together over the cornea was intact toward the outer surface of the lids, but entirely broken by a protuberance of corneal tissue on the inner surface. Just here, in several cases, the young epithelium of the inner side of the eyelid and that of the cornea seemed to be so mixed up and detached that it was hardly possible to distinguish the palpebral from the corneal. At places, there were very few epithelial cells between that part of the mesoderm which was to form the body of the embry- onic eyelid and that forming the corneal substance. We 792 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. can easily imagine that these two portions of the meso- derm might coalesce, and remain attached to each other during after-life. If this should occur, the shape, extent, and kind of a congenital symblepharon would then de- pend only upon the manner and extent of attachment of the young lid to the embryonic cornea. The mode of formation of acquired symblepharon is much more easily studied, since we can note the cause and examine every stage of the development. All the acquired forms are caused by some extreme violence to the eye, such as extensive burns either with hot materials or with some strong chemical reagent com- ing in contact with the eyeball and the lid at the same time. The entrance of unslaked lime into the eye is almost certainly followed by symblepharon; the tears slake the lime, and the heat so produced destroys not only the epithelium but a large portion of the substance of both the lid and the cornea. Symblepharon may also be caused by the careless use of very strong solutions of nitrate of silver or any of the energetic caustics which are sometimes put into the eye. And we may also have it caused by conjunctivitis degen- erativa, in which the epithelium and submucosa of this membrane have been destroyed. This condition is then usually the result of the adhesion of two opposing raw surfaces, but union does not occur immediately, as it does in congenital symblepharon, but through the medium of organized granulations. In those cases in which the con- junctiva is reflected over the bands the membrane is of a later formation. When the connecting tissue is very strong, it is prob- able that after the band has been produced by the organ- ization of granulating tissue, it increases in volume on account of the continual irritation caused by the almost constant motions of the eyeball and the lid. The shape which the symblepharon will assume ulti- mately will depend upon the extent and configuration of the original lesion, as well as upon the amount of irrita- tion caused by the motions just referred to. Treatment.-If we have seen the patient after he has experienced any of the above traumata, and have noticed that there has been a destruction of the palpebral and bul- bar conjunctiva, or of the cornea, our duty is simply to keep these denuded parts separated from each other, since it is oftentimes easier to prevent the formation of sym- blepharon than it is to correct one after it has been formed. In many cases we can accomplish this by telling the patient to move his eye as much as possible, and every half hour or so to seize the lid between his thumb and forefinger and raise it away from the globe. When granulations exist, they should be painted over with a moderately strong solution of nitrate of silver several times daily. In case the symblepharon has commenced to be formed near the fornix conjunctivae, this mode of procedure will ac- complish but little toward breaking it up, since in any possible motion of the eye the two raw surfaces will make the same excursion, and remain in the same rela- tive position. We should do all in our power to prevent the attachment from taking place any further from the fornix conjunctivae than possible, and if it cannot be ac- complished by any other method, the lid should be everted, and held in that position until the granulations have become at least partially cicatrized. Such a pro- ceeding is easily accomplished in the case of the upper lid, but the anatomical relations of the parts are against it in the under lid, unless we prolong the palpebral fis- sure by freely cutting the lids apart at the outer canthus in the same manner as we do in the first step in the oper- ation of canthoplasty (see the section on treatment of Blepharophimosis). The under lid will then fall away from the eyeball, and may be kept away from the globe as long as we please. Of course, after the cicatrization of the denuded sur- faces on the eyeball and the lid, we can easily replace the lid by freshening up the edges of our cut at the outer canthus and stitching the wound. All such methods as putting any hard substance, such as glass or gutta-per- cha, between the two granulating surfaces to keep them apart, painting the parts with collodion, or pasting court- plaster over them, are not to be recommended, since they are found by experience to do but little good, and they are certainly the cause of great irritation when in situ. The only method which we can rely upon is that of keeping the granulating surfaces apart, with nothing be- tween them but the atmosphere, and even this is irritat- ing enough. If the symblepharon have been already formed, we can only rely upon an operation, and even the effect of this will depend upon the nature and also upon the ex- tent of the symblepharon. In whatever condition we find the connection, we must always remember that after we have finished the operation we must not leave two raw surfaces opposite each other, lest we invite the re- turn of the condition for w'hich wre have just operated. Therefore, if the symblepharon is of the trabecular or membranous variety, we can detach it close up to the eye- ball, but let it remain hanging to the lid. We can then pass a thread through the free end, and suture the cut end in the conjunctival sac as far as possible from the cor- neal wound. It should be allowed to remain in this po- sition until the globe has cicatrized, when we may cut it off close to the lid, with a reasonable hope that the sym- blepharon will be radically cured, especially if it was not an extensive one. However small the wound may be which was pro- duced by detaching the neoplastic tissue from the globe, we should always try to cover it with the conjunctiva by dissecting the latter up for some distance around, and putting delicate sutures in it to unite it over the cut sur- face. The same may be said of the wound resulting from the detachment of the new tissue from the eyelid. If the connecting link be so short that we cannot stitch the end of it out of the area of the corneal w'ound of the operation, it would be well to stretch it as much as we can, and it may also be well to slit the outer canthus, as already described. We should give a symblepharon no chance whatever, that we can help, to re-establish itself, for it is remarkable how quickly and how persistently it will take advantage of it, no matter how small and inno- cent-looking it may be. If the symblepharon is of moderate dimensions and sit- uated at the fornix conjunctivas, we can seldom cure it by the foregoing operation. We can often reduce its size materially by cutting as much of it away as possible, and by painting the wounds with nitrate of silver, and break- ing up the intervening granulations with a probe when they commence to form. But, as has been said before, if the neoplastic tissue is small in the beginning, we may often neglect it entirely, since it will not impede the mo- tions of the eye to any great extent. By far the most troublesome variety to treat is that W'hich commences at the fornix conjunctivae, and extends all the way up to the free margin of the lid. It has been found by experience that it is better to first cut away that part of it which lies near the fornix and allow it to heal, if possible, and then to attack the remaining portion. In doing away with the former part we can almost always find enough healthy conjunctiva in the vicinity to trans- plant in between the cut surfaces, and if we can accom- plish this our chances of success are greatly improved. Some operators seize the symblepharon and raise it away from the eye, with the lid everted as much as pos- sible, and then pierce the neoplastic tissue, and run a piece of wire through it and let it remain. I should pre- fer a thick piece of catgut or india-rubber ; but, whether it be wire or one of the latter substances, it is to remain in the canal made for it until the walls of this canal shall have become covered with epithelium, making a kind of fistula through the neoplasm. This is very much to be desired, because in all cases in which the symblepharon is to re-establish itself, it always commences near the fornix conjunctivae. After the fistula has been well established the succeeding steps of the operation will be much easier. If we find that the wire or the catgut is not easily kept in place, we may bring the ends out and bend them over on to the outer surface of the lid, and secure them with court-plaster or some such contrivance. It may be that, after waiting about two weeks, if we 793 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tighten the wire or catgut by pulling it gently out and again attaching it, we can destroy a second portion of the neoplasm by pressure. By doing this several times we may even succeed in removing the w'hole neoplastic tissue, but we can hardly hope to accomplish this in all cases. It is, however, well worth a trial. Great care must be taken not to shorten the wire or catgut too early, or we may cut away some of the tissue before the canal, in which it was lying just previously, has become lined with epithelium. If this be the case the symblepharon will certainly return. There is still another method, which, though more rapid, is not so sure. This consists in detaching the neo- plastic tissue from the cornea and the globe throughout its whole extent, and then passing a suture through each corner of the new tissue which was before in contact with the cornea. The needles should be passed through the fornix conjunctivae, and brought out on the outer sur- face of the lid. By drawing on the sutures we can then evert the whole new tissue so as to bring what was before its top (running across from the cornea to the lid-margin) into apposition with the wound made along the globe by the operation. After the two sutures have been tied on the outside of the lid, we must then cover the wound on the globe, or as much of it as possible, by transplanting conjunctiva over it. When this has become cicatrized we may then proceed to remove the whole neoplastic tissue from the lid, and the operation will be complete. Our success will depend much upon the amount of healthy conjunctiva which is at our disposal to cover up the fresh surface on the globe ; in fact, even more upon this than upon the extent or char- acter of the symblepharon. If there be none in the vicin- ity our chances are very much reduced. Several operators have tried the experiment of grafting the conjunctiva of a rabbit over the wound in lieu of the natural membrane of the eye, but their efforts have not been very successful. Nevertheless, where there is abso- lutely no conjunctiva left for us, we may try the experi- ment, since the idea is a decidedly rational one. Trichiasis, Distichiasis.-Trichiasis is a term applied to the condition in which the eyelashes are so changed in their direction that they come in contact with the cor- nea or conjunctiva. The true condition of trichiasis-or trichiasis in a restricted sense-is that in which the eye- lashes themselves are at fault, in that they have so changed the direction of their growth as to bend down upon the globe of the eye. We, however, include in the term also those cases in which the hairs are made to touch the eyeball from malposition of the free margin of the lid, even if the lashes are still growing in a relatively normal direction to the position of the lid (slight entropium). The lashes themselves may be wholly normal in trichi- asis, or they may be bent and short, and growing in every direction. We may also have, in addition to the usual quantity of large eyelashes, numerous smaller, col- orless ones, which frequently come, several from one hair- follicle. This condition must not be confounded with distichiasis, since in the latter case there is an increase in the number of follicles forming two rows of lashes, whereas in the above conditions this number is not in- creased. When the eyelashes lie constantly in contact with the cornea and conjunctiva, or come in contact with them when the lids are closed, they act as any other foreign body would do, and cause great irritation. They produce an irritation, with photophobia and increased lachrymation, which is very apt to be combined with spasm of the lid. The latter causes still greater irritation, and we soon have an acute or chronic conjunctivitis, and often also all the stages of keratitis, from simple corneal irritation to deep ulceration and keratitis pannosa. The conjunctiva may become hypertrophied in the beginning and then atrophic, and the cornea opaque, either in part or over its whole extent. The inflammation may extend to the inner tunics of the eye, producing panophthalmitis and a total atrophy of the globe. Distichiasis is an affection in which there are two dis- tinct rows of hair-follicles with eyelashes. In this con- dition the second row often has an abnormal direction and comes in contact with the eyeball. The lashes are often more luxuriant in their growth near the canthi, and may be only isolated along the middle portions of the lids. They are always more numerous on the upper lid than on the lower. The hairs of this inner row may be of about the same size as the normal lashes, but they are more frequently very fine and colorless, so that they must be looked for with the utmost care in order to be detected. However, if we place the edge of the lid in such a position that it has the black pupil as a background, and then look along it we can usually see them, even if they were invisible when the other parts of the cornea or sclera were behind them. In a great number of cases distichiasis must be looked upon as congenital, the presence of a second row, or at least an increased number of hair-follicles having been produced at the same time at which the follicles of the ordinary eyelashes were formed. The probable reason why we find that these supernumerary lashes, or pseudo- cilia, make their appearance for the first time at the age of puberty, is that this is the particular time of life at which extra hairs appear on other portions of the body, their follicles having hibernated, as it were, up to this period. However, the rule is that both distichiasis and trichiasis are secondary affections, depending upon an earlier blepharitis ciliaris (q. ®.) or a long-standing chronic conjunctivitis, especially of the trachomatous variety. It is easy to imagine that in an excessive inflammation of the follicles of the lashes they may so send out their hairs as to force them into an abnormal direction, just as we find a similar condition in the " kinky " hair of the negro. The hairs themselves may split, or the original hair-folli- cles sprout and increase their number. All of this has been observed under the microscope ; not, of course, the active process, but its result. Treatment.-The first thought which will occur to every one is to get rid of the hairs which are rubbing on the cornea, and this by pulling them out. This is good practice, at least for temporary relief, and es- pecially if the offending lashes are few in number; indeed it may happen in rare instances that by re- peatedly pulling them out the hair-follicles will atrophy, and the entire condition be corrected. In the great ma- jority of cases, however, this will not be the case, but the lashes will return again and again. Our next idea will then be to so change the anatomical relations of the parts that the eyelashes will not point in the direction of the cornea, but assume a natural posi- tion. The removal of offending eyelashes is best done with a pair of epilation forceps, made specially for that purpose. Great care should be taken that every one of the hairs be seized and extracted. They are sometimes exceedingly fine and colorless, so that they will not be seen at first, unless we use a lens for that purpose, either as a magni- fier or as a condenser of light on the parts inspected. It is, indeed, good practice, after we have removed all that we can actually see, to go over the ground again, slowly, and close the forceps at every point, whether it catches a a lash or not. By the oft-repeated extraction of the lashes we may be able to cause an atrophy of the hair-follicle, especially if the disease be restricted to a small area. But if any considerable extent of lid-margin be included in the trichiasis or distichiasis, we can hardly hope for such a result, and should at once proceed to operate by one of the several recognized methods for entropium (see the sec- tion on Entropium). If only one or a few lashes are offending, the resort to an operation for entropium is not to be advised. It will be found far better to destroy the hair-follicle, or follicles of these lashes, so as to do away with them entirely. This is best done by running a small lance-shaped knife along the hair, up into the follicle, and then passing a sharp stick of nitrate of silver into the wound. It may also be done with an electro-cautery, and, in fact, the latter is to be pre- ferred, since there is far less danger of serious damage to the cornea in its application. If there are several follicles 794 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. to be destroyed, we should not undertake to accomplish their destruction at one sitting, but let the patient return several times, if necessary, since too extensive a destruc- tion of the lid-margin tissue at one time is apt to set up so great an amount of reaction that other hairs, which have before had a normal direction, may be displaced, and their destruction become also necessary. The other diseases of the lids are rare, and we would therefore refer the reader to the general ophthalmologi- cal literature for their description, and also for the min- ute details of operations on the eyelids. William C. Ayres. the part at which the enveloping material is the weakest, unless, perchance, that part, at the time of the stress, is better supported by the pressure of neighboring parts, or unless some other portion is made comparatively weak by the pressure of some foreign substance which bends or indents it, and so places on it a local strain that cannot be transmitted. Contke-coup.-Rupture by contre coup is not possible in the eye, though it is sometimes spoken of as having taken place. If contre-coup means anything, it means a blow from the opposite direction, as when a walnut held on the edge of the table is struck by the hammer, and broken by the table on the side opposite the hammer (see Fig. 1069). This explains certain fractures at the base of the skull, but not at the posterior pole of the sclerotic, which is so cush- ioned in fat as to render such a condition of things improbable. Contre-coup may also be used to designate the kind of fracture which takes place in a body whose strength is distributed like that of the shell in Fig. 1070, so that the force of a blow struck at a will be transmitted to b, where the fracture will occur, whether it has or has not the support of any other substance at c. Such conditions are not possible to any flexible body like the sclera, and it is hardly justifiable to speak of a rupture as by contre- coup, when it is merely the case of a flexible hollow sphere, whose walls are put by pressure in a state of uni- formly increased tension, until they give way at the weak- est part to which the force is transmitted. The conditions which better illustrate ruptures of the globe that take place at a point somewhat removed from the point of contact with the foreign substance are seen in a rubber ball compressed between two flat surfaces, as in Fig. 1071. If the walls are of uniform strength, the friction of the compressing bodies at the points of contact, a, a, a, and b, b, b, will prevent the separating of the walls which are thus supported, but the break will take place at some part which is not thus supported, as at c or d. Without having at hand any experiments which may be quoted as giving definite knowledge of the actual strength of the materials used in the structure of the eye, it is possible to state, from re- cords kept in cases of injury, that the part which is least capable of resisting strain put upon it by external pressure is the sclerotic, three or four mil- limetres from the s c 1 e ro - c o r n e a 1 margin. This is by far the most frequent seat of rupture, which nearly always takes place in a direction parallel to the sclero-corneal margin. The fact that it is usually found to have broken through the meridional fibres in the upper and inner quadrant is probably explained by the position of the surrounding parts, which are such as to protect it from external pressure, and yet to give little or no support when the eye is pressed upon from some other direction. The cornea rarely ruptures, and when it does, it is from some ragged extension of an irregular sclerotic tear, and is not to be looked upon as primarily a EYE, INJURIES OF. It will be proper, in writing on injuries of the eye, to take for granted that the reader is well acquainted with the anatomy and physiology of that organ, and such of its appendages and surroundings as, on account of structure, function, or situation, are likely, in case of injury, to require treatment differing in any way from that which would be suggested by the prin- ciples of general medicine and surgery. It is understood, too, that the reader has acquired the art of using easily and well all the instruments and methods needed by the oculist for the diagnosis and treatment of those affections which are not traumatic. One requires, in handling cases of injury, not only to have at command an ophthalmoscope and a full case of surgi- cal instruments, but to be well drilled in their use, and to possess also a certain adaptability to the situation and independence of thought and action, which will allow him to depart occasionally from conventionalities, and in emergency to use instruments for what they are worth, not necessarily for what they are made. For, though the results of violence may be routined off and classified as to the kind of operative inter- ference that they may require, it is oftener in this branch than in any other that the surgeon will discover new and unprecedented situations, or conditions which occur so infrequently as to have existed in literature only as for- gotten curiosities. Physical Conditions. - A word or two relative to the physi- cal conditions which exist in the healthy eye may be of service in helping to appreciate those which are likely to exist in the injured organ, or in one in which inflammatory changes following injury have not been met by the necessary surgical inter- ference. The eye is a globe ; it is filled with fluid, semifluid, or gelatinous matter which is practically incompressible. Its walls, though elastic and flexible, cannot be stretched very much, and as the sphere is that form which will con- tain the largest amount of matter within a given area of covering, the result is, there being no outlet, that if pres- sure is put upon this globe it will not change its shape very much without rupture. The physical conditions are very much the same as those of a leather ball filled with water-not those that exist in a rubber ball filled with air. The walls of this globe are very flexible, and when emp- tied, any part of the sclerotic or cornea can be bent on itself like cloth. Neither of these tissues, either with or without its lining membrane, is subject to fracture in the true sense of the -word, as the shell of a walnut would be fractured ; and when there is any complete and violent solution of continuity in these parts it is due either to laceration, to puncture, to cutting from some sharp sub- stance, or to tension-never to any other cause. And the particular part at which the rupture takes place will be Fig. 1070. Fig. 1069. Fig. 1071. 795 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. corneal lesion. The thickness of the sclerotic and cornea in the accompanying cut is not to show the actual size, but to indicate diagrammatically the relative liability of different parts to give way whenever, from any cause, sufficient pressure is put upon the eye itself to make a rupture of its tunics inevitable. In the same figure the choroid is drawn as if it were attached to the inner side of the sclera only at the nerve, at the venae vorticosae, and at the ciliary processes (Nos. 1, 2, 3). This is not really the fact, but it is so much more loosely attached at the in- termediate points that, whenever the choroid itself rupt- ures-as it sometimes does if pressure so distorts the eye as to pull this membrane away from the overlying sclera- the break does not occur at any of the three points named above, but at some intermediate place. Such ruptures are most frequently seen, of course, in the posterior part of the eye, often nearer the nerve than the equator. They also do occur anterior to the vense vorticosae, and some- times so far forward as to be unrecognizable during life. The lens, in its capsule, and the suspensory ligament form rather an unsubstantial partition between the anterior and posterior chambers, and, while the outer tunics are intact, this structure is not very likely to be ruptured by any pressure which is uniformly distributed over the outside surface of that organ; but a distortion of the form when removed from that element. When the sup- port of the lens is removed from behind it, it trembles with every movement. If there is a leak in the cornea in front of it, it is drawn into the opening, however slight, and unless extra precautions are taken it is sure to get in the way and interfere with the execution of any op- eration which is planned in the cavity that contains it. It is well, of course, to know the strength as well as the weakness of different parts. The cornea is as deceptive in its strength as is the iris in its weakness. The reason that the amateur of the workshop so often fails to remove small foreign bodies which have stuck fast in the cornea is because he has been afraid to more than touch it for fear of penetration. This is an accident much more likely to happen to the professional than to the amateur; but in view of the serious result of such accidents, it is well perhaps that the popular impressions be allowed to obtain. Still, though the cornea looks as fragile as a bubble, it will withstand considerable rough treatment from the hand of an expert. It is hard and almost liga- mentous in its texture, and though extremely sensitive on the outside, is somewhere near one millimetre in thickness. Examination.-In examining an injured eye one must look at it as if he had never seen an eye before, and were going to find out just how it was made, and what had been going on around it. Knowledge of what ought to be will call attention to what is. But injuries do not come tagged and labelled, and with haemorrhage, in- flammatory swellings, lymph deposits, discoloration, and destruction of tissue, there is often as much difficulty in the diagnosis of injury as of disease. The lids should be pulled wide open and examined thoroughly for cuts, scars, perforations, and foreign bodies ; neighboring cavi- ties should be probed, and foreign substances removed. One should look the cornea over at the window as he would examine any other lens for chips or scratches ; hunt for perforations also by focal illuminations at the gaslight, and explore all depths of aqueous, lens, and vit- reous by the lenses in the ophthalmoscope which will put them in and out of focus, being careful not to be so ab- sorbed and interested in one injury that some other is overlooked and neglected. Some readers of this Handbook, who do not make or do not wish to make special study of ophthalmology, will doubtless be called on for advice, and will feel obliged to assume the care of diseased and injured organs of sight until such cases can be transferred to other hands. There is no better advice in regard to such cases than that given by George Sand to those hearing evil of a friend, " Hope for the best and believe the worst." This will be appre- ciated by those who have seen eyes seriously injured by the use of astringents, where atropine would have been given had the serious nature of the trouble been realized. The first lesson to be learned by those feeling their way is what not to do. Cases may be divided into those which need astrin- gents and those which need anodynes. There is one as- tringent that must never be used, it is acetate of lead. Use- ful as it might be in some cases, it is so dangerous to many corneal affections that it should never be given except by an oculist so proficient as to be able to ignore rules and in- dulge in ophthalmological jugglery ; but by him it is sel- dom needed. There is one anodyne that excels all others -it is atropine. The cases which are injured by atropine when they need astringents are so few as to be counted on the fingers of one hand. The cases which are injured by astringents when they need atropine are very many, so, when in doubt, if you use atropine you will benefit half the cases and injure none, whereas the astringents blindly used will benefit half the cases and injure many. The fact that atropine is poisonous to swallow, while most astrin- gents are much less so; that atropine blurs the sight, while astringents do not; that atropine is nearly always used in serious cases, astringents in those comparatively simple, leads the novice to hope for the best and use as- tringents where he would much better, if he feels him- self at all off his ground, believe in the worst and use atropine. The cases where atropine must not be used globe which tends to lengthen any diameter of the ciliary ring will do serious injury to this delicate structure, and a rupture of its walls in the immediate proximity of the lens or zonula so disturbs the equilibrium between the two chambers that dislocation is almost sure to follow, and quite often lens, iris, and zonula are all carried away by the pressure and expelled through the wound which has taken place in the stronger membranes. The suspensory ligament is so delicate that it is said to have been ruptured by blows upon the head, which, not touching the eye at all, have caused the comparatively heavy lens to tear away its support by rapid and violent vibrations thus imparted to it; though dislocations first discovered after such blows may be congenital. It would be wrong to leave this subject without a word concerning the iris. The iris is one of the weakest muscles in the body, and the contractile tissue, which changes its size and shape so readily, is not able to do so against any appreciable resistance. In health it floats in the aqueous, attached only at the periphery in about the same manner that a delicate film of sea-weed exhibits its natural conformation in water, but collapses and loses its Fig. 1072. 796 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. are easy to diagnose, with the exception of glaucomatous trouble, with which this paper has nothing to do. Atro- pine should not be used, or should be used with caution, where there is perforation or rupture of the globe near the sclero-corneal margin, or any open wound through ■which the iris is more likely to prolapse when dilated than when contracted. Atropine, generally speaking, should not be used when a foreign body is lodged on the iris or loose in the anterior chamber, and likely from slight disturbance to fall down behind the iris or be- hind that part of the sclera which forms the opaque peripheral front wall of the chamber. In most other in- juries atropine is the one remedy which the surgeon can- not well dispense with, while astringents, though some- times useful, are seldom indispensable in the treatment of recent injuries. Arlt found it convenient to divide injuries into : 1. Those produced by sudden compression or concus- sion. 2. Those produced by foreign bodies not acting chemi- cally : (a) Those in which the foreign substance does not remain in the eye ; (b) those in which the foreign body does remain in the eye. 3. Those produced by scalds, burns, and corroding sub- stances. This is a classification which must naturally run through any attempt to consider this subject, whether from a medical or a mechanical standpoint. Before considering each separate tissue in order, it may be well to supplement what has already been said con- cerning physical conditions, by calling attention to the fact that the enclosing tunics of the healthy eye are more than full, and once their integrity is broken a small part of the contents is likely to be forced out by the elasticity of the tissues ; that the secretion of aqueous and vitreous, and the supply of blood to the interior of the organ, keep its elastic covering always in a state of tension, and when, by rupture, cut, or puncture, or by ulceration, or decay of injured tissue, there is any solution of continuity, a part of the contents will have a tendency to escape ; and while the opening remains, the constant building up of material to supply the place of what has been lost often forms a serious obstacle to the rapid healing of the wound, or the successful return of any part of its contents, such as protruding iris or vitreous, to the eye. Haemorrhage.-A word or two may be said in a gen- eral way concerning hagmorrhages, which are not con- nected with any lesion more definite than the breaking of a blood-vessel, the location of which is often unknown. Conjunctival extravasations of blood, such as come from slight blows, or from straining, coughing, stooping, or any violent disturbance of the circulation or increase of the heart's action, are of no particular importance, and require no treatment ; apart from their gorgeous coloring they would scarcely attract the attention even of the pa- tient. Parts should be examined carefully, to make sure that there is no solution of continuity. Then, if there has been no impairment of vision, either peripheral or central, the patient may be assured of certain recovery. Haemorrhage into the anterior chamber is almost al- ways due to violence, rarely from scurvy or from some neoplasm, and very rarely it has been reported due to other causes, such as menstrual or diathetic influence. The blood generally comes from the iris, and unless caused by some dislocation or rupture other than that of the vessel's wall, is rapidly absorbed, sometimes disap- pearing within three days, sometimes remaining as much as three weeks. When enough blood has been effused to conceal the inner structures of the eye, the diagnosis should be guarded, as they may have suffered serious injury. Haemorrhage also takes place occasionally into the pos- terior chamber, leaving no trace of injury by which to account for the presence of blood. The ruptured vessels are supposed to be in the anterior extremity of the cho- roid. The depreciation of vision is often just as much as would attend choroidal rupture or ot^er serious injury, so that it is impossible to tell at the time whether or not such injury has occurred. The treatment, of course, should be the same as that of the serious injuries which it sometimes accompanies and conceals, and it may not be possible, for six weeks or more, to say decidedly that no separation of retina or rupture of choroid has taken place near the posterior pole of the eye. Commotio Retina.-It is seldom nowadays that a sur- geon is called upon to examine either disease or injury of the eye to which he is not able to give a name, or in the naming of which his ignorance must take the old time masquerade as wisdom in Greek or Latin. The ophthal- moscope has cleared away nearly all the mysteries of in- traocular disease, and those that are not thoroughly un- derstood are so far outlined as to admit of classification ; so that when it is not possible to say exactly what, it is generally easy to state exactly where. It is the same with injury as with disease. The only ghost that is left is that occasionally discussed by able writers under the name of commotio retinae. It is not easy to explain in every case the refusal of the iris and ciliary muscle, after sudden injury, to perform their proper functions ; neither is it in every case possible to give a reason for partial and temporary suspension of the perceptive powers, after a sudden shock from a blow on the head which has left no trace behind it; and the name of commotio retinae has been given to those cases in which a depreciation, or per- haps an entire loss of vision, follows a blow on or near the eye, and can be explained only as the result of numbness due to the same changes in the retina which occur in the central organ of patients suffering from concussion of the brain. There is little to be said of this affection, apart from the arguments for and against its existence. It has been for years under the cross-fire of ophthalmic experts, many of whom believe that its Scylla or its Charybdis will al- ways prove it to be a mistaken diagnosis, or a misnomer. Symptoms of this injury, as has been said, are sudden loss of vision, partial or complete, at the time of injury, producing no organic disturbance, except in some cases a change of color in certain parts of the retina, the same as would take place from local oedema or anaemia. These cases recover, but before allowing them to do so unaided, it is necessary to satisfy one's self that there is no rupture of the choroid or partial dislocation of the lens ; that the amblyopia is not due to fracture of the skull at the optic foramen, stretching of the zonula, or paralysis of the ac- commodation. Paralysis of Sphincter of Pupil and Ciliary Mus- cle.-Another injury which seems rather intangible, as far as its etiology is concerned, but which has actual existence, is the paralysis of accommodation, with partial or com- plete mydriasis, which sometimes follows a severe blow upon the eye. In mild cases recovery may be expected in a few days, but where the pupil is widely dilated and there is total loss of accommodative power, the patient does not recover. The indications are for the instillation of esorine. Lids.-Passing now to those injuries in which actual damage has been done to the tissues themselves, it is only necessary to remark, concerning the lids, that whatever may happen to them they may be well treated in accord- ance with the usual methods of general surgery, always remembering that they are much needed coverings for the eye itself, and when destroyed should be replaced at the expense of the surrounding tissue ; care being taken to adjust the parts so that the contraction of the scars will not result in turning the lashes in upon the cornea or con- junctiva. Conjunctiva.-Wounds of the conjunctiva, unless by some instrument that causes contagion, such as cuts, punctures, or tears, which do not involve other tissues, are not of a serious nature. They are amenable to the same treatment as mild forms of conjunctivitis. The extent of danger varies with situation of wound, nature of offending instrument, and condition of system to undertake repair. In the first examination after re- ceipt of injury, attention should be directed to the exist- ence of other injury. It is quite important, however, to remember that a slight cut in the conjunctiva of the lid may be the avenue through which some sharp instrument 797 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. any irritation or tendency of the cornea or iris to in- flame. If attended with much pain, cocaine should be used as often as necessary to secure the comfort of the patient. When the destruction of tissue extends so deeply in the cul-de-sac that there is no bridge, or only a narrow bridge of sound conjunctiva between the two injured parts, little or nothing can be done to prevent their growing together during the healing process. The opposed surfaces must be separated frequently, and in spite of this the contrac- tion of cicatricial tissue will most always bring them to- gether as they heal, and do this with a persistency that reminds one of foreordination. Plates of wax, glass, or silver may be worn for a while at some risk of irritating the eye, but they will be crowded out, and are more likely to do harm than good. After every- thing is healed the chance is scarcely better for improve- ment by operative measures. Cutting the bridles and at- tachments gives only temporary re- lief, and the only thing to be done with promise of success is in the nature of plastic operations on the conjunctiva. These sometimes relieve the conditions to a certain extent. If there is a free passage for a probe beneath the sub- stance of the symblepharon, considerable improvement, or perhaps permanent relief, may be expected; but fre- quently the surgeon will exercise his ingenuity in vain. It may be put down as entirely improbable that any ex- tensive symblepharon or ankyloblepharon which has grown up from the bottom of the cul-de-sac will be greatly decreased in size. The accompanying cuts are from Lawson, and repre- sent very admirably the conditions indicated by the text. Fig. 1073 "represents the appearance produced by an in- jury to the eye from some fresh mortar, which was thrown into the eye the day before the boy was brought into the hospital." The coloring, of course, is not present, and cannot be well reproduced by any printing process. But the ap- pearance of a burn caused by mortar is very characteristic, and once seen is always rec- ognized. Fig. 1074 " is a good illustration of a case of partial an- kyloblepharon, and shows very well the posi- tion of the fistula which is frequently met with when the inner portions of the lids are united." The particular case here pictured happens to have been the result of mechanical violence, but it may well have hap- pened from either mechanical or chemical injury. Cornea.-Though the cornea is never ruptured by blow or pressure causing momentary increase of tension, and though it seldom suffers from any force transmitted to it through the closed lid (unless the lid itself is perforated), it often suffers severely from the impact of small bodies having appreciable weight, which so bruise without breaking its substance as to cause local death of the part struck. This results in the formation of what is known as corneal abscess. The abscess thus formed is, on account of the thinness of the membrane, not likely to exist as a sac filled with fluid of a purulent nature, but consists of tissue infiltrated with purulent matter which discharges itself either forward on the conjunctiva or backward into the anterior chamber, or more likely in both directions. This abscess may be of any extent, small or large; it may be superficial or involve the inner and deeper layers of the membrane. Its extent cannot be told at the or foreign body has entered the orbit and done serious in- jury to the optic nerve or the brain itself, a specially dan- gerous fracture of the orbital walls being produced by thrusts from sharp instruments which penetrate the upper part of the inner wall. Hence, wounds near the peripheral part of the ocular conjunctiva should be examined, and evidence of foreign substances remaining in the wound or of serious injury to the orbit carefully weighed. Small cuts or punctures limited to the conjunctiva are of little moment. The edges should be carefully cleansed with cool water, so that any particles of foreign matter that may have been left by the instrument may not be al- lowed to remain. Rest and cleanliness are the necessary conditions of recovery, and, though these wounds are not likely to be of an especially dangerous character, they demand some attention. The surgeon will often be called upon to decide just how much interference with the pa- tient's business or pleasure is called for in trivial or even in serious affections, and considerable latitude is neces- sary in deciding this question. If wmunds are compara- tively large and the inflammation seems likely to affect the corneal tissues, or if there is any danger of serious results from the contraction of cicatricial tissue wThich may produce symblepharon, or ankyloblepharon, or en- tropion, or lachrymal obstruction, conjunctival wounds may be considered serious, and the patient should be made to consider recovery his first duty. It may be necessary in some cases to put a stitch or two in the conjunctiva, to keep it in place until the healing process is established. Fine silk may be used, and can usually be put in so lightly as to come out of its own ac- cord when it is no longer needed. In putting in sutures about the eye it is very useful to have acquired sufficient dexterity to make the forceps take the place of one hand in tying the knot. Should granulations spring up in or near the wound, they may be touched with nitrate of silver every other day. This and a one per cent, solution of alum for in- stillation will cause them to disappear. If one of the recti muscles has been completely divided by a wound through the conjunctiva, it will be noticeable from an inability to move the eye toward the affected muscle, or by the occurrence of double vision, in which the image is displaced toward the injured side. The end of the muscle should be sought with a pair of fixa- tion forceps and fixed in its proper place, as in the oper- ation of bringing forward for strabismus. The most serious wounds of the conjunctiva are, how- ever, those which are made by burns from hot metals, acids, unslacked lime, and other irritating and corroding substances. The cornea is more than likely to be in- cluded, and upon the depth and extent of the corneal in- jury the final result is in great measure dependent. The principal danger, as far as the conjunctiva is concerned, is not so much the destruction of tissue as that, in healing, two surfaces which usually move freely over each other should become firmly united, causing symblepharon or ankyloblepharon, thus closing in part a cavity which should remain open, and on account of adhesions formed by the conjunctiva of the lids uniting with each other, with that of the globe, or with the cornea, seriously lessen the mobility of the eye, or disfigure and inconven- ience the patient by unsightly deformity, or by constant irritation of an organ so attached. The first thing to be done in such cases is to remove the irritating substance, if it has not already been re- moved. Melted metal, which has cooled into place, must often be removed by the use of considerable force, and with some mechanical injury to the parts. Lime and sand may be scraped carefully from the cul-de-sac with a Daviel's curette or spoon. Solid bits of nitrate of silver, caustic potash, and similar substances which are equally injurious in watery solution, as well as pitch and wax, which are insoluble, may be washed out with oil, but not with water, if they cannot be more easily removed by forceps. These injuries, when the cornea is not implicated, call for quiet antiphlogistic treatment with the instillation of olive oil, linseed oil, or vaseline, and of atropine to allay Fig. 1073. Fig. 1074. 798 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. time of the accident. The first sign of serious injury, apart from accompanying pain, is the conjunctival redden ing and well-marked ciliary injection, which may extend entirely around the organ or may be confined to the im- mediate proximity of the part struck. Pain, photophobia, and lachrymation are naturally attendant on this condi- tion, which may continue two or three days before the grayish discoloration and opacity that follows has marked out the seat and the limits of the destructive process. After this the disease follows the course of corneal abscess from any cause. Pus soon forms in the layers of the cornea and also in the anterior chamber, settling down to the lower part between the cornea and iris. By this time the inflam- mation is threatening the iris and ciliary region, the pain may be exceedingly severe and if the process is not checked by operative interference it may end in panophthalmitis. Pus at the bottom of the anterior chamber may be distin- guished from that in the layers of the cornea by placing the patient on the side for a moment or two and witness- ing the change of place by gravitation. The treatment for corneal abscess of traumatic nature, either actual or threatened, is atropine, rest, and shade. During the early stages, before the formation of pus has begun, cooling applications externally and iced compresses are said to be in order. After suppuration is established, lukewarm or even hot water will be more gratefully borne and probably hasten the progress of the disease. Absolute cleanliness is of course necessary, and to insure this, frequent bathing in water of suitable temperature, to which four per cent, of boracic acid has been added, or one-tenth of one per cent, of corrosive sublimate, or one two hundred and fiftieth of one per cent, of biniodide of mercury (about one grain to fifty ounces). With pus in the anterior chamber and threatened or existing complication of iritis or irido-cyclitis, it will often be necessary to administer morphine to relieve pain and to give the patient sufficient rest and comfort to in- sure the best recovery. , Whatever the attitude of the patient is toward the use of this narcotic, it will be well to remember that pain is often worse than poison, and the surgeon should demand the right to choose. If the pus at the bottom of the anterior chamber is more than two millimetres in depth, or if the abscess takes on at its edge the halo of light-gray, which indi- cates that the process at first due to traumatism is extend- ing beyond the margin of the original injury, it will be necessary to evacuate the anterior chamber, and perhaps, to open the abscess according to Saemisch's method, by passing a Graefe knife, which is held with its back to the pupil and iris, into the anterior chamber on one side of the abscess and out on the other, and so cutting entirely through the abscess from within outwards. After this, the wound must be kept freely open until recovery is well established. This operation is not always nec- essary, paracentesis of the lower part of the cornea, in such a position as to favor the evacuation of pus from the anterior chamber, being often attended with the best re- sults. This opening should be renewed at least every second day, until no pus remains, some of it having been evacuated, but most of it reabsorbed. The prognosis in these cases depends upon extent and location of the abscess and depths of tissue involved. Wherever the abscess is there will remain a white scar, which is of little importance if small and at the periphery, but which, if over the pupil and of such an extent as to obviate the possibility of making an artificial pupil, will render the eye practically blind. If the abscess perforates, lens or iris is likely to be left against the wound and become permanently attached, giving rise to unpleasant symp- toms of irritation and inflammation, which may be well borne for many years, but which in some cases finally result in panophthalmitis and phthisis bulbi, or some- times cause large and unsightly staphylomata. The use- fulness of atropine and eserine in placing the iris in given positions should not be forgotten during the progress of the disease. Wounds of the cornea entailing solution of continuity may be mere superficial scratches, in which hardly more than epithelium has been removed, or they may penetrate the anterior chamber, injuring iris or lens, or extending to the deeper tissues of the eye. As the cornea is the principal lens in this physiological camera, the danger is twofold-that of its destruction as part of the firm en- veloping membrane which holds the structures together, or that of distortion, deformity, or opacity, which de- stroys its usefulness as an optical instrument. If the wound is a mere superficial abrasion, complete recovery may be expected, though such injuries are often attended with great pain, neuralgic in its nature, with photopho- bia, lachrymation, and ciliary injection. The use of cold compresses, or a bandage which keeps the eye closed and prevents the lid from rubbing up and down over the abraded surface, will allow it to heal in a few days, and the instillation of atropine, thrice daily, will banish the pain and hasten recovery. Occasionally, a slight abrasion made by some rough instrument, often by the nail of an infant, on the cornea of its mother or nurse, will apparently heal within a few days, giving rise to no trouble at the time ; but two or three weeks afterward, when the inci- dent may have been entirely forgotten, severe and persist- ent neuralgic pains will call the surgeon's attention to a slight irregularity on the surface of the cornea, and with the instillation of atropine and a light bandage worn for a few days, the patient will entirely recover. The prognosis for these wounds is favorable for the most part. Unless the loss of substance extends as deeply as the membrane of Descemet, there will be no visible scar, the transparency of the tissue remaining; though if the wound is at or near the centre of the organ, and not of a rather superficial nature, so much irregularity of surface will remain as to materially affect the eye as an organ of sight. Very slight injuries, such as those just considered, are often fraught with considerable danger to old people who are poorly nourished, or to those suffering from debilitating disease, such injuries taking the form of persistent and progressive ulceration, which is checked with difficulty. After the character of such trouble is established, it is no longer traumatic in its nature, and should be treated like any other similar ulceration. When the cornea is penetrated by a clean, sharp instru- ment, which does not at the same time injure iris or lens, unless the wound is quite large, it may be expected to heal up quietly without any very great disturbance. The aqueous will, of course, be evacuated, except in very minute punctures; then, if the lips of the wound be ad- justed by gentle pressure (preferably through the lid with a Daviel's curette), they will often unite by first intention, and allow the chamber to be re-established by the secretion of aqueous, which is very rapid, and oftentimes the iris will not become attached to the wound against which at first it was pressing. Punctured wounds made by rough or blunt instruments, often give rise to much more trou- ble. There is a larger vent for the escape of aqueous. The iris or the lens is likely to be pressed against the wound, or perhaps pushed through it. The healing pro- cess does not take place without some destruction of tis- sue and the formation of a white scar, to which either iris or lens or both may be permanently attached. If the wound is seen at the outset, some effort should be made to get the eye into something approaching its normal condition. Ragged edges of the wound or of the protruding iris, which cannot live, should be snipped off with the scissors. Gentle manipulations with Daviel's cu- rette scoop or rubber spatula may cause the iris to return into the chamber. If not, it should be excised, unless it has become adherent, or seems to occupy a useful position in preventing the further escape of the contents of the an- terior chamber. Should it be necessary to allow the iris to heal into the wound, and later it becomes irritable, an iridectomy can be done to set the matter right. Any wound which so opens the walls of the globe as to allow the escape of any appreciable part of its contents, is a serious affair, and demands perfect quiet on the part of the patient-usually, indeed, a recumbent posture, es- pecially during the early part of recovery. So many ac- cidents may happen on account of the disarrangement of forces which have been evenly balanced while the walls of the globe were entire. When the anterior cham- 799 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ber is opened extra strain is put upon the suspensory- ligament, and it may stretch or rupture with straining or coughing, or any sudden disturbance of the circulation. Separation of the retina, or extravasations of blood into the choroid or vitreous, may give equally unwelcome evi- dence of lack of equilibrium between internal and exter- nal pressure. Consequently, in all ruptures, cuts, punc- tures, and other injuries which perforate, absolute rest is essential. Next to that, in corneal injuries, give fre- quent irrigations with perfectly pure water or boracic acid, or some similar solution, and atropine, unless its mydriatic action draws the iris toward the wound and threatens hernia or anterior sy- nechia. In such cases eserine may be used. Avoid al 1 depleting meas- ures ; allay pain with atropine or cocaine instilla- tions, or with mor- phine subcutane- ously if necessary to give the patient needed rest. If a fistula remains af- ter the healing process is well un- der way, through which aqueous continually escapes, touch it with nitrate of silver, or burn it very slightly with the electro-cautery. It may be, and often is necessary, after recovery, to perform an iri- dectomy, to relieve from the irritating effects of iris attach- ments, or for the purpose of making an artificial pupil. Burns, scalds, and injuries of the cornea from irritat- ing and corroding substances are of a more serious nature than similar accidents to the conjunctiva ; any deep de- struction of tissue in this way is followed by serious reactionary inflammation, and resulting opacity. The danger of symblepharon is great in some cases, and should be guarded against as in conjunctival injuries. If the wound is seen immediately after the injury, it will in most cases give very little evidence of the amount of damage which has resulted or will result, but a space of two or three days is likely to develop much more exten- sive destruction of tissue than is at first apparent. The instillation of oil and atropine is called for, also cocaine to relieve pain, if necessary, with such precautions as have already been describe(1 against the devel- opment of attach- ments to opposing or adjoining con- junctival surfaces. Another word of warning should be given here against all collyria contain- ing preparations of lead. Many cases, where the eyes have been burned by acid or other corroding sub- stance, have been made hopelessly blind by the use of acetate of lead collyria from the hand of some well- meaning apothecary who must needs do something in the emergency, who gave acetate of lead, and so in- sured that every scar on the corneal tissue should become so thoroughly opaque as to be entirely useless for the transmission of light. Oil and atropine is always a good guess, if one must guess. Rupture of the sclerotic usually takes place upward and inward, the rent is from six to twelve millimetres in length, and nearly always parallel to the sclero-corneal margin. It may occur outward or downward, and it may be irregular in shape, extending through the sclero- corneal margin, but is not as often seen in these situa- tions. It has taken place very rarely in the posterior part of the globe. In that position it does not admit of positive diagnosis, but may be suspected in cases where haemophthalmus posterior is attended with very consider- able decrease of tension. The complications which may exist are in great meas- ure dependent on the force of the blow, and the extent to which iris, lens, or vitreous have been forced out at the time of the accident. Sometimes the lens is forcibly ex- pelled, and may be found under the lid, or may be lost. Sometimes it may be seen at the seat of the rupture in a sac formed by the unbroken conjunctiva, where, with part of iris, it should be allowed to remain until the wound is healed and normal tension re-established, when the conjunctiva should be incised for its removal. Rupt- ure of the sclera is usually attended by haemorrhage into the anterior chamber, often by prolapse of iris and escape of the lens. The treatment is, of course, first and foremost, perfect rest, as for all cases where opening of any size has been made into the interior of the eye. The patient should be confined to the room, and, if not kept in a recumbent posture, should avoid sudden move- ments or stooping, coughing, straining, which may lead to complications from haemorrhage into the choroid or retinal separation. Iris or vitreous which protrudes from the wound may be removed with the scissors if such in- terference can be borne without the administration of ether, but it is not nec- essary. If the lens is so situated as to prevent the lips of the wound from closing, or if it seems to press on the iris or ciliary body, an attempt should be made to extract it. Atropine should be given, unless the tendency of the iris to present in the wound suggests the employ- ment of eserine. Prognosis in cases of rupture of the sclera is not so bad as one would be inclined to fear. Sometimes p a n o p h - thalmitis, with its at- tendant train of de- structive changes, supervenes; but often the usefulness of the eye is not entirely destroyed, and occasionally the result is that the patient retains a visual organ somewhat simi- lar in condition and appearance to that which remains after a successful cataract operation. Incised and punctured wounds of the sclerotic differ from those caused by rupture in this respect. They are more varied, both in size and situation, and from the fact that some foreign substance has penetrated and entered the globe, and may have inflicted other injuries there than those already described as likely to be associated with the tearing of the tissue from the effects of pressure alone. It is necessary to ascertain, if possible, what other tissues have suffered, and to make sure that no foreign substance has remained in the eye. Cuts and punctures in the ciliary region are almost sure to end disastrously as far as sight is concerned. The best result that can be expected is a quiet subsidence of the immediate inflammatory action, to be followed very likely by gradual cessation of function and partial atro- phy of the tissues of the globe. Suppurative irido-chor- oiditis is very likely to follow any punctured wound of the sclera, even though it is so far back as to have escaped the ciliary region. It is not absolutely impossible that a clean cut with smooth, sharp instrument, through the sclera Fig. 1075.-Represents the effects of a burn from molten lead, which splashed into the eye from a pot the patient was carrying. (Lawson.) Fig. 1077.-Staphylomatous Appearance. Result of blow on the eye, which caused at the time rupture of sclera and dislo- cation of lens beneath the unbroken con- junctiva. Fig. 1076.-Rupture of Sclerotic, in which lens and upper half of iris were lost at the time of the injury. (Lawson.) 800 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. at the ciliary region, should heal and leave a useful visual organ, but such a result is not to be expected. The treat- ment for cut or punctured wounds is the same as for open ruptures. Tissues presenting in the wound 'should be trimmed away as much as possible, without so disturbing the condition of affairs that more of the contents of the eye will be forced out to take the place of those removed ; gentle manipulation with spatula or scoop should be used in the attempt to leave the edges of the wound as nearly in their normal places as possible. If there is much gaping of the wound a very fine suture should be put in, if pos- sible, through the outer edge of the sclera only • both eyes should be kept closed and under gentle pressure. Even after the wound has healed and given promise of fair recovery, the con- traction of cicatricial tissue may be the cause of retinal separations, followed or at- tended by gradual destruc- tion of the wounded eye or sympathetic trouble in the other. Iris. - Non-penetrating wounds of the globe are sometimes the cause of rup- ture or tear of the iris. Radiating rents and fiss- ures are quite rare, and are not accompanied by any haemorrhage. The most frequent injury is a dialy- sis or separation of the peripheral portion from its attachment. This separa- tion may be of almost any extent, large or small. It lias been known to include so much of the membrane that it might be said to be entire, not enough of its ordinary support being left to retain any part of it in its normal position. The effect of a dialysis is usually to allow that part of the iris which is separated from its attachment to hang somewhat smoothly in the position of a chord to the arc which origin- ally marked its place, so that both peripheral and pupil- lary margins are altered, as is seen in the accompanying cut, which is taken from Lawson. The kidney-shaped pupil is quite characteristic. This injury is often at- tended with considerable haemorrhage into the anterior chamber, which is of no particular moment and rapidly absorbs. Little or no treatment is necessary, except reasonable quiet on the part of the patient, as there is very seldom any active inflammation subsequent to the injury, and the harm that results, apart from cosmetic effect, is principally optical, due to the presence of two pupils instead of one. The patient either suffers from monocular diplo- piaoranindistinct- ness of sight, due to the entrance of light into the eye without passing through that part of the lens which is capable of for- ming a distinct image. It has seldom been thought worth while to attempt any operative correction other than an iridectomy to remove any portion of the membrane which interferes with visual abil- ity by hanging directly across the optical axis. This should only be done when time enough has elapsed after the acci- dent to prevent any unusual tendency to inflammation. Cuts and punctured wounds of the iris are concomitant with the injuries of the cornea or sclera, and require no special treatment other than what has already been men- tioned in connection with those injuries. Lens and Zonula.- I he position occupied by the lens and zonula may be represented by a circle formed by the intersection of the walls of the globe with a plane which cuts the visual axis at right angles, a few millimetres be- hind the iris. A blow or pressure which causes the globe to de- part momentarily from its approximately spherical shape, is likely to lengthen any one of the diameters of this circle and stretch or tear the zonula or the capsule containing the lens. And further, any pressure on the anterior part of the globe which increases the tension of the walls of the anterior chamber is likely to throw the lens backward, be- cause the larger area of the walls of the posterior chamber allows of more increase of capacity before the same ten- sion is reached, a bulging backward of lens and zonula is likely to follow, so that each and every diameter of the circle in which they lie is increased. One of these two conditions has probably existed in most of those injuries where the only organic disturbance is a partial or total dislocation of the lens, either with or without rupture of the capsule. It is said also that a severe blow on the head will cause such shaking or oscillating of the comparatively heavy lens as to tear the delicate m e m - brane which sus- pends it between the fluid a n d semi-fluid h u - mors. It seems almost necessary to allow this to account for cer- tain dislocations that arc reported, where the eye it- self has not been touched by the body inflicting the blow. The disturbance that takes place in all these cases varies greatly, from the slight displacement forward which indicates a mere stretching of the ligament, to an entire breaking away from its support on all sides, so that it is thrown back in the vitreous, and sinks eventu- ally to the bottom of the eye, or so that it is forced for- ward entirely through the pupil and lies entirely in front of the iris. Occasionally the lens is pushed a part of the way through the pupil, or lying a little to one side behind the iris, so that its edge may be seen across the centre ; and the fundus is visible clearly with a minus glass if the observer looks through that part of the lens which is in sight, or with a strong convex glass if looked at through that part of the pupil from which the lens has been removed. Whenever the edge of the lens is in sight, if brilliantly illuminated, it may be recognized by a thin meniscus of vividly contrasted light and dark, caused by refraction, and total reflection at the edge where the front and back surfaces round to meet each other. Where the suspensory ligament is torn, of course, the lens is left free to assume the convexity natural to ex- treme accommodation. So that one of the symptoms of subluxation is (in the emetropic eye) apparent myopia with entire loss of accommodation, and amblyopia, which may be due in part to astigmatism. If the lens has been moved backward and to one side, so that it only partially covers the pupil, monocular diplopia may be present ; and if it is entirely removed from its place, as when it has fallen back toward the bottom of the vitreous humor, an apparent hypermetropia of somewhere near eleven diop- ters will be found ; and on looking at a reflection of the candle flame in the eye, only that image due to reflection from the corneal surface will be seen. The two fainter pictures which are made from anterior and posterior lens surface will, of course, be wanting. A tremulous iris calls attention to the fact that its pupillary border has been deprived of the support usually given it by the an- terior surface of the lens ; still this symptom is not path- ognomonic. Partial dislocations of the lens backward are likely to become complete in time, that body finally sinking into Fig. 1078. - Punctured Wound of Sclerotic Successfully Treated with a Fine Suture. (Lawson.) Fig. 1080.-Partial Dislocation of Lens which is Becoming Cloudy. (Lawson.) Fig. 1079. 801 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the bottom of tbe posterior chamber, and undergoing partial atrophy, where it will stay for years, perhaps the least dangerous foreign body that can exist in that place. The eye is subject to the same inconveniences and acci- dents as were entailed by the old operation of couching. In all posterior dislocations, unless there is some cogent reason for extracting, such as ciliary irritation or threat- ened sympathetic, it will be best to leave it as it is and make no attempt at removal. But if it presses forward on the iris, or has partly or wholly passed through the pupil and remains immediately behind the cornea, it should be removed as soon as the chemosis that immedi- ately follows the accident has disappeared. The danger of attempting to remove a dislocated lens from the pos- terior chamber is very considerable. The cut is made of course as if for the operation for cataract, but the lens wfill rarely present on pressure, and recourse must be had to the spoon or the hook, and with the utmost care the lens will sometimes sink into the vitreous, w'here it cannot be recovered, or its extraction will only be accomplished with the loss of vitreous, and perhaps subsequent accidents of haemorrhage and retinal separation. If a dislocated lens is allowed to remain in the anterior chamber it gradually diminishes in size and sinks to the bottom of that cavity, where it remains in a shrunken opaque condition, and usually causes deterioration and opacity in the part of the cornea on wdiich it rests. When the lens is injured by a penetrating wound the cornea, or possibly the sclera, must of necessity have been punctured, and injury of the iris and ciliary body may also have taken place at the same time. Apart from the danger of these accompanying wounds, which of them- selves may or may not be of a serious nature, there is every reason to expect serious trouble with the crystalline body. Any cut or puncture of the anterior capsule which brings the substance of the lens proper in contact with the aqueous humor is followed by an opacity and a swel- ling in that body, which seriously interferes with nutritive and functional processes. Such an accident is much less serious in a child than in an adult, the softness and solubility of lens substance being such in the child as to admit of somewhat rapid disintegration and absorption, which may take place so quickly and completely as to produce no serious injury other than the loss of the lens itself, or a capsular opacity wdiich may be removed by any of the methods usually employed after the operation for cataract. If much of the lens surface has been exposed by the opening of the capsule the swelling will be greater, and the consequent increase of tension in the globe, and the pressure of the lens on the iris more irritating; and w-hen the patient has reached, or is nearing, adult life, the reac- tion caused by this disturbance will be quite severe, usu- ally dangerous, and the result, as far as disappearance of the lens is concerned, in no wray complete. The closure of the capsular wound in such injuries is an impossibility. The indications are for temporizing and antiphlogistic treatment. Atropine should at once be gjven to prevent anterior synechiae. Iritis and cyclitis should be met with anodynes ; if the pain is severe with anodynes and ice-cold applications. Extraction should not be attempted unless the lens or a greater part of it has found its way into the anterior chamber. If the iris is pushed forward by the swollen lens and the symptoms are dangerously severe, the anterior chamber may be tapped repeatedly to allow the escape of aqueous and any sof- tened lens matter wdiich has found its way into it; and in this way the process may be allowed to go on until suffi- cient absorption has taken place to permit the organ to return to its natural quiet. After all inflammatory symptoms have subsided, if nothing but opaque capsule is left it may be operated on as before suggested, but if the rent in the capsule has been closed by a false membrane and considerable nu- cleous and cortical remains, it may be removed as in cata- ract operation, discission being the method which promises the best results, especially in children. It is very impor- tant to delay such operations until all danger of inflam- matory reaction has passed away. The processes above described will seldom be completed in less than two or three months, and during this time the patient should be kept continually under the care of the surgeon, and pro- tected during convalescence by shaded glasses. In spite of every precaution many cases of lens injury will end far less happily for patient and surgeon. Capsular in- flammation will block up the pupil with a dense mem- brane to which the iris will be strongly fastened, pus will show itself in the anterior chamber, and panophthalmitis and complete destruction of the eye result. The Choroid.-The choroid is often ruptured as the result of sudden compression. The rent may be so far forward as not to admit of diagnosis during life, and from such accidents no doubt come many of the cases of haemophthalmus posterior which make fair recovery with- out any special mark to indicate the source of the haemor- rhage. These anterior ruptures also are supposed to ac- count for some of the hypothetical cases of commotio retinae. Though ruptures are sometimes seen anterior to the venae vorticosae, most of those which fall under sur- gical observation are near the posterior pole of the eye. They do not come at a point directly opposite the blow or pressure which causes them, but are situated on the same side of a vertical plane which passes through the centre of the globe from front to back. This seems to be in ac- cordance with d priori reasoning concerning ruptures. The choroid has been known to rupture in two places at once, both ruptures being situated in the same meridian and on the same side of the eye as the compression which caused them. Very often the perception of light becomes quantitative as soon as the accident happens, but sometimes the dim- inution of vision is not very great until the lapse of some days. However this may be, the power of accommoda- tion is at once suspended, and after recovery vision has rarely reached its normal acuteness. When first seen, if there has been no very great haemorrhage, the wound is filled with blood which conceals its edges. The unin- jured retinal vessels may sometimes be traced over the wound ; at other times the retina is broken through and separated at its edges from the choroid. The indications for treatment are the same as in other ruptures of the external tunics, except that constant recumbency is not so imperative and the patient may be allowed a little more freedom after the first few days. The inflammatory dis- turbance that follows rupture of the choroid, though sometimes destructive, is not usually very severe, and the amount of useful vision that is recovered is dependent very much on the seat of the lesion. Of course, if the tear has extended through the macula there will be a perma- nent central scotoma. The size of the final scotoma is not always commensurate with that of the original injury, it being sometimes much less than would have been thought probable. Foreign Bodies.-Concerning foreign bodies in gen- eral, that have entered the eye and remained in it, a word or two is necessary. The eye is never safe as long as they remain. Still there is hardly any place inside its walls where, according to reported cases, foreign bodies have not remained for months and years. But in all, or nearly all, the cases so reported serious trouble ensued, which finally brought the patient to the oculist. Yet it is fair to suppose that patients have sometimes carried for- eign bodies with them to the grave without serious trou- ble, but this is so exceedingly rare that in general, when a foreign body has penetrated the globe, it is good sur- gery to remove it as soon as the diagnosis is made, and if not possible to remove it from the eye, to remove it with the eye. This rule admits of one or two exceptional cases to be mentioned hereafter, where foreign bodies, on account of slight existing inconvenience, invite delay to escape for a time the reaction which is sure to follow operative in- terference. Temporizing may be allowed only when the success of operative interference is not compromised by delay. The history of a patient whose globe has been pene- trated by a foreign body which is allowed to remain, of- ten records months of suffering and danger, and almost 802 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. certain loss of sight in one eye, and frequently blindness in both eyes. The surgeon can only advise the patient, and many persons will, after every effort has been made in vain, insist on risking months of sickness and ul- timate loss of vision in both eyes rather than acquiesce at once in the inevitable result and so avoid unlimited dan- ger and delay. In a few cases only is it pardonable to make exception to this rule. If a patient presents himself having in the lens, or on the iris or retina, a small bit of copper or steel, a cilia, or other substance which has been forced through to its position without exciting any last- ing reaction, and if the eye has retained its usefulness in great measure, it is not necessary to attempt to remove it if it is so fastened in its position that any ordinary acci- dent or change in the surrounding tissue is unlikely to make it at some future time more difficult of access. If so situated that to remove it is an easy and safe procedure, it would of course be the part of wisdom to do so. But if, as is often the case, it is where it can be reached only by serious disturbance and operative interference attended with great risk of injury or failure, it would be better to delay, giving the patient emphatic warning that when any change for the worst does occur he has no longer time to trifle. Ciliary injection, pain, tenderness, photophobia, or lachryma- tion, or any of the symptoms of begin- ning iridochoroiditis should warn both surgeon and patient that his unusual good fortune is at an end. Magnets.-Quite a large percentage of the foreign substances that penetrate the eye and remain there, are chips of iron and steel; and wherever situated, the ex- perience of the last ten years has demon- strated that many of these, though so sit- uated as to render their extraction with ordinary instruments very* improbable, have been easily removed by the use of magnets constructed especially for that purpose. These' magnets are of two kinds, and are mentioned here as the only instruments of any importance which are used exclusively in cases of in- jury. The best form of permanent mag- net is that constructed by Dr. Emil Griin- ing, of New York. It is a very conve- nient instrument, but not so powerful as the electro-magnet such as was first brought prominently before the public by Dr. J. Hirschberg, of Berlin. The most powerful foreign-body-magnet in use is one constructed, in 1876, by Dr. H. W. Bradford, of Boston, Mass. The electro-magnet is perhaps not quite as convenient as the permanent magnet, though it is now sold with battery, wires, points, and all attachments contained in a case five inches square and four deep. Its great strength and its occasional value in diagnosis, where the presence of iron or steel is indicated by a slight pain felt whenever the current is made or broken, while the magnet is held near the eye, much more than compensate for any possible disadvantages. Both magnets have points of varying size and shape, which may be attached at pleasure. The size of the point chosen should be in some way com- mensurate with the size of the foreign body to be re- moved. The cut of Dr. Griining's magnet is about one-third ac- tual size. That of Dr. Bradford's magnet the exact size of the instrument. In selecting an instrument for the removal of bits of iron or steel, large or small, wherever situated, the mag- net should be the first choice. It is usually necessary to touch the substance with the point of the magnet; some- times the iron will come to meet it, and sometimes the conditions are such that the magnet alone will not suc- ceed, but will give valuable assistance by touching the hook, forceps, or other instrument which is being used. It will not be necessary to refer to the magnet when con- sidering foreign bodies in their different situations, but to take for granted that the surgeon will determine, if pos- sible, the character of the intruding substance, and use the magnet as often as occasion is given. Foreign Bodies.-Foreign bodies that find their way between the lids, and stick fast in the conjunctiva with- out deeply penetrating it, seldom give rise to any trouble after they are discovered. If they are not easily seen by everting the lids in front of the window, it may be on account of their minute size, or because they have been carried up to the fold of transmission beneath the upper lid. Particles of glass are particularly apt to escape ob- servation. Focal illumination and careful exploration with a Davicl, is all that is needed for their recovery, and this is easily managed unless there is considerable spasm of the orbicularis, when it may be necessary to anaesthetize the eye with cocaine, or possibly, in children, to resort to general anaesthesia. The seat of injury should be carefully examined to see that nothing has penetrated beyond the limit of the con- junctiva and lodged in the or- bit or sclera. Foreign bodies most fre- quently presented are those which have lodged in the sub- stance of the cornea. They are sometimes very small and difficult to see, on account of their color being such as to harmonize with that of pupil or iris. They can be detected readily in the direct light of the window, or by focal illu- mination, and can be removed nearly always without the aid of a magnifying glass. The point of a discission needle, cataract knife, or any other sharp instrument is used. For this purpose the patient should sit or stand before the window, and fix the eye on some object w'hich will insure its being held in the right position, while the surgeon stands where- ever the substance can be most distinctly seen. Some patients will fix better by looking with both eyes, others with only the injured one. It is not always possible to pick up a small particle of steel or emery on the point of a needle without repeated ef- forts. Until the epithelium has been thus accidentally removed by repeated picking, each attempt may be in- tensely painful to the patient. When one or two trials have shown that some time may be taken in fruitless ef- forts, it is not a bad idea to scrape off the epithelium from the very small surface (less than a millimetre in diameter) immediately surrounding the foreign body with one stroke of the needle held sideways, when after that the patient will have less pain and the surgeon less inconven- ience. Great care should be taken, when these small substances have penetrated deeply into the cornea, not to push them through into the anterior chamber. Such an accident is of a most serious nature ; it is quite likely to necessitate an iridectomy for its removal, and the loss of the eye is an accident that is not at all unheard of in such cases. When the foreign body is so deeply situated that this acci- dent seems imminent, it is best to enter the anterior chamber with a Graefe knife, which should go in two or three millimetres to one side of the foreign body and out on the other. Held in this position with the flat of the knife close under the body to support it, removal may be ac- complished without accident. Care should be taken not to turn the knife so as to allow the escape of aqueous. Fig. 1082.-Dr. Bradford's Elec- tro-magnet. Fig. 1081. - Dr. Gr'uning's Magnet. 803 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sometimes a splinter penetrates the layers of the cornea and seems to be placed lengthwise in its substance in such a manner that it can neither be removed by forceps nor grasped by a needle. In such case, the upper layers of the cornea may be opened by a Graefe or Beers knife, held back to the anterior chamber. Rarely, a small bit of matter is driven through so that one end of it is hanging loose in the anterior chamber, while the other remains fast in the deeper layers of the cornea; removal has been effected by making a cut in another part and removing the offending substance from within with a pair of deli- cate forceps. Foreign bodies in the anterior chamber, unattached to the iris or lens, often sink to the lower part of the scler- otic border. Very small bodies may be concealed there or behind the iris or the opaque sclera. They sometimes be- come partly encapsulated or surrounded with lymph be- fore exciting destructive inflammation. They may some- times be removed by an iridectomy. Occasionally one has ulcerated through and been discharged before the eye was entirely ruined. If such a process is going on when the pa- tient first appears, it may be well to temporize, but never to delay operation with the hope that this process will be established. Lens and iris seem particularly tolerant of foreign bodies ; a small foreign body on the iris which seems so firmly fastened that it is not likely to fall to the bottom of the anterior chamber, may be left in situ as long as it is causing no disturbance, provided the chance of suc- cessful removal is not growing less. A foreign body in the lens, if the opening in the capsule is small, may be left in place until it can be successfully removed by cataract operation. If the capsule is widely opened, the case should be treated as a traumatic cataract, and the foreign body re- moved if possible with the swollen cortical. A foreign body in the vitreous, immediately behind the lens, will sometimes present at the wound and be ex- pelled by gentle pressure, or be removed by a scoop or hook, after the lens has been removed by cataract opera- tion. Such result, though gratifying, is hardly to be de- pended on. In fact, the removal of a foreign body from anywhere in the vitreous is something of a forlorn hope. An incision may be made back of the ciliary region, either equatorial or meridional, and in such a manner as not to divide entirely any of the muscles. Through this open- ing the foreign body may come, or may be made to come. Such cases are occasionally recorded, but no one has had so many, or been so successful, as to establish any rule or definite course of action which shall be generally suc- cessful. The surgeon can consider, in such cases, that the instruments and the eye are at his disposal, and subject to his ingenuity ; that there is everything to gain and nothing to lose. When these foreign substances have been in the eye so long as to cause considerable inflammation, which has rendered the vitreous opaque and full of connective- tissue opacities, removal is out of the question as a means of preserving sight, and a constant watch should be kept over the patient, so that the globe itself may be enucle- ated before the establishment of severe or dangerous in- flammation. Small substances (less than two millimetres in their longest diameter) that rest on the retina, or are suspended in the vitreous, do not demand surgical inter- ference if, when they are first seen, the symptoms of irritation have passed away, and delay in removing them does not seem likely to make the difficulty greater. Foreign bodies, both large and small, may pass through the conjunctiva and remain in the orbit. If their pres- ence is not recognized at the time, the external wound is quite likely to heal, when in rare cases the body becomes encysted. More commonly it gives rise to orbital abscess, and is discharged or removed with the contents of the ab- scess. Orbital abscesses are not unattended with serious danger, on account of possible pressure on the globe or ex- tension to the cerebral cavity. William S. Dennett. serving to close the apertures of their shells when the ani- mals withdraw themselves into them. They are of dif- ferent shapes and variously developed in different species -in many species they are absent altogether. Those which are used as Eye-stones are hard, stony, plano- convex bodies, about as large as split-peas, 0.005 to 0.01 metre in diameter (£ to | inch), rather longer than broad, with a smooth but rather dull plane, and a very smooth and shining, convex surface. The former has an ex- centric white nucleus, from which a brown, right-handed, spiral line reaches the edge in about two turns ; the outer portion of this surface is variegated with light-brown markings, and finely striated with numerous lines run- ning in opposite directions. The convex surface is slightly asymmetrical, the thickest point being nearly oppo- site the nucleus of the spiral just mentioned. It is brownish flesh-colored in the centre, shading to white at the margin. Many specimens are much worn by the ac- tion of the sea ; these are white as coral, and the spiral structure is difficult to make out. Eye-stones are com- posed mostly of lime carbonate, and perform entertaining movements occasioned by the discharge of carbonic acid from the surface when placed with the flat side down, in a vessel containing dilute acids. They have long been a popular resource in treating foreign bodies in the eye, for which one is placed under the lid, where it is carried around by the movements of the eye. When it comes in contact with the mote, this is carried along with the "stone" by capillary attraction, and finally expelled with it. They are a clumsy means of doing what a small amount of skill will accomplish with far more cer- tainty, and are deservedly nearly obsolete. The belief that they are alive and move themselves about in the eye, until they " find" the mote, is a popular fallacy. The demand for them now is very limited, and confined to the ignorant. The supply is also small and uncertain, those of this port (Boston) coming mostly in little lots from sailors who bring them from the Bahamas and elsewhere, as curiosities or private ventures. Allied Products.-" Crab's-Eyes," lenticular con- cretions found in the lining membrane of the stomach of the crawfish, look much like eye-stones, and are described for them by several authors. The description just given will easily distinguish them. W. P. Bolles. EYE, TUMORS OF THE. I. Tumors of the Eye- lids. A. Benign Tumors.-The benign tumors of the lids are partly congenital, partly acquired later on in life. Their growth is but seldom accompanied by any inflammatory symptoms. These tumors, of course, during their growth, are influenced by the nature of the tissue from which they spring and into which they grow, and the variety of tissues which constitute what we term the eyelids neces- sarily brings about a number of distinct forms of tumors, and an endless variety in their shape. 1. Warts and epithelial horns (not to be confounded with epithelial growths) are sometimes found on the outer dermoid surface of the lids, more frequently on the upper lid. They may be congenital, and keep on growing grad- ually until they have attained such a size that they have to be removed on account of their unsightliness ; or be- cause their weight is felt disagreeably and has become a hindrance to the free movements of the lids ; or, Anally, because they actually obstruct sight by obscuring a part of the visual fleld in certain positions of the eyeball. Such warts usually spring from the lid, with a broad basis. They are not easily confounded with epithelial growths, because they are lacking a zone of inflammation and infiltration, which with the latter is never wanting. Furthermore, epithelial growths show usually points of ulceration. Moreover, epithelial growths of the eyelids, although observed in young subjects, are more frequently found in the declining years of life, and lie most fre- quently near one of the canthi or at the lid-margin. Warts and horns, however, are found in all ages, and seem to be more frequent near the middle portion of the eyelids than at any other locality. According to their superficial arrangement, such epi- EYE-STONES. The opercula of certain species of gas- tropod mollusks. These organs are horny or calcareous valves, situated in the so-called foot of the mollusks, and 804 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. thelial warts of the eyelids have been described as papil- lomata when resembling cauliflower, and as condylo- mata when resembling the broad or pointed condylomata observed in other regions of the body. The histological structure of these warts has nothing that would distinguish them from other warts of the skin ; they consist of hypertrophic capillary structures, covered by very thick and horny layers of epithelial cells. Although such warts are in themselves benign tumors, we must state here that in later years epithelial growths often begin from such warts, and their removal is to be recommended. 2. Granuloma or chalazion of the eyelid is, in contra- distinction to the other benign tumors of the eyelids, an inflammatory tumor. Its origin is a hordeolum, that is, an inflammatory process caused, in the more superficial or the deeper layers of the eyelid, by the stoppage of one or more secretory canals of the Meibomian glands, be this merely mechanical (by foreign substances) or due to an inflammatory process, which only secondarily involves the secretory ducts of these glands. Such a Meibomian hordeolum is originally the dis- tended Meibomian gland, filled with its own secretion and pus, and later on with an atheromatous detritus. This sac, so to speak, lies, as is clear from its mode of development, embedded within the tarsal tissue, and presses the skin of the lid forth as a roundish elevation, the periphery of which falls off into the surrounding tis- sue at a more or less acute angle. These tumors vary considerably in size, and, aside from the deformity their presence causes, they may have to be removed on account of obstruction of sight. We find, then, usually, that these tumors (tarsal tumors, as they are often styled) consist, at a later period, to a great extent, or even totally, of granulation tissue, which, hav- ing sprung from the walls of the sac, has forced the semi- fluid contents of the original'Cyst to one side and partially absorbed them. Later yet, we may find solid granulo- mata, and no vestige of the atheromatous or purulent contents of the sac. This is undoubtedly the form of tumor most frequently met with on the eyelids. 3. Xanthelasma or xanthoma of the eyelids is not a rare affection. It seems, however, to be more frequent have nothing in common except their yellow aspect. This latter is due to a large number of stellate connec- tive-tissue cells in the subcutaneous tissue, which contain yellow pigment granules. Aside from these, the tumor may consist of connective tissue which has undergone fatty infiltration and degeneration, or it may show plainly a hypertrophic condition of the sebaceous glands, with stop- page and perfect occlusion of their excretory canals. We find then large, round sacs of connective tissue filled with the enormously swollen epithelial cells of these glands, which are undergoing retrogressive metamorphoses. (See Fig. 1083.) In other cases we find simply a dense connec- tive tissue, void of even a trace of the glandular structure, but containing the pigmented, stellate _ cells which these tumors all have in common, and from which they derive their name. According to their form, these tumors have been de- scribed as xanthelasma planum or tuberosum. 4. Angiomata of the eyelids are almost always congeni- tal tumors, although, from their slow development, they may become noticeable only several years after birth. They are either cavernous or arterial as to their character. The cavernous angiomata cause a swelling of the lid in which they are embedded, which is usually of a dark- blue color. If the upper lid be the one affected, it cannot be raised freely, or else it shows the condition known as ptosis. Any impediment to the continuous flow of the venous blood (stooping down, coughing, pressure, etc.), causes the tumor to swell. These growths frequently ex- tend backward into the tissues of the orbit, or into the tissues surrounding this cavity. From their site, color, and conformation, such caver- nous angiomata may be, in rare cases, confounded with orbital cysts, which sometimes cause a very similar as- pect of these regions. The histological structure of these cavernous growths shows, of course, nothing peculiar. The teleangiectatic tumors are usually smaller than the cavernous ones, and since they generally reach to the cutaneous surface, they are recognized at a much earlier period. There is very often but little or no swelling; but the bright-red, enlarged blood-vessels can be seen through, or even in, the skin. This kind of angioma is but seldom confined to the eyelid alone. Yet there are also teleangi- ectatic tumors of the eyelids so well defined that they can be almost enucleated like a granuloma. While cavernous angiomata are apt to grow with ad- vancing years, the teleangiectatic angiomata do not seem to have this tendency to a very marked degree. 5. Fibromata.-a. Hard fibromata of the eyelids are of very rare occurrence, and may possibly take' their origin from a granuloma formed in the cystic distention of a Mei- bomian gland by what is called a hordeolum. The writer has seen and examined only two such cases. In both, the round tumor was implanted in the tarsal tissue, ahd raised the skin of the lid just like a chalazion. In both, the tumor was situated in the upper lid, and was harder to the touch than a chalazion usually is. The size of the tumors was about that of a cherry-pit, and they consisted altogether of a dense connective tissue with short spindle- cells. 3. The soft fibroma (fibroma molluscum) of the eyelids is also of very rare occurrence, and is usually at the same time found on other parts of the body. These tumors, which appear always in large numbers, vary in size from that of a pea to that of a large pear, and even much larger ones have been observed. As they grow they become usually pedunculated, and hang pouch- like by this pedicle. Their histological structure has not as yet been satis- factorily explored. Some authors found only soft con- nective tissue, while others found cells, probably epithe- lial cells of the sebaceous glands, in a peculiar condition of retrogressive metamorphosis. 7. A third form of fibroma of the eyelid has been de- scribed as plexiform neurofibroma. This rare kind of growth is said to be congenital, to consist of a series of swellings and cords which lie in the subcutaneous tissue, and which in parts are extremely painful to the touch. Fig. 1083. among females than among males. It is a roundish or lobulated elevation of the skin, of a peculiar yellowish appearance, which has given it its name. Its development has often been brought into relationship with diseases of the liver. Very frequently these elevations appear symmet- rically situated on both eyes, especially on the upper eye- lids. They are not found in early youth, and undoubt- edly belong to the later years of life. In females they often develop in the catamenial years. There is, besides the deformity which they cause, hardly any reason for their removal. Histologically there can be no doubt that different forms of tumors may be taken for xanthelasmata, which 805 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The histological examination has not cleared up their nature very materially. They are said to consist of dense connective tissue, rich in nuclei, and surrounding simply atrophic nerve-bands, or nerve-fibres undergoing fatty degeneration. 6. Lipomata of the eyelids are of rare occurrence. They may be congenital, or come on in very obese people in ad- vanced life. In the latter case they are apt to grow, and may have to be removed in order to get rid of the obstruc- tion of sight caused by them, especially when they develop in the upper lids and hang over the lid-margin. intp the tissues and breaks them down in a very short period. This rapid progress is soon followed by infiltra- tion of the lymphatic glands, and of the parotid, or it may spread over the conjunctiva bulbi into the cornea, and eating its way through it, may enter the eyeball, or grow around it and invade the tissue of the orbit. This form is, luckily, observed rarely, and the prevalent form is the one at first described. Epithelioma of the lid is a disease which is found in individuals of advanced age only. Histologically we find the same elements in this form of tumor in the eyelid as we do elsewhere. The pre-ex- isting epithelial cells of the cutis, as well as those of the sebaceous glands, become hypertrophic and grow in the typical way into the underlying and surrounding tissues, in the shape of cylinders. Frequently the rapid increase in number of the epithelial cells causes the formation of pearl-nodules. The periphery of the growth shows the usual zone of infiltration and inflammation. 2. Adenomata of the lids have been described ; it is, however, very likely that small, epitheliomatous growths have been mistaken for such. At least, since their first description, adenomata have never been observed again, and this very description does not give anything that would be characteristic enough to warrant the histological diagnosis of adenoma. 3. Sarcomata of the eyelids, at least primary ones, have been but seldom observed : the eye- lids are more frequently invaded by sarcomatous growths from the orbit and the surrounding tissues. In the few cases of primary sarcoma of the lid which have been observed, the patients were nearly all children. The tumors grew rapidly and soon infiltrated the whole tissue of the lid which was attacked. The neoplasms were mostly of the round-cell type, and sometimes me- lanotic. Of course, the danger to life due to sarcomatous growths makes their removal as urgent when they origi- nate in the eyelid as when they develop in any other region of the body. II. Tumors of the Conjunctiva.-A. Benign Tumors of the Conjunctiva.-1. Lymphangiectasia of the conjunc- tiva appears usually as a conglomeration of small, roundish elevations, filled with a watery fluid, and often strung to- gether like beads. These little tumors give but very rarely rise to an inflammatory condition of the surrounding con- junctiva, and, as a rule, cause the patient no annoyance to speak of. When punctured they collapse, but are usu- ally soon refilled. Their usual seat is the bulbar con- junctiva. From the histological appearance they are undoubtedly Fig. 1084.-Transverse Section of Epithelioma of Eyelid. No further importance is attached to this kind of growth. 7. Lymphangiomata and lymphomata have also been found in the eyelids. The case of lymphangioma seems to be unique. It is said to have been situated at the lid margin, the size being that of a split pea. It consisted of fibrous con- nective tissue, containing a large number of cavities of different sizes. These cavities contained a fine, granular substance in which lymph-cells were suspended. The walls of the cavities were lined with an endothelium. In harmony with this description the tumor was styled a cavernous lymphangioma. Lymphomata of a very large size were found in all the four eyelids of a man suffering from leukaemia. B. Malignant Tumors of the Eyelids.-1. Of the ma- lignant tumors of the eyelids the most frequent are epithelial tumors, and among them especially the flat epithelioma. The epithelioma of the eyelid begins al- most always at the lid-margin, especially on the lower lid, and it seems to grow with preference near the inner or outer canthus. In the beginning we usually find a small, round- ish, reddish nodule, which is quite hard. Sometimes this hardness and some redness around the original nodule are the only symptoms by which we may distinguish it from a common wart. After a while, either spontaneously or because the patient keeps irritating it with his fingers, the surface of this nod- ule becomes slightly ulcerated, and a crust is formed. Now* this one nodule may keep on growing and spreading, and becoming excoriated at its surface, or new nodules spring up around it and share the same fate. Thus finally results a flat ulcer, with a hard base, and hard, ragged edges, which frequently bleed profusely when but slightly injured. As the ulcer creeps along some parts may heal up, and the tough white bands of scar-tissue give the affection then an aspect very similar to scirrhous cancer in other parts of the body. The infiltration of the tissues, the breaking down of the lid-margin, and the development of bands of cicatricial tissue-all these alterations, singly or combined, may cause very annoying and unsightly deform- ities of the eyelids. The lower lid, as a rule, becomes everted, and to all other afflictions is added a continuous flow of tears. The growth of this kind of epithelioma is but slow and quoad ritam, decidedly to be dreaded much less than another form of this growth which eats rapidly Fig. 1085.-Lymphangiectasia of the Bulbar Conjunctiva. distended lymph-vessels. The little tumor consists of a system of canals and cavities, which are in no way con- nected with the blood-vessels. The latter show the more plainly, as they are usually hypenemic. The cavities and canals just spoken of are separated from each other by trabecules of dense connective tissue, but communicate with each other. The surrounding conjunctival tissue appears condensed and pressed aside. This system of canals contains a perfectly translucent serous fluid in which are suspended a number of lymphatic cells. The 806 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. walls show, now and then, some traces of an endothelial coat. (See Fig. 1085.) 2. Serous cysts of the conjunctiva may undoubtedly result from what was originally simply a lymphangiec- tasia ; the septa existing between the canals and cavities of such a tumor, having gradually yielded to the pressure, and all the cavities having thus become united into one. But serous cysts have also been found in the conjunctiva at birth, and they may develop without being preceded by a typical lymphangiectasia, especially after injuries. They appear as round or oblong or oval swellings in the conjunctiva, which, from their contents, usually have a somewhat yellow tinge. They are not, as a rule, mov- able under the conjunctiva, but they may become large enough to annoy the patient, and must then be removed. They have a "well-defined cyst-wall, consisting of con- nective tissue, and are usually lined with a layer of endo- thelial cells. 3. Teleanyiectatic tumors are also occasionally found in the conjunctiva of the lids and eyeball, and usually there is then, at the same time, a teleangiectatic tumor in the lid. The seat of these tumors seems to be mostly in the region of the lachrymal caruncle. Their histological structure is the same as that of other teleangiectatic tumors. 4. Granulomata, commonly called polyps, of the con- junctiva are comparatively frequent. They are red, soft- ish nodules projecting into the conjunctival sac, sitting on the conjunctiva, either with a broad base or having a slender peduncle. They are found chiefly near the in- ner canthus. They are either due to injuries or to chronic inflammatory affections of the conjunctiva, and may at- tain a considerable size, especially on phthisical eyeballs. They now and then make their appearance at the site of a tenotomy for strabismus. Their structure is that of all granulomata. They con- sist mainly of newly formed round cells and small spindle-cells, here and there intersected by connective- tissue trabeculae. This tissue is often full of blood-ves- sels, and usually contains a number of cavities filled with serous fluid. In rare cases the tissue is found to be of a higher organization, the granu- loma being changed into a fibroma. 5. What has been described as lipoma of the conjunctiva is, from all descriptions, a subcon- junctival growth of fat-tissue. In the few cases which have been described this kind of tumor was con- genital, in some it increased in size in later life. The subconjunctival lipoma is said to appear as a yellow, roundish, and soft swelling, usually consisting of several lobules. They seem to be generally situated between the external and superior rectus muscles. According to the descriptions given of their histologi- cal structure these tumors are very closely allied to the dermoid tumors; it even seems as if they were dermoid growths with an excess of subcutaneous fat-tissue. 6. Dermoid tumors of the conjunctiva are always con- genital tumors. Their seat is at the corneo-scleral junct- ure, and very frequently they lie partly in the corneal and partly in the conjunctival tissue. The tumor appears as a grayish or yellowish round elevation, about the size of a pea-sometimes, however, much larger. Where it ends in the corneal tissue it is usually surrounded by a zone of gray corneal tissue, not unlike an arcus senilis. Conjunctival blood-vessels may enter it. Its surface is usually smooth and shining, and it may be partially or totally covered with fine hair. Sometimes one or more of these hairs grow very long and protrude through the palpebral fissure. Such a tumor may remain stationary a whole lifetime and cause no greater annoyance than what may be due to the growth of the hair. In other cases some irritation causes the tumor and its surroundings to become inflamed, and then the tumor may begin to grow and invade the thus far healthy tissue of the cornea. In such a case, or from cosmetic reasons, the<emoval of a dermoid tumor may become necessary, and is, as wall be seen from the histological conditions, easily accomplished. The dermoid tumor, as its name indicates, consists es- sentially of the elements of the skin. It is covered by epithelium, the outer flattened cells of which are, how- ever, not always horny, but often undergoing a retrogres- sive metamorphosis. This is probably due to the moist- ure in which the surface of the tumor is continuously bathed. There are also usually a number of mucous cells to be found in this layer. This epithelial coat is uneven, like the surface of the skin, and numerous off- sets are sent into the depth surrounding the papillae of the tumor. From almost all of these indentations one or two fine hairs spring forth, and here lie also the orifices of the acinous glands, which are usually found in these growths. The connective tissue under the epithelium is very dense and fibrous. It contains elastic fibrillae, and, as a rule, but few cellular elements, unless the tumor be in an in- flammatory condition. The basis of the tumor, which is only very loosely connected with the epi-scleral tissue, is made up of fat-tissue. Where the tumor lies on the cor- neal tissue, the union is usually a very firm one. These tumors contain a moderate number of blood-vessels, but it seems that they are but scantily supplied with nerves. 7. True osteomata of the conjunctiva have been ob- served in a small number of cases. The formation of bony tissue seems not to have been congenital. There appeared, in one case, a small tumor on the eyeball near the outer canthus, which was removed on account of the annoyance which it caused. In another case the tumor had attained the size of a bean. The histological exami- nation revealed true bone-tissue. Fig. 1086.-Sarcoma of the Conjunctiva. 8. The writer, a short time ago, had occasion to remove a tumor from the eye of an infant, which must be styled a chondro-adenoma of the conjunctiva. The tumor sat on the bulbar conjunctiva with a broad base, was whitish and perfectly smooth. The parents had observed it at the time of the child's birth, and thought that it had been gradually growing since that time. Its size was about that of a split pea when the writer saw it. The histological examination of the tumor revealed the fact that it consisted of a large cluster of glandular tu- bules, resembling somewhat in their arrangement those of the lachrymal gland, and a large, roundish piece of embryonic cartilage. These two kinds of tissue were separated from each other, and together were surrounded by a dense connective tissue. B. Malignant Tumors of the Conjunctiva.-1. Sarco- mata of the conjunctiva are of rare occurrence. They are either unpigmented, or, what is more frequently the case, pigmented. These tumors take their origin almost invariably from where the conjunctiva bulbi joins the cornea, that is, from the epi-scleral tissue at the corneo- scleral juncture. Their development has, in a number of cases, been ascribed to an injury. The sarcomatous tumors of this region usually form roundish, sometimes lobulated swellings, which soon en- croach upon the corneal tissue. They are very vascular, and bleed easily. They are usually of a rusty brown color, 807 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. or they may even be almost black, at least in parts. Their surface appears smooth and shining, which is due to the fact that the growth for a long period remains covered by the conjunctival and corneal epithelium. Sometimes new nodules appear at some other point of the corneo- scleral margin, occasionally at a point diametrically op- posite the original tumor. In their further development these tumors may spread into the interior of the eye, and by the dissemination of their elements death may ulti- mately result. Histologically, the sarcomata of the conjunctiva are usu- ally small, round-celled sarcomata. The original nodule, when growing on to the cornea, spreads for a time be- tween the corneal epithelium and Bowman's layer, in the way pannus-tissue is known to spread. Later on, Bow- man's layer is destroyed at the periphery, and the sarcoma- tous elements invade the corneal tissue proper (see Fig. 1086). Yet the resistance of Bowman's layer is so great, that the tumor will now spread underneath this layer into the cornea. In rarer cases the elements of the sarcoma are spindle-cells. The pigmentation of the cells varies con- siderably in one and the same tumor. The more super- ficial parts are, however, usually the least pigmented ones. There is but very little intercellular substance. The large quantity of blood-vessels which these tumors usually contain has already been mentioned. There are always signs of former haemorrhages, and usually recent ones, to be found. In the propagation of these tumors the blood-vessels seem to play an important role, as they are sometimes found to be filled with pigment molecules and pigmented cells. The periphery of these tumors is formed by a well-pronounced zone of inflammation. 2. Epitheliomata of the conjunctiva are more frequently observed than any other kind of conjunctival tumors. Although they are seen more frequently in an advanced age, they make their appearance also in young persons. They are generally situated on the bulbar conjunctiva, and, like the sarcomatous tumors, they most frequently start from a point near the corneo-scleral juncture. Their formation may begin with the development of a small phlyctaenula-like nodule covered with hyperaemic blood-vessels ; usually a number of larger and distended blood-vessels going to this nodule may be seen in the scleral conjunctiva. The growth may for a long period remain stationary, or keep on increasing gradually in size; or upon some special irritation it may start to develop rapidly, and be accompanied by inflammatory symptoms, and sometimes by considerable pain. The tumor usually spreads upon the cornea, which it may gradually penetrate, and thus find an entrance into the interior of the eyeball. The pain and suffering usually force the patient to sub- mit to the removal of the eyeball before any further spread- ing of the elements of the tumor has taken place. In its early stages the new formation may be removed from the eyeball without much difficulty, as this has been stated of the sarcomatous new formations. Such epithelial growths of the conjunctiva have sometimes been found to be pig- mented, and have then been described as melanocan- croids. The epitheliomata of the conjunctiva, like those found in other parts of the body, originate in a hyperplasia of the pre-existing epithelium. Thus we find in the begin- ing the epithelial layer considerably thickened, the ser- rated cells very numerous and well pronounced. In some cases we find a layer of horny cells of considerable thick- ness. This original tumor is usually surrounded by a tissue which is hyperaemic and infiltrated with round cells. When the tumor grows, epithelial-cell cylinders begin to dip into the underlying tissue and send off new branches. Gradually the new formation invades the cor- nea, this invasion being always preceded by the new for- mation of blood vessels and by round-cell infiltration. Bowman's layer gives way, and the epithelial-cell cylin- ders spread into the corneal tissue proper. In the same way the epithelioma spreads into the sclerotic. Some- times the surface of the tumor is ulcerated. The epithelioma may spread into the interior of the eyeball. Thus it has been seen to invade the ciliary body and the choroid along an anterior ciliary artery, or the iris, after perforation of the cornea and anterior synechia had taken place. In some cases the conditions seemed to warrant the assumption that the external tumor had spread to the interior of the eyeball by metastasis. III. Tumors of the Cornea.-The cornea proper does not seem to be the seat of primary tumors. What has been described as such is to be found under II. Tu- mors of the Conjunctiva. IV. Tumors of the Sclerotic.-The sclerotic, like the cornea, does not seem to be a field for primary new formations. What has been described as such probably belongs to the conjunctival (epi-scleral) tumors, and has, therefore, been treated under II. V. Tumors of the Iris.-A. Benign Tumors of the Iris.-1. Simple granulomata of the iris have sometimes been observed, and have a number of times been men- tioned in the older ophthalmic literature. They were de- scribed as small, round, yellowish, or grayish swellings, which made their appearance usually in the lower half of the iris. Gradually such a tumor would grow until it reached Descemet's membrane, and finally it would lead to perforation of the cornea. This generally was fol- lowed by shrinkage of the eyeball and the formation of scar-tissue. Histologically, these tumors are found to consist of round cells, and to contain numerous giant-cells (" myelo- plaxes"). Such a structure is so similar to that of tu- bercles that some recent authors have described the simple granuloma of the iris as tuberculosis of the iris. It is certainly strange that, since we know what tumors may grow in the tissue of the iris in consequence of syphi- lis and tuberculosis, no further case of simple granuloma of the iris seems to have been observed. 2. A special kind of tumor has been observed a few times to spring from the iris ; it is generally mentioned among the cases of granuloma. This is a very vascular swelling, from which on slight provocation the anterior chamber would be filled with arterial blood. I should suppose that in such a case we would have to deal with a telangiectatic tumor, rather than with a granuloma. 3. Traumatic granuloma of the iris is sometimes met with, in some cases after the corneal wound is perfectly healed, in most cases where the iris is prolapsed and ex- posed to the air. In the former cases the granulation tissue was found to perforate the cornea, and cause per- fect loss of sight in the manner of malignant intra-ocular tumors. In the latter cases the tissue of the granuloma gradually becomes organized and forms scar-tissue, and may thus bring about a spontaneous cure. Such granulomata also consist of round cells and small spindle-cells, and contain but little connective tissue and new-formed blood-vessels. Later on, the round cells gradu- ally are changed into spindle-cells, and finally we find a dense connective tissue containing but few cellular ele- ments. The granulomata which start from a prolapsed portion of the iris are usually covered with epithelium. 4. Melanoma of the iris has occasionally been observed. It appears as a darker raised spot in the tissue of the iris, and it is, to say the least, as yet questionable whether what has been called melanoma was not a melano-sarcoma. The authors usually state that a benign melanoma may at any time assume a malignant sarcomatous character. Such a melanoma is said to consist of a circumscribed accumulation of " stroma-cells of the iris, the larger part of which were pigmented, had many offsets, and anasto- mosed with each other. They passed without a sharp boundary into the neighboring tissue, and the remainder of the iris was normal." 5. Cysts of the iris have been observed in a large num- ber of cases. They are either serous cysts or cysts filled with epithelial material, epidermoid (atheromatous) cysts. Cystic formations in the iris, as a rule, develop only after an injury. They begin as small, round, yellowish, or grayish tumors. The yellowish color is more character- istic of the epidermoid character, the grayish or grayish- white color seems to be that of the serous cysts. 3hch cysts gradually grow until they reach Descemet's mem- brane, and may become firmly adherent to it. Oblique illumination will usually show plainly if we have to 808 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. deal with a serous cyst, since its walls and contents are translucent. In some cases the presence and the growth of such a cyst seem to cause but little discomfort, in other cases severe inflammatory symptoms make their appearance, and sight may be destroyed. The manner in which the formation of such cysts takes place is as yet not absolutely settled. But from recent experiments it seems that these cysts usually de- velop in small portions of glandular tissue which have been forced into the iris by some previous injury ; these parts enclosing organs which are apt to retain their con- tents and secretion. There can be no doubt, however, that in some cases serous cysts are formed if a fold of the iris becomes adherent to Descemet's membrane, or to a wound-canal in the cornea. The cyst-walls have usually been found to consist of atrophied and attenuated iris-tissue, lined with a layer of endothelial cells, and usually firmly adherent to the cor- nea. There is scarcely any pigment found in the cyst- walls. The contents of tlie serous cyst are a perfectly transparent fluid, while the contents of the epidermoid cysts correspond with those of other atheromatous cysts and sometimes contain hair. B. Malignant Tumors of the Iris.-Sarcomata of the iris have been met with in but a few cases. They have been mostly pigmented, but in a few cases they were un- pigmented, or at least partially so. These tumors of the iris seem to have originated mostly in the parenchyma of this membrane, and near its sphinc- ter-edge. When allowed to grow, the tumor slowly spreads over the iris, and at the same time presses against the cornea, which it finally perforates. During its de- velopment it causes increase of intra-ocular pressure and inflammatory attacks, with subsequent destruction of sight. Later on, it leads to metastases. The rule is, un- doubtedly, that these tumors grow on the anterior sur- face of the iris. The writer has once had occasion to see a darkly pigmented sarcoma spring from the posterior surface of the iris near the pupillary margin, and, press- ing the lens backward, spread into the interior of the eye- ball. In its early stages sarcoma of the iris has been suc- cessfully removed by iridectomy; later on the eyeball has to be sacrificed. In the few cases which have been histologically exam- ined the tumors were either pigmented round-cell or pig- mented and unpigmented spindle-cell sarcomata. They seem to take their origin from the parenchyma of the iris. VI. Tumors of the Ciliary Body.-A. Benign Tu- mors of the Ciliary Body.-1. Myoma of the ciliary body has only once been observed and described. In this case a brownish-red tumor was found to press part of the iris against the posterior surface of the cornea and to protrude for some distance into the pupillary space. The tumor showed smooth elevations. There was increase of intra- ocular tension, and attacks of severe pain were complained of. The tumor grew slowly but continually, and was considered to be a sarcoma. Finally the patient consented to the enucleation of the eyeball. The tumor was found to have the size of a filbert, and to be firmly attached to the ciliary muscle. When divided its cut surface was of a roseate color, and it was only little pigmented in peripheral parts. On microscopical exam- ination it was found to consist almost exclusively of non- striated muscular fibres. 2. A cyst of the ciliary body has also been observed and described only once, but this case has not yet come to be examined microscopically. The cystoid formation in this case followed an injury to the lid and eyeball. The cyst is described as an oval body lying just behind the lens, springing from the ciliary region, and reaching with its larger end half-way across the eye into the vitreous. By oblique illumination the edge of the cyst looks white, and can be clearly defined. Its surface is dotted, here and there, with pigment deposits. By direct examina- tion with the ophthalmoscope the cyst-walls are trans- parent, and the details of the background of the eye may be dimly recognized through them. This cyst has been observed to grow slowly, and to cause attacks of intra- ocular tension. B, Malignant Tumors of the Ciliary Body.-Primary leu- co-sarcoma and melano-sarcoma undoubtedly occur in the ciliary body, but are comparatively rarely seen, and yet more rarely examined microscopically. Moreover, these forms of tumors have nothing which would distinguish them from the sarcomatous growths of the choroid, and they are, therefore, best considered under that head (VII. B). VIL Tumors of the Choroid.-A. Benign Tumors of the Choroid.-1. Granuloma of the choroid is sometimes found histologically. Whether it has ever been clinically diagnosticated the writer does not know. In literature no mention is made of such a diagnosis. In eyes in which the choroid has been injured (through the sclerotic), or after round-cell accumulations have, after the manner of abscesses, perforated the lamina vitrea of the choroid, we find occasionally a small tumor consist- ing of granulation-tissue, viz., free nuclei, round cells, and small spindle-cells, and newly formed blood vessels. These tumors may either lift the retina from the choroid and thus cause a circumscribed detachment of the former membrane, or they may have pierced the retina also and protrude into the vitreous body. Later on, these granula- tion tumors are changed into connective tissue, and ulti mately, when contracted, they form a simple scar. There is one observation on record of small granulo- mata of the choroid in the eye of an individual who had long been suffering from " granular lids." 2. Cystoid formations in the choroid have been seen but once, it seems, at the microscopical examination of an eye by the writer. They were found situated in the peripheral portions of this membrane, and formed a small number of round and oval cavities embedded in the pa- renchyma of the choroid. They had a membrana propria and were lined with endothelium. Their nature was probably that of dilated lymph-vessels. The tissue of the choroid, which was displaced by these cystoid formations, was infiltrated with round cells and hypersemic. B. Malignant Tumors of the Choroid.-The only form of malignant tumor found in the choroid (and ciliary body) is the sarcomatous form, with a number of varieties. Since sarcoma of the choroid (and ciliary body) is un- doubtedly the kind of intra-ocular tumor most frequently met with, we will give it a more extensive consideration, the more so as its clinical development is typical for that of all malignant intra-ocular tumors. It happens but comparatively seldom that we have oc- casion to see and diagnosticate a choroidal sarcoma, and verify our diagnosis by a microscopical examination at the period which is usually described as the first one in its development. At this stage the patient usually complains only of a diminution of sight. If the tumor springs from the ciliary region it can usually be recognized by the protrusion of the iris, and be seen under oblique light. The diagnosis is more difficult when it is situated more centrally, or, as is frequently the case, near the optic-nerve entrance. The difficulty may be considerably increased if the retina at the site of the choroidal tumor has become detached. This seems, however, to be less frequently the case than was formerly stated by the authors. At this stage the ophthalmoscope may reveal one larger-sized, roundish elevation in some part of the background of the eye, or a flat elevation with a smooth or undulating sur- face covered by the retina, whose blood vessels appear ac- cordingly distorted in their course. The pigment of the sarcoma may perhaps be seen through the retina ; even in cases in which the retina at the site of the tumor is detached it may be possible to recognize the latter through the retina with the aid of strong illumination and a high magnifying power. It will, in most cases, however, be necessary to observe the case for some time, to note whether there is any change in the picture and whether the supposed tumor increases in size. If an ap- parent detachment of the retina lying in the upper half of the eyeball, or to one side, remains confined to its origi- nal seat, and the lower half of the retina does not become involved, the condition must be considered very suspi- cious of the presence of a choroidal sarcoma. 809 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The growth of a choroidal sarcoma may vary consider- ably as to rapidity. While some reach the second period in, say, one year, others may take a number of years to reach the same stage. The second period in the development of a choroidal sarcoma is characterized usually by an increase of the in- tra-ocular tension to a varying degree (glaucomatous stage), combined with inflammatory attacks and often severe pain. In some cases glaucomatous symptoms are wanting. In this period the tumor fills the vitreous cham- ber more and more, and pushes the retina, the condensed vitreous body, the usually cataractous crystalline lens, and the iris toward the cornea. Or it spreads through the whole uveal tract, forming, so to speak, a sarcomatous shell which encloses the retina, the condensed vitreous body, and the cataractous crystalline lens. In this period the eye usually shows the signs of a chronic inflammation externally. The third period in the development of a choroidal sar- coma is usually called that of perforation and the spread- ing of the tumor outside of the eyeball. Thus the ele- ments of the tumor usually grow through the sclerotic, along, or even by way of, a blood-vessel (venae vorticosae, anterior ciliary arteries, etc.), or through the channel of a ciliary nerve, or, what is quite often the case, when the tu- mor originated near the optic nerve, by way of this nerve or its sheaths, or the intra-vaginal space. In other cases, the tumor will cause a staphyloma-like distention of the anterior parts of the sclerotic or of the cornea, and cause a more frequently pigmented than unpigmented, The pig- mentation varies considerably, however, even in one and the same tumor. The elements of the tumor are either round cells or spindle-cells. The spindle-cells seem to be prevalent in the unpigmented sarcomata. The round cells of the pig- mented sarcomata (melano-sarcomata) are usually very large. The round-cell sarcomata are mostly very vascu- lar. The spindle-cell sarcomata have generally but few blood-vessels, and are more of a fibromatous character. They also seem to grow more slowly than the round-cell sarcomata. The sarcomata of the choroid may take their origin from the different layers of the choroidal parenchyma. The statement has been made, and its correctness has been de- nied, that the unpigmented spindle-cell sarcomata spring usually from the outer layers of the choroid. The writer is satisfied that it is the correct view, and that the pig- mented sarcomata spring, as a rule, especially the darkly pigmented ones, from the inner layers of the choroid. They get their dark pigment from the broken-up cells of the pigment epithelium. Sarcomata starting from the outer layers of the choroid may remain perfectly unpig- mented, and grow to quite a size, until by the final per- foration of the lamina vitrea of the choroid, and the sub- sequent breaking up of the pigment epithelium, a large quantity of pigment molecules is set free, and then only does the tumor become to some extent pigmented. Be- fore this happens the pigment epithelium is usually found in a state of proliferation. Occasionally there may be more than one primary sar- coma nodule in the choroid of one eye. From the pri- mary nodule the sarcoma spreads in the choroid in the following manner: When the elements of the original tumor have perfo- rated the lamina vitrea of the choroid, detachment of the retina may take place, or the retina may remain in con- tact with the inner surface of the tumor, and become firmly adherent to it. The choroid surrounding the tumor, which at first may appear normal or hyperaemic, and slightly infiltrated, is gradually invaded by the ele- ments of the tumor. This invasion takes place at first in the outer (venous) layers. In these cases the growth of the tumor is a more diffuse one. In other cases metasta- tic nodides are formed in other regions of the choroid, at some distance from the primary nodule. Gradually the elements of the tumor reach the lamina supracho- roidea, and the tumor soon adheres to the sclerotic. This union is sooner or later followed by the perforation of the sclerotic, and the growth of secondary nodules on the outer surface of the eyeball. As stated before, this perforation of the sclerotic takes place along a pre- existing canal (nerve or blood-vessel) in the sclerotic. In rarer cases the cornea is perforated by ulceration, and thus the tumor spreads outside the eyeball. On the other hand, the tumor may spread backward by way of the optic nerve. This happens in one of the following ways the elements of the tumor may invade the substance of the nerve itself, or they may enter into the porus opticus along the central blood-vessels, or they may invade the in- tra-vaginal spaces of the optic nerve-sheath. The glauco- matous symptoms, which are observed in most cases of choroidal sarcoma, are due to the pressure exerted by the growth. The sarcoma of the choroid is sometimes found to con- tain deposits of amorphous lime. In rare cases osseous tissue is found to have been de- veloped within the sarcoma (osteo-sarcoma). Chondromatous tissue is found somewhat more fre- quently (chondro-sarcoma). It usually appears in the shape of round or oval islets, which are generally sur- rounded by a tough connective-tissue capsule, and lie near or around a larger blood-vessel. In a few of the cases observed the sarcoma was a cystic sarcoma, and in another small number it was an alveolar sarcoma. The spindle-cell sarcomata are, as a rule, hard and tough, while the round-cell sarcomata are softer, some- times even semifluid. Fig. 1087.-Sarcoma of the Choroid. rupture there. In this case the lens is usually expelled from the eye, and the tumor, no longer restrained in its growth by a resistant capsule, grows rapidly outward until the lids can no longer be closed over it. At the same time the dissemination of elements of the tumor has usually taken place. Such elements taken up into blood-vessels are carried away by the current of the blood, and wherever they are deposited new (metastatic) tumors are formed, which ultimately cause the death of the patient. The organs which are usually attacked by such metastatic tumors are chiefly the liver, the lungs, pleura, intestines, kidneys, spleen, brain, etc. In very rare cases sarcoma has been found to attack both eyes of the patient. ' The development of sarcoma of the choroid is usually observed at an advanced age,yet it has also been found in very young individuals. It seems to be somewhat more frequent in males than in females. In a considerable num- ber of cases its development may be considered due to an injury. From the foregoing it is evident that, as soon as the di- agnosis of choroidal sarcoma is made, the eye should be removed, as it is impossible to state when the tumor will spread outside the capsule of the eyeball, although this usually takes place only at a late period. Histologically, we find the choroidal sarcoma to be 810 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. VIII.-Tumors of the Retina.-A. Benign Tumors of the Retina.-Telangiectatic tumors and small fibroma - tons tumors have been occasionally found in eyes exam- ined anatomically, but they do not seem to have ever been observed during life, nor are they of any impor- tance. B. Malignant Tumors of the Retina.-The only malig- nant tumor observed to take its origin from the retinal tissue is the glioma of the retina. Glioma of the retina (fungus haematodes) is essentially a disease of childhood, the oldest patient in whom it was undoubtedly observed having been but twelve years old. It is probably, in most cases, a congenital affection. As with the sarcoma of the choroid, we may divide the clinical history of the development of a glioma into three periods. In the first period the growth causes but slight outward symptoms, and is but seldom observed. The first symp- toms, on account of which the parents bring the child for examination, are usually diminution or total loss of sight, and the observation of a light yellowish or yellowish-red reflex from the pupil (amaurotic cat's eye). In this stage the pupil is also generally found to be dilated, probably from paralysis of the nerves of the iris. The reflex from the background of the eye may at first be only visible in certain parts, and then the ophthalmo- scope may reveal only a partially swollen retina, and the optic papilla may as yet be visible. Gradually the back- ground of the eyeball is shifted more and more forward in the vitreous chamber, and it may now be possible to see different round nodules by the aid of oblique illumi- nation. On the anterior surface of this yellow nodular mass a number of blood-vessels may be visible. Usually some whitish spots are seen, which correspond to parts which have undergone fatty degeneration, or to deposits of lime. Finally, the whole of the vitreous chamber is filled, and the tumor reaches the crystalline lens and presses it forward. This is usually soon followed by the formation of cataract. Before this stage is reached, as a rule, the second period has begun, which is characterized by an increased intra- ocular tension, pain, and inflammatory symptoms. The eyeball is now frequently ectatic in the equatorial region ; there is iritis, and soon the cornea ulcerates and is per- forated. The blood-vessels of the conjunctiva and epi- scleral tissue are hyperaemic and tortuous. These symp- toms are often combined with cerebral ones ; there may be fever and vomiting. The ulceration and perforation of the cornea, in rare cases, may be followed by the for- mation of scar-tissue and shrinkage of the eyeball. Such cases have been described as cases of spontaneous healing of glioma ; but even after a considerable period of latency the tumor makes its appearance again, and valuable time may have been lost. The third period is that of perforation. The glioma grows outward usually after the perforation of the cor- nea, more rarely of the sclerotic. If it grows out through the cornea it increases very rapidly in size. The soft, easily bleeding, often partially necrosed tumor soon pro- trudes between the eyelids, and may in a short time attain an enormous size. When the tumor has spread through the sclerotic, be- fore the cornea has been perforated, the epi-scleral tumor, or tumors, may cause a considerable degree of exoph- thalmus. The tumor may furthermore invade the optic nerve and grow thus backward toward the chiasma. Usually during this period secondary tumors are formed in the lymphatic glands of the face, the parotid or sub- maxillary glands, in the bones of the skull, in the brain, liver, and other organs. Death follows from exhaustion. In a large proportion of the cases (eighteen per cent.) glioma of the retina attacks both eyes. The affection of the second eye seems, however, not to be due to an infec- tion from the one first affected. Frequently several chil- dren of one family suffer from this new formation. It seems that it is more frequently found in males than in females. In a few cases purulent choroiditis, with purulent hya- litis (pseudo-glioma) has been confounded with true glioma. In such cases, however, the intra-ocular tension is, as a rule, reduced, and pain seems to be wanting. Moreover, the eyeball appears rather shrunken, than dis- tended, as it does in a case of true glioma. Glioma is known to be pre-eminently a malignant growth ; therefore the removal of the eyeball, or even of the whole orbital contents, is necessary at the earliest possible period. In this way the life of the patient has been saved in a number of cases. Histologically considered the glioma (or glio-sarcoma) of the retina must be counted among the small round- cell (medullary) sarcomata. Its elements are round cells, smaller or larger than white blood-cells, or identical with them. Sometimes these cells have small offsets. Be- tween them we find free nuclei and some spindle-cells. There is a very small quantity of intra-cellular substance. The tumors are usually very vascular, and their blood- vessels are very wide. The cells seem to be very prone to degenerate. The tumor usually takes its origin from the outer retinal layers, especially the granular layers ; in rarer cases its primary seat is in the inner layers, especially the nerve-fibre layer. In some cases it appears as if the whole thickness of the retina had been primarily affected, and, in fact, the tumor may take its origin from the con- nective tissue of all the layers of the retina. As already stated, the glioma cells are apt to undergo Fig. 1088.-Glioma of the Retina. fatty degeneration, and deposits of lime are often found in these tumors. When the tumor starts from the outer layers, the retina in its neighborhood becomes soon detached and is pressed toward the axis of the eyeball. In these cases the inner layers of the retina may remain intact for a long time. On the other hand, when the tumor has started from the inner layers, the rods and cones may be preserved for a long period. The tumor gradually spreads all over the retina, and enters the choroid either simply by its con- tiguity or by infection (metastasis). During the growth of the tumor, parenchymatous haemorrhages frequently take place within it. Later on, the tumor may spread into the ciliary body and the iris, and we may thus find an eyeball filled per- fectly by glioma, and but few traces of its former struct- ures left. At a comparatively early period, usually, the elements of the tumor invade the substance of the optic nerve. The perforation of the sclerotic, and the formation of secondary tumors outside of it, generally take place along a preformed channel (nerve or blood vessels), as we have" seen it take place in the development of the sarcoma of the choroid. IX. Tumors of the Optic Nerve (Orbital Por- tion).-The tumors of the orbital portion of the optic 811 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. nerve have a number of symptoms in common, whatever the nature of the growth may be, the chief ones of which are loss of sight and exophthalmus. The latter is often the first symptom to be observed. This exophthalmus is, as a rule, in a straightforward direction, yet there may also be a deviation in another direction, if the tumor should develop more rapidly to one side. The eyeball can usually be moved, but its movements are restricted in all directions; later on, they may be totally abolished. If the tumor is large enough to be palpated, it is found to move with the movements of the eyeball, and to be nowhere attached to the orbital walls. When it is small it cannot be felt. In a number of cases the development of the tumor is attended with severe pain, in most cases this symptom is wanting. In all cases sight gradually fails. In early stages the ophthalmoscope reveals optic neuritis ; later on, we find white atrophy of the optic nerve. The rapidity with which sight is abolished varies considerably in the different cases, and this is, of course, due to the manner in which, in the given case, the nerve itself is constricted or invaded by the elements of the neoplasm. Thus, when the tumor originates in the outer sheath, sight will be preserved longer than when the new for- mation has its origin in the perineurium or the substance of the nerve itself. As the tumor grows and pushes the eyeball out of the orbital cavity, the cornea becomes less and less protected by the lids, and finally this membrane ulcerates and is perforated. It seems that in all the known cases, except one, the tumor with the eyeball, or the tumor alone has been re- moved and a perfect cure has been obtained. From this it would seem that tumors of the optic nerve, quoad vitam, are not to be considered malignant. The nature of the tumors of the orbital portion of the optic nerve seems to be chiefly myxomatous (myxo-sar- around their nucleus. Their contours are not sharply defined, and some of them have long offsets. Giant-cells are not wanting. These cells, the nature of which is that of endothelial cells, are often grouped concentrically around a round or oval shining body (arenoid body), from which these tumors have also received the name of psam- moma. 4. In the one case of true neuroma of the optic nerve thus far described in literature, the whole egg-shaped tumor consisted of double-contoured as well as of non-medul- lated nerve-fibres. X. Tumors of the Orbit.-The chief symptoms of orbital tumors, and the one which they all have in com- mon is exophthalmus-protrusion of the eyeball. This exophthalmus may, of course, lie in all directions, and we can only state, as a general rule, that it is in a direction opposite to the site of the tumor or to its greatest develop- ment. Usually the movements of the eye in the direction toward the tumor are impaired or abolished. While some orbital tumors cause a great deal of pain, others do not seem to cause any. According to the seat and size of the tumor, sight will be more or less impaired or to- tally destroyed, and we find accordingly with the oph- thalmoscope simple anaemia, optic neuritis, and partial or total atrophy of the optic nerve. Orbital tumors do not seem to be apt to invade the optic nerve, or the eyeball, but they generally grow around it. It is usually possible by palpation to locate the tumor, and it is then recognized from a tumor of the optic nerve by its situation outside of the cone formed by the exter- nal muscles of the eyeball, and by its being in many cases adherent to the walls of the orbit. As the tumor (and consequently the exophthalmus) grows, the upper lid is dragged along, and it often yet protects perfectly the cor- nea of an eyeball which protrudes to an enormous degree. The lid is then in the condition which we call paralytic ptosis. When the lid can no longer protect the cornea, ulcera- tions take place, and perforation of the cornea may be the result. According to the nature of the tumor it may, of course, invade the brain, and cause metastatic tumors to be formed in other organs, and thus bring about the death of the individual. A. Benign Tumors of the Orbit.-1. Cysts of the orbit have been described according to their contents, as hy- groma, meliceris, oil- and fat-cysts, atheromatous, haema- tomatous, and steatomatous cysts. They all are prob- ably congenital and dermoid in character, and owe their existence to faulty development during foetal life. This is the more probable, since some of the cysts were found to contain a tooth, or hair, or other epithelial formations. In many of the cases the cysts were distinctly known to have been congenital, and in another number they were observed in small children. There is usually but one cyst, although in some cases several have been found. Their size varies considerably. They lie mostly outside of the cone formed by the external muscles of the eye- ball, and seem to be situated more frequently in the outer parts of the orbit than in any other region. They may extend far back into the orbital cavity. These tumors increase but slowly in size, unless stimu- lated to a more rapid development by an injury, and do not give the patient much discomfort until they are large enough to cause exophthalmus and displacement of the eyeball, which is, of course, in the direction opposite to the growth. They now may generally be seen as blu- ish swellings in the lid (generally the upper one), and may even be directly demonstrated by eversion of the lids. It may be possible to detect fluctuation in the tumors, yet this can hardly be done with any degree of satisfaction, and it is therefore better to make sure of a correct diag- nosis by the use of an aspirator. Cysts of the orbit seem to be equally frequent in both sexes, and have mostly been observed in young people. 2. Angiomata of the orbit are either cavernous or tcle- angiectatic (erectile tumors). a. The cavernous angioma of the orbit, which can at- tain a very considerable size, is congenital or develops in Fig. 1089.-Myxo sarcoma cf the Optic Nerve. comatous), or gliomatous ; in some cases the tumors had to be interpreted as endotheliomatous (psammoma), and a few cases described as cancers of the optic nerve most probably belong to this latter class. In one case the tumor was found to be a true neuroma. Being enclosed within the space which is limited by the muscles of the eyeball, and the posterior aspect of the sclerotic, all of these tumors are more or less spindle- shaped (see Fig. 1089). 1. Myxoma or myxo-sarcoma of the optic nerve consists of spindle-shaped and stellated cells, with long offsets. These cells are usually packed more densely in the centtai parts of the tumor than in the peripheral ones. They are sepa- rated from each other by a hyaline intercellular substance. The cells appear often concentrically arranged, and thus form nests which resemble the pearl-nodules of epithelio- matous neoplasms. These tumors are, furthermore, well provided with blood-vessels. The mucoid substance is often found to be accumulated in cysts of varying dimensions. Closely adherent to the new formation are the sheaths of the optic nerve, which form a capsule around it. Sometimes some traces of the optic nerve may yet be found in the centre of the tumor. 2. Glioma (glio-sarcoma) of the optic nerve shows the same elements as we find in cases of glioma of the retina, viz., round cells varying in size, cells with offsets, and spindle-cells. 3. Endothelioma (psammoma) of the optic nerve con- sists of alveolar connective tissue, in which cells lie em- bedded in more or less concentric layers. These cells are large, flat, membrane-like bodies, somewhat thicker 812 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Eye. Eye. later years. It is usually situated in or starts from the fat- tissue within the cone formed by the external muscles of the eyeball. The tumor is often surrounded by a tough capsule of connective tissue. It may, as a rule, be seen as a bluish swelling under the skin of the lid, and from this similarity with orbital cysts mistakes in diagnosis have occasionally occurred. A characteristic symptom of the angioma is, however, that everything tending to hin- der the reflex of the venous blood will cause a swelling and protrusion of the angioma ; furthermore, the tumor may be compressed and emptied. The growth of the tumor is slow, and it is not apt to cause any pain. In rare cases a spontaneous cure has been observed. The removal of the tumor is practicable, and the more so the earlier it is undertaken. 3. The teleangiectatic tumors of the orbit are usually found to be accompanied by similar tumors in the lids and neighboring tissues, and form also a soft, compressi- ble swelling. This kind of angioma seems to grow more quickly than the cavernous angioma. It had also best be removed at an early period. 3. Lipoma of the orbit has been described a few times. Yet it seems that these cases were actually cases of lipo- matous tumors of the eyelids. 4. Enchondromatous tumors of the orbit occur but rarely, if at all. The descriptions of such tumors thus far laid down in literature are, to say the least, doubtful. 5. Osteoma of the orbit has been often observed. It takes its origin from the diploe of the walls of the orbit. It is generally an ivory exostosis, sometimes partially spongy or cartilaginous. Its seat of predilection seems to be the upper inner w'all of the orbit. In some cases osteoma has been found to develop symmetrically in both orbits of the same individual. These osteomata are usu- ally round tumors, hard, and with a smooth or nodulated surface, and are mostly attached to the underlying bone by a broad basis. Their growth into the orbits may take place simultaneously with the growth of similar tumors into the neighboring cavities, or they may originally have started in one of the neighboring cavities and from there have grown into the orbital cavity. Their growth is most likely due to some faulty development during foetal life. Such tumors grow very slowly ; in some cases their de- velopment is accompanied by pain. They may cause ex- ophthalmus with all its sequels. When superficial, they are easily recognized by their seat, and by their consistency and immobility. It has, however, happened that reten- tion cysts pointing into the orbit from a neighboring cav- ity have been mistaken for osteomata. The tumors under consideration may have to be removed on account of their danger to the eyeball and its functions. Their removal is sometimes comparatively easy, yet it may be attended with danger from subsequent meningitis. Histologically these tumors are found to consist of bone-tissue. In most cases this tissue was found to be extremely compact and to be almost bare of Haversian canals (ivory exostoses). In other cases they contained varying quantities of marrow. 6. Lymphoma and lymphadenoma of the orbit have been described, but they took their origin probably not from the orbital tissue proper. B. Malignant Tumors of the Orbit.-1. Cancer of the orbit has been described as epithelioma, cancroid, adenoma, and adeno-carcinoma. It seems, however, that such new formations do not take their origin from the orbital tissue, but having originated in the tissue of the eyelids, the epi-scleral tissue, or the lachrymal gland, have gradu- ally invaded the tissues of the orbit. It is, therefore, not probable that a primary cancer of the orbital tissue has ever been observed. 2. Sarcoma of the orbit has a number of times been observed and described. Its clinical diagnosis is ex- tremly difficult, since we have but scanty means on hand wherewith to distinguish the nature of a tumor which has its seat in the deeper parts of the orbit. When the nature of the tumor is recognized, its removal with or without the simultaneous removal of the eyeball is, of course, imperative. A variety of forms of sarcoma have been described. a. Cylindroma, a form of sarcoma characterized by a system of wide, anastomosing canals with larger cyst-like cavities filled with fluid, or gelatinous, or fibrinous con- tents, has but very rarely been found in the orbital tissue. 0. Myxo-sarcoma of the orbit has been observed in about a dozen cases. These tumors were seen more frequently in children and young individuals than in older ones. In some their growth was a very rapid one, and in some it was accompanied by severe pain. The tumors consisted of long spindle and stellate cells, with a mucoid inter- cellular substance. 7. Round-cell and spindle-cell sarcomata are the most frequent ones among the orbital sarcomata. In some cases they were melanotic. 4. Osteosarcoma of the orbit always springs from the bony walls of this cavity. It seems to spring most often from the inner upper part of the orbital wall. It is usually a small round-cell or spindle-cell sarcoma, with spiculse of bone-tissue embedded in it. These spiculae of bone-tis- sue may be very numerous, and make the tumor appear very hard to the touch. XI. Tumors of the Lachrymal Gland.-The tu- mors of the lachrymal gland may be diagnosticated by their situation in the outer upper part of the orbit, and by the consequent exophthalmus inward and downward (at least at the beginning of the development). These tumors generally grow but slowly. Gradually they cause a bulging of the upper eyelid, most marked near the outer canthus, and it is, as a rule, now possible to pal- pate the tumor, or even to see it protruding into the con- junctival sac, pushing the upper fornix downward. By palpation a tough, tabulated swelling is felt, which may be slightly movable; in most cases, however, it is immova- ble. When the tumor grows it often fills the posterior parts of the orbit, and thus it may cause the exophthal- mus to change its direction, and when the tumor has filled the apex of the orbit altogether, and grown around the optic nerve (which tumors of the lachrymal gland never seem to invade), the eye may stand straight forward, as if there were a tumor of the optic nerve. For this reason the movements of the eyeball, which at first are restricted only in an upward and outward direction, may become, later on, restricted in other directions too, and even finally be totally abolished. If the tumor grow still further, ulcerations of the cornea, etc., may take place. During the development of such a growth, the optic nerve is, of course, considerably pressed upon and stretched, and ac cordingly we find it anaemic, or swollen and inflamed (optic neuritis), or atrophied. From the state of nutri tion in which the nerve is when the tumor is removed, it will depend how far sight may be recovered. This re- moval may frequently be accomplished without sacrificing the eyeball. Tumors of the lachrymal gland are usually observed in individuals of an advanced age, and their origin is some- times attributed to an injury. Sometimes the lachrymal glands of both orbits in one individual have been found to be similarly affected. The tumor may, by entering the cavity of the brain and the brain-substance, cause the death of the patient. Various forms of tumors of the lachrymal gland have been observed, but opinions differ very considerably with regard to what may be considered a tumor of the lach- rymal gland and what not. The writer has seen and examined the following forms of tumors, which unquestionably took their origin from the lachrymal gland. 1. Adenoma of the lachrymal gland shows the typical picture of an epithelial neoplasm. Epithelial-cell cylin- ders, which compose the bulk of the tumor, lie embedded in a small quantity of connective tissue. The cells of every one of these cell-cylinders are arranged around a central canal, which, in some cases, is very considerably en- larged by a transparent fluid. The cell-cylinders are made up of one layer of polyhedral, almost cuboid epi- thelial cells, and have a distinct membrana propria. 2. Myxoma and myxosarcoma of the lachrymal gland are characterized by the development of spindle-cells with 813 Eye. Eye. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. long offsets, and stellate cells embedded in a mucoid in- tercellular substance, and by the gradual disappearance of the glandular structure. This kind of tumor of the lach- rymal gland is, however, but seldom observed alone. There is more frequently, at the same time, instead of the disappearance of the glandular tissue, in parts at least, an atypical growth of such tissue, which assumes the char- acter of an epithelioma. In some cases we find, more- over, besides these two kinds of new formations, a num- rapidly, and consisted of densely-packed spindle-cells in its older portions. The younger portions of the tumor showed round-cells and small spindle-cells. Not a trace of glandular tissue was found. 4. In lymphosarcoma of the lachrymal gland the bulk of the tumor consists of densely-packed lymphatic cells, with hardly any intercellular substance. 5. Epithelioma of the lachrymal gland is formed when an atypical growth of the epithelial elements of the glandular tissue takes place. We find, then, in- stead of the glandular apparatus, solid epithelial cell- cylinders and nests of epithelial cells. This form of growth seems, however, generally to be combined with the development of myxomatous tissue in the lachrymal gland. 6. In the older ophthalmic literature, a number of cases of cystic degeneration of the lachrymal gland, or its ducts, have been described as dakryops. These cysts grew very slowly, and had to be removed on account of their im- pairing the motility of the eyeball. It is not known whether the whole of the lachrymal gland is likely to undergo such a change. XII. Tumors of the Lachrymal Caruncle.-The lachrymal caruncle is sometimes the seat of a new for- mation. Thus, congenital dermoid tumors have been ob- served in this region. In advanced life it may become the seat of epithelioma- tous new formations as well as of sarcoma. The latter kind of tumors are usually pigmented. The develop- ment of these tumors is almost always attributed to an injury. XIII. Tumors of Lachrymal Drainage Appara- tus.-In rare cases small granulomata (polyps) have been found in the lachrymal sac, and even in the lachry- mal canaliculus. It is obvious that such little tumors may gain some clinical importance by the stoppage of the canals through which the tears ought to be carried off. Their formation is due to chronic inflammatory conditions of the mucous membrane of these channels. Adolf Alt. Fig. 1090.-Lympho-sarcoma of the Lachrymal Gland. ber of islets of hyaline cartilage-tissue. Thus, instead of a simple myxoma or myxo-sarcoma of the lachrymal gland, we have then a myxoma carcinomatodes, or a myxoma carcinomatodes chondromatodes. In other cases the hya- line cartilage may be the prevailing tissue, then we would have to call the tumor an enchondroma myxomatodes car- cinomatodes. 3. A spindle-cell sarcoma of the lachrymal gland has been described by the writer. The tumor developed quite 814 END OF VOLUME II.